Tropical Health Matters

By Jordan Kerr and originally posted in the Social and Behavioral Foundations of Primary Health Care Blog.

Malawi is making strides in increasing HPV vaccinations among adolescent girls across the nation. Since the official implementation of the HPV vaccine program in 2019, 20 out of the 29 districts in Malawi have begun administering the vaccine to adolescent girls between the age of 9 and 14. Despite this success, Malawi continues to be one of the leading countries worldwide in cervical cancer-related mortality. New cases of cervical cancer in Malawi are reported at a rate five times higher than the global average.

This highly preventable disease places a more significant burden on low-income countries like Malawi due to poor access to healthcare services and resources. International agencies are improving their outreach efforts to reach girls not enrolled in school and address vaccine hesitancy in districts with higher vaccine refusal rates. Due to this outreach vaccine registration is improving however healthcare facilities are experiencing stockouts. In some districts, healthcare facilities are reporting that the main reason individuals are not receiving vaccinations is that they are running out of vaccine stocks.

The World Health Organization (WHO) set a goal in 2018 to eliminate cervical cancer by increasing HPV vaccination uptake globally. This initiative has shown to be successful in addressing disparities in low- and middle-income countries however, in 2020 an HPV vaccination shortage began and is expected to continue through 2025.

The Center for Strategic and International Studies (CSIS) presents several strategies that can be used to address this shortage to keep on track with the goal to eliminate cervical cancer. Efforts must be taken to support facilities developing the HPV vaccine to ensure stockouts do not continue. We need policymakers to lobby for policies that increase funding for vaccination development and establish priority vaccination allocations to countries like Malawi that are experiencing high mortality rates from cervical cancer

By Lauren Koranteng and originally posted in the Social and Behavioral Foundations of Primary Health Care Blog. “Overcoming poverty is not a task of charity, it is an act of justice. Like Slavery and Apartheid, poverty is not natural. It is man-made and it can be overcome and eradicated by the actions of human beings. Sometimes it falls on a generation to be great. You can be that great generation. Let your greatness blossom.” – Nelson Mandela According to the World Health Organization, Schistosomiasis is a “disease of poverty that leads to chronic ill-health “. It is caused by a parasitic worm that lives in freshwater snails. The larval forms of the parasite is released by the snails. Humans who make contact with the water during various activities like recreation, agriculture and also for livelihood get infected. The prevalence rate in Ghana is 23.3% , however there are some areas that have localized prevalence levels that are >50% ( Kulinkina et al). A vulnerable population that is often infected are school aged children who access the waters mostly for recreational reasons (Antwi et al). These are usually school aged children who live in hard to reach areas in the country with poor sanitation. It is important for the disease to be controlled because chronic ill health also impacts the cognitive abilities of the children. Praziquantel is a drug used for preventative chemotherapy against Schistosomiasis. It offers a solution to eradication of the disease and could be executed through drug administration of praziquantel through the school system. This kind of mass administration has been done before in the country, but unfortunately, the behavior of children swimming in these infected waters did not change. This behavior of continuous exposure of children to these water bodies presented a limited factor in the eradication of this disease and intervention. Using the national health insurance program in the country, praziquantel can be made available again but through school programs in these rural areas.  Additionally, the school curriculum can include health education that will encourage children to avoid fresh water bodies where possible. Sanitation improvement and reduced human and infected water contact will also be a priority health development goal. So, in working with stakeholders such as the Ghana Health Service and the Ministry of Education, a realistic plan can be developed and executed.  This can include a mass drug administration program, health education and sanitation improvement.  This may be reasonable interventions to use to support children who are in contact with fresh water bodies and at a high risk of contracting Schistosomiasis.

