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Malaria Cases Expected To Spike In India As Rainy Season Approaches: Why Does This Happen During Monsoon?

Monsoon is right around the corner, which means, mosquito borne diseases like Malaria are about to be unleashed on us. But have you ever wondered why Malaria is particularly prevalent during the rainy season?

Malaria is a mosquito-borne infectious disease caused by the Plasmodium parasite, said the World Health Organisation, and it remains a significant public health concern in India, particularly during the monsoon season. Several factors contribute to the increase in malaria cases during this time:

Favourable Breeding Conditions

Monsoon brings heavy rainfall and increased humidity, creating ideal breeding conditions for mosquitoes, especially the Anopheles mosquitoes responsible for transmitting malaria. Stagnant water pools become common, providing ample breeding sites for mosquitoes to multiply rapidly, said the Centres For Disease Control and Prevention.

Malaria Cases Expected To Spike In India As Rainy Season Approaches: Why Does This Happen During Monsoon?

Increased Mosquito Population

With the availability of more breeding sites and favorable environmental conditions, the mosquito population tends to surge during the monsoon. This leads to a higher density of mosquitoes in residential areas, increasing the risk of malaria transmission.

Waterlogging and Poor Drainage

Monsoon rains often result in waterlogging in many areas, particularly in urban areas with inadequate drainage systems. Waterlogged areas become breeding grounds for mosquitoes, posing a significant risk to nearby populations.

Human Behaviour

During the monsoon, people tend to spend more time indoors or in sheltered areas to avoid heavy rainfall. However, this can lead to increased indoor mosquito exposure, especially if homes are not adequately protected with screens or mosquito nets.

Migration of Mosquitoes

Some mosquito species, including those that transmit malaria, may migrate to new areas during the monsoon in search of suitable breeding sites. This movement can contribute to the spread of malaria to previously unaffected regions.

Reduced Access to Healthcare

In remote or rural areas, monsoon rains can disrupt transportation and access to healthcare facilities. This can delay diagnosis and treatment of malaria cases, leading to a higher burden of the disease in these communities.

Agricultural Activities

Monsoon is a crucial time for agricultural activities such as rice cultivation, which often involves the use of water-filled fields. These agricultural practices can create additional mosquito breeding sites, contributing to the transmission of malaria in rural areas.

Challenges in Vector Control

Controlling mosquito populations during the monsoon can be challenging due to the rapid breeding cycles and the vast areas that need to be covered. Moreover, we do not have a vaccine for Malaria yet. Inadequate vector control measures can lead to persistent mosquito-borne disease transmission.

Also Read: WHO Approves 2nd Malaria Vaccine: Here's Everything You Need To Know About It

Malaria Cases Expected To Spike In India As Rainy Season Approaches: Why Does This Happen During Monsoon?

Addressing Malaria Spike During Monsoon

To address the increase in malaria cases during the monsoon in India, comprehensive strategies are needed, including:

Vector Control Programmes

IImplementing effective mosquito control measures, such as larval source management, insecticide-treated nets, indoor residual spraying, and community-based vector control initiatives.

Public Awareness and Education

Educating communities about malaria prevention measures, including the use of bed nets, wearing protective clothing, eliminating standing water around homes, and seeking prompt medical care for symptoms.

Improved Healthcare Access

Ensuring that healthcare facilities, especially in rural and remote areas, are equipped to diagnose and treat malaria cases promptly, including access to antimalarial medications and diagnostic tools.

Environmental Management

Implementing sustainable environmental management practices to reduce mosquito breeding sites, such as proper drainage systems, water resource management, and urban planning strategies.

Also Read: World Malaria Day 2023: Understanding The Risk Of Reinfection And Ways To Prevent Malaria

By addressing these factors comprehensively and implementing targeted interventions, it is possible to mitigate the impact of malaria during the monsoon season and reduce the burden of this preventable disease on communities across India.

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Where Malaria Is Spreading

A new Washington Post analysis shows that climate change and demographic growth could put more than 5 billion people at risk for malaria by 2040

Rachel Chason and Jahi Chikwendiu traveled to Nampula, Maputo and Niassa provinces in Mozambique to report on how malaria is making new inroads in a warming world. Kevin Crowe analyzed the potential for spread around the world. John Muyskens visualized the findings.

Published Oct. 23 at 6:00 a.M.

NAMETIL, Mozambique

Unica Cardoso leaned against the walls of the overcrowded health center, her body aching and her fever spiking.

