Medicinal Spices and Vegetables from Africa: Therapeutic Potential against Metabolic, Inflammatory, Infectious and Systemic Diseases

Medicinal Spices and Vegetables from Africa

Therapeutic Potential against Metabolic, Inflammatory, Infectious and Systemic Diseases

Edited by

Victor Kuete

University of Dschang

Dschang, Cameroon

Table of Contents

Cover

Title page

Copyright

List of Contributors

Preface

Part I: Diverse Degenerative Diseases in Africa

Chapter 1: Diseases in Africa: An Overview

Abstract

1. General overview of disease burden in Africa

2. Infectious diseases

3. Neglected tropical diseases

4. Noncommunicable diseases

5. Malnutrition

6. Conclusions

Chapter 2: Management of Inflammatory and Nociceptive Disorders in Africa

Abstract

1. Introduction

2. Epidemiology of inflammatory and nociceptive disorders

3. Gender and age of patients versus inflammatory and nociceptive disorders in Africa

4. Prevention

5. Inflammatory pain control policy in the African context

6. The inflammatory response

7. Pain processing and nociception pathway

8. Conventional drugs used for the management of inflammatory and nociception disorders

9. Medicinal plants used for the management of inflammatory and nociception disorders

10. Conclusions

Chapter 3: Burden and Health Policy of Cancers in Africa

Abstract

1. Introduction

2. Common cancers in Africa

3. Government control policies for cancer in African countries

4. Conclusions

Chapter 4: Metabolic Syndromes and Public Health Policies in Africa

Abstract

1. Introduction

2. Prevalence of metabolic syndrome in Africa

3. Systematic review of public health policies on metabolic syndrome in Africa

4. Framework to develop public health policy for medicinal herbs—the case of pepper

5. Conclusions

Chapter 5: Management of Infectious Diseases in Africa

Abstract

1. Introduction

2. HIV/AIDS

3. Dengue

4. Ebola

5. Chikungunya

6. Cholera

7. Cryptococcal meningitis

8. Malaria

9. Schistosomiasis

10. Antimicrobial resistance

11. Management of infectious diseases using African biodiversity

12. Conclusions

Chapter 6: Overview of Governmental Support Across Africa Toward the Development and Growth of Herbal Medicine

Abstract

1. Introduction

2. Encouragement of use of medicinal plants in health care programs

3. Policies for conservation of medicinal plants and local community participation

4. Policy for restoring plants harvested in the wild and sustainability of use

5. Incentives to collectors and farmers to keep production of medicinal plants sustainable

6. Government support on medicinal plant research

7. Policies regarding export of medicinal plants

8. Policy for trade in herbal medicine

9. Herbal medicine regulation in Africa

10. Conclusions and recommendations

Chapter 7: Preparation, Standardization, and Quality Control of Medicinal Plants in Africa

Abstract

1. Introduction

2. Factors that affect the use of medicinal plant preparations

3. Modes of preparation of medicinal plants used in traditional medicine

4. Modes of preparation of extracts in research laboratories in Africa

5. Parameters for selecting an appropriate extraction method

6. Standardization of medicinal plant preparation in Africa and other parts of the world

7. Quality control of medicinal preparations

8. Conclusions

Part II: Therapeutic Potential of African Medicinal Spices and Vegetables

Chapter 8: Antimicrobial Activities of African Medicinal Spices and Vegetables

Abstract

1. Introduction

2. Antimicrobial secondary metabolites and their modes of action

3. In vitro screening methods of phytochemicals for antimicrobial activities

4. Antimicrobial effects of African medicinal spices and vegetables

5. Other antimicrobial spices and vegetables from Africa

6. Antimicrobial mode of action of African spices and vegetables

7. Conclusions

Chapter 9: Anti-inflammatory and Anti-nociceptive Activities of African Medicinal Spices and Vegetables

Abstract

1. Introduction

2. Methods used in the screening of antiinflammatory and antinociceptive activity of African spices and vegetables

3. Selected African spices with antiinflammatory and antinociceptive activity

4. Prominent antiinflammatory active ingredients found in African spices and vegetables

5. Clinical trials

6. Conclusions

Chapter 10: Anticancer Activities of African Medicinal Spices and Vegetables

Abstract

1. Introduction

2. In vitro screening methods of phytochemicals for anticancer activities

3. Anticancer potential of phytochemicals

4. Antiproliferative effects of African medicinal spices

5. Cytotoxicity of other African medicinal vegetables

6. Mode of action of African spices, vegetable’s extracts, and derived products

7. Conclusions

Chapter 11: Antiemetic African Medicinal Spices and Vegetables

Abstract

1. Introduction

2. Modes of action of antiemetics

3. Antiemetics screening methods

4. In vitro and in vivo antiemetic activities of chemicals

5. African medicinal spices as sources of antiemetics

6. African vegetables as sources of antiemetics

7. Conclusions

Chapter 12: African Medicinal Spices and Vegetables and Their Potential in the Management of Metabolic Syndrome

Abstract

1. Introduction

2. In vitro screening methods of phytochemicals against metabolic syndrome

3. Potential of phytochemicals against metabolic syndrome

4. Effects of African medicinal spices on metabolic syndrome

5. Conclusions

Chapter 13: Other Health Benefits of African Medicinal Spices and Vegetables

Abstract

1. Introduction

2. African medicinal spices and vegetables in the treatment of age-related and Alzheimer’s diseases

3. Oxidative stress and antioxidant effects of African medicinal spices and vegetables

4. Medicinal spices and vegetables from Africa used in the treatment of epilepsy

5. Prevention of rheumatoid arthritis with African medicinal spices and vegetables

6. African spices and vegetables and their potential effects on obesity

7. Role of African spices and vegetables in human fertility

Conclusions

Part III: Popular African Medicinal Spices and Vegetables, and Their Health Effects

Chapter 14: Allium cepa

Abstract

1. Introduction

2. Cultivation and distribution of Allium cepa

3. Chemistry of Allium cepa

4. Pharmacology of Allium cepa

5. Patents with Allium cepa

Conclusions

Chapter 15: Allium sativum

Abstract

1. Introduction

2. Cultivation and distribution of Allium sativum

3. Chemistry of Allium sativum

4. Pharmacology of Allium sativum

5. Toxicity of Allium sativum

6. Patents with Allium sativum

Conclusions

Chapter 16: Canarium schweinfurthii

Abstract

1. Introduction

2. Botanical aspects and distribution of Canarium schweinfurthii

3. Chemistry of Canarium schweinfurthii

4. Pharmacology of Canarium schweinfurthii

5. Conclusions

Chapter 17: Cinnamon Species

Abstract

1. Introduction

2. Botanical aspects

3. Chemistry of Cinnamomum cassia and Cinnamomum zeylanicum

4. Pharmacology of Cinnamomum cassia and Cinnamomum zeylanicum

5. Conclusions

Chapter 18: Cymbopogon citratus

Abstract

1. Introduction

2. Chemical constituents of C. citratus

3. Pharmacological activities of C. citratus

4. Patents

5. Conclusions

Chapter 19: Curcuma longa

Abstract

1. Introduction

2. Cultivation and distribution of Curcuma longa

3. Chemistry of Curcuma longa

4. Pharmacology of Curcuma longa

5. Patents with Curcuma Longa

6. Conclusions

Chapter 20: Lactuca sativa

Abstract

1. Introduction

2. History

3. World and African distribution

4. Chemistry

5. Pharmacological activities

6. Other pharmacological activities

7. Clinical trials

8. Conclusions

Chapter 21: Mangifera indica L. (Anacardiaceae)