By Blessing George & Chino Nduaka and originally posted in the Social and Behavioral Foundations of Primary Health Care Blog. More than 50% of deaths from malaria are from four African countries, and Nigeria heads the list, contributing a significant part at more than 30%. Nigeria faces a major public health burden, with an estimated 65 million cases and over 100,000 deaths in 2021, representing over 50% of malaria cases in West Africa. With most outpatient visits in Nigeria being caused by malaria, this disease has taken a toll on the economy. Malaria is among the top five causes of under-five mortality in Nigeria. Over the years, various organizations have joined hands in the fight against this deadly disease. However, Nigeria remains at the top of the list contributing significantly to the mortality rate. Insecticide-treated nets (ITNs), indoor residual spraying, and free sharing of anti-malaria drugs for prophylaxis and treatment constitute ways the country has tackled the disease burden. With the funding allocation repeatedly given by international organizations such as the WHO, the World Bank, and the Global Fund channeled to these interventions that have proved somewhat ineffective, we are at crossroads that begs the question, what next? In 2016, the world’s pioneer malaria vaccine, RTS, S, sold with the brand name, Mosquirix, was introduced for pilot implementation in three malaria-endemic countries. It has been administered to over a million children with positive results on its effectiveness. In 2022, the Nigerian government officially applied to receive the vaccine through GAVI but was hit back with the response that currently, there is an insufficient supply of vaccines. Nigeria tops the list of the global malaria mortality rate and should be prioritized. The Nigerian Ministry of Health, in collaboration with the Nigerian Primary Healthcare agency, needs to fight for the health of its citizens, respond to GAVI, and state the concrete reasons why the country should be prioritized. The goal is to ensure that these vaccines are made available for the under-5 population in Nigeria by 2025 such that in the malaria world report of 2030, Nigeria should not be named a major contributing country to malaria mortality.

By Peace Ige, and originally posted in the Social and Behavioral Foundations of Primary Health Care Blog.

In Nigeria, typhoid fever continues to be a significant disease, and its prevalence is on the rise. The disease is transmitted through the oral consumption of contaminated food or water and can also be spread through personal contact due to unsanitary practices (Enabulele et al., 2016). The increasing incidence of antibiotic-resistant strains of the bacteria makes treating typhoid fever challenging. The lack of proper surveillance, limited laboratory capacity, and inadequate data availability in Nigeria make it difficult to assess the actual prevalence of typhoid fever.

There needs to be more reliable and consistent data on the incidence of typhoid fever in Lagos and Nigeria, making it challenging to assess the disease’s prevalence accurately. This under-reporting is due to several reasons, including using antibiotics before confirmatory laboratory tests and patients’ failure to seek medical attention, as laboratory services are often not affordable (Enabulele et al., 2016).

According to a study published in The American Journal of Tropical Medicine and Hygiene (primary article), the lack of epidemiological data tracking regarding typhoid fever in sub-Saharan Africa prompted the World Health Organization (WHO) to call for a continent-wide approach to generate more accurate disease incidence and antimicrobial susceptibility data in 2008. The study emphasizes the importance of antibiotic resistance as a significant health security issue, as S. Typhi has developed resistance to multiple drugs, making it difficult to treat.

Typhoid fever remains endemic in Lagos, Nigeria, and the larger sub-Saharan Africa region, posing a significant public health challenge. To address this issue, coordinated efforts are needed from all stakeholders. Strengthening surveillance systems to collect accurate data on typhoid fever incidence, prevalence, and antimicrobial susceptibility is critical (Enabulele et al., 2016). This requires government funding to improve laboratory infrastructure and trained personnel. Accessible data can guide policy decisions and interventions. Improving sanitation and hygiene practices is also vital to combating typhoid fever.

The government should invest in improving access to potable water, wastewater management systems, and community education on personal hygiene practices. Public and private sector partnerships can be established to improve water and sanitation infrastructure in vulnerable communities. Increased vaccination campaigns are a cost-effective intervention in reducing the incidence of typhoid fever. The Nigerian government should increase the coverage of the typhoid fever vaccine in Lagos state, especially for vulnerable populations such as children and those in low-income communities.

A robust public health campaign should promote vaccine uptake and raise awareness of typhoid fever and its causes. A multi-sectoral approach is needed to address the root causes of typhoid fever in Lagos. Collaboration between the government, healthcare providers, the private sector, and other stakeholders is necessary to ensure the implementation of effective interventions. Advocacy efforts are necessary to ensure political commitment and support for policies addressing typhoid fever in Lagos. By implementing these strategies, Lagos can reduce the incidence and impact of typhoid fever on its population.

