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Monthly Archive for "December 2007"

ITNs Bill Brieger | 26 Dec 2007

Do communities appreciate free bednets?

The New Vision (Kampala) reported on Sunday the abuse of a free ITN program in Tororo, Uganda. Not only was the paper concerned that, “The fight against malaria in Tororo district is facing setbacks as residents use mosquito nets, which are intended to control the spread of the disease, to make wedding gowns.” They were also appalled that members of the local council, “cannot support voluntary programs if there is no kitu kidogo (bribe).” Concern even extended to the health workers who manage the project and who were warned not to “use the project’s bicycle or motorcycle to take your wife or children for leisure rides.” This raises the age old question of whether people appreciate things they receive for free.

in-uganda-nets-are-both-sold-commercially-and.jpgIn contrast, Noor et al., in PLoS Medicine make the case for free distribution of nets as not only being pro-poor (equitable) but also effective in increasing coverage in neighboring Kenya. Their conclusions are in keeping with WHO’s Global Malaria Program in a recent position paper stated its preference for net distribution as follows:

“In most high-burden countries, ITN coverage is still below agreed targets. The best opportunity for rapidly scaling-up malaria prevention is the free or highly subsidized distribution of LLINs through existing public health services (both routine and campaigns). LLINs should be considered a public good for populations living in malaria-endemic areas. Distribution of LLINs should be systematically accompanied by provision of information on how to hang, use and maintain them properly.”

The Tororo experience contrasts with expectations in Benin Republic according to Aplogan and Ahanhanzo (Bull Soc Pathol Exot. 2007; 100(3): 216-7) where, “The major expectations of the households are supply of impregnated bed nets free of charge.” The key to successful ITN distribution and utilization rests on thorough community involvement, demand creation and culturally appropriate health education.

Environment Bill Brieger | 25 Dec 2007

‘Tis the season … the environment, the location

Malaria control activities need to be planned with specific local conditions in mind. This is the lesson derived from three articles which appear in the January 2008 issue of Acta Tropica.

Reporting from Burkina Faso Ouedraogo et al. observed that, “The gametocyte prevalence was significantly higher at the start and peak of the wet season compared to the dry season when corrected for asexual parasite density and age.” In fact they estimated only one infective mosquito bite a month during the dry season. While malaria control programs must clearly have their major interventions in place before the rainy season, they should also educate people to be on their guard during the dry season when people traditionally slack off on ITN use because of heat.

okinna1sm.jpgThe man-made environment was the focus of concern for malaria transmission in western Kenya. Howard and Omlin went searching for fish ponds and found that 29% of 261 in Kisi Central District of Nyanza Province had been abandoned. Without the fish these a unused ponds became better mosquito breeding sites. The link with economic development was important since access to markets and agricultural extension services may influence whether ponds are abandoned or stocked. Thus, sustaining efforts to improve economic development through aquaculture may help prevent mosquito breeding.

Meissner et al., looked at another geo-environmental concern, variations in chloroquine resistance in urban and rural areas of Burkina Faso. They propose that higher drug pressure in urban areas may explain greater chloroquine resistance in urban communities. This has implications for phasing in changes of national malaria drug policies and well as targeting health education about malaria drug regimen adherence.

These three studies show that one size does not fit all communities when it comes to malaria control. The economic, ecological and epidemiological characteristics of each location should be considered for optimal program implementation.

Health Systems &IPTp &Malaria in Pregnancy Bill Brieger | 24 Dec 2007

Attending ANC does not Guarantee IPTp

Tanzania has been noted for its high levels of antenatal care (ANC) attendance. Four out of five health facilities offer ANC. Over 94% of pregnant women attend ANC offered by a trained provider including nurse/midwifes, other clinicians and MCH Aids. It appears that 95% of these attend ANC two or more times, making it theoretically possible for Tanzania to achieve the RBM target of 80% of pregnant women receiving two doses of Intermittent Preventive Treatment (IPTp). National Policy has supported IPTp in ANC for over six years. Unfortunately the DHS also shows less than 22% of pregnant women receiving two doses.

tanzania-mip.jpgTarimo (2007) offers some explanations for this “IPTp Gap” in the East African Journal of Public Health. ANC clinic exit interviews revealed that only 60% of women received IPT and some of the reasons for the gap. A key problem was unavailability of sulfadoxine-pyrimethamine (SP) for IPTp. About 40% of those who actually received SP did not take it as directly observed treatment in the clinic for reasons including not wanting to take it on an empty stomach and aversion to sharing drinking cups with other women. Who knows what they did with the SP when they got home?

