Posts or Comments 17 June 2024

Monthly Archive for "April 2008"

Advocacy &Integrated Vector Management &Mosquitoes Bill Brieger | 29 Apr 2008

Learn your vectors

An editorial marking World Malaria Day in Nigeria’s Daily Trust exhorted readers as follows: “If only we can learn to clean our gutters, fumigate our drainage channels, evacuate our rubbish heaps and take other simple and sensible steps to eradicate or reduce the vector that causes malaria, we will not have cause to embark on the yearly ritual of lamenting about how we suffer so much from this public health challenge.”

While mosquitoes may breed in discarded cans and tires in rubbish heaps or in gutters in out cities, the likely culprits are Aedes species, which carry yellow and dengue fevers, and Culex species, which carry filariasis and a variety of viral diseases. Eliminating such breeding sites will certainly go a long way to promoting public health, but may not elimnate the breeding of the Anopheles species of mosquitoes that carry malaria.

For Anopheles mosquitoes the US Centers for Disease Control and Prevention states that, “The larvae occur in a wide range of habitats but most species prefer clean, unpolluted water. Larvae of Anopheles mosquitoes have been found in fresh- or salt-water marshes, mangrove swamps, rice fields, grassy ditches, the edges of streams and rivers, and small, temporary rain pools.”  In contrast a study from Cameroon identified the following breeding sites for Aedes, many of which could be found in a refuse heap.:

Used tire, Plastic container, Can and broken bottle, Plastic cup, 200-L barrel, Abandoned car part, Cement washtub, Flowerpot, Tree hole, Cow horn, Cocoa pod, Enameled plate and Snail shell

slide1.JPGThe Press is an important Advocate in the fight to eliminate malaria, but it’s role is only as good as it’s access to scientifically sound information, which these days can be obtained on internet sites like those of WHO, RBM and CDC, but just as easily – a phone call to a local expert in the Ministry of Health or a local University.

Advocacy Bill Brieger | 28 Apr 2008

Is the internet a tool to eliminate malaria?

If you are reading this now, you might answer yes. For those who cannot access this website, who live across the digital divide, the answer might be no. What is it that the internet can do to help control, eliminate and maybe even eradicate malaria? Information is one key internet service that can help people plan and advocate as the sample of sites below indicate.

  • To keep us up with latest news and scientific developments the RBM partnership sends out weekly news summaries and updates and occasional announcements for those on its e-mailing list
  • The Malaria Roundtable Group of the Global Health Council sends out regular updates on key program and legislative activities
  • Friends of Africa send out an e-newsletter on malaria control progress especially as related to Global Fund grants
  • Malaria World also sends out e-mail updates on malaria news and scientific publications (MalariaWorld,
  • Malaria Journal offers a service to sign on for notices of newly published articles

The internet is a place where people can donate. Reuters reports that, “Now 25 and a fourth-year political science student at Harvard University, Hadfield came up with the idea for after a trip to Zambia last summer that gave him a close-up look at the mosquito-born disease.” At this site one can review ongoing malaria research projects and donate to these. At Malaria no More one can actually donate toward ITN supplies for Africa, and learn about ‘your gifts in action’ as in Uganda. Nets for Life offer a similar service. Other sites abound these days.

In Europe the Malaria Consortium is ‘mobilizing for malaria.‘ The European Alliance against Malaria is also engaged in education and advocacy. Individual endemic countries have websites for their Global Fund Central Coordinating Mechanisms that give updates on programming, including malaria. Every time one looks, there is news coming out on malaria. One can even set up on Google and Yahoo special daily e-mail notices about topics of interest – that is where I get many timely malaria ideas for these blog entries.

Can the internet mobilize enough political will and financial resources to eliminate malaria? Maybe not in the immediate future. But it’s role and scope has grown greatly since the launch of the US President’s Malaria Initiative and continues to grow. Let’s all continue to contribute to the flow of information, advocacy and donations on the internet and hope that constant attention to the challenge of malaria will ultimately bring about a critical mass of civil society, government, private sector and NGO support to eliminate the disease.

(PS – the sites mentioned above are only a sample – let us know if you have other examples.)

Indoor Residual Spraying Bill Brieger | 27 Apr 2008

Pesticide safety – lessons from the green revolution

In light of the current world food crisis the BBC has re-examined the experiences of the Green Revolution. This high tech approach to increasing farm output appears on the surface to be a success in the Punjab of India. The BBC’s David Loyn reported on the experiences of one farmer: “Before Mr Singh’s father died young of cancer in 1992, none here suspected that the technology that had brought wealth to these farmlands in the 1970s might have a downside as well.”

