Posts or Comments 03 December 2021

Monthly Archive for "January 2007"



Malaria in Pregnancy Bill Brieger | 30 Jan 2007

Research Needs for Malaria in Pregnancy

The Lancet Infectious Diseases had a recent special issue on malaria in pregnancy (MIP).  Of special interest is an article by Greenwood et al. (2007) that outlines some of our knowledge gaps in MIP and hence the need for future research.

One important research question is “The importance of malaria as a cause of maternal mortality in areas of medium or high malaria endemicity.”  These data would go a long way in advocacy efforts to increase support for funding MIP programs.

Another challenge is, “Finding new drugs for the treatment of malaria in pregnancy.” The authors point to the demise of chloroquine and SP. While come countries are including ACTS as accepted treatment in the second and third trimesters, studies are not available to confirm safety.  Designing drug research with pregnant women will remain a serious ethical problem, but one that cannot not be shied away from. Another crucial drug issue is “New drugs for IPTp.”   Drug efficacy studies have been done mostly with children, but the rapidly declining effectiveness of SP in treating childhood malaria naturally raises concern about SP for IPTp.

A basic assumption in MIP control programs is that intervention must be integrated within quality antenatal care.  The authors raise the need for, “Identification of optimum delivery strategies for scaling up the use of insecticide-treated nets and IPT,” that consider viable alternatives (see for example, item on community directed interventions in previous blog).  They note the low level of ANC utilization in many countries. This is coupled with the fact that the dropout rate between IPTp1 and IPTp2 is often substantial.  One therefore questions whether effective MIP control should be in the business of strengthening the quality of ANC services or find ways to deliver MIP control services in the most direct and safe way to pregnant women.

Of particular concern is the fact that women register for ANC late, and even if ITNs/LLINs are available at ANC, they could not protect most women in their first trimester as seen in the attached graph of ANC registration from Oyo State, Nigeria. The cultural elements of this problem include beliefs that one should protect a pregnancy by not letting others know until it shows and perceptions that since pregnancy is ‘normal’, one should not disrupt regular work routines to attend ANC.  Further social and operational research is definitely needed to find a MIP control package delivery mechanism that really reaches women.

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The challenge of these and other suggestions for future research rest on funding sources.  In addition to the usual expected sources such as foundations and international development agencies, one would hope that those applying for Global Fund malaria grants would build operations research into their monitoring and evaluation systems so that countries can learn from real life experiences.

Funding &Partnership &Performance Bill Brieger | 29 Jan 2007

Politicians stress NGO involvement in malaria control

A theme of non-governmental actors in the battle against malaria was echoed by two politicians recently. One stressed the importance of NGOs at the national level, while the second emphasized the role of non-governmental players on the international scene.

Alhaji Umaru Musa Yar’Adua, one of Nigeria’s presidential candidates, asked civil society groups in the country to brainstorm and produce a framework for monitoring the implementation of government projects, according to ThisDay. The candidate observed that, “Some of our health policies like the free malaria treatment is based on this policy and it is (sic) working efficiently,” although success overall in health and social programs requires a partnership between government and civil society, especially in monitoring and guaranteeing efficiency. Just last year Nigeria added a coalition of NGOs concerned about malaria to the constituencies electing representation to their Global Fund Country Coordinating Mechanism (CCM). A greater role for these constituents in grant implementation is needed in Nigeria and elsewhere.

Great Britain’s Prime Minister Tony Blair delivered the closing speech at World Economic Forum in Davos. Blair emphasized that, “Into the void between identifying an issue’s importance and securing the means of acting on it, has increasingly stepped the non-governmental and non-state actors. The resource of the Gates Foundation is being put to the eradication of Malaria – a preventable disease which kills one million a year.”