Finally while 90% were aware of IPTp, only 30% knew the correct timing and dosage. Thus, they were not even in a position to make educated demands on service providers for timely and adequate provision of IPTp. These problems represent a clear failure of the health system: failure to stock SP, failure to ensure conducive conditions to take SP and failure to educate clients thoroughly.

We have previously raised the question about community delivery of IPTp, which while effective in increasing coverage, raises concerns about reducing utilization of ANC and delivery services. But what do we do when the health service is clearly squandering an opportunity to deliver this live saving intervention through ANC?

ITNs &Malaria in Pregnancy Bill Brieger | 23 Dec 2007

ITNs – pregnant women or all women?

Providing an insecticide treated bednet (ITNs) for all pregnant women as early in pregnancy as possible is a key malaria control strategy that not only protects the woman from malaria but improves birth outcomes and child survival. Ideally ITNs for pregnant women should be a routine service provided through antenatal care (ANC) since in many countries over 80% of pregnant women attend ANC at least once.

pregnant-women-should-get-itns-as-part-of.jpgA major problem in achieving this goal is that in many malaria endemic communities, pregnant women who do attend ANC do not register until well into their third trimester after many months of exposure to malaria transmitting mosquitoes. At the same time, campaigns to distribute ITNs in the community usually target children under 5 years of age, not pregnant women.

A number of social and cultural factors explain poor access and timely acquisition of ITNs by pregnant women. In some cases pregnancy is considered normal and thus there is no need to register early for ANC. Pregnant and unmarried teens,who are among the most vulnerable to the effects of malaria in pregnancy (MIP), are often embarrassed to register and thus make their pregnancy publicly known.[1,2] ANC requires payments in some countries, and even when free, attendance at ANC has indirect economic costs when women miss work.

Poor service quality is another issue that keeps many women from attending ANC early or often. Finally a cultural issue that has been documented in many countries, is the reluctance of revealing one is pregnant until ‘it shows’ due to fears that jealous or evil people may curse or damage the pregnancy.[3-6]

One solution to this problem of ensuring that pregnant women get and sleep under ITNs is to give all women of reproductive age an ITN. This would make access easier and would also avoid any embarrassments or cultural fears that would come from singling out a pregnant women for a net. The Global Fund has created the capacity to distribute ITNs to over 30 million people by mid-2007. This ITN capacity should be extended to include all women.


  1. Sow F. To be a woman in Africa. On the danger of being a mother. Mortality [Article in French] Vivre Autrement. 1994 Oct:13-4.
  2. Magadi MA, Agwanda AO, Obare FO. A comparative analysis of the use of maternal health services between teenagers and older mothers in sub-Saharan Africa: evidence from Demographic and Health Surveys (DHS). Soc Sci Med. 2007; 64(6): 1311-25.
  3. Ndiaye P, Dia AT, Diedgiou A, Dieye EH, Dione DA. Socio-cultural determinants of the lateness of the first prenatal consultation in a health district in Senegal [Article in French] Sante Publique. 2005; 17(4):531-8.
  4. Morse JM. Cultural variation in behavioral response to parturition: childbirth in Fiji. Med Anthropol. 1989; 12(1): 35-54.
  5. Beninguisse G, De Brouwere V.Tradition and modernity in Cameroon: the confrontation between social demand and biomedical logics of health services. Afr J Reprod Health. 2004; 8(3): 152-75.
  6. Chapman RR.Chikotsa–secrets, silence, and hiding: social risk and reproductive vulnerability in central Mozambique. Med Anthropol Q. 2006; 20(4): 487-515.