It was Mozambique's winter season, when cooler and drier weather have historically meant less malaria transmission. But there'd been so many suspected cases that day that the health center had run out of quick tests. Cardoso, 35, had just tested positive and feared her 2-year-old daughter at home was sick with the same.

"I am not surprised anymore," she said of falling sick during the winter. "But it is not normal."

The threat posed by malaria stands to soar as the planet warms because of longer transmission seasons, more frequent and severe extreme weather events, and the migration of malaria-carrying mosquitoes to new latitudes and altitudes, according to a Washington Post analysis of climate modeling and reporting from the southern African country of Mozambique.

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Health data obtained and analyzed by The Post reveals how dire the situation is becoming, with Mozambique's malaria cases on pace this year to reach their highest level since 2017, when the government began its current process for counting cases.

The results of the Post analysis reveal which countries and regions are at most risk, in particular as seasonal changes benefit disease-carrying mosquitoes. In some regions of the world, transmission seasons could increase by up to five months by the year 2070.

Sub-Saharan Africa has long faced the highest risk from malaria, with some regions seeing transmission seasons all year. Hot spots for malaria transmission are emerging at higher altitudes and latitudes.1 / 4

In the United States, warming temperatures and increased rainfall are projected to lengthen malaria transmission seasons across the South. Once endemic, malaria was eradicated in the United States last century.1 / 4

Hotter temperatures are allowing these mosquitoes to spread in areas where malaria has not historically been a problem, especially in the Andes Mountains of Colombia, Peru and Ecuador.1 / 4

In the highlands of African countries such as Ethiopia and Kenya, where the population has little resistance to the disease, currently short transmission seasons could stretch up to four months a year.1 / 4

Hotter temperatures are allowing these mosquitoes to spread in areas where malaria has not historically been a problem, especially in the Andes Mountains of Colombia, Peru and Ecuador.

The Post analysis relied on data produced by three models that estimate how long each year conditions are favorable for mosquitoes and parasites in given areas, by projecting how the heat, humidity and precipitation would change in coming years, and how much of the human population is at risk in each of them. The Post averaged the data to account for differences among them.

While infectious-disease experts have for years documented that rising temperatures expand the range of deadly pathogens, the ominous trend here underscores the extent to which nearly two decades of global progress against malaria is being eroded in part because of climate change. The world has seen global case counts ticking up over the past six years, according to the World Health Organization, with case rates increasing by 10 percent during that period in Mozambique, which researchers rank among the countries most vulnerable to climate change.

"Despite all the interventions, we are not seeing results," said Baltazar Candrinho, who leads Mozambique's national malaria control program. "The temperatures are going up, the rainfall is strange … and when a cyclone comes, people lose everything — and we lose the tools to fight malaria. It is a big challenge."

People gather water for their daily activities in Mozambique.

Malaria carried by these mosquitoes is part of an accelerating wave of sickness and death due to climate change. Humanity is increasingly confronted with lethal heat, malnutrition linked to ever more common droughts and floods, and illnesses borne by mosquitoes and ticks — including dengue, Zika and chikungunya. Malaria, alone, was responsible for more than 600,000 deaths worldwide in 2021, the last year for which data was available, and more than three-quarters of the victims were under the age of 5.

In some countries where malaria is already endemic everywhere, such as Mozambique, case counts are on the rise in part because climate change is disrupting traditional rainfall patterns and causing extreme weather events, in turn fostering conditions in which mosquitoes thrive and breed, such as standing water and humidity. Other nations could have areas that experience shorter transmission seasons, as they become so hot and dry that it will be harder for mosquitoes to survive.

Mozambique and other countries with the highest malaria case totals also have some of the world's fastest-growing populations. By 2040, the combined effects of longer transmission seasons and demographic growth could put more than 5 billion people at risk of contracting malaria worldwide, including a billion on the continent of Africa alone. In Mozambique, that figure could reach 29.5 million people. By 2070, this population could increase to 1.5 billion in Africa, and in Mozambique, it could reach 42 million people — more than 75 percent of the projected total population of the country, the Post analysis shows.

In the health center in Nametil, a rural town in Nampula province where the Post analysis shows that malaria case rates increased 43 percent between 2017 and 2022, Cardoso wove her way through crowds of other patients, many of them sick with malaria and all waiting for medicine. Already, she had lost three children to malaria, all before their fifth birthday.

She walked quickly, eager to get back to her daughter, who she feared might have grown sicker in her absence. Cardoso, a petite woman with expressive eyes, said she had wanted to bring the girl to the clinic that day but had neither the money for medication nor the strength to carry her.

