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Monthly Archive for "May 2008"

Malaria in Pregnancy Bill Brieger | 31 May 2008

Malaria in Pregnancy Weblinks

Malaria in Pregnancy is sometimes called the forgotten component of malaria control, and yet malaria puts the mother, fetus and newborn at risk of death. Here collected in one place are a number of weblinks to sites providing factsheets and details about MIP.

MIP Weblinks

WHO Global Malaria Programme – MIP

Jhpiego – What We Do – Malaria Prevention and Treatment

Jhpiego – Malaria during Pregnancy Resource Package

MiP (Research) Consortium

Roll Back Malaria – Malaria in Pregnancy Working Group

President’s Malaria Initiative: Prevention of Malaria in Pregnant Women

The Malaria in Pregnancy Library

Malaria Journal – BioMed Central

Malaria during Pregnancy – US Centers for Disease Control and Prevention

The Malaria Site – Pregnancy and Malaria

Malaria Matters – Malaria Free Future – MIP Category

USAID – Infectious Diseases – Malaria in Pregnancy

Burden Bill Brieger | 28 May 2008

High Burden – High Challenge

This Day Newspaper reported in May 2007 that, “Unfortunately, Nigeria, according to the World Bank, carries Africa’s greatest malaria burden with 110 million cases per year out of her 140 million people. Malaria accounts for 30 per cent of infant mortality in Nigeria. According to Professor Eyitayo Lambo, Nigeria’s Health Minister and chairman of RBM, malaria costs the country an estimated US$1 billion a year.”

Likewise WHO observed that, “Malaria is the most significant public health problem in Nigeria. It accounts for 25% of under-5 mortality and 30% childhood mortality and 11% maternal mortality. At least 50% of the population will have at least one episode of malaria annually while children that are aged below 5 years (about 24 million) will have 2 to 4 attacks of malaria annually. The economic cost of malaria, arising from cost of treatment, loss of productivity and earning due to days lost from illness, may be as high as 1.3% of economic growth per annum. The disease is a major cause of poor child development.”

Nigeria has been in the forefront of the RBM partnership and hosted the 2000 Abuja Summit that launched the partnership in Africa. Nigeria is also important because as noted above, with the largest population of any single African country, Nigeria bears the greatest burden of malaria. Without progress in Nigeria, there will be little overall progress in the fight against malaria in Africa. Therefore, how far have we progressed in reducing the malaria burden in Nigeria? Unfortunately the Malaria Consortium reports that. “Previous efforts to control malaria in Nigeria have not led to a sustained reduction in the burden of mortality and morbidity.”

nigeria-malaria-indicators-2007.jpgNigeria has kept up with national strategies and planning, but 10 years after RBM was launched and 8 years after the Abuja Summit, the coverage indicators for malaria interventions remain extremely low as seen in the attached chart (UNICEF). Obviously there will be regional and state variations, but even with input from among others, GFATM, USAID, DfID, UNICEF, the World Bank and of course the oil rich national government, the overall picture is bleak. Public statements announcing the imminent demise of malaria in Nigeria had to be withdrawn, yet Nigeria still hopes to reach the 2010 RBM targets.

What can be done? Nigeria was on the verge of losing its Global Fund malaria grants in 2006. Quick work to address management and health systems bottlenecks around procurement and supply, monitoring and evaluation and coordination among the three levels of government (federal, state and local) helped save the grants, but these problems obviously have not been banished completely.

When RBM started in 1998 the founders said that malaria could never be rolled back unless these efforts were carried out in the context of health system reform and strengthening. Nigeria may be the most obvious case study for the importance of health systems. Donors who focus only on outcome statistics are missing the point – outcome cannot be achieved, let alone sustained, where systems are weak.

Mortality &Peace/Conflict Bill Brieger | 26 May 2008

War and Malaria

Today Memorial Day is being observed in the USA where the services of troops past and present are being remembered. Being in war exposes troops to more dangers than bullets and bombs. In fact war can increase malaria, among both troops and civilians through three main processes.

  1. movement of people – troops and displaced persons – into malaria endemic areas
  2. changes in local ecology that facilitate mosquito breeding and make malaria more prevalent
  3. disruptions of health infrastructure that limits or stops malaria control services

The effect of malaria on US troops exemplifies the problem. Records were available for Union troops during the US Civil War and documented 1.3 million cases and 10,000 deaths. presents war related malaria deaths dating back to Alexander the Great, but more recently notes that “60,000 U.S. troops died in Africa and the South Pacific from malaria. U.S. Forces could succeed only after organising a successful attack on malaria.” During the Korean War “U.S. military hospitals were inundated with cases of malaria, with as many as 629 cases per week,” and in Vietnam “over 40,000 cases of Malaria were reported in US Army troops alone between 1965 and 1970 with 78 deaths.”

The Stars and Stripes news service reports the continuing threat of malaria to troops. Troops are still in South Korea, and South Korea’s own Center for Disease Control issued a malaria alert for northern Gyeonggi province where they are based. Several malaria cases have been documented according to a 15th September 2007 story, which also explained that, “None were provided with repellent-treated uniforms or mosquito nets, nor had he seen anyone issued military-grade skin lotion to protect themselves in an area known for malaria-carrying mosquitoes.” Another article titled “Afghan hazards include malaria as well as bombs,” shows the global reach of malaria when troops are spread across the world.

It is not surprising that the US Military has one of the most prominent malaria research centers in the Walter Reed Army Institute of Research. WRAIR is not modest in saying, “No organization in the world has WRAIR’s experience in the complete spectrum of malaria research. The rapidity with which malaria becomes resistant to new drugs drives researchers’ efforts to develop candidate drugs and vaccines. WRAIR has been extremely successful in developing and field testing antimalarial drugs, such as mefloquine, halofantrine, and tafenoquine, which provide treatment alternatives for drug-resistant strains. Scientists at one of the Institute’s overseas research facilities demonstrated the efficacy of doxycycline in the prevention of malaria.”

