Tropical Health Matters

Gloria Oramasionwu just completed her MPH at the Johns Hopkins Bloomberg School of Public Health and did her Capstone Project by analyzing the 2003 Nigeria Demographic and Health Survey in greater depth concerning correct treatment of childhood malaria. Among 1603 children under five years of age who had a febrile illness in the two weeks prior to the survey (a proxy measure for malaria) 26.9% received the appropriate malaria drug (as of 2003) by the second day of onset.

An important finding, seen in the chart below was that correctness was related to source of care. Those who got care from a public sector health facility were the most likely (41.7%) to have received correct treatment. Unfortunately only 24.5% of children got their treatment from a public facility. In contrast 42.1% got treatment from drug vendors, but only 27.8% of this treatment was correct. This has important implications for planning national malaria treatment programs.

Two key concerns arise – training of providers in the non-public sectors to give correct treatment and the cost and availability of new first line ACT drugs. With training, we have found that among staff of orthodox health facilities, those in the public sector are more likely to be included in in-service training programs compared to their counterparts in private facilities. Additionally few programs exist to train drug vendors even though they provide the bulk of malaria medicines in some countries. These training gaps need to be closed in order to increase the likelihood that children will receive correct and timely malaria treatment.

The ACT issue poses different challenges. ACTs may cost up to 10 times that of the chloroquine or sulfadoxine-pyrimethamine that children were given in 2003. This may influence access to correct treatment unless ACTs are free or highly subsidized. Usually ACTs are free in the public sector because of programs like GFATM, PMI and the World Bank Booster Program. These programs may not cover 100% of need, and so cash strapped local health services may buy inappropriate but cheaper alternatives. Additionally, these donor programs have not so far extended into the private sector. There are exploratory efforts to make ACTs available at subsidized rates for the private sector, and those need to be expanded because it is the private sector that meets to bulk of need, for example, nearly 50% of parents get their antimalarial drugs from drug vendors and medicine shops in rural Nigeria.

In conclusion, a proper national malaria treatment plan or strategy requires coordination and planning among all sectors so that whenever a parent of a child with malaria seeks care he/she will be guaranteed to get correct treatment at whatever type of source or facility that is convenient and acceptable.

The Sixtieth Session of the World Health Assembly (WHA) endorsed the creation of Malaria Day to bring global awareness to what has been to date Africa Malaria Day Resolution (A60/12). This follows on the heels of creation of Malaria Awareness Day in the US to compliment Africa Malaria Day. In the process the WHA wound up officially excluded Intermittent Preventive Treatment for pregnant women (IPTp) from the list of key interventions to being simply an activity that is implemented in Africa. This follows elevation by the WHO’s Global Malaria Program of IRS to a key global strategy and demonstrating that pregnant women in Africa are no longer important to the global fight against malaria – just a regional anomaly.

One excuse for demoting IPTp is supposed sulfadoxine-pyrimethamine (SP) resistance. Interestingly it is the same WHO along with researchers who have found that SP for IPTp is effective even at rates of 50% resistance among non-immune children under five years of age. No less an authority than peer reviewed Lancet articles have recently made the case for continuing IPTp with SP. Maybe the WHA has been tricked by people who don’t realize that even in a ‘global’ malaria program, the greatest burden of malaria falls on children and pregnant women in Africa.

The issue of DDT for malaria control continues to raise emotions. Even though the World Health Organization has endorsed the use of DDT for indoor residual spraying (IRS), people make emotional claims that the banning of DDT has causes millions of deaths, because of political wrangling over its safety. A common response to the situation is to blame Rachel Carson.

The WHO position paper on IRS traces the history of its use in malaria control dating back to the 1950s, a time of optimism for eradicating malaria. While acknowledging that changing opinion about DDT safety was involved in its discontinued use, the position paper points out other serious constraints including “lack of government commitment and financing to sus­tain these efforts over the long term and to concerns about insecticide re­sistance and community acceptance.” A major reason why malaria eradication efforts of the 1950s and 1960 failed in Africa was the lack of health system infrastructure to maintain continued IRS.