Abstract

1. Introduction

2. Botanical description

3. Origin and distribution

4. Classification and cultivars of Mangifera indica

5. Phytochemistry of Mangifera indica

6. Pharmacological activity of Mangifera indica

7. Clinical trials

8. Toxicity status of Mangifera indica

9. Conclusions

Chapter 22: Moringa oleifera

Abstract

1. Introduction

2. Cultivation and distribution of Moringa oleifera

3. Chemistry of Moringa oleifera

4. Pharmacology of Moringa oleifera

5. Conclusions

Chapter 23: Myristica fragrans: A Review

Abstract

1. Introduction

2. Botanical aspects and distribution of Myristica fragrans

3. Chemistry of Myristica fragrans

4. Pharmacology of Myristica fragrans

5. Toxicity of Myristica fragrans

6. Patents with Myristica fragrans

7. Conclusions

Chapter 24: Passiflora edulis

Abstract

1. Introduction

2. Botanical description

3. Propagation

4. Traditional or ethnomedicinal uses

5. Phytochemistry

6. In vitro and in vivo pharmacological studies

7. Clinical trials

8. Safety profile and pharmacovigilance data

9. Conclusions

Chapter 25: Petroselinum crispum: a Review

Abstract

1. Introduction

2. Plant description

3. Geographical distribution

4. Ethnomedicinal uses

5. Pytochemical constituents

6. Pharmacological properties

7. Toxicity

8. Clinical trials

9. Patents

10. Conclusions

Chapter 26: Sesamum indicum

Abstract

1. Introduction

2. Origin of the crop

3. Chemical properties of Sesamum indicum

4. Phytochemical studies

5. Pharmacological evaluation of plant extracts

6. Production and cultivation of Sesamum indicum

7. Conclusions

Acknowledgments

Chapter 27: African Medicinal Spices of Genus Piper

Abstract

1. Introduction

2. Taxonomy of the genus Piper

3. Diversity in the Piper species

4. Distribution of the genus Piper

5. Ethnobotanical and ethnosocial importance of the genus Piper

6. Ethnomedicinal applications of the genus Piper

7. Economic and commercial prospect of the genus Piper

8. Bioprospecting and conservation status of the genus Piper

9. Phytochemical constituents of the genus Piper

10. Biological and pharmacological effects of the genus Piper

11. Toxicity profile

12. Conclusions

Chapter 28: Thymus vulgaris

Abstract

1. Introduction

2. Cultivation and distribution of Thymus vulgaris

3. Chemistry of Thymus vulgaris

4. Pharmacology of Thymus vulgaris

5. Patents with Thymus vulgaris

Conclusions

Chapter 29: Syzygium aromaticum

Abstract

1. Introduction

2. Botanical aspect and distribution of Syzygium aromaticum

3. Chemistry of Syzygium aromaticum

4. Pharmacology of Syzygium aromaticum

5. Patents with Syzygium aromaticum

6. Toxicity of Syzygium aromaticum

7. Conclusions

Chapter 30: Zingiber officinale

Abstract

1. Introduction

2. Botanical aspect, distribution, and production of Zingiber officinale

3. Chemistry of Zingiber officinale

4. Pharmacology of Zingiber officinale

5. Patents with Zingiber officinale

6. Conclusions

Index

Copyright

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List of Contributors

Sherif Babatunde Adeyemi,     Department of Plant Biology, University of Ilorin, Ilorin, Kwara, Nigeria

Christian Agyare,     Department of Pharmaceutics, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana

Ketchaji Alice,     Department of Public Health and Hygiene, Faculty of Health Sciences, University of Buea, Buea, Cameroon

Stephen O. Amoo,     Agricultural Research Council–Roodeplaat Vegetable and Ornamental Plant Institute, Pretoria, South Africa

John Antwi Apenteng,     Department of Pharmaceutical Sciences, Central University College, Accra, Ghana

Theresa Appiah,     Department of Pharmaceutics, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana

Tanue Elvis Asangbeng,     Department of Medical Laboratory Sciences, University of Buea, Buea, Cameroon

Jules Clement Nguedia Assob,     Department of Medical Laboratory Sciences, Faculty of Health Sciences, University of Buea, Buea, Cameroon

Nudewhenu O. Avoseh,     Natural Products Research Unit, Department of Chemistry, Faculty of Science, Lagos State University, Lagos, Nigeria

Udo Bakowsky,     Department of Pharmaceutical Technology and Biopharmaceutics, Marburg University, Marburg, Germany

Veronique P. Beng,     Department of Biochemistry, Faculty of Science, Biotechnology Centre, University of Yaoundé I, Yaoundé, Cameroon

Yaw Duah Boakye,     Department of Pharmaceutics, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana

Samba Melvis Bora,     Department of Public Health and Hygiene, Faculty of Health Sciences, University of Buea, Buea, Cameroon

Phillip Taderera Bwititi,     Faculty of Science, Charles Sturt University, Bathurst, NSW, Australia

Achangwa Chiara,     Department of Public Health and Hygiene, Faculty of Health Sciences, University of Buea, Buea, Cameroon

Zofou Denis,     Department of Biochemistry and Molecular Biology, Faculty of Science, University of Buea, Buea, Cameroon

Solomon Derese,     Department of Chemistry, University of Nairobi, Nairobi, Kenya

Doriane E. Djeussi,     Department of Biochemistry, Faculty of Science, University of Dschang, Dschang, Cameroon

Christian Phillipus Du Plooy,     Agricultural Research Council–Roodeplaat Vegetable and Ornamental Plant Institute, Pretoria, South Africa

Kibu Odette Dzemo,     Department of Medical Laboratory Sciences, University of Buea, Buea, Cameroon

Jean P. Dzoyem

Department of Biochemistry, Faculty of Science, University of Dschang, Dschang, Cameroon

Department of Pharmaceutical Technology and Biopharmaceutics, Marburg University, Marburg, Germany

Eric M. Guantai,     Department of Pharmacology and Pharmacognosy, University of Nairobi, Nairobi, Kenya

Abdulmumeen Amao Hamid,     Department of Chemistry, University of Ilorin, Ilorin, Kwara, Nigeria

Lucian Hritcu,     Department of Biology, Alexandru Ioan Cuza University, Iaşi, Romania

Oğuzhan Karaosmanoğlu

Department of Biology, Science Faculty, Anadolu University, Eskişehir

Department of Biology, Kamil Özdağ Science Faculty, Karamanoğlu Mehmetbey University, Karaman, Turkey

Victor Kuete,     Department of Biochemistry, Faculty of Science, University of Dschang, Dschang, Cameroon

Oladipupo A. Lawal,     Natural Products Research Unit, Department of Chemistry, Faculty of Science, Lagos State University, Lagos, Nigeria

Fawzi M. Mahomoodally,     Department of Health & Sciences, Faculty of Science, University of Mauritius, Réduit, Mauritius

Tshepiso J. Makhafola,     Department of Life and Consumer Sciences, College of Agriculture and Environmental Science, University of South Africa, Pretoria, South Africa

Esembeson Malika,     Department of Public Health and Hygiene, Faculty of Health Sciences, University of Buea, Buea, Cameroon

