Posts or Comments 18 April 2024

Monthly Archive for "November 2007"

Advocacy Bill Brieger | 21 Nov 2007

Malaria Day in Southern Africa

Ruth Ansah Ayisi shares her experiences from Mozambique.

dsc_1392sm.JPGHundreds of people in different regions of Mozambique gathered to join in festivities marking Malaria Day, 9th November, for the countries of the Southern African Development Cooperation (SADC). The theme “Leadership and Partnership for Malaria Control and Economic Development” is particularly pertinent for Mozambique, one of the world’s poorest countries whose economic development continues to be undermined by malaria and HIV/AIDS.

In the southern province of Maputo, the District Health Authorities in Moamba joined with partners like Malaria Consortium, the National Islamic Council and different cultural groups in what was a vibrant event. The event featured cultural and educational activities including traditional dances, educational songs and quizzes. Mosquito nets, T-shirts and caps with messages on malaria and HIV/AIDS were given out as prizes.

Ivete Meque, a doctor at the local hospital, explained how the IRS program is safe and kills mosquitoes. She introduced some of the sprayers and urged people to allow the “sprayers” into their homes, since some people had refused, believing that IRS was ineffective.

Arminda Langa, a young volunteer who visits people sick with HIV/AIDS, stressed that people living with HIV/AIDS need to be extra careful to protect themselves against malaria. “I lost a woman who I visited two months ago,” Langa said. “She was HIV positive, and had malaria. She had no mosquito net, because she could not afford one, and she died before the spraying began.”

“Such events are an important opportunity to transmit key messages to a large number of people at once through entertainment,” said Ali Mecusserima, a member of the National Islamic Council and president of Roll Back Malaria-Facilitator’s Group for Maputo province. He explained that “now we talk about malaria prevention, too” in the mosques.


The SADC countries do have something to celebrate with Mozambique, South Africa and Swaziland reporting major declines in malaria incidence. Zimbabwe also observed progress on Malaria Day toward meeting its malaria targets. Over 850,000 ITNs have been distributed by UNICEF there since 2004. In Namibia, Malaria Day corresponds with the start of the rainy season, and this year the country is appealing to citizens to take advantage of ITNBs, IRS and malaria treatment. Health education was also a key feature of Malaria Day in KwaZulu Natal. Again in Mozambique, UNICEF and health officials used Malaria Day to announce that, “A wide-ranging campaign to distribute over 500,000 mosquito nets is currently under way in 5 of Mozambique’s 10 provinces.”

Malaria Day is a good opportunity for advocacy and education, and these activities need to continue throughout the year.

IPTp &ITNs &Monitoring Bill Brieger | 19 Nov 2007

DHS Uganda: Some Malaria Progress, More Work Needed

The 2006 Demographic and Health Survey report for Uganda is now available. It was possible to compare the malaria indicators with the survey done in 2000-01. Some progress can be seen in the attached picture. The definition of the indicators is somewhat different between the two periods. For example IPTp did not begin as a national policy/program until 2002, so the comparison indicator in 2000 was the proportion of women who received antimalarial prophylaxis at Antenatal Clinic. Likewise, distinctions between types of nets were not reported for all users in 2000.


While there have been increases in all the indicators, none reached the 2005 RBM targets of 60%. Uganda has been fortunate to receive donor support for its malaria efforts. Uganda’s $23m Round 2 Global Fund Grant started in 2004, and by September 2006 over 91% of the funds had been disbursed. The final grant progress report (2006) indicates that 15% of children under 5 years had slept under an ITN the night before, compared to 9.7% in the 2006 DHS. The progress report shows that 35% of pregnant women had received IPTp2 compared to 16.2% in the DHS. The Global Fund Round 4 Grant in Uganda focused primarily on treatment with ACTs.

