Tropical Health Matters

A recent posting by Christine Afandi summed up succinctly most of the human health concerns about DDT.  While not downplaying human health effects, a bigger issue is, how can we keep DDT confined to the walls of homes? Shortly after Uganda announced its intentions to use DDT, neighboring Rwanda made the opposite decision and expressed concern that DDT use in Uganda would pollute its neighbor’s environment.  How could this happen if countries follow WHO guidelines and use DDT only for indoor residual spraying (IRS)? Unfortunately, the answer is simple: leakage.

The newer donor programs are often focusing heavily on getting commodities out to communities at the expense of strengthening the management and oversight systems that ensure these commodities are used properly.  Hence, one finds ACTs intended for public clinic use being sold in private pharmacies and drug shops. Stories about chemicals abound: pesticides intended for cocoa trees being used to kill and harvest fish; supplies of ‘abate’ intended for guinea worm control gone missing.

Leakage of malaria medicines costs individual lives by denying free treatment to poor children. Leakage of DDT supplies into the commercial and agricultural sectors threatens the whole environment. The question must be addressed: are malaria control programs and public health systems capable of safely managing and controlling DDT supplies?  Until that question can be answered with strong assurance, IRS programs should be kept on the back burner.

The Tropical Disease Research (TDR) program of UNDP/World Bank/WHO/UNICEF piloted Community Directed Intervention (CDI) for ivermectin distribution for onchocerciasis (river blindness) control in 1995, and found that it provided greater coverage than distribution efforts organized by only the health authority. With CDI communities made decisions when and how to collect their annual ivermectin supplies, about the preferred mode of distribution (house-to-house, central), and days when distribution would occur, and who would be their volunteer Community Directed Distributors (CDDs). This model was adopted by the African Program for Onchocerciasis Control (APOC) and has become possibly the largest community participatory disease control mechanism in Africa, and possibly the world, reaching millions residents in isolated villages who often rarely see the formal health service. While the health system provides training, supervision and commodities, it is the villagers themselves that organize their own ivermectin distribution.

Two years ago, TDR embarked on new research that tested whether other health interventions could be integrated within the CDI model. Thus, in selected districts in Cameroon, Nigeria, Tanzania and Uganda CDDs are also promoting home management of fever with antimalarials drugs, distributing insecticide treated nets, undertaking case detection for TB, and giving Vitamin A, in addition to annual ivermectin doses. One new intervention was introduced at each site in each of four trial districts, while the fifth serviced as control (offering only ivermectin as usual). A second intervention was added in year two. In the third and final year, all five interventions will be taking place in the four study districts at each site. Effort was made to ensure that the district health departments had supplies of all commodities, but only in the intervention districts were the commodities made available through the CDI approach.

The research teams recently completed a data analysis workshop on progress made by year two. ITN ownership, net use and timely and appropriate home management of malaria episodes in children under five years of age showed significant progress over baseline and compared with the control areas where only ivermectin distribution was provided through the CDI approach.

The key lesson is that even though malaria commodities are supplied to district health services, they do not always reach people unless the community is involved. Some countries are including community volunteers in their malaria strategy, such as Role Model Mothers in Nigeria. We hope that with the preliminary results of TDR’s CDI study, more countries will take seriously the need to get communities actively involved in their own malaria control efforts.

Two recent articles demonstrate how countries, anxious to treat malaria cheaply with the newer artemisinin-based combination therapy (ACT), are exploring ways to grow Artemisia anua locally and feed that into the local pharmaceutical industry. Growing Artemisia anua in Kenya may offer local farmers a chance to ‘triple their income.’ This assumes large scale multinational commercial growers don’t get the edge on production and that more the one current extracting facility begins operation. Likewise in Nigeria laws are being considered that would promote local growing and production. These actions promise a boon for both national health and economic development.

Reliance on the ‘shrub’ that produces artemisinin is a challenging process requiring the right soil and climatic conditions, as well as attention to the relatively short period when the chemical is at optimal levels within the foliage. Success also rests on meeting infrastructural demands such as good quality roads and transport.

A question exists whether a short-term gain in local production might eventually be offset by efforts to synthesize artemisinin. Discover Magazine in its December 2006 issue named Jay Keasling, a Chemical engineer at the University of California at Berkeley, as its scientist of the year (2006) for pioneering ways to use ‘synthetic biology’ to produce artemisinin in the lab (or eventually factory) using genetically engineered bacteria and/or yeast. Keasling’s team has already been working several years on this process and has received awards from the Gates Foundation to advance the effort further. They may have a viable process ready for production by 2010 and bring the cost of a dose down to 10 US cents. Even with major price reductions by one of the major international manufacturers of ACTs, the cost today is at least one US dollar through programs receiving support from the Global Fund to Fight AIDS, TB and Malaria.