Armelle T. Mbaveng,     Department of Biochemistry, Faculty of Science, University of Dschang, Dschang, Cameroon

Lyndy J. McGaw,     Phytomedicine Programme, Department of Paraclinical Sciences, Faculty of Veterinary Science, University of Pretoria, Pretoria, South Africa

Jacob O. Midiwo,     Department of Chemistry, School of Physical Sciences, University of Nairobi, Nairobi, Kenya

Marius Mihasan,     Department of Biology, Alexandru Ioan Cuza University, Iaşi, Romania

Hamdalat Folake Muritala,     Department of Biochemistry, University of Ilorin, Ilorin, Kwara, Nigeria

Mikhail Olugbemiro Nafiu,     Department of Biochemistry, University of Ilorin, Ilorin, Kwara, Nigeria

Abdel Jelil Njouendou,     Department of Medical Laboratory Sciences, University of Buea, Buea, Cameroon

Jaures A.K. Noumedem,     Department of Biochemistry, Faculty of Science, University of Dschang, Dschang, Cameroon

Dickson Shey Nsagha,     Department of Public Health and Hygiene, Faculty of Health Sciences, University of Buea, Buea, Cameroon

Ezekiel Uba Nwose,     Faculty of Science, Charles Sturt University, Bathurst, NSW, Australia

Dominic O. Ochwang’i,     Department of Veterinary Anatomy and Physiology, University of Nairobi, Nairobi, Kenya

Jemimah A. Oduma,     Department of Veterinary Anatomy and Physiology, University of Nairobi, Nairobi, Kenya

Akintayo L. Ogundajo,     Natural Products Research Unit, Department of Chemistry, Faculty of Science, Lagos State University, Lagos, Nigeria

Isiaka Ajani Ogunwande,     Natural Products Research Unit, Department of Chemistry, Faculty of Science, Lagos State University, Lagos, Nigeria

Victor Maduabuchi Oguoma,     School of Psychological and Clinical Science, Charles Darwin University, Darwin, NT, Australia

Alfred Oghode Misaiti Okorogbona,     Agricultural Research Council–Roodeplaat Vegetable and Ornamental Plant Institute, Pretoria, South Africa

Leonidah Kerubo Omosa,     Department of Chemistry, School of Physical Sciences, University of Nairobi, Nairobi, Kenya

Idris Ajayi Oyemitan

Department of Pharmacology, Faculty of Pharmacy, Obafemi Awolowo University, Ile-Ife, Osun, Nigeria

Division of Academic Affairs & Research, Directorate of Research, Innovation & Development, Walter Sisulu University, Mthatha, South Africa

Roumita Seebaluck-Sandoram,     Department of Health & Sciences, Faculty of Science, University of Mauritius, Réduit, Mauritius

Wirsiy Frankline Sevidzem,     Department of Public Health and Hygiene, Faculty of Health Sciences, University of Buea, Buea, Cameroon

Hülya Sivas,     Department of Biology, Science Faculty, Anadolu University, Eskişehir, Turkey

Germain Sotoing Taïwe,     Department of Zoology and Animal Physiology, Faculty of Science, University of Buea, Buea, Cameroon

Jean-de-Dieu Tamokou,     Department of Biochemistry, Faculty of Science, University of Dschang, Dschang, Cameroon

Serges Tchatchouang,     Department of Biochemistry, Faculty of Science, Biotechnology Centre, University of Yaoundé I, Yaoundé, Cameroon

Sonia L. Venter,     Agricultural Research Council–Roodeplaat Vegetable and Ornamental Plant Institute, Pretoria, South Africa

Ayima Charlotte Wenze,     Department of Public Health and Hygiene, Faculty of Health Sciences, University of Buea, Buea, Cameroon

Souaibou Yaouba,     Department of Chemistry, University of Nairobi, Nairobi, Kenya

Preface

Medicinal plants constitute a good alternative to conventional medicine, considering the rich biodiversity of the continent. They are widely used in Africa to heal various types of health conditions and it has always been stated that about 80% of the population in the continent use traditional healing as primary health care. This could be true, but these are very irregular consultations that cannot be definitively attributed to a class of persons in the population. For example, a person may appeal to traditional therapy in context of a specific disease and unfavorable financial conditions, but used conventional medicine in case of financial ease or another disease. In Africa, traditional medicine is often stigmatized by many people, especially the middle- and high-income people.

Governments in Africa are also providing few incentives to boost traditional medicine including the use of medicinal plants. This position is understandable insofar as there are few studies on the safety of plants used as well as the methods used to obtain various therapeutic preparations. Meanwhile, African populations are disproportionately affected by infectious and cardiovascular diseases, cancers and other illnesses. This remains a contrast if we take into account the exceptional floral biodiversity of the continent and the number of medicinal plants found in each African country. If African countries are endowed with appropriate infrastructure to demonstrate the efficacy and safety of medicinal plants used in the continent, it would be likely that governments would change point of view and encourage not only the use of these plants, but also the production of improved phytodrugs.

Until this is done, and given the fact that the miseries of the people in health matters will not wait, African researchers should propose acceptable alternatives to conventional medicine, which is very expensive for the majority of the population. One of the most acceptable solutions is to propose the use of functional foods and medicinal herbs, such as spices and vegetables, not only as a palliative to the conventional medicine, but as effective therapeutic alternative. This could be more accepted and popularized worldwide.

Given the scarcity of reference updated books adapted to Africa in this theme, I undertook to edit this document, also having an academic purpose. Hence, the background on diverse degenerative diseases in Africa will be discussed from Chapters 1–7. To place African research globally and for a possible academic use, emphasis was put on the methods used in pharmacological surveys in Part II, dealing with the therapeutic potential of African medicinal spices and vegetables (Chapters 8–13). The reviews of the most popular African functional foods, medicinal spices, and vegetables have been discussed in details in Part III (Chapters 14–30). The topics of this book are of interest to scientists of several fields, including Pharmaceutical Science, Pharmacognosy, Complementary and Alternative Medicine, Ethnomedicine, Pharmacology, Medical and Public Health Sciences, Medicinal Chemistry, Phytochemistry, and Biochemistry. The highlight of this book is an exhaustive compilation of scientific data related to the Pharmacological survey of African medicinal spices and vegetables by top scholars from several countries worldwide. Finally, I would like to thank Molly McLaughlin, the Editorial Project Manager at 50 Hampshire Street Cambridge, Massachusetts 02139, the technical assistant, and Karen East and Kirsty Halterman, the production managers for their help and fruitful collaboration.

Prof. Dr. Victor Kuete

Part I

Diverse Degenerative Diseases in Africa

Chapter 1: Diseases in Africa: An Overview

Chapter 2: Management of Inflammatory and Nociceptive Disorders in Africa

Chapter 3: Burden and Health Policy of Cancers in Africa

Chapter 4: Metabolic Syndromes and Public Health Policies in Africa

Chapter 5: Management of Infectious Diseases in Africa

Chapter 6: Overview of Governmental Support Across Africa Toward the Development and Growth of Herbal Medicine

Chapter 7: Preparation, Standardization, and Quality Control of Medicinal Plants in Africa

Chapter 1

Diseases in Africa: An Overview

J.C.N. Assob

D.S. Nsagha

A.J. Njouendou

D. Zofou

W.F. Sevidzem

A. Ketchaji

A. Chiara

T.E. Asangbeng

K.O. Dzemo

B.M. Samba

A.C. Wenze

E. Malika

V.B. Penlap

V. Kuete

Abstract

The chapter gives a general overview of disease burden in Africa. It starts by presenting the trends of various diseases including viral, bacterial, parasitic, and fungal infections by country with emphasis on epidemiology, diagnostic, treatment, control strategies, WHO policies, and challenges. It also highlights the burden of noncommunicable disorders, giving clues on their prevalence, incidence and distribution, on the major risk factors associated, the signs and symptoms of each disease as well as measures put in place for their control.