She passed a door with a poster that reminded patients: "Families who are protected from malaria smile together forever."

The malaria parasite typically spreads when a female mosquito in the Anopheles family bites a person who is already infected. The mosquito takes in the parasite along with the human blood and, about a week later, can transmit malaria by biting another person.

Scientists are trying to better understand how climate affects malaria transmission but know that the parasites and the mosquitoes that transport them tend to thrive in conditions that are warm, humid and rainy. The insects do best when temperatures are around 80 degrees Fahrenheit.

Endemic malaria was eliminated in North America and Europe in the mid-1900s, with a better understanding of how to control it. The disease has remained widespread in sub-Saharan Africa but saw dramatic declines in case and mortality rates in the 2000s following a multibillion-dollar health campaign led by Western governments and international nonprofits that prompted the widespread use of insecticide-treated bed nets, quick tests and more readily available treatments.

Some of those gains in Africa have been reversed since 2017, and experts say this trend is likely to continue, although gains in development and technological advances, including improvements to the malaria vaccine, could improve the outlook. Researchers and government officials attribute this troubling trajectory not only to climate change but also to the increased resistance of mosquitoes to insecticides and of the parasite to drugs. Improved disease surveillance and data collection could also be contributing to higher case counts.

The projections for South America are also grim. There, 330 million people could be at risk of contracting malaria by 2070. The projections take into account changing climate and demographic factors but do not factor for public health efforts or mosquito control programs.

Researchers check blood samples for the presence of the malaria parasite Plasmodium falciparum at the Manhiça Health Research Center.

"Efforts to fight malaria are at this crossroads and have been seriously challenged by climate change," said Sherwin Charles, the co-founder of Goodbye Malaria, which has been working to end malaria in southern Africa. "We thought we knew how to deal with this epidemic, but the complication of climate change brings different factors to bear that maybe we are not ready for."

Tatiana Marrufo, a doctor who studies climate change and disease at Mozambique's National Health Observatory, said that the same environmental conditions that foster the breeding of mosquitoes can also often handicap efforts to contain malaria.

Nonprofits, for instance, try to spray insecticide inside homes in advance of the rainy season, but erratic rainfall is making it hard to time effective spraying. Additionally, cyclones and floods can wipe out a family's supply of bed nets in seconds and force them out of their homes, leaving them more exposed to mosquitoes.

Outside the low-slung Nametil health center on an August morning, the skies were foreboding, clouds heavy. Even though August is typically cold and dry, within the hour, rain would begin to fall. The warm and rainy season, so predictable for generations, has turned capricious, offering little respite from malarial mosquitoes.

"Malaria used to come in a certain period — the rainy, hot season," said health coordinator Adamo Palame, who works for Doctors Without Borders raising community awareness about how to control malaria and other tropical diseases, punctuating his words with emphatic hand gestures. "But right now, throughout the year, the mosquitoes multiply."

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"Even when you think you are in the dry season," he added, eyebrows arching above his round-rimmed glasses, "all of a sudden, it rains."

In front of the clinic's triage center, Joca Formiga, a mother of seven, held a quick test in her hand. Two pink lines indicated that her 2-year-old daughter had just tested positive for malaria. In her other hand was a yellow booklet in which doctors had marked each previous positive result. This was the fifth time her daughter had tested positive, just this year.

Mothers bring their children to the Nametil health center in August to be treated for malaria.

Within two minutes, another woman whose child had tested positive joined her. Then another, then another, until a dozen women with babies swaddled on their backs and tests in their hands had gathered round.

"I cry within my heart," said Olga Victorino, "and ask myself, 'Why do my children have malaria again and again and again?'"

Victorino, 25, a short woman in a yellow wrap, held her crying 2-year-old son, who had just tested positive. There was more malaria now than when she was growing up, she said. She suspected it might have something to do with the weather, especially the water that no longer seemed to recede.

"If it rains, it is difficult to stop their infiltration," Victorino said of the mosquitoes. "The pools of water are everywhere."

Historically, malaria cases peaked once each year in Mozambique, around February or March, according to Abuchahama Saifodine, a country adviser to the U.S. Agency for International Development who grew up in Mozambique and has long studied malaria. But in recent years, he said, rain is so erratic that in some parts of the country, there are now two or more peaks.

Mozambique's extended transmission season could be a harbinger for other parts of the world.

