Disrupting Malaria: How Fyodor Biotechnologies is changing the diagnostics game

Efosa Ojomo, Senior Researcher, Harvard Business School, Forum for Growth and Innovation looks at the new innovation award recipient, the designers of the Urine Malaria Test, and explains how the technology disrupts the system that has made it difficult to reach the average malaria sufferer with appropriate diagnostics and treatment.

In 2015, 214 million people were infected with malaria, 190 million of whom were in African countries. Of those infected, 438,000 died, 91% of who were in Africa. In addition, malaria has significant financial implications on families, companies and countries. Experts estimate that in countries burdened with malaria, the disease is responsible for as much as 40% of public health expenditures, 30 to 50% of in-patient hospital visits, and 50% of out-patient visits.

From a financial standpoint, direct costs of managing the disease is up to $12 billion annually, while the cost in lost economic growth is many times more. Considering the scale of malaria’s impact on Africa, there have been many innovations that have helped curb the spread of the disease, but perhaps one of the most significant is Fyodor Biotechnology’s disruptive Urine Malaria Test (UMT).

UMT-DiagThe UMT, a Significant Malaria Milestone

Fyodor’s UMT is a simple urine test where patients simply pee on a stick in order to find out whether they have malaria. The World Health Organization states that “Early diagnosis and treatment of malaria reduces disease and prevents deaths. Access to diagnostic testing and treatment should be seen… as a fundamental right of all populations at risk.” In other words, if we diagnose early, we will save many more lives and limit transmission.

fyodortableUMT is an inexpensive (introductory price: ~$2 per test to end user) malaria diagnostic test that does not require the expertise of a trained professional. The UMT kit also does not require a lab or special disposal due to its simplicity. It is a three step process that lets patients know, in 20 minutes, if they have malaria.

Why the UMT is Disruptive

The most important hallmark of a disruptive innovation is that it makes complicated and expensive products simple and affordable, enabling many more people in society to benefit from the innovation. The UMT fits this model as the differences between the UMT and existing blood-testing kit below clearly illustrate.

One of the most exciting things about the UMT is Dr. Agbo’s goal to manufacture the product in Africa. “With an investment of $5 million, we can build a fully equipped manufacturing plant in Nigeria. That amount will only get us a building in the United States,” he explained.

Innovation Prize of Africa winners IPA2016winners-1200x590 at Forbes2It is solutions like these that African investors and policy makers need to support in order to get Africa on a path to sustainable economic development. As reported by Forbes, the UMT is an innovative product by Africans for Africans. This is why the UMT is an innovation winner.

(A longer version of this posting appeared on the World Bank Africa Can blog.)

Malaria Plus Brexit – let’s hope no Malexit

brexit and africaNo one knows for certain the full implications of Britain’s narrow vote to leave the European Union (EU). Since Britain has been a major player in malaria research and development aid, questions naturally arise of whether the British exit (Brexit) from the EU will affect development aid and global research generally and malaria aid and research specifically.

Earlier this week the Brookings Institution examined the ways that a Brexit could affect Africa. Here are some of the possibilities adapted to malaria –

  • Volatility in the global economic market will affect not only the British economy but also those of malaria endemic countries, possibly reducing the reducing available funds for national contributions to malaria control at home, a major goal for sustaining malaria control and elimination
  • Britain specifically may not be able to sustain its financial contributions to malaria aid through the Global Fund, bilateral malaria programs and of course it would no longer contribute to the European Development Fund which currently stands at nearly 15% of its total.
  • The British economy which like all modern nations depends on trade would be affected by the need to renegotiate hundreds of trade agreements around the world. Less trade likely means less income and less development aid.

In both 2014 and 2015 the United Kingdom contributed 8% of the total contributions received by the Global Fund to fight HIV, TB and Malaria. In addition “UK’s official development assistance (ODA) is expected to rise to £11.3bn when it hits the 0.7% target. With a population of about 63 million, the figure works out at roughly £137 per Brit.” In 2012 the malaria component was estimated at 2%.