Keywords

burden

infectious diseases

noncommunicable diseases

epidemiology

Africa

1. General overview of disease burden in Africa

The notion of disease burden refers to the impact of a health problem as measured by financial cost, mortality, morbidity, or other indicators. It is often quantified in terms of quality-adjusted life years (QALYs) or disability-adjusted life years (DALYs), both of which quantify the number of years lost due to disease (YLDs). One DALY can be thought of as 1 year of healthy life lost, and the overall disease burden can be thought of as a measure of the gap between current health status and the ideal health status (where the individual lives to old age free from disease and disability) (David Kay and Carlos,  2000; Prüss-Üstün et  al.,  2003; Murray et  al.,  2013).

People around the world are living longer than ever before, and the population is getting older. The number of people in the world is growing because many countries have made remarkable progress in preventing child deaths. As a result, disease burden is increasingly defined by disability instead of premature mortality. The leading causes of deaths and disabilities have changed from communicable diseases in children to noncommunicable diseases in adults; whereas eating too much has overtaken hunger as a leading risk factor for illness (Institute for Health Metrics and Evaluation, 2013). Across the African region, overall progress has been made in decreasing death rates between 1970 and today. Each country has witnessed an increase in its average age of death with some variations; Cape Verde demonstrating the greatest gain (about 28 years) and Chad showing the smallest improvement (1.4 years). Decline in mortality rates largely varied by age, with greatest improvements for young children (Institute for Health Metrics and Evaluation, 2013).

Death rates for children between 1 and 4 years old declined by 65% between 1970 and 2010, whereas mortality rates rose for women and men at different ages (a 39% increase for women aged from 25 to 39 and a 50% increase for men aged from 30 to 34). Premature death and disability caused by some communicable diseases and newborn conditions have decreased, but they remain leading causes of premature death and illness. Between 1990 and 2010, the African region had succeeded in decreasing premature death and disability, also known as healthy years lost, from lower respiratory infections, diarrheal diseases, and protein-energy malnutrition; however, these conditions are still the leading causes of disease burden in the region, especially in lower income countries like Niger and Sierra Leone. Malaria and human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) are now the first- and second major causes of premature death and disability (Institute for Health Metrics and Evaluation, 2013).

Noncommunicable diseases are rapidly rising, especially for wealthier countries in the region. Road injuries have taken a growing toll on health in the African region. Healthy years lost from road injuries have increased by 76% between 1990 and 2010, with substantial country variation (ranging from a rise of 9% in Madagascar to 87% in Congo) (Institute for Health Metrics and Evaluation, 2013). To ensure a health system is adequately aligned to a population’s true health challenges, policymakers must be able to compare the effects of different diseases that kill people prematurely and cause ill health. The original Global Burden of Disease (GBD) study’s creators developed a single measurement, DALYs, to quantify the number of years of life lost as a result of both premature death and disability (Institute for Health Metrics and Evaluation, 2013). One DALY equals one lost year of healthy life. DALYs will be referred to by their acronym, as years of healthy life lost, and years lost due to premature death and disability.

Decision-makers can use DALYs to quickly assess the impact caused by conditions, such as cancer versus depression using a comparable metric. Considering the number of DALYs instead of causes of death alone provides a more accurate picture of the main drivers of poor health. GBD provides high-quality estimates of diseases and injuries that are more rigorous than those published by disease-specific advocates. Beyond providing a comparable and comprehensive picture of causes of premature death and disability, GBD also estimates the disease burden attributable to different risk factors (Institute for Health Metrics and Evaluation, 2013). The GBD approach goes beyond risk-factor prevalence, such as the number of smokers or heavy drinkers in a population. With comparative risk assessment, GBD incorporates both the prevalence of a given risk factor and the relative harm caused by that risk factor. It counts premature death and disability attributable to high blood pressure, tobacco and alcohol use, lack of exercise, air pollution, poor diet, and other risk factors that lead to ill health.

According to the World Health Organization (WHO) figures, the Ebola epidemic in West Africa claimed 11,323 lives (WHO, 2003). Although the virulence and rapid spread of the Ebola virus were major causes of concern, it is important to understand the mortality figures in the broader sub-Saharan African context. Deaths in Africa, for example in 2012, fell largely in all the WHO groups. This was such that:

• Group 1: (death through communicable diseases, and perinatal, maternal, and nutritional causes): 5.9 million deaths amounting to 61.7% of all deaths in sub-Saharan Africa.

• Group 2: death as a result of noncommunicable diseases accounted for 2.7 million deaths or 28.6% of all deaths. This category includes heart disease (293,000 deaths), various forms of cancer (426,000), and diabetes (175,000).

• Group 3: deaths through injury, amounted to 939,000 deaths, or 9.8% of the total. Group 3 causes of death include unintentional injuries, such as road accidents (207,000), and intentional injuries, such as interpersonal violence (132,000) and collective violence (14,000).

Noncommunicable and lifestyle diseases are the top killers in high-income countries, accounting for 67.8% of deaths in 2012. In contrast, many of the top killers in sub-Saharan Africa—lower respiratory tract infections, tuberculosis (TB), diarrheal disease, and malaria—are preventable and treatable, given adequate health care systems and resources. According to WHO’s figures, the five top killers in Africa in 2012 were the following: HIV/AIDS, lower respiratory tract infections, diarrheal diseases, malaria, and strokes.

People living in the African region of the WHO confront the world’s most dramatic public health crisis, with the hope that over time the region can address the health challenges it faces, given sufficient international support (WHO, 2006a). HIV/AIDS continues to devastate the WHO Africa region, which has 11% of the world’s population but 60% of the people with HIV/AIDS. Although HIV/AIDS remains the leading cause of death in adults, more and more people are receiving life-saving treatment. The number of HIV-positive people on antiretroviral medicines increased eightfold, from 100,000 in December 2003 to 810,000 in December 2005 (WHO, 2006a). More than 90% of the estimated 300–500 million malarial cases that occur worldwide every year are in Africans, mainly in children under 5 years, but most countries are moving toward better treatment policies. Of the 42 malaria-endemic countries in the African region, 33 have adopted artemisinin-based combination therapy (ACT)—the most effective antimalarial medicines available today—as first-line treatment (WHO, 2006a). River blindness has been eliminated as a public health problem, and guinea worm control efforts have resulted in a 97% reduction in cases since 1986. Leprosy is close to elimination—which means there is less than one case per 10,000 people in the region (WHO, 2006a).