While it is good that many approaches are being followed to bring ACTs closer to the people who need it at a cheaper price, synthetic production is the process that in the long run will likely provide the cheapest route. Hopefully governments and pharmaceutical companies are not setting up local farmers in Africa for economic disappointment down the road when the synthetic production of artemisinin becomes viable.

Adolescent health is often a neglected issue. To illustrate this, BBC recently featured the story a young Nigerian woman who married at the age of 12: “No-one has asked me whether I liked the man or not. When it was time for the marriage, I just heard that I had been married to him.” With early marriage comes early birth. The 2003 Nigeria Demographic and Health Survey reported that half of first births occur during adolescence. The Lancet Infectious Diseases in December 2006 reported that “in pregnant adolescents, the consequences of malaria are of great concern.”

The Lancet article was concerned that the problem of malaria in adolescence is overshadowed by that of young children, and yet the consequences of malaria on adolescents are not trivial. One quarter of young adolescents may develop severe anemia as a result of malaria. Somewhere between 1-10% of school days are missed because of malaria. Unfortunately adolescents often do not seek treatment, often for financial reasons, especially with the more expensive ACTs.

A RBM publication on gender and malaria reports that, “In many sub-Saharan African settings, adolescents are often parasitaemic and anaemic at the time that they first become pregnant,” but the Nigerian DHS found that only 50% of pregnant adolescents attend any antenatal care where they might benefit from malaria prevention.

Generally adolescents are not targeted for free ITNs and treatment by the common donor-supported malaria programs, and government health services are not making up the difference. This may lead to a dangerous ‘malaria’ generation gap.

The Global Fund to Fight AIDS, TB and Malaria (GFATM) has delivered more than 18 million insecticide-treated bed nets as of December 2006. In Malawi alone, UNICEF reports nearly 4 million nets distributed since 2002 from various sources. During a campaign in May 2006, 2 million nets were distributed in Niger through IFRC, CIDA and GFATM support. It is hard to know exactly how many ITNs/LLINs have been distributed in Africa, but in any given year nearly 50 million children under five years of age and pregnant women need protection from malaria.

But is counting nets distributed the right approach? The ultimate test is whether those for whom the nets are intended actually sleep under them.  One of the most crucial problems facing Global Fund grantees is monitoring and evaluation, not only of nets purchased, but generally keeping track of malaria interventions in their countries.  Integrated and functional national health management information systems are rare.

Monitoring is possible though, and on the positive side the President’s Malaria Initiative reported that in early 2006, PMI and the Global Fund distributed more than 230,000 ITNs in Zanzibar, which subsequently saw a dramatic decrease in reported malaria cases and quicker recovery for those infected. According to PMI, the number of confirmed malaria cases on Pemba Island dropped 87% from January to September in 2006.

On the negative side, not long after the net campaign in Niger, the LLINs distributed began appearing for sale in the markets of Kano, Nigeria, just to the south. In addition social research in Ghana and Nigeria revealed that communities often believe that working adults, particularly males, are more vulnerable to malaria, more severely affected and thus, more in need of nets. These perceptions threaten net access within households.

Two key issues must be addressed to ensure bednets reach the intended beneficiaries. First is donor coordination, and second is community education and follow through. Many groups are getting on the malaria bandwagon these days. The newly formed “Malaria No More” featured prominently at the White House Malaria Summit from where it solicited donations for bednets. A visit to its website shows that fortunately MNM is not going it alone, but will be working through UNICEF and IFRC, which already have the infrastructure in endemic countries to get nets to those in need.  Similarly JICA channels most of its net donations through UNICEF.  These efforts help get nets into endemic countries in a coordinated fashion. Likewise on the ground, coordination is needed among the various players. Reports from Zambia, Malawi and Tanzania show that events such as national Child Health Weeks provide an opportunity for all partners to work together to provide nets.

The second issue, education and follow through, links directly with the need for accountability in achieving Roll Back Malaria usage or coverage indicators, which now aim for 80% of vulnerable groups sleeping under nets by 2010.  IFRC provides a toolkit (worksheet) for local chapters involved in net distribution that includes key messages about malaria and nets as well as directives on the need to demonstrate appropriate use to community members. The toolkit guides volunteers to monitor net use and report results.  Recently we reported here that using community-directed intervention with local volunteers produces substantially better net acquisition and use than typical health department distribution efforts. Local volunteers selected by the community are better able to communicate and monitor health interventions because they live with the people and understand culturally appropriate ways to communicate health information including issues of vulnerability to malaria.

Recently the Executive Director of Church World Service addressed the intentions of governments and donors by noting that, “For those children who suffer the ravages of malaria, promises that come and go mean absolutely nothing, only action makes a difference.” Hopefully by this time next year we are not counting promises to distribute nets ¾ or not even counting nets distributed ¾ but counting the number of children and pregnant women actually sleeping under those nets and lives saved.