The early success of IRS was not just a matter of health infrastructure, but also of epidemiology. Greater success was recorded in areas where malaria was seasonal/epidemic – areas where IRS did not have to be maintained year round.

Issues of epidemiology and entomology, not emotion are leading groups like the Malaria Consortium to encourage dialogue on appropriate use of IRS, especially in highly endemic areas with year round transmission. In particular, Kolaczinski et al. note “In high transmission settings, IRS must be implemented indefinitely and at high quality to achieve control. As current infrastructure limitations and unpredictable funding make this unlikely, each country must carefully consider the role of IRS.” In short each country must examine its own financial and epidemiological situation and make a rational choice. A combination of strategies, including ITNs, is available as no one intervention fits all circumstances. Kolaczinski and colleagues also point to the need for better costing data to aid national malaria programs in making such hard decisions.

There are donors who can help make the financial decisions easier in the short run. PMI is pledging to make IRS available in all 15 of its countries in an appropriate manner based on “environmental assessments.” The Global Fund also acknowledges the use of IRS. The GFATM malaria grant to Liberia is an example of a grant proposal that includes IRS, and IRS is being implemented in Yemen. Now that IRS has been added to the current arsenal of anti-malaria weapons, it is time to stop complaining and start fundraising to guarantee adequate supplies as well as well trained and equipped malaria control staff who will apply IRS in a safe and epidemiologically sound manner.

Debate has gone back and forth as to whether malaria is a serious urban health problem or not. This issue itself is important to consider since the world’s population continues to urbanize, making it very necessary to understand the nature of urban health problems for better planning.

The key issue is the anopheles mosquito, which likes relatively clean collections of water, like puddles, exposed to sunlight. The crowding and pollution characteristic of urban areas does not favor anopheles mosquitoes, and yet studies continue to document some degree of malaria prevalence in urban communities of endemic countries.

Lagos, Nigeria represents anopheles scarcity. As far back as 1946 Muirhead Thomson observed an inhospitable environment for the breeding of anopheles. USAID partners revisited three neighborhoods in Lagos in 1998 and found malaria parasites in only 0.9% of over 900 children between 6 and 60 months of age. A. gambiae mosquitoes were not found in knockdown and human baiting studies, and a larval breeding density of only 0.3 was detected. The predominant mosquitoes were culex. Ironically in these neighborhoods, local shops were selling over US$ 3,000 per week in antimalarial drugs. Residents still perceived that they had ‘malaria’ and expressed similar cultural beliefs and perceptions as the outlying rural communities from where they had emigrated.

Clearly some level of malaria prevalence in the cities arises from traveling back and forth between rural and urban areas for economic and social obligations, for example the traders who travel back and forth guaranteeing food supplies for the cities. Urban health services therefore do need some stocks of antimalarial drugs to treat people coming in from the rural areas who are incubating a malaria infection.

A more complex issue is the nature and extent of urban malaria transmission. A recent study in Ghana found that malaria in urban areas displayed a heterogeneity and complexity that differed from the rural environment. Marked intra-city variation indicated the need for targeting specific areas, especially neighborhoods of the urban poor. A major contributory factor to malaria prevalence in many cities is urban agriculture, an informal economic activity of the urban poor.

Urban areas present a special challenge for ITN distribution. Epidemiological and entomological studies are recommended to map each city to determine target areas, and yet such targeting may be seen as discrimination by the general population who do not distinguish among types of mosquitoes and febrile illnesses. It may be politically necessary to provide ITNs in all poor neighborhoods regardless of mosquito ecology. In the area of treatment, health providers can be a bit more focused through using laboratory or rapid diagnostic tests to reduce inappropriate use of expensive antimalarials. As cities grow, are urban planners and health policy makers ready for the problem of urban malaria?