The long term solution to malaria control will ultimately rest on a partnership between government and non-governmental actors, and even leadership by the latter. Part of the reason why malaria eradication failed in the 1950s and 1960s was inability of the health systems to incorporate and sustain the effort. Hopefully, 40-50 years later, health systems are stronger, but challenges seen in Global Fund Score Cards for malaria grants commonly point to systems and management issues as threats to malaria grant performance. National and international civil society groups, NGOs, corporate sponsors and philanthropic organizations must maintain an active role in the fight against malaria.

Diagnosis &Treatment Bill Brieger | 27 Jan 2007

Rapid Diagnostic Tests – Costs and Consequences

A few years ago a colleague who works for a large corporation in Nigeria showed me malaria diagnosis laboratory results from their company clinics.  The company was able to test workers and family members in their labs after a clinical diagnosis of malaria and before dispensing drugs. Over a span of 5 years only 20-25% of patients were found to be parasitaemic, and without the tests, most people would have been given malaria treatment.  Those were the days when the company was still dispensing cheap chloroquine. Today with ACTs that cost 10-50 times more than chloroquine, these lab tests are even more important.

Zurovac et al. (2006) found that when both clinical and laboratory skills were improved, major cost savings resulted in malaria treatment. Ochola et al. (2006) concluded that dipsticks can perform better than standard microscopy in clinical (field) settings in endemic areas.  Rennie et al. (2006) reported that community health workers can be trained to perform rapid diagnostic tests.

dscn8366.JPGReyburn et al. (2007) compared RDTs with microscopy in Tanzania among clinic attenders.  Patients were assigned equally to receive one or the other form of test.  In both groups approximately 80% of patients had complained of fever within 48 hours.  Fourteen percent of patients in the microscopy group were found to have malaria parasites, while 16% in the RDT group tested positive. Clinical diagnosis might have overestimated the proportion of malaria case by three or four times.

The reality is that few front line health facilities in malaria-endemic have laboratory services, and thus rapid diagnostic tests are being considered. RDTs are estimated to cost between US$0.60 – $1.00, and as implied from research mentioned above, the cost savings from reducing over-prescribed ACTs could be substantial and might offset these costs.   The question is whether malaria control programs will be able to adopt, buy and distribute rapid test materials to front line facilities. Hopefully financial resources like GFATM and PMI can help address this question.

Funding Bill Brieger | 27 Jan 2007

Malaria Funding Battle Continues

It is hard to argue against principles of fiscal responsibility – except where lives are at stake. What some might have thought was a somewhat simple matter of continuing the US Government’s Fiscal Year 2006 budget through FY 2007 now appears to be provoking potentially long debates in the US Congress. Associated Press notes that the budget tightening dilemma arises in part because, “There are, however, scores of exceptions for agencies and programs that simply must have increases to avoid imposing furloughs and hiring freezes, or cutting critical services.”

Celebrities are getting into the picture, according to the AP article. “Pressing for a $1 billion boost to fight AIDS, malaria and poverty in Africa, Bono wrestled with (Representative) Obey in a meeting last month – with House Speaker Nancy Pelosi, D-Calif., looking on – only to emerge without a commitment. ‘This isn’t over,’ Bono said in a statement issued after the meeting.”

Although the President’s Malaria Initiative (PMI) was underway during FY06, no specific funding was allocated for the program. $30 million was carved out of the existing USAID malaria budget to start PMI in the first three targeted countries. Since then two rounds of announcements have brought the total PMI countries to 15. Another year of ‘borrowed’ $30 million will hardly maintain the PMI in the first three countries let along conduct assessments and begin intervention to save lives in the remainder. A number of malaria advocates argue over how malaria funds should be spent – commodities versus capacity building. This debate will become irrelavant if there are inadequate funds to allocate.

Congress has some tough decisions to make – and the world is watching.