Mr. Loyn looked more closely into the issue of the pesticides required by these crops. “The sprays all have instructions demanding that they should only be used with face masks and protective clothing. But the farm workers here do not use protective equipment, and they spray far more than the recommended amount. The cause of cancer is always a contentious issue, but a new study from the Punjabi University at Patiala ruled out other potential factors like age, alcohol intake and smoking, concluding that the way the sprays are used is causing cancer.”

Around a dozen insecticides are approved for use in Indoor Residual Spraying. WHO cautions that, “When implementing IRS, it is critical to ensure that adequate regulatory control is in place to prevent unauthorized and un-recommended use of public health pesticides.” Safety should be a major concern –

Another major consideration when selecting an insecticide is safety. Insecticides recommended by WHO are deemed safe for public health use under the recommended conditions of use. Concerns over the safety of DDT, a persistent organic pollutant, have also been comprehensively addressed in the framework of the Stockholm Convention on Persistent Organic Pollutants (POPs). The Convention bans the use of DDT, except for public health purposes. Therefore, DDT can be used for IRS where it is indicated, provided that stringent measures are taken to avoid its misuse and leakage outside public health.

lrg-102-img_1606_ethiopia_lowres-sm.jpgIn a comparison of the cost advantages of various insecticides that can be used for IRS, Walker (2000) emphasizes that safety measures must be included in the cost calculations. Even in the re-treatment of ITNs, WHO recommends that, “The use of rubber gloves is essential; mouth and nose masks should be worn when dipping large numbers of nets, especially with emulsifiable concentrate formulations.” The document also stresses that people who pack, mix and spray insecticides should also wear protective devices/clothing.

We hope that with proper care, supervision and protection of malaria workers, the community members they serve and the environment, we will see the history of today’s malaria control efforts written without the downside as experienced in the Green Revolution.

ITNs Bill Brieger | 26 Apr 2008

Taking stock after malaria day – net usage

The US President’s Malaria Initiative has certainly been able to work with partners, such as national malaria control agencies with GFATM grants, to boost coverage with major malaria interventions. A success story from Mali was posted on the PMI website for World Malaria Day as an example. The story reports –

itns-in-mali.jpgAccording to survey results announced by the Malian Ministry of Health, 88 percent of households in Mali and 80 percent of children received an LLIN during the campaign. Usage of LLINs by vulnerable groups is also high. Some 63 percent of households surveyed declared using LLINs the previous night. Some 51 percent of all under fives included in the survey were reported to have slept under an LLIN the previous night. This is a significant increase from 27 percent of children under five reported to have slept under a treated net from the 2006 DHS survey in Mali.

This is certainly a major logistical effort and bodes well for promises by the UN to achieve 100% coverage by 2010, but we are still concerned that owning a net does not always mean using it. Stories abound about ‘alternative’ net uses ranging from fishing to wedding gowns to keeping in a trunk as dowry. None of these protect people who need to be free of malaria.

As we have advocated, there needs to be a strong health education component using local/community people who speak in a language people understand and can be on the spot to encourage net use. Mass media may reinforce use, but the personal touch is needed to ensure use.

Advocacy &Indoor Residual Spraying &ITNs Bill Brieger | 25 Apr 2008

United Nations – ambitious plans for 2010

buttonwhite_fr.gifWorld Malaria Day is time for hope, and the United Nations Secretary-General, Ban Ki-moon, is not disappointing. The BBC reports that, “In a video message for a UN World Malaria Day event, the Secretary-General announces an initiative offering household sprays and bed nets treated with insecticide “to all people at risk, especially women and children in Africa” by the end of 2010.”

This is an almost unbelievable though desirable goal, much over the 80% RBM targets for 2010. The Secretary-General prefers to call this goal “bold, but achievable.” Even with help from GFATM, PMI, the World Bank Booster program, UNITAID and others, many countries are struggling to meet the 2005 target of 60% coverage of vulnerable populations with ITNs and medicines. The new UN malaria envoy, Ray Chambers has done the math –

  • 500 million additional people
  • 250 million additional ITNs/LLINs
  • less than 1,000 days to achieve this
  • “That’s four-to-five times what we’ve done in the past”

While this effort will push us toward eradication, Chambers is realistic in stating that the goal of complete elimination of the disease will depend on vaccine development, which is still some years away.