The American Journal of Tropical Medicine and Hygiene published a unique article in its May 2007 issue that documents how the timing and number of malaria infections during pregnancy influences child birth weight outcomes in Burkina Faso. Infection after 6 months of pregnancy was the strongest factor associated with low birth weight (LBW), but LBW was also associated with infection in early pregnancy. The challenge in determining the latter is that women in the study, as is the case in much of Africa, tended to register for antenatal care later in pregnancy. Fortunately in this study one-third of the women enrolled had first attended ANC in the first trimester and could be followed longer. This helped provide information for another important finding, that LBW is also more likely when women are infected with malaria multiple times during pregnancy.

These findings highlight the challenges of reaching pregnant women in a timely manner with malaria prevention measures including insecticide treated nets (ITNs) and intermittent preventive therapy during pregnancy (IPTp). The authors note the value of a full course of IPTp in preventing LBW, but lament that there are currently no safe drugs to use for IPTp in the first trimester. An additional challenge is that many women register for ANC too late or attend too infrequently to benefit from at least two doses after quickening at one month apart.

This points to the need to ensure that all ANC clinics have ITNs to give women on their very first visit. For those who attend and are not yet eligible for IPTp, ITNs too, prevent LBW and will provide the protection for the early infections that lead to LBW. Then if a woman gets a net early in pregnancy, she will be less likely to suffer multiple malaria infections, another risk factor for LBW.

The challenge if one of policy versus logistics. Although most malaria endemic countries point to guidelines that say a pregnant should sleep under an ITN, few have figured out the logistics of guaranteeing a regular and dedicated supply of ITNs for ANC clinics. At present ITN distribution favors campaigns as opposed to integration into routine Maternal and Child Health services. While this may favor achieving large targets among children under five years of age, it usually bypasses pregnant women.

Last week a colleague at JHPIEGO suggested that all women of reproductive age should be given an ITN. This would certainly help keep them safe from malaria whenever they get pregnant. Are donors willing to take up this challenge?

Recently we examined a proposal that financial support from the Global Fund to Fight AIDS, TB and Malaria (GFATM) be used to sustain health systems.  Two decisions by the GFATM Board in April make this proposition seem less like wishful thinking.  The first of these challenging decisions was to attempt to mobilize resources to reach $US 8 billion annually by 2010. This represents a quadrupling of current resource levels and approximately one-quarter of what the partners project as total resource needs to fight the three diseases by that time, i.e. US$ 28-31 billion per year.

The second key decision was the establishment of the “Rolling Continuation Channel” (RCC). The RCC would provide CCMs with the opportunity of applying for continuing funds for existing grants before they expire as distinct from submitting new grant proposals. The caveat is that eligibility would be reserved for high performing grants.

How would malaria grants fare under the RCC regime? The GFATM’s Progress Report 2007 notes that two malaria indicators/targets, ITNs distributed and anti-malarial treatments provided, fall below achievements for TB and HIV targets. To date, malaria grants have the lowest proportion scoring a performance rating of ‘A’, 16% compared to 25% for HIV and 32% for TB grants. If both ‘A’ and ‘B1’ ratings are defined as ‘high performance’, malaria does a little better comparatively (71%), through still in last place after HIV (74%) and TB (84%).

How can malaria grants become stronger performers and thus qualify for RCC? Recently Roll Back Malaria partners have provided concerted assistance to a number of countries to ensure that they submit the strongest GFATM Round 7 grants possible.  At a discussion forum sponsored by the Global Health Council, Dr. Michel Kazatchkine, the new Executive Director of GFATM, talked about the need not only for assistance in grant development, but also in quality implementation when he said that, “I’ve been saying when talking about partnerships that we need those not only to design the grant and be the best request possible but also to help it being implemented.”