Uganda is also fortunate to be one of the first recipients of the US President’s Malaria Initiative. PMI selected Uganda in part because it envisioned potential synergies and scale ups because of the presence of GFATM efforts. Now that RBM targets are 80%, it is incumbent on Uganda to make the most of this multiple donor funding achieve better and faster results while the opportunity exists.

We are lucky that there are various monitoring tools like the DHS to compare reported achievements from progress reports to donors. Other countries should take similar advantage of such tools in order to monitor and improve their malaria control performance.

Development Bill Brieger | 17 Nov 2007

Can Malaria Control End Poverty?

Poverty and Human Development has been the major these of over 200 scientific and medical journals this fall. As part of that theme, PLoS Medicine asked a 30 commentators worldwide, “Which single intervention would do the most to improve the health of those living on less than $1 per day?” The respondents ranged from community activists to international experts.

Food, nutrition and related issues were common with 7 mentions. People mentioned direct food support, ensuring food security, exclusive breastfeeding as well as improvements in agriculture policy and land tenure systems that could boost food production. Five people stressed the importance of basic education, especially for females. Cash transfer and credit schemes received 4 mentions, while 4 people stressed basic water and sanitation interventions. There was some overlap in ideas.

Health related interventions fell in two broad categories, health technologies and health systems improvements. Five people suggested direct help that would provide medicines, vaccines and other technologies at the community level. Jeffrey Sachs was the only one to single out malaria when he said that, “n tropical Africa, a mass distribution of free long-lasting insecticide-treated bed nets to fight malaria accompanied by free access to artemisinin-based combination anti-malaria medicines. In other parts of the world, the situation will be different. I should add that I’ve spent years objecting to posing the question this way, since at low cost we could achieve major health advances through more comprehensive approaches.”

Health systems issues, mentioned by 5, were far ranging from community intervention to change in international agencies. Trained community health workers were suggested as the best way to deliver the above mentioned health technologies. Community/consumer participation in health policy formulation was mentioned. One person even suggested that the World Health Organization be made more effective. Better focused health/development aid was another more global approach.

Now that the malaria eradication vision has been put on the table, an economic rational for pursuing that strategy will become very important. We just need to remember that there are many other deserving interventions that will compete for funds and attention. Fortunately, taking a cue from the Millennium Development Goals, we can see the interrelationship among all these health and development issues.

IPTp &Malaria in Pregnancy Bill Brieger | 14 Nov 2007

Intermittent Preventive Treatment: Community and/or Clinic?

This posting looks at some of the issues in the debate of whether Intermittent Preventive Treatment during pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) should be based on a platform of Antenatal Care (ANC) or delivered through community volunteers or even a combination of strategies. (References for the information provided herein are found as an attached comment.) Roll Back Malaria has set minimum target 80% coverage of two IPTp doses (IPTp2) by 2010, but even though a high proportion of African women attend ANC during pregnancy, IPTp2 coverage is below target.

Those in favor of a community approach believe this is the best way to reach out to all women and achieve the 2010 high coverage targets. Those against the idea think that community distribution will detract from ANC attendance and deprive women of the services that come with ANC and thus, adversely affect women’s health.

prema-sm.jpgWhat is actually feasible? Eckert, Hyslop and Snow analyzed recent Demographic and Health Survey data from 20 African countries to see what proportion of pregnant women attended ANC in a way that was compatible with receiving two doses of IPTp. This ranged from 17-91% with a median of 70%. Even when ANC attendance seems good, IPTp2 coverage may not meet targets as for example in Malawi a in 2004 where 78% received one dose of SP but only 47% got two doses. Even more discouraging was a study from Kenya which reported that while 91.9% of pregnant women made more than one ANC visit, only 19.1% received IPTp1 and 6.8% received more than one dose.

Different studies have identified factors associated with not receiving IPTp2. These are a combination of system and personal variables as seen below. Some may be addressed through quality improvement of ANC services while others might require a community based strategy.