Patrick Vallance and Tim Wells examine the importance of global collaboration on malaria research. This requires the free flow of researchers and their needed supplies across national borders, especially malaria research that has had to date a pan-European character. They describe the collaboration needed “between commercial and non-profit organizations, and between academic science and medicine. Without such partnerships, advances in fighting this deadly disease would not have been possible.”

Vallance and Wells give the example of “GSK’s research site in Tres Cantos, Spain. The lab operates with the support and advice of a broad range of actors, including GSK, the Wellcome Trust, the European Union, and MMV (Medicines for Malaria Venture), as well as various other product-development partnerships and academic centers.” Such efforts may be jeopardized when permits for malaria scientists to work in other countries are more difficult to obtain.

There may be other aid mechanisms too, the Commonwealth Secretariat being one. During World Malaria Day in 2012 the Commonwealth Secretariat pledged to assist in sustaining the gains made in tackling malaria.  We hope that Brexit will not become an exit for malaria commitments and saving lives.

Tanzania – Malaria Indicators Low, Still Need Work

Success in the war against malaria is not guaranteed. Two articles to that effect have appeared The Citizen of Dar es Salaam following presentation of findings from the most recent (2015-16) Tanzania Demographic and Health Survey (DHS)/Malaria Indicator Survey (MIS).

Slide2On Tuesday (21 June 2016) the news story noted the increase in malaria prevalence among children below the age of 5 years, which was attributed to “the decline in the use of mosquito nets and low distribution of nets to households.” Then in a Wednesday (22 June 2016) Editorial, the paper noted that this “backtracking” is a “worrisome situation, for malaria is a problem that puts such a heavy burden on the government and the country’s economy.”

Slide1A look at the preliminary DHS does confirm the concerns about insecticide treated nets (ITNs).  After nearly 10 years of progress, reported ITN availability in households declined. This was reflected in a drop in reported use by children below 5 years of age as well as pregnant women. It should be noted that targets set in 2000 in the Roll Back Malaria Abuja Declaration had been 80% by the year 2010, and those had almost been achieved in 2012, but the fall to around 50% in 2015-16 is discouraging.

Another preventive measure has also faced difficulty. Pregnant women should receive doses of Sulfadoxine-pyrimethamine (SP) as part intermittent preventive treatment (IPT) during antenatal care (ANC).  Until 2012 the recommendation was two contacts, but the World Health Organization has raised this to three or more depending on the number of times a woman attends ANC. So far IPT has not reached 40% or half of the Abuja target.

Slide3This low IPT coverage is ironic since most women attend ANC at least once in Tanzania. At present only 68% of women who had been pregnant received the first dose of IPT even though 98% registered for ANC. Granted that some may have registered in their first trimester when they would not yet be eligible for IPT, but the gap is quite large and signals missed opportunities, which are often caused by stock-outs. Even though the proportion of women attending up to ANC visits could be better, these attendances should produce better delivery of the 3rd IPT dose.

Slide4Malaria can also be controlled through prompt and appropriate treatment. While testing and treatment of children with appropriate artemisinin-based combination therapy (ACT) has increased, this are is still problematic. In particular, while WHO recommends that all cases of fever should be tested, less than a third received a test (rapid diagnostic test – RDT or microscopy). Testing helps distinguish malaria from other fevers, and ACTs should not be given unless malaria is confirmed. We can see that more ACTs are provided than the number who were tested, so treatment based solely on signs and symptoms is still the norm. Again there is need to explore the availability of both RDTs and ACTs as factors that have made these targets difficult to achieve.

Tanzania continues to receive support from the Global Fund and the US President’s Malaria Initiative, among other partners. It is incumbent on all partners, global and national, to use these results as a wake up call to to plan for better delivery of malaria services and thus a reduction of both the economic and health burden of malaria in Tanzania.

 

Kenya – the long road to controlling malaria in pregnancy

Augustine Ngindu, the Technical Advisor for Malaria in Kenya’s Maternal and Child Survival Program (USAID, Jhpiego) shares with us the steps and processes in building a national response to controlling malaria in pregnancy (MIP) in Kenya.