Most countries are making good progress on preventable childhood illness. Polio is close to eradication, and 37 countries are reaching 60% or more of their children with measles immunization. Overall measles deaths have declined by more than 50% since 1999 (WHO, 2006a). While drawing the world’s attention to recent successes, the report offers a candid appraisal of major hurdles, such as the high rate of maternal and newborn mortality overall in the region. Of the 20 countries with the highest maternal mortality ratios worldwide, 19 are in Africa; and the region has the highest neonatal death rate in the world (WHO, 2006a). Then there is the strain on African health systems imposed by the high burden of life-threatening communicable diseases coupled with increasing rates of noncommunicable diseases, such as hypertension and coronary heart disease. Basic sanitation needs remain unmet for many with only 58% of people living in sub-Saharan Africa having access to safe water supplies. Noncommunicable diseases, such as hypertension, heart disease, diabetes, are on the rise, and injuries remain among the top causes of death in the region (WHO, 2006a).

2. Infectious diseases

2.1. HIV/AIDS in Africa

HIV, the virus that causes AIDS, acquired immunodeficiency syndrome has become one of the world’s most serious health and development challenges. In Canada, and most other western countries, these drugs are readily available and are used by nearly all AIDS patients. These drugs, in addition to effective education and awareness regarding the disease, have helped developed nations get their HIV/AIDS epidemics under control. However, sadly it is not like that everywhere in the world. In Africa particularly, one of the world’s poorest places, AIDS remains a wildly virulent disease that is still killing millions and debilitating entire swaths of the population, mainly a result of people not being able to afford treatment. It is a major public health concern and cause of death in many parts of Africa (Michael, 2014). Although the continent is home to about 15.2% of the world’s population, sub-Saharan Africa alone accounted for an estimated 69% of all people living with HIV and 70% of all AIDS deaths in 2011 (Apps.who.int, 2016).

Countries in North Africa and the Horn of Africa have significantly lower prevalence rates, as their populations typically engage in fewer high-risk cultural patterns that have been implicated in the virus’s spread in sub-Saharan Africa (UNAIDS, 2010). Southern Africa is the most affected region in the continent.

2.1.1. Epidemiology of HIV/AIDS in Africa

There are many reasons why Africa has such a high number of AIDS cases. Between 1999 and 2000 more people died of AIDS in Africa than in all the wars on the continent, as mentioned by the previous UN Secretary General, Kofi Annan (Globalissues.org, 2016). The death toll is expected to have a severe impact on many economies in the region. In some nations, it is already being felt. Life expectancies in some nations are already decreasing rapidly, whereas mortality rates are increasing. Each day, 6000 Africans die from AIDS. Each day, an additional 11,000 are infected (Globalissues.org, 2016). The first cases were reported in 1981 and HIV prevalence rates and the number of people dying from AIDS varied between African countries in 2010 (UNAIDS, 2010): in Somalia and Senegal—HIV prevalence is under 1% of the adult population, whereas in Namibia, Zambia, and Zimbabwe, 10–15% of adults are infected with HIV, in South Africa, the HIV prevalence stands at 17.8%, exceeding 20% in Botswana (24.8%), Lesotho (23.6%), and Swaziland (25.9%). In Cameroon and Gabon, HIV prevalence is 5.3 and 3.6%, respectively, while the prevalence in Nigeria is 4.1%. In East Africa including Uganda, Kenya, and Tanzania the prevalence is above 5%.

2.1.2. Control

2.1.2.1. Prevention

Numerous prevention interventions have been developed to fight HIV, and new tools, such as vaccines, are currently under investigation. Effective prevention strategies include behavior change programs, condoms, HIV testing, blood supply safety, harm reduction efforts for injecting drug users, and male circumcision. Additionally, recent research has shown that providing HIV treatment to people with HIV significantly reduced the risk of transmission to their negative partners. Preexposure antiretroviral prophylaxis (PrEP) has also been shown to be an effective HIV prevention strategy in individuals at high risk for HIV infection. Experts recommend that prevention be based on knowing your epidemic, that is, tailoring prevention to the local context and epidemiology, and using a combination of prevention strategies, bringing programs to scale, and sustaining efforts over time.

2.1.2.2. Treatment

Treatments include the use of combination antiretroviral therapy (ART) to attack the virus itself, and medications to prevent and treat opportunistic infections that can occur when the immune system is compromised by HIV. In light of recent research findings, WHO released a guideline in 2015 recommending starting HIV treatment earlier in the course of illness (UNAIDS, 2015). Approximately 76% of all people receiving ART in sub-Saharan Africa are virally suppressed, which means they are likely healthier and less likely to transmit the virus (WHO, 2013).

2.1.2.3. WHO policies

Since 2002, ART programs have slowly improved in Africa. Initially, HIV-infected people had to wait until they were seriously immunocompromised, with a CD4 T-cell count below 200 mm−3, to begin ART. In 2013, WHO released a guideline that recommends daily oral PrEP as a form of prevention for high-risk individuals in combination with other prevention methods (WHO, 2013). The threshold was raised to 350 and then 500, as the importance of earlier initiation of treatment was recognized. Improved tools and strategies followed, as did consensus on treatment guidelines and international funding. The trajectory toward ending AIDS seemed assured, and international goals grew from 3 by 5 (treating 3 million people by 2005), to 15 by 15, to a call from the Joint United Nations Programme on HIV/AIDS for 90-90-90 by 2020: 90% of people living with HIV tested, 90% receiving treatment, and 90% with an undetectable 1-viral load.

2.1.2.4. Challenges

Major progress has been made in Africa’s fight against HIV/AIDS but one of the major problems remaining is giving the thousands living with AIDS the drug therapies that can let them live a long life. In terms of the reality, unfortunately the reality is that while there’s been huge progress made in the fight against AIDS, there still remains important efforts to do (Ellman, 2015).

In addition, the main reason is because many Africans are having unprotected sex, and many people in Africa are not educated about the dangers of AIDS or unprotected sex. Recently the President of South Africa made a comment doubting the existence of AIDS. This is one of the other reasons why people in Africa have high cases of AIDS. Many just don’t believe that AIDS exists, and so they don’t take proper precautions to avoid contracting the disease. In most of Africa, despite shortages of health workers, initiating ART in a healthy HIV-positive adult is the begining of monthly queues at clinics and pharmacies to see overburdened medical staff. To obtain treatment, such patients face lots of challenges like long walks to health centers or high transportation costs, hours of queuing, and poor, sometimes stigmatizing, consultation. Unlike symptomatic patients, these patients see no short-term benefit from treatment.

Hence, HIV/AIDS is still a challenge in Africa; providing health care, antiretroviral treatment, and support to people with HIV-related illnesses can help to reduce the annual toll of new HIV infections. As guidelines edge closer to universal treatment for HIV-infected people regardless of CD4 count, more people can choose to receive ART before they develop symptoms. Earlier treatment represents an opportunity not only to prevent illness and transmission but also to inform and empower people living with HIV–AIDS while reducing the burden on health care systems.

2.2. Overview of TB in Africa

TB remains one of the world’s deadliest communicable diseases; it is currently responsible for more years of healthy life lost (2.5% of all DALYs) than any other infectious disease, like AIDS and malaria (Ibrahim et al., 2015). In 2013, an estimated 9.0 million people developed TB and 1.5 million died from the disease, 360,000 of whom were HIV positive (Corbett et al., 2003). TB is slowly declining each year and it is estimated that 37 million lives were saved between 2000 and 2013 through effective diagnosis and treatment (Corbett et al., 2003). TB is present in all regions of the world and the Global Tuberculosis Report 2014 includes data compiled from 202 countries and territories. The report shows higher global totals for new TB cases and deaths in 2013 than previously, reflecting the use of increased and improved national data (Corbett et al., 2003). A special supplement to the 2014 report highlights the progress that has been made in surveillance of drug resistant TB over the last two decades, and the response at global and national levels in recent years (Corbett et al., 2003).

