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Monthly Archive for "March 2008"

Community Bill Brieger | 28 Mar 2008

Do Mangoes Cause Malaria??

The New Vision (Kampala) reported on a project by A team of medical students from Makerere University that identified important communication problems in our attempts to control malaria. As long as health communication programs “don’t take account of what people know”, the students suggest, we will actually “fail to teach people what they need to know.”

dscn3993.JPGPeople have plenty of information, it seems, but they not understand or believe it all. In contrast, when interviewing villagers the students heard ideas like, “Mangoes cause malaria in this village. When I eat mangoes I get sick.” Another villager suggested that, “Malaria is caused by witchcraft or bad spirits. When I got malaria, I found out that my neighbor was responsible for it. And when he was sent away from the village, I got cured.” Such beliefs make health communication about using nets to prevent the disease sound strange.

Our experiences in Nigeria have shown that people can say in response to a questionnaire that mosquitoes cause malaria when in fact they hold multiple beliefs like malaria is caused be eating too much (red) palm oil, working too hard, being exposed too long to the hot sun, and dust, among others. If this is the case, it is hard to imagine a rural agricultural population preventing malaria by avoiding work and sun, and hence they usually take prophylactic herbal mixtures to hold the disease at bay.

When one understands local beliefs, one can frame plausible connections and solutions when communicating with villagers. One should always show respect and not criticize people because of their malaria thoughts. The students from Makerere realized that mangoes are more common in the rainy season when mosquitoes are also more common and suggested this link as a communication bridge with the villagers. We have used this process as a major approach in training village health workers to enable them to translate western ideas into locally acceptable information.

Money spent on fancy health communication materials will not go far to changing behavior unless there are people on the ground who can communicate directly and respectfully with local populations in terms they understand.

Treatment Bill Brieger | 27 Mar 2008

Viagra at 10 – what of malaria drugs?

National Public Radio reported this morning that Viagra, Pfizer’s erectile dysfunction drug, has now been on the market for ten years, NPR explained that, “In Viagra’s first month on the market, doctors wrote more than 500,000 prescriptions. Former presidential candidate Bob Dole once plugged the pill in TV commercials. The drug has been a long-term boost for Pfizer’s profits. Last year, it brought the pharmaceutical giant more than $1.7 billion.”

Nearly a year ago, NPR also reported that, “The male impotence drug Viagra may have a new use. It could be helpful in battling jet lag. A scientific journal carried that finding. Scientists came up with it after feeding Viagra to hamsters. The hamsters then had the lights turned off and on in ways that simulate jet lag. The hamsters on Viagra recovered from jet lag up to fifty-percent faster than those without.”  No studies have shown that Viagra cures malaria.

So what is Pfizer doing about malaria? Doubtless a new malaria product will not net $1.7 billion in a year. Is there any incentive for big pharmaceutical companies to get involved in solving the malaria problem?

Pfizer is undertaking some drug trials. “Through our Zithromax®/chloroquine clinical trial program, Pfizer scientists are developing a potential malaria treatment based on our widely used antibiotic, Zithromax®. Dosed in combination with chloroquine, Zithromax® demonstrated positive results in the treatment of adults with malaria in Africa. Currently, clinical studies are ongoing at centers in South America, India and Africa.”  Usually though, WHO does not making combination therapy for malaria that contains a drug for which there is already widespread resistance like chloroquine.

On a more practical basis, Pfizer is sponsoring ‘Mobilize Against Malaria‘, which is “A five year, three country initiative that engages and educates treatment providers and patients to improve the utilization and effectiveness of malaria treatment and patient adherence” in Ghana, Kenya and Senegal. Hopefully Pfizer will do more to address challenges of malaria drug potency with the profits it makes from male impotency.