Recently Stephanie Dellicour and colleagues wrote about the challenges in the delivery of interventions to prevent malaria in pregnancy in Kenya in Malaria Journal. They examined MIP services in Nyanza Province of western Kenya between February and May 2010. At that time they found that, “… delivery of  IPTp (intermittent preventive treatment in pregnancy) and ITNs (insecticide treated nets) through ANC (antenatal care) was ineffective and more so for higher-level facilities. This illustrates missed opportunities and provider level bottlenecks to the scale up and use of interventions to control malaria in pregnancy delivered through ANC.”

Kenya National malaria StretegySince that time the National Malaria Control Program (NMCP) has made efforts to address these problems by building on the national malaria strategy (NMS) 2009-2017 that recommend provision of IPTp only in high malaria transmission areas based on strong epidemiological evidence.  In 2010 NMCP revised the national guidelines on diagnosis, treatment and prevention of malaria in line with the NMS 2009-2017. Then in 2011 NMCP in collaboration with Jhpiego developed simplified MIP guidelines on provision of IPTp in line with the national guidelines (each pregnant woman to receive at least 2 IPTp doses starting from 16 weeks of pregnancy at 4 weeks interval). Also in 2011 Maternal and Child  health care workers in all 14 high malaria transmission areas were trained on provision of MIP using the simplified guidelines.

Trends in IPTp in Malaria Endemic Areas fromIn 2012 health facility in-charges in the same high transmission areas were trained on MIP quality performance improvement. Then in 2013 promotion of early start of  IPTp in the second trimester through sensitization of pregnant women was started in two out of the 14 malaria endemic counties. This resulted in increased IPTp2 coverage from 25% as reported in the kenya Malaria Indicator Survey) (KMIS 2010) to 63% (US-CDC survey 2013).

From 2014 to date the practice of sensitizing pregnant women using community health workers/volunteers has been replicated in other counties. IPTp2 coverage has increased from known 25% (KMIS 2010) to 56% (KMIS 2015) in the malaria endemic counties. Likewise use of ITNs by pregnant women increased from 50% in 2010 to 79% in 2015.

Although IPTp coverage is still below national target, the lost opportunities are being addressed. Kenya is still confronting multiple challenges including SP stock-out and devolution of health services to county governments but is set on making progress and saving mothers’ lives.

The biggest risk of Ebola re-introduction is animals – the human variety

ebola virus ecologyIn the early days of the Ebola outbreak in West Africa much emphasis was placed on avoiding ‘bushmeat’. Health communications materials prominently featured monkeys, bats and deer (oh my!). In mid-2014 a Red Cross team went door to door in Kailahun province, the border region where Ebola first arrived in Sierra Leone on a sensitization mission, explaining to people exactly how the virus spreads and how to avoid it with three simple rules. “Rule three: Don’t eat bushmeat, the meat of wild animals.”

After thousands of deaths, it turns would that most likely only the December 2013 index case in the forests of Guinea was the only one that was associated with wild animals. The rest spread from human to human.

Liberia Ebola Free 20160609We are happy today that WHO has declared Liberia Ebola-free for the fourth time. With previous declarations from Guinea and Sierra Leone, the region does not have current transmission.

This is not a cause for letting down our guard. As Tolbert Nyenswah, head of Liberia’s Ebola response team, told Reuters, “the country had strengthened its surveillance and response capacity and its laboratory system since the start of the outbreak. We’ve proven we can contain the outbreak, we can intervene very swiftly,” said Nyenswah.

Science Daily reports from the University of Georgia, “Sexual transmission of Ebola is likely to impact course of outbreaks.” Data have shown that “viable Ebola virus remained in the semen of disease survivors for months after it was no longer detectable in their blood — and by a study reporting at least one instance of sexual transmission of Ebola.” Sexual transmission was hypothesized as “the source of Ebola transmission that killed a 17- year-old boy in Liberia” back in the summer of 2015 when another mini-outbreak occurred. As Annalisa Merelli reported, with the worst of the epidemic over, Ebola is essentially an STD.

Ebola is not the only tropical virus that has become an STD. While WHO notes that “Vector control is critical in substantially reducing the risk of Zika transmission … avoidance of unprotected sexual activity with a partner possibly exposed to Zika virus,” is also necessary. As of June 1st, 11 out of 618 cases of Zika reported to CDC in the U.S. were sexually transmitted.