In the United States, for example, where broad land-use changes and public health initiatives helped eradicate malaria in the past century, the changing climate could create favorable conditions for the disease to spread if travelers arrive carrying the parasite. Warming temperatures and increased rainfall are projected to lengthen the period when malaria could propagate across the South. Portions of North Carolina, Tennessee and Virginia could see transmission seasons of at least four months by 2070.

More than 200 million people, many without acquired immunity, could be at risk, according to the Post analysis.

"The fact that [malaria] will be affecting immunologically naive populations means that there's going to be higher morbidity and likely higher mortality within those populations," said Felipe Colón-González, lead author of the Lancet study evaluating the malaria models on which The Post based its analysis.

"And the fact that the health systems in those areas are unprepared for that means that they will have to change the allocation of resources that might already be scarce in some areas of the world," added Colón-González, an infectious-disease modeler with Wellcome, a nonprofit that supports global research in health and climate.

Unica Cardoso, seen with her family after testing positive for malaria, said she was determined to get medical treatment for her 2-year-old, who she feared also had malaria.

After returning to her one-room concrete home, Cardoso, who had tested positive at the health center on that August afternoon, said she was determined to find the strength to bring her daughter for treatment and to find the money — the equivalent of about 9 cents — to pay for medication at the public clinic. (At the private clinic, each dose costs the equivalent of $5 — a prohibitive amount in a province where the average wage is less than $1 a day.)

Each night, Cardoso said, she carefully stretches nets over her three surviving children as they sleep. But the house's walls cracked during the most recent cyclone, she said, and mosquitoes are also able to get in through a hole in the roof.

"I don't know what is causing the change in the weather," she said, stroking her little girl's hair. "But there are more mosquitoes now, and every month, these children are getting sick."

Alberto Charles shook his wife awake one night early this year after being awakened by the sound of rushing water. The couple and their children had only 10 minutes to grab what they could, including a freezer, a radio and a few sets of clothes, as water filled their home. When they left, the water was already knee-deep. Outside, the floods had ripped their orange trees and banana plants out of the ground.

A few weeks later, when Charles and his family were still sheltering at a crowded emergency center surrounded by stagnant water, chills started to rack his body. Then, he lost his appetite, and the fever set in. When he went to the health center in Boane district, about 20 miles southwest of the capital, Maputo, there was a long line of people waiting to be tested for malaria.

Helena Ubisse, who works with Goodbye Malaria, drops mosquito larvicide into pools of standing water on a flooded-out road in Boane. A long line of people wait to be tested for malaria at the Boane Health Center in August.

Like much of southern Mozambique, Boane is wealthier and more developed than much of the north, including Nametil. The malaria rates are also dramatically lower here because of the climate, higher level of development and a years-long anti-malaria campaign, led by Goodbye Malaria, which sprays insecticide inside and outside homes.

But Olivia Chissaque, the head doctor at the Boane Health Center, said the flooding upended that progress, with case rates afterward jumping to where they had been years earlier. And treating the patients was more difficult, she explained, because many of the doctors and nurses had lost their homes.

Globally, extreme weather events driven by the burning of fossil fuels are becoming more common and more intense. Mozambique, which has more than 1,500 miles of coastline, is especially vulnerable to cyclones, which studies show have become fiercer in recent years. Government officials say extreme flooding in Mozambique has also surged, including the destruction in Boane this year, when roads turned to rivers and thousands were displaced.

Beyond the immediate damage caused by cyclones and floods, malaria and other diseases such as cholera tend to surge weeks later due to extensive standing water and the disruption of disease control efforts. Teams from Goodbye Malaria had just completed indoor spraying when the floods arrived, washing away the spray — and sometimes entire houses.

Alberto Charles, 34, said that within hours of the floods starting, his entire house had been submerged except for the antenna on the roof.

His family eventually returned home, though he said he worries that mosquitoes are breeding in the stagnant water still sitting in their fields six months later, and he's nervous because his house has not been resprayed. But Charles, his face tired and his clothing worn, said there was no choice but to return.

"We don't have anywhere else to go," he said.

Each year, Tatiana Marrufo leads an effort at Mozambique's National Health Observatory to predict where outbreaks will occur. Her team has been surprised in recent years, she said, to see upticks in malaria in some of the country's highest-elevation districts.

Typically, higher altitudes have been associated with lower temperatures that are not suitable for malaria-carrying mosquitoes. But a recent study by researchers at Georgetown University found that the range of such mosquitoes in Africa extended to higher elevations at an average of about 6.5 meters per year — more than 200 feet per decade — during the past century.