Lagos, Nigeria, must take responsibility for addressing the issue of typhoid fever and external support. The World Health Organization (WHO) has already called for a continental approach to generate accurate disease incidence and antimicrobial susceptibility data, and Nigeria must take advantage of this support. One of the critical areas where external support is essential is strengthening the healthcare system’s capacity for surveillance and diagnosis of typhoid fever. This includes improving laboratory facilities and providing training for healthcare workers.

Support from organizations such as WHO and the Centers for Disease Control and Prevention (CDC) can help develop effective policies and programs to control the spread of typhoid fever. Another area where external support is critical is promoting research into new and effective treatments for typhoid fever. This includes developing new antibiotics and vaccines and studying the disease’s epidemiology and ecology to understand better how it spreads and can be prevented.

External support is essential in helping to raise awareness of the issue of typhoid fever and its impact on public health in Nigeria. By working with local communities and stakeholders, external organizations can help to educate people about the disease, how it is spread, and how it can be prevented. This can create a sense of urgency around the issue and mobilize local communities and governments to take action.

The bluish line in the graph shows the rate of S. Typhi that can resist ampicillin. The orange line shows Chlora6mphenicol-resistant S. Typhi. Co-trimoxazole-resistant Staphylococcus typhi prevalence is shown by the gray line. S. the yellow line shows Typhi tetracycline resistance. The dark blue line shows the proportion of S. Typhi resistant to ciprofloxacin. The green line shows cefuroxime-resistant S. Typhi.

In 2003, cefuroxime entered clinical use. The red line shows the proportion of S. Typhi strains resistant to cefotaxime. In 2008, cefotaxime was made available to the public. In conclusion, typhoid fever remains a significant public health issue in Lagos, Nigeria. The persistence of the disease can be attributed to poor surveillance, inadequate data availability, restricted laboratory capacity, and resource and financial limitations that contribute to poor quality water, sanitation, and hygiene infrastructure.

The adoption of proper measures can significantly reduce the incidence of typhoid fever in Lagos. The Lagos State Government and stakeholders in Nigeria must show more commitment and will to provide the necessary means to combat the endemic disease. The involvement of external forces such as WHO, CDC, and other international organizations in promoting the eradication of the disease is essential. Their support in generating more accurate disease incidence and antimicrobial susceptibility data, improving laboratory capacity, and providing resources for disease surveillance and control is a significant step toward eradicating the disease.”

All stakeholders must work together to ensure the necessary measures are taken to end the endemic disease. With proper measures in place, we can significantly reduce the incidence of typhoid fever in Lagos, Nigeria, and ultimately eradicate the disease.

Ref.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4924394/

Adegbola and colleagues note that “the efficacy of SP-IPTp is threatened by the emergence of sulfadoxine-pyrimethamine resistant malaria parasites, “which has been observed in East Africa. They therefore, studied the situation in Nigeria, the country with the highest malaria burden in the continent. Their study showed that “the prevalence of VAGKGS haplotype seems to be increasing in prevalence.”

In conclusion, they worried that, “If this is similar in effect to the emergence of 581G in East Africa, the efficacy of SP-IPTp in the presence of these novel Pfdhps mutants should be re-assessed” in Nigeria. This situation threatens the use of sulfadoxine-pyrimethamine (SP) in two major prevention programs including intermittent preventive treatment during pregnancy (IPTp) and seasonal malaria chemoprevention (SMC) for children.

The benefits of IPTp using SP is the ability to administer chemoprevention in a single directly observed dose. Alternative medications are being explored, but from the behavioral intervention perspective, the low cost and simplicity afforded by SP is ideal.

The IPTp strategy had been modified a decade ago from requiring 2 doses, to monthly doses from the second trimester onwards because of parasite resistance or what is also termed drug tolerance by the parasite. Tolerance implies that the drug may still work, but at higher or more frequent doses. Such changes have cost and behavior change implications. Many country reports from the Malaria Indicator Surveys show an expected drop-off in uptake of SP between the first and third doses. For example in the 2021 Nigeria MIS IPTp1 uptake was 58%, while IPTp3 had reduced to 31%.

A related problem in Nigeria is the ubiquitous availability of SP in medicine shops across the country in contrast to official policy limiting it to use in IPTp and SMC. The challenge is finding affordable and feasible alternative medicines for IPTp. In the meantime, we have not even reached coverage targets using SP nor fully achieved rollout of companion interventions such as the use of Insecticide Treated Nets. Much work is still needed to protect pregnant women and fetuses from the malaria induced problems of anemia, low-birth-weight, stillbirth, and more.