The lines dividing zoonotic, infectious and sexually transmitted diseases are blurring. The common thread is the need for strong surveillance systems and proper communication of research findings so that the public can protect itself.

Husbands, Wives and Malaria: what do we know about male involvement?

A recent article in PLoS One highlights the positive role husbands’ involvement can have in saving the lives of their pregnant wives. A 9-item scale of husband involvement was developed, and although it did not include malaria related content because the Tigre Region of Ethiopia is not malaria endemic, the items relating to support for antenatal care attendance are certainly relevant to malaria elsewhere. Overall, maternal survival was strongly associated with higher levels of husbands’ involvement.

DSCN7129a pregnant women get ITNs when register for ANC RwandaThe importance of male or husband involvement in malaria in pregnancy services is usually assumed. For example, in Rwanda husbands are encouraged to attend at least the first ANC visit with their wives where HIV testing is done and ITNs provided.

Unfortunately the assumption about male involvement is backed by little published literature. In Mali, for example, “health facilities operating under the cost-recovery model strive to provide free IPTp, their own financial constraints often make this impossible.” When costs are connected to this malaria preventive service, “Costs … complicate household budgeting for health care, particularly as women often rely on their husbands for money.”  In Uganda husbands’ encouragement was a significant factors influencing adherence to IPTp with SP.

Use of insecticide treated bednets in prevention of malaria by women in India was indirectly influenced by their husbands. Use was positively associated by women’s decision making power as well as by husband’s educational level, with an implication that husbands are important in understanding women’s decision making.

DSCN7276There is more information about male involvement in antenatal care generally. These studies show positive outcomes in terms of ANC services uptake, and from that one may make the assumption that greater access to and use of these services can help prevent maternal deaths.

In Indonesia, “full family, particularly husband’s, support” is associated with adherence to maternal iron-folic acid (IFA) supplementation during pregnancy. The researchers concluded that husband’s support is especially important for less educated women. A study in Pakistan reported that “restriction from husband or mother-in-law” was a barrier to ANC attendance. Likewise in Uganda lack of support from husband/partner was a barrier to attending ANC and skilled delivery.

A qualitative study in Ghana aptly titled, “What men don’t know can hurt women’s health” showed a reluctance to be involved. Findings suggested that, “Although many men recognize the importance of skilled care during pregnancy and childbirth, and the benefits of their involvement, most did not actively involve themselves in issues of maternal healthcare unless complications set in during pregnancy or labor. Less than a quarter of male participants had ever accompanied their wives for antenatal care or postnatal care in a health facility.” Four barriers to male involvement included –

  1. perceptions that pregnancy care is a female role
  2. belief that men who accompany their wives are being dominated by their wives
  3. unfavorable service factors – hours, staff attitudes
  4. high costs associated with accompanying women to seek maternity care (direct and indirect)

Finally, going back to Rwanda, making male involvement a requirement, might in some cases backfire. The recommendation was seen as “a clear link in the chain of delays and led to severe consequences, especially for women without engaged partners.” Clearly not every pregnancy is the result of a loving mother-father dyad.

Since malaria is a major cause of maternal morbidity and mortality, more work is needed in malaria endemic areas to understand the life-saving role of male/husband involvement. This role will vary by culture, the local economy and the structure of health services, but a better understanding of the male role and practical interventions based on the findings will be valuable investments.

Poorly Managed Lassa Fever Outbreak in Nigeria

Dr. Obinna O E Oleribe, Chief Executive Officer, E&F Management Care Centre, Abuja Nigeria (Twitter: @OleribeO) shares with readers his view and experiences concerning the August 2015 – May 2016 Lassa Fever outbreak in Nigeria and sees its handling as a strong indicator of weak and failing National Health System.

111435-EPR-Nigeria-Lassa-Fever-Outbreak-20120322On February 6th, 2016, the Vanguard Newspaper reported the growing Lassa Fever outbreak that had killed over 101 persons out of 175 suspected and confirmed cases since August 2015 when the outbreak began in Nigeria. More recently, the World Health Organization (WHO) announced that it had been notified of 273 cases of Lassa fever, including 149 deaths in Nigeria between August 2015 and May 17, 2016. Of the 273, 165 cases and 89 deaths were confirmed through laboratory investigation from 23 states of Nigeria. These deaths include two health care workers out of 10 infected with Lassa fever virus. As at the time of the WHO report (May 17, 2016), eight states were still reporting Lassa fever cases (suspected, probable, and confirmed), deaths and following 248 contacts for the maximum 21-day incubation period.

