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[08/04/2005]
 Mali | |
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Authors: Dr Francis Louis, Yaoundé, Cameroon –
Acknowledgements : Pr Abdourahamane Sideye MAIGA, I.N.R.S.P.,
Bamako, Mali
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General Statistics
Area: 1,241,133 km²
Population: 10,800,000 inhabitants
Capital: Bamako
Currency: CFA franc (1 FCFA = 0,01 FF)
Official Language: French
Bordering countries: Algeria, Niger, Burkina Faso,
Ivory Coast, Guinea, Senegal and Mauritania 
Out of 192 countries Mali ranks 184th for life
expectancy, 190th for infant mortality, 176th
for GNP, 139th for daily calorie intake,
181st for literacy, 170th for the percentage
of children in full-time education (source: Atlas Encyclopédique
Mondial, Nathan Ed., Paris 1996, pp.118-119). Concerning climate, Mali can be divided into
two parts: The South, characterized by a rainy season from May to October,
with maximum rainfall in August.
The north, above 16° of latitude, where the climate is
desert-like.
The map below shows the isohyets (S. Maiga, comm.
pers.): 
| Epidemiological Facies
1. South of 16° latitude north, malaria is of the
sahelian type: this means that transmission is
seasonal and short from June to November and that relative immunity
takes a long time to acquire. During the rainy season malaria is at
the origin of more than 2/3 cases of fever (S. Maiga, comm.
pers.).
In 1942, in this part of Mali, the splenic rate was
at 56.2% in the 2-5 years old age group; 45.7% in 6-10
year olds, and at 32.4% in 11-15 year olds
(1). Plasmodiumfalciparum
represented 95% of identified hematozoon, the remaining 5% were
divided between Plasmodium ovale
and Plasmodiummalariae
(1 ). In practice however, the malaria situation varies from one area
to another. These variations are linked to the presence, or not, of
a river (Niger, Senegal, Bani) and to ecological systems: a mosaic
of savannah-forest in the extreme south,
savannah and trees in the Bamako region, flood plains the length of
the river Niger, steppes and shrubs to the west etc. According to
A. Escudié and J. Hamon, schematically we can consider there being
a gradient from the west (mesoendemic, i.e.the parasite prevalence
rate is between 11 and 50% in 2-9 year olds) to the east
(holoendemic, i.e. the parasite prevalence rate is superior to 75%
in children aged under 1) (2). In a recent study, I. Kleinschmidt
et al. stated the exact opposite: that the risk is far greater in
the west than in the east ... (41 ). In 1977, E. Ngombé found a parasite prevalence rate in Bamako of
70% in children aged under
10. Plasmodiumfalciparum
was found in 94% of cases (7). These findings were confirmed in
1978 by P. Ballester (9 ). Also in 1978, the study of 938 school children aged between 6
and 18, south of Bamako, showed a parasite prevalence rate of 70.5%
and Plasmodiumfalciparum
was found in 94.4%
cases, Plasmodiummalariae
in 6.2% and Plasmodiumovale
in 3.6% (8 ). In 1980 in,Kambila, 25 km north of Bamako,
the plasmodium prevalence rate was at 73.6%
in children aged under 9
and Plasmodiumfalciparum
was found in 95.7% cases (10 ). Further north, at the very limit of 16° latitude north
the plasmodium prevalence rate was at 63% in
the general population even though it was not the rainy season
(11).In 1989, the plasmodium prevalence rate
varied from 35.4% in May to 61.9% in November in Tieneguebougou and
from 54.3% to 75.1% in Kambila, two villages at 15 km
from Bamako (12 ). 2. In the north, malaria strikes periodically, and is
inconsistent from one year to another. | Vectors
In 1943, J. Sautet and H. Marneffe identified
the vectors Anopheles coustani, Anopheles paludis similis,
Anopheles funestus, Anopheles gambiae, Anopheles pharoensis
Anopheles rufipes rufipes and Anopheles
squamosus (1 ), with a huge predominance
of Anopheles gambiae.
In 1960, A. Escudié and J. Hamon pointed out
that Anopheles funestus dominated
during the dry season and that, Anopheles gambiae and
Anopheles nili were dominant during the rainy season
(2 ).