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A related study from Cameroon: The occurrence of sub-microscopic P. falciparum parasites resistant to SP and intense malaria transmission poses persistent risk of malaria infection during pregnancy in the area. ITN usage and 
monitoring spread of resistance are critical.

https://malariajournal.biomedcentral.com/articles/10.1186/s12936-023-04485-7

Dr Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization, reminds us in this year’s edition of the World Malaria Report (WMR 2022) that, “Although hard hit, most countries held the line and were able to maintain services to prevent, detect and treat malaria – a remarkable feat in the midst of a pandemic. Nonetheless, more than 600 000 people still die of malaria every year – most of them children. Even with the heroic efforts to maintain services during the pandemic, malaria control efforts face many hurdles in addition to the already significant COVID-related disruptions and other health system challenges.”

Even though there was an increase in cases between 2020 and 2021, there are now more strategies in the malaria control and elimination toolkit than ever before. One in particular is an updated take on an old concept of chemoprophylaxis, which fell out of use due to mounting drug resistance. Years of research with pregnant women and young children led to the development over time of using regularly scheduled treatment doses of malaria medicines as chemoprevention. Intermittent Preventive Treatment for pregnant women (IPTp) and Seasonal Malaria Chemoprevention for young children, both targeted to appropriate epidemiological settings, are now common. Countries are also exploring IPT for children in other settings.

We were, therefore, curious what the current WMR shares on chemoprevention initiatives. Specifically, the WMR summarized WHO recommendations as follows: “Updated guidelines provide recommendations on intermittent preventive treatment of malaria in pregnancy (IPTp), perennial malaria chemoprevention (PMC) and seasonal malaria chemoprevention (SMC), intermittent preventive treatment of malaria in school-aged children (IPTsc), post-discharge malaria chemoprevention (PDMC), mass drug administration (MDA) and elimination.”

In summary, WMR 2022 notes that, “The average number of children treated per cycle of SMC increased from about 0.2 million in 2012 to almost 45 million in 2021,” and “Using data from 33 countries in the WHO African Region, the percentage of IPTp use by dose was computed. In 2021, 72% of pregnant women used ANC services at least once during their pregnancy. About 55% of pregnant women received one dose of IPTp, 45% received two doses and 35% received three doses.” This is not just progress over time, but also represents an expansion targets and work required for success. For pregnant women the increase represented a change in target from only two doses during pregnancy to a minimum of three. Starting with pilot efforts, SMC now covers children in 15 countries.

The targeted three doses for IPTp shows that two thirds of women who register for antenatal (prenatal) care (ANC), fail to achieve full coverage. Stronger collaboration is needed between malaria control and maternal health programs to ensure that pregnant women actually attend ANC and do so early and often enough to receive 3 monthly doses minimum in their second and third trimesters. More emphasis is needed on community IPTp distribution, since we know that community health workers have been crucial in achieving SMC as well as integrated community case management efforts.

Similar challenges exist for SMC as research looks into whether additional doses are needed based on mosquito breeding and malaria transmission season factors in endemic countries. Adding extra months to the program will tax resources, but also save lives.

Both maternal and child efforts at chemoprevention will need to address research that first shows increasing resistance to the common medicines used, and the potential for introducing new drug combinations in light of that resistance. Challenges here reflect another aspect of SMC, the need for CHWs to guarantee that on any given distribution round, three doses on medicine are required. Recent reports show that within any given round, community adherence to SMC has been good. We need to apply those lessons to IPTp when the regimen changes.

Ultimately, chemoprevention has proven to be an important life saving tool. The challenges of multiple contacts and doses that lead to success rely not only on having effective medicines, but also on culturally appropriate behavior change strategies and well-funded efforts to strengthen the health systems that deliver preventive treatments.

 

 

Jean Louis Ndikumana Mangara, Marcel Manariyo, Michée S. Kabera, Yvette Muyirukazi, Jean Modeste Harerimana, Christine Mutaganzwa, Marie Rose Kayirangwa, Noella Umulisa, Aimable Mbituyumuremyi report on Improving insecticide treated net coverage through antenatal care services in Rwanda at the 2022 Annual Meeting of the American Society of Tropical Medicine and Hygiene.