Malaria in Pregnancy Bill Brieger | 23 Mar 2008

Training community distributors to control malaria in pregnancy

By this time next week Jhpiego with a grant from the ExxonMobil Foundation will have trained approximately 600 volunteer community distributors for controlling malaria in pregnancy (MIP) in 14 health facility catchment areas of four local government areas in the southern part of Akwa Ibom State, Nigeria. Very few efforts to involve the community directly in MIP control activities have been reported, but what distinguishes the Jhpiego effort is conformity with the standards set by the African Program for Onchocerciasis Control’s community directed treatment with ivermectin strategy. The key is linking the effort with the local health service to enhance supervision, monitoring and commodity flow.

a baseline survey in the study area showed that only around 5% of pregnant women had received two doses of SP for IPTp from a health service during their last pregnancy and less than 2% has slept under a LLIN anytime during their pregnancy. Community involvement was a clear need.

from-left-to-right2.jpgEffort started by building a team of core trainers among state health ministry and NGO partners. This team in turn trained local government health health management staff, who in turn trained local health facility staff in the area of malaria control and community directed interventions. During the past two weeks these local health staff have undertaken community mobilization including community meetings to answer questions about community roles in selecting and supervising their own volunteers.

There can be three to eight communities in a health facility catchment area. Once communities have agreed to take part, they look to the next smaller unit, the kindred or clan, and this extended family unit is the one that actually selects volunteers so that these can be immediately accountable to their own family members.

Eleven catchment areas have completed training and are embarking on community resource mapping and census to help estimate the need for commodities including ACTs for children under five, LLINs for pregnant women and children under five and sulfadoxine-pyrimethamine (SP) to use in IPTp for pregnant women. The state ministry is expecting malaria commodities soon from the World Bank Booster program, and these will be channeled through the local governments to the front line health facilities and to the community volunteers. A monitoring and evaluation system is being put in place so that the volunteers report back to the facilities who in return report to the local government and state.

Finally the volunteers will also refer pregnant women to the nearest facility to get all the required services for antenatal care. Jhpiego is working with the facility staff to develop quality assurance standards because poor quality was reason given by community members for not utilizing ANC in the past. Hopefully this community-clinic partnership will go a long way to reducing MIP in Akwa Ibom State.

Development &Integrated Vector Management &Mosquitoes Bill Brieger | 22 Mar 2008

Malaria and World Water Day

Greetings on World Water Day, which interestingly is taking place just about one month before World Malaria Day. The theme for the upcoming World Malaria Day focuses on malaria’s lack of respect for borders, and the challenge of guaranteeing and preserving safe water supplies also cuts across national boundaries.

dscn8553.JPGThe connection between water and the breeding of malaria carrying mosquitoes is well known. In a most simple example, one can visualize many of the newly installed borehole wells around Africa that were installed without adequate community involvement. in very little time, these become poorly maintained and spill off water collects into puddles ideal for anopheles mosquitoes.

One can also recall numerous agricultural projects that create mosquito breeding grounds through irrigation canals or simply land clearing that allows rain water to collects. When floods come, which has been very common in southeast Africa recently, communities lose access to safe water while ironically being surrounded by expanses of rivers that overflowed their banks, creating breeding opportunities for mosquitoes.

The ultimate lesson is that both programs, safe water and malaria control, cannot be solved in a vertical way. There needs to be collaboration and a broader development approach that addresses underlying

Vaccine Bill Brieger | 21 Mar 2008

Malaria vaccine concerns

Sobering thoughts arise when contemplating the review of HIV vaccine failure in the Washington Post. Not only have vaccine candidates to date failed, there is even evidence that they put people at greater risk by stimulating receptivity of target cells to HIV invasion. Have decades of research dollars, notably over $500 million, been wasted? The Washington Post quotes Robert Gallo, co-discoverer of the human immunodeficiency virus, as saying “This is on the same level of catastrophe as the Challenger disaster” (the NASA/USA Space Shuttle disaster).

Efforts to find a malaria vaccine have also spanned decades. A new review of the status of malaria vaccine research by Pizon-Charry and Good concludes that, “the disappointing results of clinical trials have resulted in reappraisal of current strategies. Whole-parasite approaches have re-emerged as an alternative strategy.”

The Malaria Vaccine Initiative (MVI) is a little more upbeat about vaccine prospects and feels that “government, industry, and academia partners” may be able to solve the problem. At the same time they do caution that, “There has, however, never been a vaccine developed against a complex multi-stage parasite. Since malaria is caused by such an organism, developing a vaccine to prevent it is especially challenging.” While MVI talks of accelerating malaria vaccine development, it appears cautious also on predicting a date when such may become a reality.

Much of the talk of malaria eradication seems based on the assumption that a malaria vaccine will be in place at some time in the foreseeable future. We hope researchers succeed sooner than later. In the meantime people should not put away their bednets and stop the search for new anti-malaria drugs. At least so far the existing malaria vaccine candidates do not appear to have increased people’s risk of getting malaria.