  • Charges at some types of facilities
  • Health worker confusion about spacing of IPTp doses
  • Less access and utilization in rural compared to urban areas
  • Clinic logistics including overcrowding, lack of resources to provide clean water and inadequate supply/distribution systems
  • Community perceptions about side effects and need to take with food
  • Late first registration
  • Being multigravida

Alternatively a pilot community based distribution in Malawi achieved 95% IPTp2 coverage, and another in Uganda reached 67.5% for IPTp2 among the community distribution group compared to 39.9% in the control group. The former may have detracted from ANC attendance while the latter apparently did not make a difference in ANC utilization.

As resistance to SP grows, health programs are not abandoning the drug, but may start to give it monthly. This may put additional pressure on coverage based solely on ANC attendance. The solution appears to lie first in a thorough situation analysis of the current levels of ANC acceptance and factors influencing IPTp delivery. In cases with existing high levels of ANC attendance strengthening ANC quality may be the best approach, while in those with low attendance, a community approach may be needed. Ultimately a combination may work best, but programs need to be flexible to investigate what is appropriate in each setting.

Funding Bill Brieger | 13 Nov 2007

Malaria Grants Approved

The Global Fund to Fight against AIDS, TB and Malaria at its 14th Board meeting has approved 49% of the 150 eligible proposals received according to The Global Fund Observer (GFO). The number of eligible grants submitted has dropped from 202 in Round 5 and 196 in Round 7, but the malaria grants have fared much better in Round 7.

round-7-grant-approval-sm.jpgThe attached chart shows a steady increase in approved malaria grants over the past 3 rounds as well as an increased proportion of the total approved grants allocated to malaria. GFO also reports in an increase in funding going to malaria. The approved two-year (Phase 1) budgets for malaria have risen from a total of $198m in Round 5 to $471m in Round 7.

Of the 46 Malaria proposals submitted, 25 (55%) come from Africa. Sixteen (64%) of these African proposals were approved and include Angola, Benin, Burkina Faso, Chad, Liberia, Malawi, Niger, Sao Tome and Principe, Senegal, Sierra Leone, Northern and Southern Sectors of Sudan, Tanzania, Uganda and Zambia. The Roll Back Malaria Partnership took an active role in helping develop quality proposals in many of these countries. While the overall news is good, we are reminded by RBM that, “Over 90% of the world’s malaria deaths occur in sub-Saharan Africa, where a child dies very 30 seconds of the mosquito-borne disease,” and therefore we must also think about the nine African malaria proposals that were not accepted and that represent at least a third of sub-Saharan Africa’s population.

The Rolling Continuation Channel (RCC) concept also appears to have kicked in with the 14th Board meeting. A GFATM press release noted that, “The Board has also approved US$ 130 million for renewal of five grants that have reached the end of their five year life.” Details on disease components of this first RCC dispensation are not yet available, but CCMs need to find out how their malaria grants can become eligible for RCC to ensure continuity of malaria control.

Health Systems &Morbidity &Mortality Bill Brieger | 08 Nov 2007

Measuring Malaria

The new series in The Lancet, “Who Counts?”, has serious implications for malaria programming and funding. Without being able to count the expected decreases in morbidity and mortality, program managers will lack the credibility to ask for continuing support. Ngozi Okonjo-Iweala and Philip Osafo-Kwaako explain that, “First, without adequate capacity for obtaining statistics, assessment of the magnitude of the development problems to be faced is often impossible. Second, if we get the numbers wrong, tackling development problems effectively is difficult.” They conclude that, “Governments and donors must view reliable data as an important tool in the development process, and must invest both financial and human resources in strengthening their statistical systems.”

dscn0043sm.JPGPhilip Setel and colleagues in the first of the “Who Counts?” series raise the question, “How much longer support for efforts to expand immunisation, and confront AIDS, tuberculosis, and malaria will last is questionable if counting the lives saved, and providing direct evidence of reduction of deaths due to these causes—particularly in the poorest of the poor—remains undone?” They worry that few countries in Africa have the capacity to measure the indicators for achieving the Millennium Development Goals, including those related to malaria and its effects on maternal and child health.