Funding &Health Systems Bill Brieger | 21 Dec 2007

Implementation Science – Scaling-up Malaria Interventions

An policy forum article on implementation science in Science Magazine is quite timely considering the recent criticism appearing in the Los Angeles Times about large scale funding for single purpose disease control programs. Some of the discussion focused on the need to strengthen health systems, support human resource development and retention and integrate into broader public health programming. Questions about how this can be done fall in the realm of implementation science as described by Madon et al.

The Global Fund has issued a response to the original article, which was commented on in the LA Times on 20 December. Although the authors criticize the Global Fund for not providing convincing data to challenge their claims of health system damage, both the original article and the rejoinder rely on the claim that 1) more time is needed to see the effects of this relatively young effort (5 years only) and 2) available statistics from international organizations do not yet reflect actual Global Fund achievements, such as massive distribution of ITNs.

Implementation science as described by Madon et al. requires a more rigorous approach. They bemoan the fact that “Instead, planners often assume that clinical research findings can be immediately translated into public health impact, simply by issuing ‘one-size-fits-all’ clinical guidelines or best practices without engaging in systematic study of how health outcomes vary across community settings.”

implementation-science.jpgThe article in Science further explains that, “implementation science creates generalizable knowledge that can be applied across settings and contexts to answer central questions. Why do established programs lose effectiveness over days, weeks, or months? Why do tested programs sometimes exhibit unintended effects when transferred to a new setting? How can multiple interventions be effectively packaged to capture cost efficiencies and to reduce the splintering of health systems into disease-specific programs?” It is answers to these questions that international donors including the Global Fund and the Gates Foundation need to address.

Funding &HIV &Partnership Bill Brieger | 18 Dec 2007

U.S. Malaria Support – a Tale of Two Countries: Ghana and Nigeria

Both Ghana and Nigeria received attention in the Press during the past week because of U.S. foreign assistance. The President’s Malaria Initiative (PMI) launched its activities in Ghana (one of 15 countries receiving PMI support) under the theme “Let’s Come Together and Drive Malaria Away.” Reports estimate that Ghana with an estimated population of approximately 23 million will receive around $US 6 million annually over the next three years from PMI. We congratulate their efforts.

Nigeria also made the headlines when President Yar’Adua visited the White House. The US President observed that Mr. Yar’Adua “is strongly committed to helping the Nigerian families affected by these diseases (HIV and malaria) get treatment and help.” The US pledged more funding for HIV, not malaria in this country of 140 million. Nigeria has received less than $US 3 million annually for malaria activities as a ‘non-focus’ country as regards PMI.

Reports noted that Nigeria has the third highest number of HIV cases in the world, which is seen as justification for continued HIV support, even though targets have not been achieved. Due to its sheer size and its location in a Plasmodium falciparum endemic zone, Nigeria is also likely to have the one of the highest number of malaria cases and the highest number of malaria deaths, too.

Nigeria met all criteria for inclusion in the PMI effort except for one fact, its population. PMI’s goal of covering 15 countries with a total population of 170 million could not have accommodated Nigeria. This is not to say Nigeria lacks malaria support. One of PMI’s criteria was that other donors, especially GFATM, be present in a country so that PMI’s efforts could be complimentary and make scale up even faster.

bare-shelves-or-inappropriate-drugs-characterize-many-local.jpgNigeria is not without external support. It has some GFATM money, but this covers only half of the 37 states/territories and aims at supporting only a portion of local intervention efforts, not achieving full coverage targets alone. Apparently the GFATM has used Nigeria’s teething problems on these early grants to deny additional funding for the past three Rounds. There is the World Bank Booster program which has been quite slow in rolling out and targets another seven states. Advance plans are underway for DfID to contribute to malaria programming in an undisclosed number of states.

One is also right to ask about the amount of internal funding for malaria is provided by this oil rich country. Still, if the issue is massive scale up of malaria interventions, all partners, national, private, bilateral and international need to increase their support to control malaria in Nigeria.

Funding &HIV Bill Brieger | 17 Dec 2007

Furor over HIV funding – what of malaria?