Policy &Treatment Bill Brieger | 26 Jan 2007

Home Management of Malaria in the Era of ACTs

The current Newsletter of the Tropical Disease Research (TDR) Program highlights the role home management of fever/malaria can have in reducing the deaths of over one million children annually. TDR notes the value of having child doses prepackaged in order to enhance provision of the correct amount of medicine to children.  The Newsletter quotes Professor Umberto D’Alessandro from the Prince Leopold Institute of Tropical Medicine in Antwerp, Belgium, who said, “There are no data available on the effects of ACT when it is given by mothers to their children without proper diagnosis. It should reduce mortality, but we simply don’t know if it does.”  This has led TDR to support Studies using ACTs in home management settings in Benin, Burkina Faso, Cameroon, Ethiopia, Malawi, Nigeria, Uganda and the United Republic of Tanzania.

Some encouraging preliminary results were published last year from independent work in Ghana. An article by Gyapong et al. reported that, “Adherence of agents and caregivers to the treatment (with Coartem) was 308/334 (92.5%). Delay in seeking care was reduced from 3 to 2 days. No serious adverse drug reactions were reported. Community members were enthusiastic about the performance of the agents.”

Turning research into practice, and thereby making ACTs available in the home, will require several steps.  There are at least two effective strategies for getting malaria medicines for prompt care of children into the home.  One is training and supplying community volunteers, while the second is selling antimalarials in licensed shops, often at subsidized prices. For these strategies to save children’s lives, policy decisions are needed concerning whether ACTs will remain prescription drugs or whether they can be sold in the licensed medicine shops which are near the home.

Policy &Treatment Bill Brieger | 25 Jan 2007

Malaria Drugs in Nigeria: Policy Change, Prescription Change

An article by Mokuolu et al. in the January 2007 issue of the American Journal of Tropical Medicine and Hygiene, reports on changes in malaria drug sales before and after the issuance of the new national antimalarials drug policy. Data come from doctors’ prescriptions at University of Ilorin Teaching Hospital pharmacy in Kwara State.  The Federal Ministry of Health, with support from WHO conducted two rounds of malaria drug efficacy trials, and based on these a new policy promoting Artemisinin-based Combination Therapy (ACT) was drafted in 2004. The policy was not officially inaugurated until May of 2005.  Data from Ilorin examine both 2004 and 2005.

The hospital pharmacy operates a revolving fund with prices pegged just above cost. Sales of drugs containing artemisinin increased by 300% in just one year.  Also, as a percentage of total malaria drug doses sold, medicines containing artemisinin rose from 18% in 2004 to 49% in 2005.  The proportion of sales of chloroquine, the former first line drug, dropped from 73% to 27% in the same period.  These changes occurred in spite of the fact that the cost of a course of chloroquine tablets was about 12 US cents compared to between US $2.30 and $7.20 for a tablets containing artemisinin.  It appears that prescribers are adopting the new policy, and consumers are paying the price.

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Three issues of concern arise from the findings.  In 2005, over two-thirds of the drugs containing artemisinin were not ACTs, but artemisinin monotherapy formulations (see photo above). WHO has demanded that sales on monotherapy drugs be halted in order to prevent the spread to resistance to artemisinin. The current approach of the Nigerian Agency for Food and Drug Administration (NAFDAC) has taken the approach of not intending to renew the license of monotherapy drugs when these expire, but not in pulling the drugs off the shelves.  A second concern is the fact that a small (~7%) but notable portion of drugs were sold in syrup form which is not only more expensive but also less stable. Child dose packets of ACT tablets are available (see photo below). Finally sulphadoxine-pyramethamine (SP) continues to be a large portion of total sales (23% in 2005) in spite of the fact that SP, according to national policy, should be reserved for Intermittent Preventive Treatment in pregnancy and not used for curative purposes.

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Hopefully the authors will continue to monitor malaria drug prescribing and branch out into the state and local governments as well as into the private sector to learn more about response to the new national ACT policy. Learning about compliance with the new policy in the private sector is crucial, because this is where the bulk of malaria drugs are sold and where the bulk of controversy about drug quality exists. (Note that pictures of malaria medicines herein do NOT constitute an endorsement.)