Advocacy Bill Brieger | 13 Mar 2008

Is the time for malaria advocacy past?

Mark Grabowsky makes the important point that coordinated and systematic malaria program monitoring and surveillance is needed so that we are not ‘flying blind‘ in our efforts to control the disease. Being blind is not an option when billions of dollars are at stake and drug and insecticide resistance, among other problems, is continuous a threat to success. Grabowsky in the journal Nature, explains that countries like Uganda are now getting adequate resources for control services, but “The challenge is to scale-up those services.” Scale-up without systematic monitoring and surveillance will leave us in the dark in terms of knowing whether we are progressing towards targets or need to make adjustments in strategies.

An editorial in Nature commenting on these observations charges that not only are programs not spending the needed money on surveillance but that the international malaria effort “is actually a hotch-potch of fragmented, country-level projects funded by multiple donors, with little regional and international coordination.” The authors revive a criticism was leveled in the same journal in 2004 that, “the WHO-led Roll Back Malaria initiative is mired in bureaucracy and anything but effective.”

The editorial diagnoses the perceived problem thus: “The international malaria effort is still geared towards maintaining donor support instead of getting teams into the field gathering data and delivering basic items such as bed nets.” This continued effort at advocacy, the editorial explains, was valuable ten years ago, but “With money now flowing in, the fight against malaria must shift from advocacy to getting results.

Obviously the authors of this editorial feel confident that the flow of malaria money will only increase and that donor fatigue will not set in.  True, donors do lose interest when they do not see results.  That is why the Monitoring and Evaluation Reference Group of the Roll Back Malaria Partnership has developed guidelines for countries and the partnership in providing technical support through its sub-regional networks to countries to strengthen monitoring.

Advocacy is a ongoing process because policy makers, donors and program managers have shifting interests and demands on their time and the resources under their control.  Collecting monitoring and surveillance results by itself will not sustain malaria control programs.  A full definition of advocacy therefore does include gathering and using data gained through monitoring and research to educate donors and policy makers about program effectiveness and gain their continued commitment to the fight against malaria.

HIV &Malaria in Pregnancy Bill Brieger | 12 Mar 2008

Malaria and mother-to-child-transmission of HIV

Brahmbhatt et al., have just reported that, “Placental malaria increases the risk of MTCT after adjustment for viral load.” They likewise found that, “HIV-positive mothers with serological ICT (rapid immunochromatographic test) malaria were significantly more likely to have low-birth-weight infants, and low-birth-weight infants had significantly higher risk of MTCT compared with infants of normal birth weight.” The following conclusion was offered: “Programs should focus on enhanced malaria prevention during pregnancy to decrease the risk of adverse birth outcomes and MTCT.” The study took place in Rakai, Uganda using data gathered from 1994-2000, and the authors did caution that different results reported in other studies could be due to epidemiological differences in different settings.

Coincidentally and unfortunately we just shared with our readers the results of another study and recent DHS results from Uganda showing how poorly pregnant women are being protected from malaria. The women in Rakai study community had been monitored during the prenatal and postnatal periods, and in the present day would be more likely to benefit from preventive malaria interventions than those in the general population where stock supply and health personnel problems would be more serious.

02photo_07apr-sm.jpgThese findings reinforce the need to integrate malaria in pregnancy control services such that maternal and child health and programs and the national malaria control programs actually work together to reach this important segment of the population at risk for malaria.

The added message is the need for better coordination between HIV and Malaria programs. Services for HIV positive women must ensure that they get LLINs and IPTp (unless receiving cotrimoxazole prophylaxis) not only to protect their own health, but also to prevent HIV transmission to their infants. When Round 8 Global Fund grant proposals come in for review, such program linkages should be be clearly emphasized. Current efforts to coordinate between PEPFAR and PMI could serve as a model.

IPTp &Malaria in Pregnancy Bill Brieger | 10 Mar 2008

Good ANC attendance does not guarantee IPTp coverage

Malaria Journal has published experiences from Luwero, Uganda that show the difficulties of getting two appropriately times doses of intermittent preventive treatment (IPTp) to women even if they attend antenatal care (ANC) clinics frequently. Among the over 750 post-partum women who were surveyed in 2005, 94% had attended ANC once and 88% at least twice.