Malaria in pregnancy (MIP) negatively affects pregnancy outcomes, including maternal and neonatal mortality and adverse fetal outcomes such as low birth weight. Therefore, among other malaria prevention interventions, Rwanda embarked to achieve the insecticide treated net (ITN) universal coverage through the ITN mass distribution to households and routine distribution to the most vulnerable groups including under five children and pregnant women.

In the period of Jan 2020 to Dec 2021, the program improved ITN distribution and the information, education and communication on challenges related to malaria behavior during ANC visits and conducted capacity building of health care providers on malaria diagnostic and case management training, integrated malaria supportive supervision, monthly data review and validation meetings at health facilities and monitoring of use of ITN program at health facility level.

A quarterly review of data from national Health Management Information System (HMIS) on ITN distributed during ANC services and changes in MIP incidence was done in the period of January 2020 to December 2021. The results show an increase from 49% (z-score (-0.8)) (Jan-Mar 2020) to 74% (z-score 0.5) (Oct-Dec 2021) coverage in the distribution of ITN among pregnant women during ANC visits.

There was a decrease in malaria incidence from 65 (z-score (2)) to 17 (z-score (-1)) cases among pregnant visiting ANC services, and a decrease from 88 to 73 malaria cases in all (567,198) pregnant women for10,000 confirmed malaria case during the January-March 2020 to October-December 2021. There has been a moderate negative correlation between the proportion of pregnant women receiving ITN in ANC services and the proportion of malaria cases in pregnancy every quarter r(9) = -0.655, P (value)=0.056.

Although malaria cases among pregnant women have declined and the distribution of ITN in ANC services increased over the studied period, there is a need to strategize innovation to reach the remaining pregnant women.

San Barro, Ousmane Badolo, Mathurin Bonzi, Moumouni Bonkoungou Youssouf Sawadogo, Andre Kone, Thierry Ouedraogo, Mathurin Dodo, Lolade Oseni, Gladys Tetteh, and William Brieger explain an innovation of Sponsorship of target children during the Seasonal Malaria Chemoprevention (SMC) campaign in order to improve malaria prevention follow-up and coverage in the Reo health district of Burkina Faso in 2021.

Malaria is a major public health problem in Burkina Faso. According to health statistics for 2020, malaria accounted for 39.8% of health center consultations, 54.1% of hospitalizations and 27.4% of deaths. Children under 5 years of age pay the highest toll with 72.4% of deaths.

In 2021, the Reo Health District and the other six districts of the Centre-Ouest region were supported by the PMI Impact Malaria Project to implement Seasonal Malaria Chemoprevention (SMC). This includes monthly preventive doses of Sulfadoxine-pyrimethamine/amodiaquine for 4 months during the main malaria transmission season. A recent multi-country article in The Lancet showed that while 75% of eligible children received a dose in any given month, only 53% received a dose on all four months.

Coverage reports indicate that better follow-up is needed once children start the SMC process. Thus, during the SMC Campaign, the district management team introduced an innovation  consisting of “sponsorship” of SMC target children as a new follow-up mechanism. These sponsors are Community Distributors (CDs) or Community Based Organizations (CBOs). They voluntarily agreed to follow up with five children each, between July and October 2021 in order …

1. To ensure that the children actually took the medication
2. To monitor whether these children did not get sick between two cycles
3. To inform the nurse in charge of the health center in case of illness of a sponsored child
4. To encourage parents to use bed nets to protect their children. In total, 1468 children were monitored and 224 (15.26%) had malaria.

This innovation on SMC distribution contributed to protect 84% of the children. Challenges include the lack of financial resources to support the sponsors and the inaccessibility of some areas due to the rains. When medicines are correctly administered to children and they are regularly monitored, protection is better.

Moumouni Bonkoungou, Ousmane Badolo, Mathurin Bonzi, Youssouf Sawadogo, Andre Kone, Thierry Ouedraogo, Mathurin Dodo, Lolade Oseni, Gladys Tetteh, and William Brieger shared information on ?Evaluation of the Implementation of Seasonal Malaria Chemoprevention (SMC) through Independent Monitoring in Burkina Faso during the 2022 Annual Meeting of the American Society of Tropical Medicine and Hygiene.?