Reuters News also adds a note of realism by quoting a statement from the U.S. National Institutes of Health which said that malaria has proven to be “remarkably resilient, resurging because of the emergence of drug-resistant parasites and insecticide-resistant mosquitoes.” Reuters also mentions the unknowns created by global warming for consideration. These concerns add a sense of urgency that simple mentioning of 2010 may not confer.

Ironically, targeting these new malaria intervention and coverage goals comes on the heels of concern that African countries, where malaria is endemic, are unlikely to meet the Millennium Development Goals, which include malaria reduction. Clearly there are serious challenges in terms of finance and health systems issues to achieving universal overage in under 1,000 days – we hope all partners will heed this challenge on World Malaria Day and work together to meet it.

Funding &Treatment Bill Brieger | 24 Apr 2008

Continued cuts in cost of Coartem

The Swiss Pharmaceutical giant, Novartis, has announced further cuts in the price of its artemether-lumefantrine (AL) anti-malarial drug, Coartem®. According to AFP, ” The new price of 37 cents (0.23 euros) for children’s doses will start from Friday which is World Malaria Day.” This reflects a 20% reduction in price. This announcement not only comes two before World malaria Day, but two days after Novartis announced for the first quarter of 2008 that, “Net income up 10% to USD 2.3 billion.”

The Novartis press release goes on to say that Coartem is “the only fixed-dose ACT that has been approved by a stringent, internationally-recognized health authority.” This refers to WHO’s pre-qualification efforts to ensure safe and effective medicines for major donor program use. The current list does now include other artemisinin-based combination therapy products such as artesunate-amodiaquine (AA) and artesunate-mefloquine, but WHO still favors Coartem and assists countries apply for Coartem at cost.

Ghana for one has chosen AA as its first line antimalarial drug, and is in the process of updating its national malaria drug policy and guidelines to reflect this and possibly include AL and atovaquone-proguanil as second line choices for people who may react to amodiaquine. Generally though, most countries are in lockstep with Coartem. While Novartis is optimistic about its “ability to satisfy Coartem production requirements in 2008 or the future,” it also issued a disclaimer about future uncertainties. It is just such uncertainties that require countries to consider alternatives, as in Ghana.

Ultimately if in the future donors do not persist in providing funding for buying anti-malarial drugs at cost, there needs to other mechanisms to bring costs in line with what countries can afford. Greater commercial availability of different types of malaria drugs that also bear WHO’s seal of approval will hopefully also bring down prices across the board for all such products and make it easier for countries to buy their own medicines as needed.

Mortality &Nutrition Bill Brieger | 23 Apr 2008

World food crisis and malaria

The Washington Post reports today that “More than 100 million people are being driven deeper into poverty by a “silent tsunami” of sharply rising food prices, which have sparked riots around the world and threaten UN-backed feeding programs for 20 million children,” according to the director of the World Food Program (WFP). The article reports that the WFP is running out of funds and may cut back on school feeding programs.

The WFP Director explained that because of rapidly rising food prices, “Those living on less than $1 a day were giving up meat and vegetables, and those living on less than 50 cents were facing increasingly desperate hunger.” WFP food rations are depicted in the WFP ‘red cup’ photo seen below.

wfp154505sm.jpgWhat are the implications for malaria?

In Mozambique, Bassat et al. (2008) found that. “For children aged eight months to four years, the risk factors [for dying from with malaria] were malnutrition, hypoglycaemia, chest indrawing, inability to sit and a history of vomiting.” In Tanzania Sunguya et al. (Tanzania Health Research Bulletin, 2006) found that, “coinfections [such as malaria] complicate the management of severe malnutrition and are associated with higher death rate.”

A review by Schaible and Kaufmann (2007) linked malnutrition with impaired immunity. They state that, “Malnourished children suffer in greater proportion from respiratory infections, infectious diarrhea, measles, and malaria, characterized by a protracted course and exacerbated disease. These malnourished children present with diminished functional T cell counts, increased undifferentiated lymphocyte numbers, and depressed serum complement activity.”

Whether the current food crises results from the international economic meltdown, global warming or diversion of food crops to make biofuels, the potential impact on mortality from malaria is serious. There has never been a greater need to link nutrition, agriculture policy and food aid with malaria programming. Vertical funding will not solve the problem.

Environment Bill Brieger | 22 Apr 2008

Malaria thoughts on Earth Day

Malaria is a disease with strong links to the environment. Here are a few thoughts on malaria in observance of Earth Day.