AbouZahr et al., in the fourth article in the series note that with new funding sources like GAVI and GFATM “pay particular attention to the importance of monitoring and evaluation, and could represent new opportunities to strengthen country capacities in vital statistics.” To this end the Global Fund provides a Monitoring and Evaluation Toolkit to grantees and their partners. This supports GFATM’s emphasis on performance based funding.

In the area of childhood immunizations GAVI is also “results oriented” and helps strengthen health systems to collect accurate country data. GAVI also has a Monitoring and Evaluation Technical Advisory Group. More Specific malaria monitoring and evaluation resources can be obtained from the Roll Back Malaria Monitoring and Evaluation Reference Group.

Two big challenges exist in order to make viable malaria M&E possible. First there is need to ensure that the existing health information system data collection processes – the forms, the registers, the summary sheets, the surveys – adequately and appropriately address key malaria indicators. Secondly, like in the HIV/AIDS ‘three ones’, there needs to be a unified malaria M&E system from community to national level that is used by all programs and partners – public, private and NGO.

Indoor Residual Spraying &ITNs &Treatment Bill Brieger | 06 Nov 2007

Island getaway … from malaria?

A press release yesterday announced that, “Research in Zanzibar, Tanzania has found a remarkable fall in the number of children dying from malaria. Within a three-year period (2002 to 2005), malaria deaths among the islands’ children dropped to a quarter of the previous level and overall child deaths to half.”

Zanzibar is an island, and that makes control of any disease special. Mabaso, Sharp and Lengeler conducted a historical review of malaria control in Africa and looked especially at IRS efforts between the 1940s and 1960s. They noted that, “IRS was not taken to scale in most endemic areas of the continent with the exception of southern Africa and some island countries such as Reunion, Mayotte, Zanzibar, Cape Verde and Sao Tome.” Malaria has returned to some of these islands, and the authors warn that IRS by itself is not a magic bullet.

dscn9483sm.JPGA key feature of the effort in Zanzibar was the use of ACTs and LLINs together. These interventions have been supported by both the US President’s Malaria Initiative and the Global Fund to Fight AIDS, TB and Malaria, which has provided assistance for both treatment and LLINs specifically to Zanzibar in Rounds 1 and 4.

Progress on Bioku Island in Equatorial Guinea is happening, but not at the same rate as Zanzibar. Marathon Oil has helped with IRS and ExxonMobil with nets. Marathon reports that annual insecticide spraying campaigns started February 2004., and the program achieved “44% reduction of malaria parasites in children and 95% reduction in malaria transmitting mosquitoes.” Researchers have also documented “42% fewer infections occurring in 2006 compared with baseline (2004)” and reduction associated with recent house spraying or net use. They also stressed the need for comprehensive monitoring of coverage and correct use of IRS and ITNs, as there were variations in mosquito populations on the island.

Sao Tome also experienced a drop in malaria prevalence after a successful pilot ITN program. Currently Sao Tome is using GFATM money to implement a mixed method strategy and scale up free distribution of insecticide-bed nets, community-based management of malaria, provision of information, education and communication (IEC) about malaria, Intermittent Preventive Treatment (IPT), and artemisinin-based combination therapies (ACTs).

While disease control on an island may appear simple, the process is obviously a microcosm of the challenges faced on the mainland. Lessons from the eradication days show that one strategy alone may not yield long term results. Hopefully Zanzibar’s lessons of mixed approaches to malaria control will guide other national malaria control programs.

Integrated Vector Management Bill Brieger | 04 Nov 2007

Oil on (Mosquito) Troubled Waters

The use of petroleum products (PPs) such as kerosene, gasoline and engine oil to control mosquito breeding and malaria dates back to early in the last century. Generally today there is not much emphasis on larviciding measures in major control programs, let alone the use of PPs.