Dr. Kazatchkine suggested that a better coordinated “reservoir of technical assistance” be made available.  The job of technical assistance is actually not within the mission of the GFATM, and so the onus to ensure that malaria grants succeed, and thus be eligible for RCC, falls back on partner groups like RBM. One could call such inputs the ‘hidden costs’ of GFATM grants. Hopefully all countries and donors will recognize that contributing to the GFATM is only one side of the coin, and that grants once awarded may not be sustained without extra resources needed for technical implementation support.

A major decision at the 15th Board Meeting of the Global Fund to Fight AIDS, TB and Malaria (GFATM) was to strengthen the role of civil society and the private sector in the Global Fund’s work. This includes involvement at both Board and country levels. Not only should Country Coordinating Mechanisms (CCMs) be more representative of all the major players in the public, private and civil society spheres, but they should also ensure “routine inclusion, in proposals for Global Fund financing, of both government and non-government Principal Recipients (PRs) for Global Fund grants (“dual-track financing”).

The evolution of CCMs from government agency-donor clubs to bodies that represent the broader society of a country has been occurring in recent years as constituencies affected by and civil society organizations working to fight the three diseases have gained a greater voice. While this voice is growing, little has occurred in the way of major funding for civil society at Sub-Recipient (SR) level, let along through simple contracting with the PRs. Until civil society groups can become PRs in their own right, they will be speaking from the sidelines.

As reported recently, grants operated by NGOs perform better than those with government or UN agencies as the PR. With dual track funding, not only will NGOs and CSOs have an equal chance to manage grants, but possibly a healthy competition between government-managed and NGO-managed grants will lift the boat of performance for all.

CSOs and NGOs come in all sizes and functions. Many, especially ones indigenous to the grant-receiving countries, are new to the concepts and processes of the GFATM. Fortunately a quartet of NGOs has put together a guide entitled, Engaging With The Global Fund to Fight AIDS, TB and Malaria: A Primer for Faith-Based Organizations. This guide will in fact be valuable to all civil society groups, not just the faith community. It should help them understand the structures, functions and proposal writing steps at the country level so that they not only have a voice in the CCM but also have a voice and a hand in how critical AIDS, TB and Malaria services are provided.

Former US President Bill Clinton recently warned that governments around the world are ill prepared for disasters, even when they have some advanced knowledge of problem, as in the case of the botched response to Hurricane Katrina. Clinton was speaking at Harvard Universities Kennedy School of Government where plans are underway to study government preparedness and response to problems ranging from global warming to stemming the effects of malaria. While much of the current talk of a malaria crisis revolves around expanding habitats for malaria-carrying mosquitoes, there are other crises in the making in current malaria-endemic environments.

One element of the looming malaria crisis is resistance to malaria drugs. We have been trying to transition from years when cheap monotherapy antimalarial drugs were nearly universally available and health systems could afford to presumptively treat any case of fever as malaria to an era of expensive combination therapies. Challenges along the way include the persistence of monotherapy versions of the new artemisinin drugs as well as major procurement and distribution problems for the new Artemisinin-based combination therapies (ACTs). Countries may be importing ACT supplies at cost from donors such as he Global Fund to Fight AIDS, TB and Malaria (GFATM), but such supplies are usually targeted for children under five years of age, and even then are not intended to be the sole source of a country’s ACT supply for that age group. Thus a crisis persists wherein old drugs like chloroquine are used to treat the remainder of the population with life-threatening results or monotherapy artemisinin drugs, thus drawing the day closer when resistance to this class of drugs arrives. So far WHO reports that there are no confirmed reports of artemisinin resistance in humans, but should this develop there are few if any immediate candidates to fill the gap.

Vigilance is needed by the relevant food and drug agencies in endemic countries work in close collaboration with national malaria control programs and policies and ensure that only ACTs are approved and dispensed or sold. Likewise there is urgency for national policy makers to make funds available to purchase ACTs for the entire population, supplemented with rapid diagnostic tests to ensure that when adults are treated with ACTs, they actually have malaria. Development of national or regional production capacity for ACTs is another need and challenge. Finally countries need to establish and maintain surveillance sites to monitor for malaria drug resistance.