The year 2015 is a watershed moment in the battle against TB. It marks the deadline for global TB targets set in the context of the millennium development goals (MDGs), and is a year of transitions: from the MDGs to a new era of sustainable development goals (SDGs), and from the Stop TB Strategy to the End TB Strategy. It is also two decades since WHO established a global TB monitoring system; since that time, 20 annual rounds of data collection have been completed (WHO, 2015). A decade ago, the problem of TB in Africa attracted little attention, not even meriting a chapter in the first edition of Disease and Mortality in sub-Saharan Africa. Part of the reason was that incidence of TB was low and falling in most parts of the continent (Organization, 2015). The burden of TB in sub-Saharan Africa is far greater today, due to continuing poverty and political instability in parts of the continent which has inhibited progress in implementing effective TB control measures. However, the principal reason for the resurgence of TB in Africa is not the deterioration of control programs. Rather, it is the link between TB and the HIV and the (HIV/AIDS) (Dye et al., 1998).

2.2.1. Epidemiology

TB is the second-most common cause of death from infectious disease (after those due to HIV/AIDS). In 2004, the incidence rate of TB in the WHO African region was growing at approximately 3% per year, and at 4% per year in eastern and southern Africa (the areas most affected by HIV), faster than on any other continent, and considerably faster than the 1% per year global increase (WHO, 2006c). In Africa, it primarily affects adolescents and young adults. In several African countries, including those with well-organized control programs annual TB case-notification rates have risen more than fivefold since the mid-1980s, reaching more than 400 cases per 100,000 people (Harries et al., 2001). Rates per 100,000 people in different areas of the world were as follows: globally, 178; Africa, 332; the Americas, 36; eastern Mediterranean, 173; Europe, 63; Southeast Asia, 278; and western Pacific, 139 in 2010. About one-third of the population of sub-Saharan Africa is infected with M. tuberculosis (Dye et al., 1998). In 2000, an estimated 17 million people in sub-Saharan Africa were infected with both M. tuberculosis and HIV—70% of all people coinfected worldwide (Corbett et al., 2003). As more people have become infected and coinfected with HIV, especially in eastern and southern Africa, the incidence of TB has been driven upward; as reflected in estimates derived from population-based surveys and from routine TB surveillance data HIV infection is the most important single predictor of TB incidence across the African continent (Jamison, 2006). Despite the emphasis placed on finding smear-positive cases under DOTS and the new WHO Stop TB Strategy, the proportion of cases reported to be smear positive has fallen in recent years in several African countries with high rates of HIV (Jamison, 2006). Before HIV infection and AIDS emerged and spread in Africa, TB incidence rates were typically under 100 per 100,000 persons per year. HIV has turned a slow decline into a rapid resurgence, especially in eastern and southern Africa. However, the worst HIV epidemics are now almost certainly decelerating, and even turning downward in some countries (UNICEF, 2004). As the interval between HIV infection and the onset of TB is 4–6 years, we can expect TB incidence rates to continue increasing for some years in some African countries.

The increase in HIV prevalence has also been accompanied by a rise in the TB case-fatality rate, and hence the TB death rate in the general population (Gilks et al., 2006). The TB epidemic in Africa is largely fueled by poverty and the simultaneous infection with HIV. Poor people living with HIV are more likely than others to become sick with TB. At least one-third of people living with HIV worldwide in 2014 were infected with TB bacteria. People living with HIV are 20–30 times more likely to develop active TB disease than people without HIV (Gilks et al., 2006).

HIV and TB form a lethal combination, each speeding the other’s progress. In 2014 about 0.4 million people died of HIV-associated TB. Approximately one-third of deaths among HIV-positive people were due to TB in 2014. In 2014 1.2 million new cases of TB were estimated among people who were HIV positive, 74% of whom were living in Africa (WHO Fact sheet number 104, March 2016).

The following have been designated as vulnerable groups at risk for exposure or transmitting TB disease: children, people living with HIV, diabetics, smokers, alcohol and substance users, people who are malnourished or have silicosis, mobile, migrant and refugee populations, and people living and working in poorly ventilated environments, including those living in informal settlements.

2.2.2. Diagnosis

Effective management of TB depends on finding (diagnosing) persons with the disease, initiating appropriate treatment early, and preventing complications and spread of the infection.

Traditionally, TB services have relied on passive case finding where persons with TB symptoms present themselves to the health care facilities. New policies encourage active case finding to look for persons with TB through community- or facility-based interventions. The aim is to screen every person for TB annually. TB diagnosis depends on symptom screening of all patients presenting to a health or workplace facility, contacts of people with laboratory confirmed pulmonary TB disease and key population groups. All those who have symptoms of TB disease must be investigated for the presence of TB infection. Until recently the primary method for rapid diagnosis of TB was through smear microscopy. In 2011, SA introduced Xpert MTB/RIF as a replacement for sputum smear microscopy for the diagnosis of pulmonary TB. Unfortunately this test cannot be used for monitoring treatment because it does not distinguish between live and dead bacilli (Crofton et al., 1999).

Culture is more sensitive than smear microscopy, detecting a higher proportion of cases among patients with symptoms. However, it is an expensive and slow diagnostic technique, and results are only available within 4–6 weeks, depending on the bacillary load (Crofton et al., 1999). A sputum culture and drug sensitivity are indicated in smear negative TB suspects (particularly if HIV-infected or sick), TB patients failing treatment or requiring retreatment, and TB patients who fail to convert their sputum from positive to negative at 2 or 3 months or those who convert from negative to positive during the treatment period. Other important testing methods include drug susceptibility testing (DST) to determine whether the isolate is susceptible or resistant to the drugs tested and molecular testing using polymerase chain reaction (PCR) technologies—Gene Xpert (GXP)—useful for rapidly diagnosing TB and screen for rifampicin resistance and line probe assay (LPA) detects resistance to both rifampicin and isoniazid at the same time and reduces time to diagnosis of MDR-TB to 7 days.

Chest x-rays (CXR) are an adjunctive test, which do not show a radiographic pattern specific for TB. However, the presence of infiltrates, lymph nodes, or cavities is highly suggestive of TB (Aisu et al., 1995). They are useful in patients who cannot produce sputum or who have negative Xpert results and are HIV positive, and where extra pulmonary TB (such as pleural effusions and pericardial TB) is suspected.

2.2.3. Treatment

Early initiation of effective treatment use of the correct drugs for the correct length of time reduces individual morbidity and mortality and stops the spread of the disease. TB is a treatable and curable disease (Aisu et al., 1995). Active, drug-susceptible TB disease is treated with a standard 6 month course of four antimicrobial drugs that are provided with information, supervision, and support to the patient by a health worker or trained volunteer. Without such support, treatment adherence can be difficult and the disease can spread. The vast majority of TB cases can be cured when medicines are provided and taken properly (Aisu et al., 1995).

2.2.4. Tuberculosis program

The TB program contributes to the reduction of the TB disease burden in the WHO Africa region through support to all member states to adopt and implement cost-effective TB prevention, treatment, care, and support interventions (WHO, 2015). Countries should continue to intensify efforts to fight HIV which is an important contributor to the TB epidemic. To reach the missing patients and move toward eliminating TB there is need to scale up TB interventions, such as DOTS and TB/HIV collaborative activities among others, especially for the most vulnerable groups (WHO, 2015).