Funding &Performance Bill Brieger | 25 Jan 2007

Ghana Monitors its Malaria Progress

According to the Ghana Chronicle of 24 January 2007, the National Malaria Control Program (NMCP) reports that the number of child deaths due to malaria has been cut in half.  The achievement is credited to the country’s grant from the Global Fund to Fight AIDS, TB and Malaria (GFATM).  Ghana is the recipient of two GFATM grants for its malaria program. The NMCP Director was quoted as saying, “Malaria reported cases dropped from 3.5 million in 2003 to about 3.1 million in 2006”, as a result of these grants. She went further to enumerate that 1.5 million ITNs had been distributed and 4 million tablets administered for malaria treatment. This sounds good in the press, but is this progress real? A visit to the Global Fund website confirms achievements.

A GFATM representative who was present stressed that the Global Fund is a performance based organization.  In short, release of funds is based on achievement of targeted indicators. During the first two years of a GFATM grant, known as Phase 1, key indicators are more along the lines of processes (staff trained, resources in place) and outputs (commodities distributed).  On entering Phase 2 a country is expected to start reporting actual epidemiological progress on disease control. Effective and integrated national monitoring and evaluation systems are crucial for measuring performance that guarantees continued release of grant money.

Ghana’s Round Two Malaria Grant has passed this hurdle and has entered Phase 2.  The ‘score card’ issued for Round 2 Phase 1 performance is quite positive in noting that, “Within the first 16 months of the Program and in spite of procurement delays, 150,000 ITNs have been distributed (reaching the Month 18 target three months ahead of schedule). Additionally, by the fifth quarter of the program, 57,623 women had received IPT (360% of target). The program’s community-based agents (4039 trained, 183% of target) raised awareness and sustained the demand for both of these interventions. In Ghana 70% of malaria attacks are managed at home. A key feature of the program has been to educate home caregivers to respond more quickly and efficiently to malaria cases as they occur within the family. 1454 health workers (309% of target) and 3828 community agents (239% of target) have been trained in home-based malaria care.”

Ghana’s second malaria grant, awarded during Round 4, is also performing well according to the progress report on the GFATM website: “PR (Principle Recipient) has achieved or overachieved most targets. Surveys are ongoing to document results related to three outcome/impact indicators. Expenditure rate is satisfactory and implementation rate is on track with planned activities.” For example, implementers report that 214% of the target for women received Intermittent Preventive Treatment, and 155% of the targeted children under five years of age had slept under an ITN prior to the survey.

Ghana sets a hopeful example for not only getting malaria resources and commodities out to people in need, but also in being able to track and report progress. Fortunately the GFATM offers guidance in Monitoring and Evaluation. The challenge in phase two will be verifying that this infusion of external funds does result in lower morbidity and mortality and that the country can sustain these efforts after the grant expires.

Funding &Policy Bill Brieger | 24 Jan 2007

Words Count – Does Malaria?

Most people anticipated President Bush’s State of the Union Speech for clues about the direction of war or domestic policy. Obviously we at Voices for a Malaria Free Future were anticipating news on the fate of the President’s Malaria Initiative, which is threatened by lack of adequate funds if the fiscal year 2006 budget levels remain in place. In fact, the President said to the assembled Houses of Congress, “I ask you to provide $1.2 billion over five years so we can combat malaria in 15 African countries.”  Hopefully Congress knows the importance of this initiative and the lives at stake, because the address was not a very strong sales pitch.

An interesting feature in the New York Times today is a comparison of the frequency of key words used in this President’s past State of the Union addresses.  Malaria was mentioned once last night, twice last year and not at all in previous years. More commonly mentioned words in last night’s address were Iraq (34), insurance (14), oil (9) and economy (8).  Africa, where the most deaths from malaria occur, was mentioned three times, and AIDS, the focus of another major Presidential initiative was voiced only once this year, but four times in 2006.