Jacques Brunhes et al.(Les anophèles de la région afro-tropicale,
logiciel ORSTOM Ed., 1998) registered 23
different species of anopheles in the country, of varing medical
interest: Anopheles arabiensis, Anopheles brohieri,
Anopheles brunnipes, Anopheles coustani, Anopheles domicola,
Anopheles flavicosta, Anopheles funestus, Anopheles gambiae,
Anopheles hancocki, Anopheles leesoni, Anopheles maculipalpis,
Anopheles nili, Anopheles obscurus, Anopheles paludis, Anopheles
pharoensis, Anopheles pretoriensis, Anopheles rhodesiensis
rhodesiensis, Anopheles rivulorum, Anopheles rufipes rufipes,
Anopheles sergentii macmahoni, Anopheles squanosus, Anopheles
wellcomei wellcomei and Anopheles ziemanni. | Chemoresistance
1. Resistance to chloroquine. The first case of reduced sensitivity to chloroquine was brought
to light in 1987 during an in vivo test on 43 school children in
Selingue, 150 km south of Bamako (28).
The first case of chloroquine-resistance was published in 1988
(14), the second in 1990 (16). That same year, Guiguemde proved the
phenomenon again, in vivo, in Bamako at a rate of 7% (2 cases of
resistance out of 29 children asymptomatic carriers, treated
with chloroquine) (19 ).
Since 1991, nothing more has been published on the subject. The
« Pr Maïga » documents the 2 year study of 2,300 children
from the same village: 19.3% were resistant to chloroquine in 1996
and 21.5% in 1997 (comm. pers.). In the same village, the rate of
drug trial failure was 10.1% in 1996 and 7.3% in 1997. 2. Resistance to other antimalarial drugs: Amodiaquine: not documented
Quinine: not documented
Sulfadoxine-pyrimethamine combination: a 1996 study conducted in
Bandiagara showed that of 89 samples, 3 had the genotype of
resistance to pyrimethamine only (3.4%) and 9 of mixed infections
(10.1%). In Mopti, out of 77 samples tested, 2 showed resistance to
pyrimethamine (2.6%) and 16 were of mixed infections (20.8%)
(26 ).
Proguanil: Out of a total of 501 strains of plasmodium collected
from malaria sufferers upon their return from Africa between 1995
and 1997, of which 59 came from Mali, R. Durand et al. showed a
rate of mutation of codon 108 of the parasite gene by
dihydrofolate-reductase pass from 19.8% in 1995 (81 strains tested)
to 43.6% in 1997 (259 strains tested). Unfortunately, the authors
only gave general results and not individual ones for each of the
29 countries involved (38). | The National Anti Malaria Program
If such a program does exist today, it is without a
leader.
According to Y. Kassankogno, the main action plan of the program is
the setting up of policies on the management of cases and the use
of treated mosquito nets (39). Nevertheless there is only one
documented trial which ran from 1989-1990 and concerned curtains
treated with permethrine (17).
| Research Institutions.
The Pr. Ogobara Doumbo (Medicine Faculty in Bamako) and
Abdourahamane Sideye Maïga (I.N.R.S.P.) are in the process of
conducting malaria research in Mali. Their main area of research is
the study of in vivo and in vitro chemoresistance , the monitoring
of failed drug trials, and compliance to the therapeutic schedule
by patients and drug prescribers alike, within the CAP studies
concerning Anti Malaria Action on a community based level. (A.S.
Maïga, comm. pers.).
| Advice to travelers
According to the B.E.H. n°24-25 of the 14th june 2005, Mali is
classified in chloroquine-resistance group II . This signifies that
a traveler spending less than 3 months in the country should take
the Chloroquine-Proguanil or the Atovaquone-Proguanil combined
treatment
This recommendation seems totally appropriate for someone traveling
to the south of the country. However, for the rest of the country,
that’s to say north of the Tombouctou-Gao line the specific
conditions of the journey should be taken into account: humid
season Vs dry ? Staying in towns or in the countryside ? Staying at
a hotel or in a traditional dwelling? etc . More often, simple
measures of precaution against mosquito bites seem to be
sufficient.
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