  • Washing Long Lasting Insecticide-treated Nets infrequently will not only preserve their effectiveness longer but might save water
  • Integrating agriculture – e.g. coffee production – into existing forest ecology saves trees, whose clearing would have opened more mosquito breeding sites
  • Appropriate and safe use of insecticides during indoor residual spraying can prevent environmental contamination

smdscn2939.JPGPeople alter the environment in many ways that make mosquito breeding possible and in the process create other environmental problems. We may thereby make the environment less economically viable – as people lose income they are less able to afford malaria treatment and preventive interventions or buy or build housing that protects them from disease. We need to look beyond medicines and nets and think about the broader social, economic and environmental factors that contribute to the spread or control of malaria.

Please feel free to add your own ideas and help celebrate Earth Day.

ITNs Bill Brieger | 21 Apr 2008

Net ownership, not always net use

It is one thing to distribute insecticide treated nets in communities, whether for free, at subsidized rates or even at cost, but quite another for people to actually use them regularly. It is only net use that will help achieve drops in disease incidence as seen recently in Zanzibar and Kenya. The question is how do we ensure use. Experiences from Sierra Leone and Ghana offer two suggestions.

The Canadian Red Cross reported that, “worked with over 4,000 Sierra Leone Red Cross volunteers who helped distribute more than 875,000 nets directly to families.” What is even more important is that one year later, “over 97 per cent of families in Sierra Leone still have their nets hung up and nearly 80 per cent of children aged five and younger from these families sleep under the nets. As well, net use increases by 23 per cent after a follow-up visit by a volunteer to teach families how to hang and properly use nets.” The Red Cross example shows the importance of follow-up reinforcement by community volunteers.
sleeping-under-nets.jpgExperiences from Ghana also have a positive tone about net use, although actual coverage with ITNs is still below target. The Ghana Health Service‘s Roll Back Malaria offers another lesson. The program has been conducting annual surveys since 2005, and these, as seen to the left, offer important information that when households have nets, they are for the most part being used by the intended groups. As seen here, without regular monitoring data, we will not know if people are actually using the nets.

Hopefully these experiences will encourage all countries to plan and donors to support and encourage programs that not only educate the public to use their ITNs, but also establish a good monitoring and evaluation system that will track net use and provide timely feedback to improve program performance.

Eradication Bill Brieger | 20 Apr 2008

Uzbekistan – a lesson for eradication

Uzbekistan describes the resurgence of malaria after successful elimination in its malaria proposal for Round 4 of the Global Fund to Fight AIDS, TB and Malaria. Below is a short description of the problem extracted from that proposal.

As the outcome of a large-scale malaria eradication campaign that started in the end-1940s, falciparum malaria was eradicated by 1951, whereas the local transmission of P. vivax continued. It was interrupted throughout the country by 1961, like in most other areas of Central Asia. Since then, small outbreaks of vivax malaria occurred from time to time following importation, mostly from Afghanistan. The situation changed dramatically in 1994 when a large-scale epidemic in Tajikistan developed. Following the course of this epidemic that started in the south Tajikistan, importation increased first into the Surkhan Darya Viloyat where a low-level local transmission established in 1999. After the epidemic moved to North Tajikistan and consequently to South Kyrgyzstan, the neighbouring areas of Uzbekistan became vulnerable. It needs to be emphasised that all the above areas of Tajikistan, Kyrgyzstan, and Uzbekistan belong to the same eco-geographic entity, namely the physiographic province of Ferghana. Receptivity of most of the areas now threatened by malaria remains probably as high as before the eradication, particularly due to the restoration of the populations of the most efficient malaria vector, Anopheles superpictus, that were at a very low level in the 1960-1980s.

imageashx.jpgSeverini et al. (2004) also reported that although malaria was eliminated in 1961, “Due to resurgence of the disease in neighbouring states and massive population migration, there has been an increase of P. vivax malaria, imported from Tajikistan, resulting in a number of indigenous cases being identified in areas bordering that country.” CDC also reports “Sporadic cases reported in Uzunskiy, Sariassiskiy, and Shurchinskiy districts (Surkhanda-Rinskaya Region).”

One must remember that the word ‘eradication’ only applies to a situation where a disease is no longer being transmitted anywhere in the world. We can ‘eliminate’ malaria from specific countries or locations, but as has been experienced in Uzbekistan, elimination does not always guard against future transmission. Full application of available tools and development of new tools will be needed before we can use the words ‘malaria eradication’ in good faith.

[We would like to thank the Head of Uzbekistan’s State Sanitary-Epidemiological Surveillance Department who visited Jhpiego recently in a World Trade Center Institute sponsored delegation for stimulating our interest in this topic.]

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