Political commentators muse that malaria control may be one of the key points in Presiden Bush’s legacy.  This will only happen if there is greater leadership and advocacy for malaria programs, and if a true bipartisan spirit prevails, putting the long term interests of children, pregnant women and workers in malaria-endemic countries ahead of short term political gains.  Malaria needs to be mentioned more than once for this interest to develop.

Policy Bill Brieger | 22 Jan 2007

Malaria Funding Threatened

Canadian Press has reported that, “A Canadian program that’s saved thousands of Africans from deadly malaria has been scaled back while federal officials decide whether to renew funding.”  These funds had been used by the Canadian Red Cross and UNICEF to run bed net distribution program in several countries.Of even greater concern is the willingness and ability of malaria endemic countries to show a commitment for tackling the disease.  News from the World Social Forum in Nairobi is that, “African governments’ failure to deliver on a 2001 vow to spend 15 per cent of budgets on health has cost the continent 40 million lives, activists including Nobel winners Desmond Tutu and Wangari Maathai said yesterday.”  The gathering further noted that, “Malaria kills more than one million Africans a year, nearly 90 percent of the global total.”

Most donor supported malaria programs are time-limited. Global Fund grants, for example are for only five years, and the President’s Initiative is currently slated only until around 2010.  This is not to say that other funds will not become available, but the inability of endemic countries to step up to the plate and commit more funds for health and malaria threatens their ability to sustain malaria control.

Another perspective is offered by the group WEMOS who report that, “Public expenditure, however, is restricted by IMF macroeconomic policies and conditions. … Budget ceilings imposed by the IMF are ineffective and have negative effects on the health sector. Although exemptions can be made (and sometimes are) if extra money becomes available for the health sector, these increases do not come anywhere near the expenditure needed to achieve the health-related MDGs.” A 4-country study found recent health expenditures as a portion of the national budget ranging between 8.6% and 12.0% as seen in the figure below.

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Clearly the problem of adequate funding for malaria is multifaceted. Multi-national organizations, bilateral donors and endemic country governments need to work together to ensure that the future is malaria-free.

Policy Bill Brieger | 21 Jan 2007

Could Malaria Feature in 2008 US Presidential Race?

While there is much concern now for securing adequate funding levels for US efforts to fight malaria, it is important to look toward future commitments, since malaria is not a disease that will be easily defeated. A quick search has found that several potential candidates for the US Presidency in 2008 have thought about the problem of malaria. Mention of any particular candidate herein does not constitute an endorsement, nor is the selection meant to be representative. The hope is that malaria control advocates can build on potential interest by candidates to heighten action throughout the country to make a malaria free future.

A recent report noted that, Senator “Brownback is laying the foundation for a broadened platform, working to draw attention to problems in Africa, including the violence in Sudan’s Darfur region, human sex trafficking and efforts to fight AIDS and malaria.”

After a visit to malaria-endemic Kenya, “Illinois Senator Barack Obama says Americans should be aware of and support African efforts to control infection disease. “What we want to make sure of is that we’re dealing with these issues [in Africa] before they get out of hand, and then start getting exported to the United States.”

Former Secretary of Health and Human Services, Tommy Thompson, shepherded the current administration’s HIV, TB and Malaria efforts and served as chairman of the Global Fund board. His continued commitment to controlling malaria would be extremely likely.

Senator Hillary Clinton stated that, “We have to have greater cooperation, creating new international alliances, treaties and conventions to deal with the challenges and dangers that confront the entire world, whether it be a potential pandemic such as bird flu, the continuing spread of diseases like HIV-AIDS, malaria and tuberculosis, or so many of the others that we read about on a daily basis.”

Senator John McCain honored Mrs. Laura Bush with these words, “Mrs. Bush has become the face of America’s commitment to the developing world, highlighting our country’s efforts to end pandemic diseases like malaria and HIV/AIDS.”

Former Senator John Edwards spoke in London saying, “Along with other countries and the UN, we should be leading the effort to do simple things like buy mosquito nets to protect children from Malaria.”

Bringing an end to the destruction caused by malaria is hopefully something that all candidates can agree upon.

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