Other studies have established the link between rising temperatures and the expansion of malaria epidemics to higher altitudes during particularly warm years and those associated with El Niño.

Areas at the edges of malaria's current reach, such as those at higher altitudes, are the places where climate change and variability are having the largest impact, said Mercedes Pascual, a biology professor at New York University who studies the ecology and evolution of infectious disease. Some of those areas, Pascual noted, are highly populated regions in the highlands of East Africa.

Lucia Eduardo, 36, a community health worker in Mandimba, is working to spread awareness about malaria prevention. Joaquin Alberto, 24, second from left, chats with friends while washing clothes in the river that runs through town.

Marrufo and her colleagues are studying whether the higher-altitude outbreaks they are seeing in Mozambique might be linked to this global trend. She noted that malaria has always been present in these areas, which are not nearly as high as more mountainous regions in Africa, but she still suspects the rising case counts could be a product of climate change.

The district of Mandimba in northwestern Mozambique is one of the higher-altitude jurisdictions in that part of the country. Since 2017, Mandimba has seen a 20 percent increase in malaria case rates, government data shows.

Lucia Eduardo, 36, a community health worker in Mandimba, said that malaria was less of a problem when she was a girl, even though her remote community knew less about combating the disease. Already this year, she said, two of her children had fallen ill with malaria. She and others here said they suspected that part of the reason was that the weather has gotten hotter.

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In winters past, Mandimba residents would typically be layered in sweaters, but in recent years, they are comfortable at times in T-shirts, Eduardo said. And during the hot season, people now sometimes sleep outside, introducing an additional risk of contracting malaria.

Since 2014, Eduardo has worked with a community group to spread awareness about the disease. The group is run by a local nonprofit and funded through the President's Malaria Initiative, which is led by USAID and along with the Global Fund provides the vast majority of Mozambique's funding for malaria prevention.

Wearing a skirt bearing the words "Zero malaria starts with you," Eduardo said she goes door-knocking every few weeks, explaining how to prevent the disease from spreading. She said she wishes those efforts were paying off better.

"It is a permanent challenge," she said, looking up, her eyes bright. "And when there is such a challenge, I will do everything I can to save my community."

About this story

Design and development by Hailey Haymond and Emily Sabens. Additional development by Yutao Chen. Editing by Alan Sipress, Anu Narayanswamy, Olivier Laurent, Monica Ulmanu, Juliet Eilperin, Joe Moore, Emily Morman, Tom Justice, John Farrell and Jay Wang.

Sources

The Washington Post analyzed data on malaria counts and deaths on a global scale and in particular for the country of Mozambique. The global modeled data projects which areas of the world will be most suitable for malaria-carrying mosquitoes based on various climate and emissions scenarios and how many people in those areas will be at risk of contracting the disease in the future.

The climatic suitability and population-at-risk data came from a set of three peer-reviewed models that eight scientists from European medical and research institutions published in the journal the Lancet Planetary Health. The models each accounted for different sets of variables, such as temperature, precipitation, humidity, local hydrology, mosquito populations and the potential immunity to malaria that had built up in the human population in an area. Using these variables, the scientists determined which areas of the planet might be suitable for mosquito and parasite reproduction and for how many months during the year. That measurement is called length of malaria transmission season.

To analyze malaria case trends in Mozambique, The Post acquired detailed monthly counts by district from the country's National Malaria Control Program. The data range from January 2017 through August 2023.

Global malaria case and death counts come from the World Health Organization's World Malaria Report and cover 2000 through 2021.

How we are projecting the length of malaria transmission seasons in 2040 and 2070

The modeled data were produced for the entire globe on a 35-square-mile grid. For each square, the scientists calculated the number of months per year that area would be suitable for malaria transmission as well as the number of people at risk for contracting malaria. They produced the data in 30-year slices from 2010 to 2100. The Post used the slices ranging in years from 2010 to 2039 and 2040 to 2069. The models measure the changes and transmission season and population at risk relative to a base period of 1970 to 1999.

The Post averaged the data produced by the three different models for a specific scenario for future greenhouse gas emissions — RCP 4.5 — which is deemed a middle-of-the-road approach. The Post then aggregated the data by country to determine which specific places could be most at risk by 2070.

Adrian Tompkins and Cyril Caminade, scientists at the International Centre for Theoretical Physics in Trieste, Italy, who helped develop two of the malaria models and ran the simulations, guided reporters on how to analyze the data and interpret results.

Study Highlights Heavy Global Burden Of Infectious Diseases

A study published this week in The Lancet Infectious Diseases highlights the substantial impact of infectious diseases on global health.