Four major interventions have been proven successful in the control of TB in the African region:

• expansion of the basic package that underpins the Stop TB Strategy (DOTS), resulting in an increased number of countries achieving TB treatment success rates of 85%;

• improved diagnostics, resulting in improved case detection and, detection and treatment of multidrug-resistant and extensively drug-resistant TB;

• implementation of WHO pediatric TB guidelines, leading to improved detection and notification of all forms of TB in children;

• TB/HIV integration, resulting in improved access to HIV testing and treatment for TB patients (WHO, 2015).

2.2.5. WHO response

The WHO End TB Strategy, adopted by the World Health Assembly in May 2014, is a blueprint for countries to end the TB epidemic by driving down TB deaths, incidence, and eliminating catastrophic costs. It outlines global impact targets to reduce TB deaths by 90% and to cut new cases by 80% between 2015 and 2030, and to ensure that no family is burdened with catastrophic costs due to TB. WHO pursues six core functions in addressing TB.

• Provide global leadership on matters critical to TB.

• Develop evidence-based policies, strategies, and standards for TB prevention, care and control, and monitor their implementation.

• Provide technical support to Member States, catalyze change, and build sustainable capacity.

• Monitor the global TB situation and measure progress in TB care, control, and financing.

• Shape the TB research agenda and stimulate the production, translation, and dissemination of valuable knowledge.

• Facilitate and engage in partnerships for TB action.

Ending the TB epidemic by 2030 is among the health targets of the newly adopted SDGs. WHO has gone one step further and set a 2035 target of 95% reduction in deaths and a 90% decline in TB incidence similar to current levels in low TB incidence countries today.

The strategy outlines three strategic pillars that need to be put in place to effectively end the epidemic:

• Pillar 1: integrated patient-centered care and prevention

• Pillar 2: bold policies and supportive systems

• Pillar 3: intensified research and innovation.

The success of the strategy will depend on countries respecting the following four key principles as they implement the interventions outlined in each pillar:

• government stewardship and accountability, with monitoring and evaluation

• strong coalition with civil society organizations and communities

• protection and promotion of human rights, ethics, and equity

• adaptation of the strategy and targets at country level, with global collaboration.

Concerning TB and HIV, WHO recommends National guidelines that an HIV test should be offered during the diagnostic work-up for TB or soon after the initiation of TB treatment and likewise, TB symptom screening should be done as part of HIV counseling and testing (HCT). On completion of TB treatment all coinfected TB patients must be on ART.

Finally, TB is really a public health issue and whatever the impact of HIV on TB in the next few years, African countries will continue to need vigorous TB control programs that fully implement the new Stop TB Strategy, founded on DOTS. Even with high rates of HIV infection, DOTS implementation is relatively cheap and cost-effective. Other methods for the prevention and treatment of HIV and AIDS will be needed too, but they should be introduced in ways that will be complementary to DOTS. Pragmatic field studies must continue to explore better ways of using the current tools for TB control as new vaccines, drugs, and diagnostics begin to emerge from laboratories.

2.3. Malaria

Malaria is a parasitic disease caused by Plasmodium species, which is spread when a female Anopheles mosquito feeds on an infected person’ s blood, gets the parasites which matures in the mosquito and later deposited via saliva when the mosquito visits an uninfected person for another blood meal. The female Anopheles mosquito is the malaria vector and in the absence of prompt and effective treatment, malaria often causes death with an estimate of 438,000 malarial deaths in 2015 (WHO, 2015). Among the plasmodium parasite species that cause malaria in humans, two of these, Plasmodium falciparum and Plasmodium vivax, pose the greatest threat. P. falciparum is the most prevalent malaria parasite on the African continent and is responsible for most malaria-related deaths globally whereas P. vivax has a wider distribution than P. falciparum, and predominates in many countries outside of Africa. Globally, an estimated 3.2 billion people in 95 countries and territories are at risk of being infected with malaria and developing the disease, and 1.2 billion are at high risk (>1 in 1000 chance of getting malaria in a year) (Prüss-Üstün et al., 2003). According to the World Malaria Report 2015, there were 214 million cases of malaria globally in 2015 (uncertainty range 149–303 million) and 438,000 malarial deaths (range 236,000–635,000), representing a decrease in malarial cases and deaths of 37% and 60% since 2000, respectively. Between 2000 and 2015, globally, incidences of malaria among populations at risk fell by 37% and malarial death rates among populations at risk fell by 60% among all age groups, and by 65% among children under 5 (WHO, 2015).

2.3.1. Life cycle of malaria parasite

The cycle of malarial infection begins when a female anopheles mosquito, in search for a blood meal, bites a person with malaria and ingests blood that contains reproductive cells of the parasite (WHO, 2015). Once inside the mosquito, the parasite reproduces, develops, and migrates to the mosquito’s salivary gland. When the mosquito bites another person, parasites are injected along with the mosquito’s saliva. Inside the newly infected person, the parasites move to the liver and multiply again. They typically mature over an average of 1–3 weeks, then leave the liver and invade the person’s red blood cells. The parasites multiply yet again inside the red blood cells, eventually causing the infected cells to rupture, releasing parasites to invade other red blood cells. At this point, the cycle can be repeated if a female anopheles mosquito feeds on the person’s blood. This causes the diseases to be easily spread from one person to the other with the help of the mosquito as the vector (WHO, 2015).

2.3.2. Overview of the burden of malaria in Africa

An estimated 6.2 million malarial deaths have been averted globally since 2001. Despite this, Africa continues to carry a disproportionately high share of the global malaria burden with 88% of malarial cases and 90% of malarial deaths in 2015 (WHO, 2015). Malaria affects the lives of almost all people living in the area of Africa defined by the southern fringes of the Sahara Desert. Most people at risk of the disease live in areas of relatively high malaria transmission (Fig. 1.1). Infection is common and occurs with sufficient frequency that some level of immunity develops (WHO, 2015). In this WHO African region, among the estimated 90% of all malarial deaths that occurred in 2015, children under 5 years accounted for more than two-thirds of all deaths (Prüss-Üstün et al., 2003). This is because the majority of infections in Africa are caused by P. falciparum, the most dangerous of the four human malaria parasites. It is also because the most effective malaria vector, the mosquito Anopheles gambiae, is the most widespread in Africa and the most difficult to control. Malaria remains a major killer of children, particularly in sub-Saharan Africa, taking the life of a child every 2 min. In the African region, the estimated number of malarial deaths in children under 5 fell from 694,000 in 2000 (range: 569,000–901,000) to 292,000 in 2015 (range: 212,000–384,000). Malaria episodes in pregnant women cause anemia, and other complications in the mother and newborn child (WHO). By 2015, more than two-thirds of children under 5 were sleeping under an ITN and the proportion of febrile children receiving ACTs rose from 0% to 13% (WHO) and a lot has been put in place by the various malaria control programs to tackle malaria among populations at risk. Despite incredible progress in fighting malaria in all regions affected by the disease, malaria continues to be one of the main public health problems in the world, especially in the majority of African countries (Prüss-Üstün and Corvalán, 2006; Prüss-Üstün et al., 2003). It particularly affects young children, young adults engaged in economic development activities, pregnant women, and recently those whose systems have been weakened by HIV/AIDS (WHO, 2015).

Figure 1.1   Distribution of endemic malaria on the African Continent. (Mapping Malaria Risk in Africa available at www.mara.org.za).