A Los Angeles Times article on HIV/AIDS funding, particularly by the Gates Foundation and through the Global Fund to fight against AIDS, TB and Malaria (GFATM), has sparked a furor. The authors question whether the large and focused support for one disease reduces support for basic health systems issues and needs including nutrition, staffing, other infectious diseases and essential supplies and equipment.

An internal brain drain is described wherein staff migrate to HIV-related positions that attract supplemental salary. What could be termed replacement mortality is discussed when people survive HIV because of ART (anti-retroviral therapy) but die of other diseases because they are poor and malnourished. It is not a pretty picture.

Responses have been strong with some criticizing the audacity of the authors to question the good will of the donors while others questioning the academic and scientific qualifications of the donors to make intelligent decisions about channeling aid. Overall it is interesting that the malaria portion of such funding appears to have escaped the most scathing complaints.

malaria-treatment-and-care-are-delivered-sm.jpgWhen the Roll Bank Malaria Partnership got underway in 1998 one of the key components of discussion was the premise that malaria control must be pursued in the context of health system reform. The assumption was that all major malaria interventions required a strong health system for their effective delivery. Malaria care was already part of Integrated Management of Childhood Illness (IMCI). We certainly haven’t heard of special malaria clinicians receiving salary supplements for dispensing ACTs.

We are aware, as is the GFATM that one of the major problems in delivering malaria interventions are basic health systems bottlenecks such as weaknesses in forecasting and procurement, supply chain disruptions and inadequate dissemination of current malaria care policies and guidelines to frontline health staff. What was not mentioned in the Los Angeles Times article is that GFATM encourages countries to include ‘Health System Strengthening’ components in their proposals, although this has not been a major component to date.

Finally we are also aware as we have recently shared that malaria prevention efforts have positive benefits on nutritional status. Use of bednets/ITNs has helped reduce all cause infant and child mortality. Are we herein defending the special attention being given to malaria after years of neglect? Maybe readers would like to comment from their own experiences?

IPTi &Nutrition Bill Brieger | 08 Dec 2007

Better Nutritional Status through Malaria Prevention

Researchers in Senegal studied the effect of intermittent preventive treatment (IPT) of malaria for children during the malaria transmission season in that country and found that, “The prevention of malaria would improve child nutritional status in areas with seasonal transmission.” In particular mean weight gain was significantly better for those receiving IPT.

These researchers also note that similar positive results have been observed in other malaria prevention research efforts in the Gambia and Tanzania. The Tanzania work included ITNs in addition to IPT.

A basic child health monitoring tool, the Road to Health Chart, comes to mind. The guidance with the charts was usually to suspect illness, such as diarrhoeal diseases and TB should a child’s weight remain static or decrease between clinic visits. It is encouraging to know that we can also improve overall child nutritional status through malaria prevention. More work is needed to document these effects of preventive interventions in areas with year-round malaria transmission. Such results also add to the economic benefits arguments for malaria control as children with better nutritional status will hopefully grow into more productive adults.

Mosquitoes Bill Brieger | 05 Dec 2007

Smoke and Mosquitoes

Based on the possibility that “Anecdotal evidence suggests that smoke may play an important role by providing protection from biting insects and that efforts to reduce smoke may increase exposure, particularly to mosquitoes and malaria,” Biran et al., recently conducted a review of previous research. Various domestic sources of smoke were found including that from cooking fires and local herbs that were burnt to repel mosquitoes. Although they did not find much research that addressed the question directly, they were able to suggest the following:

  • Smoke from domestic fuel use probably does not have much effect on mosquito feeding
  • Mosquito feeding is affected by smoke from certain plant products traditionally used as repellents
  • Soot from domestic fires, although not toxic to mosquitoes, does not impair the effectiveness of ITNs
  • Soot may, however, increase the frequency with which nets are washed and thus accelerate the loss of insecticide from ITNs

does-smoke-from-indoor-cooking-repel-mosquitoes2.jpgThe authors concluded that, “There appears to be a good health argument for continuing efforts to reduce indoor air pollution, even in areas where malaria is endemic. It is likely that such efforts will have substantial health benefits in reducing respiratory disease and unlikely that the reduction of smoke per se will have any significant health costs in terms of increased malaria.”