Only 36% of the women received two or more doses of IPTp, and 31% used a bednet during their last pregnancy, well below the 60% target set for 2005 for IPTp and ITN use by the RBM partnership. Educational level was positive associated with taking any IPTp. Even these figures look good compared to the 2006 DHS in Uganda where only 10% of pregnant women said they had slept under a bednet the previous night and 16% reported receiving IPTp twice. The DHS did agree with ANC attendance wherein it was reported that 89% of women attended two or more times.

dscn4159.JPGThis pattern of good ANC attendance and poor malaria control coverage is not uncommon. It demonstrates the neglect of routine MCH and Reproductive Health services by national malaria control programs. ANC clinics do not receive regular net supplies and pregnant women do not benefit from community campaigns that mainly target children under five years of age. Countries phase out SP for treatment and forget to keep it on hand for IPTp during ANC.

A priority for all funders – PMI, GFATM, World Bank, DfID, UNICEF and others should be to foster integration of ANC strengthening into malaria control efforts in order to prevent maternal anemia and morbidity and ultimately low birth weight and neonatal mortality. Alternative approaches that involve the community should also be considered.

Morbidity Bill Brieger | 10 Mar 2008

Malaria as a terrorist act

We tend to blame mosquitoes and plasmodia species for malaria, when in fact human beings are responsible for much of the suffering. Cetin et al. pointed our recently in the Transactions of the Royal Society of Tropical Medicine and Hygiene that, “The annual number of terrorist incidences has been associated with the annual number of malaria cases in these regions of (eastern) Turkey since the beginning of terrorist activity in 1984.”

The authors acknowledge that overt wars destroy public health infrastructure and expose refugees and displaced persons to disease, but also stress that terrorism brings about uncertainties that also increase people’s exposure to malaria. Health workers are intimidated, services like vector control are curtailed and people move to towns and cities, overburdening health services there.

Little is to be gained in arguing over the labeling of what has happened and still occurs in Turkey as terrorism, civil unrest or whatever. Instabilities are breeding grounds for malaria. As Rowland et al., found, 23 years of civil unrest in Afghanistan helped reintroduce malaria into many rural communities.

Wars and civil unrest and the consequent displacement of people are a prime example of the theme of this year’s World malaria Day – a disease without borders. Therefore people who negotiate peace, such as Kofi Annan in his recent efforts in Kenya, are truly partners in rolling back malaria.

Monitoring &Treatment Bill Brieger | 09 Mar 2008

Itching for a new malaria drug

The Daily Times of Malawi has reported that, “The Malaria Control Program has said the new malaria drug, artemisinin combination therapy (ACT)—commonly known as LA—is the best drug against malaria, even though patients have complained of unpleasant side effects. Some patients have complained of persistent headaches and itching whilst others have said some of their body parts swell after taking the drug.” One assumes that “LA” means lumefantrine-arthemeter. In contrast in neighboring Zambia researchers found that after the new treatment policy of ACTs was introduced there were high levels of acceptability, and “it was not surprising to see high levels of compliance.”

2-common-forms-acts.jpgItching and fatigue have definitely been associated with amodiaquine. But according to Malawi’s Global Fund Round 7 Malaria Proposal, “AL (artemether- lumefantrine) was chosen over other ACTs due to its co-formulation which is expected to improve compliance while artesunate+amodiaquine (AA) was chosen as second line for the management of the uncomplicated malaria.” A recent review of ACTs by Nosten and White reported that, “except for occasional hypersensitivity reactions, the artemisinin derivatives are safe and remarkably well tolerated. The adverse effect profiles of the artemisinin-based combination treatments are determined by the partner drug.”

Just because a drug is effective, it may not be acceptable. As was found with AA in Ghana in 2005, first the drug needs to be formulated correctly. Various other factors affect acceptability including cost, packaging, provider-client communication and drug color in addition to side-effects. It is quite important to test all these factors with consumers, not just drug efficacy.

Perceived problems with drugs do interfere with compliance, and poor compliance will lead to development of drug resistance. Monitoring of acceptability and compliance must be an integral part of any malaria control program.

In the meantime there is need to keep searching for new anti-malarial drugs. That is why the news is sad that after nearly a decade’s work put into developing LapDap, the drug was ultimately pulled from the market because of links with anemia. This was a good example of public-private collaboration, and hopefully such ventures will continue.

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