The analysis of data from 204 countries by researchers with the Institute for Health Metrics and Evaluation estimates that 85 pathogens accounted for 704 million disability-adjusted life years (DALYs)—the number of years lost from ill health, disability, or early deaths—globally in 2019. That figure accounts for 28% of 2.54 billion DALYs attributed to all causes in the 2019 Global Burden of Disease (GBD) study.

The impact of these pathogens was disproportionately seen in children. Nearly 44% of the DALYs attributed to pathogens (309 million) in 2019 occurred in children under the age of 5 years.

According to the World Health Organization, one DALY represents the loss of the equivalent of one full year of health.

The study authors say their methodologic approach captures the full impact of pathogens on mortality and disability and is the most inclusive approach used to date. And they believe that their estimates, which they say highlight some pathogens that are being overlooked, can help global health leaders target areas where more research, funding, and action are needed.

"We urgently call for further research in drug development, vaccinology, and pathogen biology to innovate and accelerate drug and vaccine development for the broader group of pathogens highlighted in these rankings," they wrote.

TB, malaria, HIV had biggest impact

Of the total 704 million DALYs attributed to the 85 pathogens, bacterial infections were associated with 415 million, viral infections with 178 million, parasitic infections with 172 million, and fungal infections with 18.5 million.

The three pathogens with the largest observed impact were those causing tuberculosis (TB, 65.1 million DALYs), malaria (53.6 million), and HIV or AIDs (52.1 million). Malaria parasites were the leading pathogens for DALYs in children under 5 (37.2 million).

But the study also found a substantial burden associated with Streptococcus pneumoniae (38.1 million DALYs), Staphylocococcus aureus (34.5 million), and Klebsiella pneumoniae (31.1 million). In fact, S aureus was a leading pathogen according to DALY burden in 64 of the 204 countries included in the study and was associated with the sixth highest DALY burden in children under 5.

Others among the top 20 most burdensome pathogens were Escherichia coli, hepatitis B and C virus, Pseudomonas aeruginosa, influenza virus, Acinetobacter baumannii, Helicobacter pylori, invasive non-typhoidal Salmonella, rotavirus, respiratory syncytial virus, Salmonella enterica serovar Typhi, Bordetella spp (pertussis), group B Streptococcus, and fungi as a group.

We urgently call for further research in drug development, vaccinology, and pathogen biology to innovate and accelerate drug and vaccine development for the broader group of pathogens highlighted in these rankings.

The authors say that while the estimates support the amount of attention that TB, malaria, and HIV/AIDS receive from the global health community, the substantial health burden they observed for gram-negative bacteria suggests these pathogens deserve more focus and resources. Collectively, K pneumoniae, E coli, P aeruginosa, and A baumannii accounted for 114 million DALYs.

"Such a burden poses a substantial threat in health-care settings, leading to increased treatment costs, prolonged hospital stays, and elevated mortality rates, with the additional compounding effect of outbreaks in hospital settings that further contribute to the disease burden," they wrote. "Furthermore, these infections often occur in immunocompromised individuals, hospitalised patients, older individuals, or people with chronic illnesses, and are often caused by pathogenic species carrying various resistance genes."

Higher burden in poor countries

The impact from these pathogens was significantly larger in low- and middle-income countries (LMICs) than in high- and upper-middle-income countries, where non-communicable diseases like cancer and heart disease account for a greater proportion of DALYs.

When grouped by super-region, the highest fraction of pathogen-associated DALYs was seen in sub-Saharan Africa (314 million DALYs, 61.5% of 511 million total DALYs) and the lowest in the high-income super-region (31.8 million, 9.8% of 324 million DALYs). The fraction of DALYs associated with pathogens was also high in South Asia.

The authors say the discrepancy between poor and wealthy nations can be attributed to poor sanitation, limited access to clean water, and poor hygiene in LMICs, along with notable differences in healthcare infrastructure and access to essential medicines. They also note that, of the 85 pathogens analyzed, vaccines are available for only 22.

In an accompanying commentary, infectious diseases experts from South Africa and Tanzania say defining the burden of infectious diseases is just the first step. The next step is to understand how to sustainability reduce that burden, particularly in the places that are hardest hit.

"There is an urgent need to identify why well established interventions, such as the acceptability of vaccination, water, sanitation, and hygiene, and antimicrobial stewardship, are failing, whether interventions are implemented as intended, what dynamics within a country influence implementation, and how context might affect the outcomes," they wrote.

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