In Burkina Faso, malaria is the leading cause of children < 5 morbidity (40.6% of severe cases), and 72.4% of death   in 2020. Seasonal malaria chemoprevention (SMC) was recommended by WHO in 2012, and since 2014, it has been implemented in Burkina Faso. SMC consists monthly doses (03 doses) of Amodiaquine Plus Sulfadoxine-Pyrimethamine to all eligible children (3-59 months) during the season of high malaria transmission.

To ensure the quality of the intervention and the coverage achieved, two independent monitoring surveys were conducted at the first (C1) and fourth (C4) rounds (of 2020?). In order to minimize bias, non-health care workers (mainly teachers) were recruited, trained and supervised for the purpose of this survey.

Monitoring was conducted in 43 districts, including 19 in the PMI/USAID Impact Malaria project area, where 838,000 children received treatment. The number of children seen in the houses was 6752 at C1 and 6608 at C4 (10 houses per selected village).

The results show that 98% and 98.2% of the targeted children received treatment at C1 and C4, respectively; 78.8% presented evidence of treatment (cards or empty drug packs) at C1. At C4, 65% of children (73) who did not receive treatment were ineligible. During this cycle, only 57% had cards and 75.6% of the cards were correctly filled in on Day2 and Day3 by the parents.

We also note that 97.1% of the children took the treatment at Day2 and Day3 according to the parent’s declaration at C4 and 97.4% at C1. 2.4% of the parents did not give the medication at Day2 or Day3 compared to the fourth visit. Also, 99.9% (2274) of the parents were satisfied with the SMC at C4, they were 99.7% at C1.

These results show an overall good implementation   in accordance with the guidelines of SMC. We note a reduction of lethality in many districts like Kampti (78%).  However, challenges exist such as outreach communication which needs to be improved, availability and proper storage of treatment cards, referral of cases requiring to be seen by a health care worker. Independent monitoring shows a better figure of the SMC coverage and allow the implementation of qualitative SMC campaign.

Ousmane Badolo, Mathurin Bonzi, Moumouni Bonkoungou, Youssouf Sawadogo, Gauthier Tougri, Mathurin Dodo, Gladys Tetteh, William Brieger reported on Early Seasonal Malaria Chemoprevention (SMC) Implementation Contributed to Reducing Malaria Incidence in Sud-Ouest Region in Burkina Faso at the 2022 Annual meeting of the American Society of Tropical Medicine and Hygiene in Seattle.

They explained that in Burkina Faso, malaria remains a major public health problem. According to 2020 health statistics, malaria accounted for 40% of health service consultations, 54% of hospitalizations, and 27% of deaths. Children under 5 years of age account for 72% of malaria deaths.

To help reduce this burden, the Ministry of Health, with the support of its partners, has organized annual Seasonal Malaria Chemoprevention (SMC) campaigns since 2014 during the high malaria transmission period (July, August September, and October). In 2021, the U.S. PMI Impact Malaria project provided support to the National Malaria Control Program to implement SMC in 19 districts from three regions (Centre-Est, Centre-Ouest, and Sud-Ouest).

One of the innovations of the 2021 SMC campaign was the introduction of five cycles in 7 of these 19 districts, compared to four cycles elsewhere. Therefore, SMC started earlier (in June) while all the others started in July. We compared the incidence of malaria (in the 5 districts of the Sud-Ouest region) in 2020 to that of 2021 when the SMC started earlier.

The malaria incidence is estimated based on the weekly disease surveillance form where the number of malaria cases is recorded, using updated population census data as a denominator. In 2020, the average malaria incidence from May 31 to October 6 in the Sud-Ouest region was 51.44/1000. In 2021, during the same period malaria incidence was 40.94/1000 (a decrease of 20%) The SMC coverage was 103% and 104% respectively in 2020 and 2021.

Starting SMC early can contribute to reduced malaria incidence but key challenges need to be addressed: i) Underestimation of the target population due to IDPs and gold miners; ii) youngest children are with their mothers on the farm so cannot be found at home; iii) insufficient cards for the SMC.