Looking at the distribution of malaria in Africa as revealed by the WHO 2015 report, in West Africa, about 342 million people in the 17 countries of this subregion are at risk for malaria, with 289 million at high risk (reported incidence >1 per 1000).

In Central Africa, about 158 million people in the 10 countries of this subregion are at some risk for malaria, with 145 million at high risk (Fig. 1.1). Cases are almost exclusively due to P. falciparum. All endemic countries in the subregion are in the control phase. In eastern African countries, about 313 million people in the 12 countries of the subregion are at some risk for malaria, with 254 million at high risk (Fig. 1.1). About 25% of the population of Ethiopia and Kenya live in areas that are free of malaria. P. falciparum is the predominant species, except in Eritrea and Ethiopia, where P. vivax accounts for about 31 and 26% of reported cases, respectively. All countries in the subregion are focused on malaria control (WHO, 2015). In southern African countries, about 21 million people in the 5 countries of this subregion are at some risk for malaria, with 8 million at high risk (Fig. 1.1). About 72%, or 54 million people, live in areas that are free of malaria. Countries in the subregion are focused on malaria control activities.

2.3.3. Vulnerable population

Mostly children, pregnant women, and recently those with immune system have been weakened by diseases like HIV/AIDS (WHO, 2006a; Institute for Health Metrics and Evaluation, 2013).

2.3.4. Malaria prevention and control in Africa

Malaria is preventable and curable if diagnosed early and prompt and effective treatment is used.

Malaria has been well controlled or eliminated in the five northernmost African countries: Algeria, Egypt, Libya, Morocco, and Tunisia. In these countries the disease was caused predominantly by P. vivax and transmitted by mosquitoes that were much easier to control than those in Africa south of the Sahara (Prüss-Üstün et al., 2003). Surveillance efforts continue in most of these countries in order to prevent both a reintroduction of malaria parasites to local mosquito populations, and the introduction of other mosquito species that could transmit malaria more efficiently especially in southern Egypt (Prüss-Üstün et al., 2003). Several medications are available for chemoprevention but these medicines are not 100% protective and must be combined with personal protective measures, such as using long lasting insecticidal bed nets (LLINs), wearing long-sleeved shirts and long trousers, using indoor residual spraying (IRS), and also applying insect repellent on any exposed skin, especially when going out at night when mosquitoes are most active (WHO, 2015).

Malaria also continues to prevent many school children from attending school due to illness, diminishing their capacity to realize their full potential (WHO, 2006a). The objectives of the Malaria Program in the African region are to

• reduce morbidity and mortality due to malaria,

• maintain malaria-free areas and expand areas where malaria is controlled, and

• finally reduce the adverse health and socioeconomic consequences due to malaria (WHO, 2015).

2.3.5. The challenge

Though there is a global reduction in incidence of malaria, the rate of reduction is still slow in malaria endemic regions in Africa when compared to other regions; also, surveillance in these regions is not as effective as expected.

2.4. Parasitic infections

A parasite is an organism that lives on or in a host organism and gets its food from or at the expense of its host. There are three main classes of parasites that can cause disease in humans: protozoa, helminths, and ectoparasites (Cdc.gov, 2016). Parasitic infections are common in rural or developing areas of Africa, Asia, and Latin America and are less common in developed area. Parasites usually enter the body through the mouth or skin. Parasites that enter through the mouth are swallowed and can remain in the intestine or burrow through the intestinal wall and invade other organs whereas those that enter through the skin bore directly through the skin or are introduced through the bites of infected vector, like that of female anopheles mosquitoes in the case of malaria transmission (Brooker et al., 2006a,b); walking barefoot on infected soil also favors the entry of some parasites through the soles of the feet and some through the skin when a person swims or bathes in water containing the parasites (Olsen, 2007). It must be noted that rarely, parasites are spread through blood transfusions, in transplanted organs, through injections with a needle previously used by an infected person, or from a pregnant woman to her fetus.

2.4.1. Conclusion and way forward

Enhanced collaboration with international, continental, and regional partners advocates and provides normative guidance and technical assistance for the scale-up of essential interventions in order to reverse the incidence of malaria.

Increased access to services and prevention and treatment interventions, procurement and supply of quality medicines and commodities, diagnostic capacity, routine surveillance, monitoring and evaluation concur to systems strengthening and progress toward national and international targets. Primary health care and community empowerment and involvement are critical for the success of malaria control and progress toward its elimination.

Parasites that infect people include protozoa and worms (helminths, such as hookworms and tapeworms). Protozoa, which reproduce by cell division, can reproduce inside people. Helminths, in contrast, produce eggs or larvae that develop in the environment before they become capable of infecting people. Development in the environment may involve another animal (an intermediate host). A few helminths can develop in the human intestine and cause infection in that person (called autoinfection). Some protozoa (such as those that cause malaria) and some helminths (such as those that cause river blindness) have complex life cycles and are transmitted by insect vectors (Abaver et al., 2011).

2.4.2. The burden of parasitic diseases on Africa

Diseases caused by protozoan and helminthes parasites are among the leading causes of death and disease in tropical and subtropical regions of the world like in Africa (Abaver et al., 2011). Efforts to control these diseases are often difficult partly due to lack of adequate support, except for diseases like malaria. The neglected tropical diseases (NTDs), which have suffered from a lack of attention by the public health community, include parasitic diseases, such as lymphatic filariasis, onchocerciasis, and Guinea worm disease. The NTDs affect more than 1 billion people, one-sixth of the world’s population—largely in rural areas of low-income countries (Molyneux et al., 2005). A number of studies revealed that the prevalence of these diseases also correlated with poverty, poor environmental hygiene, and impoverished health services (Nxasana et al., 2014). It is estimated that schistosomiasis, which is prevalent in poor communities without access to safe drinking water and adequate hygiene, had approximately 258 million treated for it in 2014 with 90% being in Africa. Also, according to WHO, the African Trypanosomiasis is a treat to 60 million people throughout Africa. Also, the environment and climate in the tropics favor the existence of some vectors. The infections may occur in places with poor sanitation and unhygienic practices and common in people with a weakened immune system, such as those who have AIDS or who take drugs that suppress the immune system called immunosuppressant. Intestinal parasite infections have enormous consequences on the health of HIV/AIDS patients, especially sub-Sahara Africa which is already overburdened by HIV; infection and chronic diarrhea due to intestinal parasites is also common in this region (Mariam et al., 2009). Hookworm infection occurs in almost half of SSA’s poorest people, including 40–50 million school-aged children and 7 million pregnant women in whom it is a leading cause of anemia. Schistosomiasis is the second most prevalent NTD after hookworm (192 million cases), accounting for 93% of the world’s number of cases and possibly associated with increased horizontal transmission of HIV/AIDS. Lymphatic filariasis (46–51 million cases) and onchocerciasis (37 million cases) are also widespread in SSA, each disease representing a significant cause of disability and reduction in the region’s agricultural productivity (Pappas et al., 2009). Toxoplasmolisis is worldwide and one of the most common human parasites and Africa has a prevalence of about 20–55% (Pappas et al., 2009). This is just a few of the common parasitic infections in Africa as is shown in Table 1.1. They contribute greatly to the disease burden in Africa especially in diseases comorbidities, and therefore remains a major public health problem (Tables  1.2–1.4).

Table 1.1

Common parasitic infections in Africa: protozoans