First diagnosed in Nigeria in 1969, Lassa fever (LF) is an acute viral illness caused by Lassa virus, a zoonotic, rodent-borne (multimammate rat), single-stranded ribonucleic acid (RNA) virus from the Arenaviridae, virus family. Since it first isolation in 1969 from a missionary nurse working in Lassa town of Borno State in North-Eastern Nigeria, Lassa Fever has become almost endemic in not only Nigeria, but the West African sub-region as it has continued to be a major public health concern in Nigeria, Liberia, Sierra Leone and Guinea with over 70 million people at risk of the disease. Annually, there are over 3 million cases and about 67,000 deaths from Lassa Fever globally. High association with nosocomial outbreaks, healthcare workers are at increased risk of infection and death. Also, the disease is fast spreading beyond the shores of West Africa into Europe and America from viremic travelers.

A look at the WHO website revealed that Lassa Fever has gained the importance it demanded and was rightly cited on its first page as a disease of public health importance (disease outbreak news). Also, as it is further decreasing the already very limited human resources for health in Nigeria and the rest of West Africa, one would have thought that healthcare managers across the world would have given it the attention it needed.

Heres how Nigeria beat EbolaIn July 2014, Ebola was identified in Nigeria (Lagos State) after Patrick Sawyer imported the disease from Liberia (where there was already an ongoing epidemic). The Lagos State Government, the National Center for Disease Control (NCDC), the Nigerian Field Epidemiology and Laboratory Training Program (NFELTP) and Federal Ministry of Health (FMOH) with the support of well-meaning Nigerian volunteers and some international organizations rose to the occasion and within four months (July 20 – October 20, 2014) kicked Ebola out of Nigeria. They achieved this unbelievable feat through decisive actions, interdisciplinary collaboration, intensive case management, detailed contact tracing, and active port health services. Using isolation, quarantine and supportive management of the infected, case fatality rate was kept at 40% as eight out of the 20 infected individuals succumbed to the virus including several health workers. What was more interesting was the immediate response of government and all relevant stakeholders. The success recorded was to the amazement of the entire world, and completely against all epidemic projects and statistical reasoning.

However, few months later, there is another epidemic of another viral hemorrhagic fever. This time around, by a virus that is not as deadly or virulent as Ebola.  It has lasted for ten months, killed more people (over 1100% of those killed by Ebola), affected over 800% more cases and with higher case fatality rate of 54%. One, cannot but wonder why Nigeria is finding it difficult to mobilize the same strategies that ended Ebola in Nigeria in 2014 to end Lassa Fever? Or are the structures and personnel not available for this particular outbreak? Or is the will to stop the outbreak lacking among policy makers and healthcare managers?

I believe that there is a need to focus on developing sustainable public health systems that can be mobilized to manage outbreaks across nation; have ready and equipped field workers and foot soldiers who will track, isolate and manage suspected, probable and confirmed cased of any outbreak; and maintain strong surveillance systems able to identify and contain any new, emerging or re-emerging outbreaks.

Nigeria and her leaders should value the lives of the Nigerian people. The government should take health issues more seriously. The citizens of Nigeria need a government that cares. Healthcare workers have a right to live – and not die while working to save other people’s lives. Every hand should be on deck right now to end this outbreak – and as much as possible ensure a delay of its re-emergence.

The time to end Lassa Fever outbreak is NOW. Let us all work towards stopping it once and for all.

Manufacturing Mosquito Nets ‘At Home’

The technology of insecticide treated nets (ITNs) to prevent malaria has been around for over three decades. ITNs have evolved from a process of semi-annual soaking and impregnating nets with a safe insecticide at the household or community level to long lasting insecticide-treated nets (LLINs) where the insecticide is integrated into the nets during the manufacturing process. The challenge has always been guaranteeing enough currently treated nets to cover the population and impede malaria transmission.