Therefore it was interesting to read an article by Djouaka et al. documenting the continued application of petroleum products to standing water in several villages in Benin Republic. The practice appears to have been handed down from parents to children. The authors then tested various products and found that, “The relatively high efficacy of kerosene, engine oil and waste oil is likely to be due to their elevated persistency in breeding sites after treatment.”

ofiki-in-dry-season-sm.jpgBeales and Gilles in the Fourth Edition of Essential Malariology devote two pages to explaining the use of “petroleum oils” on standing water surfaces and how these can be highly toxic to larvae and pupae. They also address the drawbacks including cost, problems of vegetation, debris and wind and of course environmental contamination. No examples of actual use in current malaria control programs are given.

To buttress this lack of emphasis on PPs, the recent article by van den Berg and Takken did not include these products in their “framework for decision-making in integrated vector management.” Even a 1982 WHO manual on environmental management of mosquitoes only gives a historical perspective of PPs: “The earliest chemical control of mosquitoes was directed against the larval stage. By the end of the last (19th) century the first larviciding technique was developed. Crude kerosene and distilled petroleum oils were applied to mosquito breeding sites.”

A hint that PPs were not totally forgotten was found in a WHO 2005 Darfur Weekly Report of August 14-20, where, in the flood-affected Ardamata IDP camp, “Larval control … is accomplished by spreading used engine oil on mosquito breeding places.”

Finally in 2002 Yapabandara and Curtis reported testing various methods to control mosquito breeding in gem puts in Sri Lanka using polystyrene beads, temephos, used engine oil and filling pits with soil as well as two concentrations of pyriproxyfen. The latter chemical proved most effective and convenient needing only two applications annually while engine oil required 12 annual applications. PPs ultimately do not appear to have much to recommend them.

So let us return to the persistence of PP use in Benin communities, which occurs, Djouaka et al. surmise, because these measures are available, cheap and convenient. The ‘history’ lesson here is not a desire to return to the use of PPs, but the need for cheap and convenient malaria control measures that communities can manage for themselves.

Vaccine Bill Brieger | 03 Nov 2007

Malaria Vaccine Progress in Mozambique

Success of another malaria vaccine candidate is being celebrated. According to the New Scientist, “A vaccine against malaria would save hundreds of thousands of lives each year. Now it seems we’re much closer to finding one.” The report in The Lancet by Aponte et al. explains that the vaccine trial in Mozambique after three doses at 10 weeks, 14 weeks, and 18 weeks of age, “Vaccine efficacy for new infections was 65% over a 3-month follow-up after completion of immunizations. This efficacy estimate is higher than the 45% reduction reported in a previous trial in older children.”

Also of note, serious adverse events and side effects were not significantly different from the control group children who received Hepatitis B vaccine in addition to the normal childhood immunizations. BMJ News observed that, “This early trial was focused on safety. Bigger trials to assess efficacy could be next.”

Ultimately, any successful vaccine needs to address social and organizational issues in addition to safety and efficacy. The best health technologies are useless if people do not adopt them correctly. The fact that this new vaccine candidate could be integrated into a normal childhood vaccine schedule may address some of the organizational concerns, and the similar level of reactions to existing vaccines may help with acceptability concerns.

Consumer expectations and beliefs may provide additional hurdles. Malaria endemic communities have many ideas about what constitutes ‘malaria’. Various conditions ranging from ‘ordinary’ malaria to yellow fever and typhoid have been conflated under the umbrella of ‘malaria’ illness in parts of West Africa. That coupled with the fact that as currently constituted, this vaccine candidate may leave 35% of children unprotected may raise doubts in the community about the perceived efficacy of the shots.

One cannot blithely say, “Health education will handle such problems.” Health educators cannot convince people to adopt something that runs strongly counter to their experiences. The answer therefore is for researchers to continue to work (with increased donor funding) to perfect the malaria vaccine candidates and make them more acceptable to the public. Only when there is a dialog between the public and public health professionals and researchers can innovations that are both efficacious and acceptable be developed.