Smoke as a mosquito control intervention is not common – in fact it was as far back as 1923 that the Transactions of the Royal Society of Tropical Medicine and Hygiene contained an article explaining how smoke from burning straw was used to drive mosquitoes from hiding places where they could be manually killed.

While the identification of local repellent herbs was important, another common source of smoke that was not addressed in the recent article was the mosquito coil. These are cheap and ubiquitous in endemic communities, although some community members do complain about the fumes causing breathing problems. According to Pauluhn and Mohr, “Overnight exposure to the smoke from burning mosquito coils (manufactured in Indonesia) is unlikely to be associated with any unreasonable health risk.” Of course people in endemic communities use coils over many nights (see comment).

ars.gifThe question is whether coils work. Lawrance and Croft reviewed literature and concluded that, “There is no evidence that burning insecticide-containing mosquito coils prevents malaria acquisition. A randomized field trial should be conducted, with malaria incidence as a primary outcome. There is consistent evidence that burning coils inhibits nuisance biting by various mosquito species. The potential harmful effects of coil smoke on human users should be investigated.”

In the end we don’t need smoke and mirrors to control malaria, but reliable and adequate supplies of interventions of known value such as long-lasting insecticide treated nets.

Community &ITNs &Treatment Bill Brieger | 03 Dec 2007

Community Directed Interventions for Malaria

Last year we reported on the second year results of the UNICEF/UNDP/World Bank/WHO Tropical Disease Research (TDR) Program’s Community Directed Intervention (CDI) Multi-Country study. CDI was originally developed for annual distribution of ivermectin as part of the African Program for Onchocerciasis Control. The current study tested whether the community and the volunteer distributors selected by the community could manage additional health interventions. Included in the trial were ITNs for children and pregnant women, home management of malaria with Coartem, Vitamin A and TB case detection.

At the end of the second year of the study “Malaria home management coverage doubled, Bednet coverage doubled to quadrupled, Vitamin A coverage was significantly higher, and TB case detection rate doubled.” One of the seven research team leaders, Richard Ndyomugyenyi of Uganda, explained that, “… if we involve them (the community) as stakeholders right from the beginning, and they are following up what you are doing, it becomes easy for them to implement, because those results would also be theirs.”

Richard further noted that, “The main reason this works seems to be that this process [CDI] empowers the communities to own the process and the programme. So they actively participate in deciding how these interventions should be delivered – so they take an interest in their own program, and it increases coverage”

According to Elizabeth Elhassan, the team leader from Kaduna, Nigeria, “Once you empower people, and they realise it is for their own benefit, it becomes a priority for the communities.” Of course community participation must be coupled with availability of commodities. “The study went well, particularly in 2006 as we had a reasonable supply of materials: nets, antimalarials, and vitamin A, to both the study and the comparison arms,” Elizabeth told RealHealthNews.

The seven teams from Nigeria, Cameroon and Uganda just completed their third year and final data analysis last week in Douala.  Interventions were added to the existing ivermectin distribution each year to observe how communities could handle the extra responsibilities. In control arms normal ivermectin distribution occurred but the other interventions were provided to the district health authorities to distribute through their ‘normal’ channels. The CDI process used in the research is described on the TDR website where a short video clip from the team that worked in Taraba State, Nigeria can be found.
cdi-preliminary-sm.jpgThe accompanying graphs show that the results have maintained a positive direction.  The study arms that received the malaria interventions by the second year had higher coverage than those in the other two arms in year two and by the third year those who had received the interventions in either year did better than the control districts/arms.  ITN coverage for pregnant women and home management of malaria showed the best results.  The improvements in ITN coverage for children were still below RBM targets, and qualitative results indicated that better follow-up by the volunteer distributors in reminding people to use the nets is needed.

Clearly the community directed participatory approach can help get basic health commodities to people living in remote and rural areas. Qualitative results found that the malaria interventions were particularly successful because communities see malaria as a serious problem that affects everybody.

The research teams are now planning advocacy meetings with policy makers in their countries, while TDR staff are sharing the results internationally to encourage other countries and donors to adopt the CDI approach.

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