IMAG0170Recently Rwanda announced its intentions to establish LLIN manufacturing in-country. The Ministry of Trade and Industry has begun screening of bidders. The government’s main rationale for this move is projected the need for a large and continuous supply of LLINs in the country through 2020, “making it a prudent to set up a production plant in the country.” When this information was shared with our malaria/tropical health update mailing list a number of readers expressed interest and hope that their own governments would follow suit. This post provides some background for readers to consider.

The idea of locally made mosquito nets is not new. MacCormack and Snow documented that, “95% of people were already sleeping under locally-made DSCN5582nets,” in The Gambia in the 1980s. Likewise in Burkina Faso it was common to find nets made from imported materials or local cotton that were sewn by local tailors.

The idea of drawing on the combination of local or regional textile and chemical industries to produce an ITN kit containing both net and approved insecticide for home/community soaking was tested in several countries by the USAID sponsored NetMark project between 1999–2009. Although the project made ITNs available at reduced prices and resulted in gains in  awareness, ownership, and use of nets, “none of the countries reached the ambitious Abuja targets.”

NARCHOct03 012Even at reduced prices the ITNs made available through this commercial sector approach were still more expensive than most families could afford. In addition partway through the project the emphasis shifted from local products to imported LLiNs leaving a leaving a very bitter taste, particularly in Nigeria with its large industrial sector, in mouths of the textile and chemical partners who during malaria partners meetings at the time expressed a sense of betrayal.

A-Z Olyset Commercial BagTalk arose in Nigeria about the potential for starting LLIN production in the country, but no one stepped forward with funding or technical assistance. In the meantime, on the other side of the continent, A to Z Textiles of Tanzania entered into a partnership and by 2003 LLINs were being produced in Arusha.  Sumitomo Chemical provided a royalty-free technology license to the company for its Olyset LLINs. “By 2010, Olyset Net production capacity (at A to Z) reached 30 million LLINs per year, creating 8,000 jobs; more than half of the global Olyset Net output and an outstanding contribution to the local economy.”

Over the years A to Z Textiles were hard pressed, just like the few other LLIN manufacturers, to meet global demand. Over the period, the focus changed from protecting young children and pregnant women to universal coverage of the population. Also research and actual use found that the lifespan of an LLIN was not the 5 years as initially projected, but more like two. These factors meant that supply could rarely meet demand for regular replacement nets. No wonder Rwanda wants its own LLIN factory!

ITNs Use TanzaniaIn addition to supply issues, does local availability of LLINs make a difference in fighting malaria? Regular studies by the Demographic and Health Survey group of USAID in Tanzania found that ITN use increased over time by children below five years of age. The most recent survey still shows that the 2010 Abuja target of 80% was not met (let alone a target of universal coverage), but the findings hint at the importance of having locally available LLINs.

Let’s wish Rwanda success in establishing its LLIN manufacturing capacity. For colleagues in Nigeria and elsewhere who have expressed interest in this issue, your advocacy work is just beginning.

 

Malaria, War and Death

In wars in malaria endemic areas, malaria can cause more damage than what occurs on the battlefield. The United States just observed its annual Memorial Day where those who died serving the country are remembered. Wing Beats, the journal of the Florida  Mosquito Associations reported on the status of malaria vectors in the state of Georgia and stressed the damage malaria did during the US Civil War:

  • “From 1861 to1866 malaria was the second most commonly diagnosed ailment – diarrhea/dysentery was first – among Union troops, with over 1.3 million cases. Although sold iers native to the South were much more likely to have experienced malaria growing up, they also suffered deaths and incapacitation that affected the timing and outcome of battles.”

UN PeacekeepingDuring the Korean conflict, “paragonimiasis, malaria, and amoebiasis were the most fatal parasitic diseases during the early 1950s in the Korean Peninsula,” and consequently were responsible for deaths of prisoners of war. The U.S. military received a severe damage during World War II in the Pacific where it was said that “more soldiers were lost by malaria than by battle itself.” The experience led to hundreds of units specialized in controlling malaria in Korea.

In Europe during World War II, people in concentration camps and prisoners of war were used in experiments. “In Dachau Professor Claus Schilling tested synthetic malaria drugs and injected helpless prisoners with high and sometimes lethal doses.” Malaria as a biological warfare agent was demonstrated in Italy where “The German army’s 1943 flooding of the Pontine Marshes south of Rome, which later caused a sharp rise in malaria cases among Italian civilians, has recently been described by historian Frank Snowden as a unique instance of biological warfare and bioterrorism.”

Today malaria continues to produce death in conflict zones. “The area of Walikale in North Kivu, Democratic Republic of Congo, is intensely affected by conflict and population displacement.” The most frequently reported cause of death among the local population was fever/malaria at 34.1% .

During the civil war in Côte d’Ivoire “the availability and use of protective measures against mosquito bites and accessibility to health care infrastructure deteriorated.” A study of resettlement camps of displaced families after the Angolan civil war “Malnutrition was the leading cause of death (34%), followed by fever or malaria (24%) and war or violence (18%).”

Some of the most highly malaria endemic countries in the world still experience conflicts. Malaria kills directly, it can be used as a weapon, and war disrupts efforts to control it. If we are to “end malaria for good,” we might also think about trying to end war and conflict, too.

We cannot end malaria for good without addressing flaviviruses

“End malaria for good”, the theme for the 2016 World Malaria Day, presents us with a double challenge.  We want to end malaria finally, or eliminate it between 2030 and 2040, but also, ending it will be good for saving lives and improving economies of endemic countries. The challenge arises when we consider whether we will have adequate resources to accomplish the task. As colleagues from the University of California in San Francisco observed, “Sustaining domestic and international funding as malaria burden decreases is a serious concern for most of the eliminating countries.”

One way to guarantee resources is through conserving what we have and only treating people for malaria when they actually have the disease and not some other febrile illness. The advent of malaria rapid diagnostic tests (mRDTs) that can be used at the primary care level, including within the community should have improved our ability to differentiate malaria from other causes of fever.  Unfortunately mRDTs do not always guide correct case management.  When a febrile patient tests negative, we may not have the ability to do further differential diagnosis. Some causes of fever do not have a direct cure. Therefore if malaria drugs are available through programs like the Global Fund, we are tempted to use them since many front line clinicians feel that, “We must do something for the patient.”

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Flaviviruses pose one challenge. Such choices not only waste scarce resources but may be harmful. A prime example is the recent outbreak of Yellow Fever in Angola. According to the World Health Organization, “The first, ‘acute’, phase usually causes fever, muscle pain with prominent backache, headache, shivers, loss of appetite, and nausea or vomiting,” making it easily confused with malaria. Treating most of these patients with malaria drugs may not cause harm, but 15% go on to develop severe disease including hemorrhaging and death. Proper use of mRDTs, follow-up observation of RDT-negative patients and provision of supportive care that treats dehydration, respiratory failure, and fever, can save lives.

Rapid diagnostic test kits are widely used in India for the diagnosis of dengue infection,  but do not feature in African clinics. Without Dengue RDTs, clinicians in Africa may assume that Dengue is a severe form of malaria and treat as malaria even without parasitological laboratory evidence. With suspected Dengue patients increased intake of oral fluids is recommended by WHO along with paracetamol (not aspirin) for fever and pains.

So far the global Zika Virus outbreak has spared Africa of its worst neurological and brain damaging effects. For the current epidemic the U.S. Centers for Disease Control and Prevention inform that, “The most common symptoms of Zika also resemble malaria and are fever, rash, joint pain, or conjunctivitis (red eyes). Other common symptoms include muscle pain and headache.”  for which CDC recommends palliative case management.

Like other flaviviruses Chikungunya “causes fever and severe joint pain. Other symptoms include muscle pain, headache, nausea, fatigue and rash,” according to WHO. WHO explains that, “Most patients recover fully, but in some cases joint pain may persist for several months, or even years.

It will be good to end malaria for good, but we must also have the means to detect and manage the other dangerous, life threatening febrile diseases that will be left behind. In the meantime we need to conduct proper differential diagnosis starting with mRDTs so that expensive malaria medicines will be used judiciously and correctly and other febrile illnesses will receive appropriate life-saving care.