The fact that army research into malaria has civilian benefits does not justify war since war itself is a major perpetrator of the disease. To quote Randall Packard, “Developing nations also need to take a more active role in both preventing and limiting armed conflicts that disrupt economies, destroy health services, and contribute to the loss and displacement of millions of lives. The human tragedies of civil wars in Darfur, Rwanda, Cambodia, Tajikistan, and Colombia – to name a few – have all been made worse by the unleashing of malaria epidemics.”

Corruption &Development &Funding Bill Brieger | 24 May 2008

Malaria – following the money

Two global financial issues appeared online today – accounting for Global Fund grants and reduced IMF loans. What do they mean for malaria control?

Three years ago Global Fund grants in Uganda were suspended basically because money was stolen. After highly visible firings of top officials and efforts to audit the program and improve accounting, the grants were allowed to continue and new grants have been awarded. A recent visit by a Global Fund official reported in the Monitor reminded the Ugandans that the US$ 1.6 million still missing has not been returned.

After sacking of 3 top officials and transferring another, some funds were returned, but no further action has been taken. 24 priority cases are yet to be prosecuted, but 373 cases should be investigated according to the Monitor. In short, the people who perpetrated the theft and mismanagement are still at large and presumably still involved in the management of the Global Fund-supported programs. The excuse is financial – no funds to investigate the cases! Will this unresolved problem jeopardize Uganda’s international malaria funding again?

ghana-nmcp.jpgWhile many countries are expanding their malaria efforts using external funding, the question arises concerning long term ability of countries to maintain programs. Overall IMF loans have dropped from US$ 117 billion in 2003 to only US$ 16 billion in 2007. The Washington Post article identified malaria endemic countries like Ghana that “had joined a long list of developing countries in Africa and beyond enjoying record periods of growth, with the robust economy leaving it no longer in need of more IMF cash.” Ghana is even issuing its own bonds to improve infrastructure. Specifically the Post says that, “The economy here turned as hot as the local pepper soup earlier in the decade, with soaring global demand for the nation’s riches — gold, cocoa and bauxite — sparking a rush to modernize Ghana’s decaying roads, rails and power grid.”

Whether Ghana will also turn some of its profits to disease control now or in the future remains to be seen, but these experiences point out the importance of promoting equitable global trade as a long term solution to helping countries fund their disease control efforts and wean countries from foreign assistance that appears too sweet and easy for some government officials to avoid tasting.

Agriculture &Indoor Residual Spraying Bill Brieger | 23 May 2008

IRS vs Organic Farmers in Uganda

Nine companies engaged in organic farming in Lango sub-region’s districts of Oyam, Apac and Lira are suing the government of Uganda over the use of DDT for indoor residual spraying according to the Monitor. The Monitor reports the case as filed states that, “The decision by the government to introduce DDT in the districts is illegal as it contravenes the provisions of the Stockholm Convention on persistent organic pollutants of 2001.” WHO does clarify that the Convention says DDT can be used for public health purposes, but the question is, who defines the public’s health?

The farmers have logical fear that if DDT spraying inside houses is not done with proper precautions, their crops and livelihoods as organic farmers could be imperiled. Those pressing the suit claim that the agency contracted to do the work is in fact not following precautions and thus opening the potential to contaminate their crops. Let’s look at what is at stake.

In an overview of organic farming in Uganda, the International Trade Center explains that, “Uganda has the most developed sector of certified organic production in Africa. About 33,900 farmers manage 122,000 hectares of land using organic methods, an area that accounts for 1% of Uganda’s arable land (IFOAM & FiBL, 2006). Although still small and far below the increasing global demand, the country’s export of organic agricultural produce has been growing substantially in recent years. In Uganda, which has one of the lowest agro-chemical usages in Africa, the majority of farmers practice de facto organic agriculture without being certified yet (ACODE, 2006). Since no significant domestic market exists, certified organic agriculture targets mainly export markets in Europe and North America.”

In fact, the Monitor reported in 2007 that, “Organic farming has become a means of generating income for farmers and consequently fighting poverty.” Furthermore, “On the world market, Uganda’s export share of organic products has increased considerably and is the highest in Africa. The coordinator of Nogamu, Mr Moses Muwanga says 38 percent of organic agricultural production in Africa is from Uganda, with over 50,000 certified organic farmers. This makes Uganda one of the countries with the highest comparative advantage for organic production in Africa.” takes us to an organic farm in Tororo District and with pictures and text concludes that a Tororo farmer could, “teach farmers in Europe or America a thing or two. His type of farming — sustainable and organic — produces lots of food and lots of varieties of food. And it doesn’t need huge tractors, diesel fuel, artificial fertilisers and chemical poisons. As I said earlier, nothing is wasted.”


The Kulika Charitable Trust Uganda “has set up a sh800 million agricultural training institute at Lutisi, 37km on the Kampala-Hoima highway,” ( In short, there have been major investments in capacity building for organic farming in Uganda. “The core of Kulika’s Community Development Programme is training of farmers in sustainable organic agriculture which focuses on experiential learning, practical work, on-farm experimentation and demonstrations to improve the skills of farmers (see photo from Kulika).”

The economic issue here may be confusing – a chicken and egg debate. Does malaria control promote economic development or does economic development strengthen societies to control malaria. Assuming it is the latter scenario, we need to think twice about interventions that will affect the livelihoods of thousands of Ugandan farmers, specially when alternative control measures are available.

WHO recognizes 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 in agriculture, and thus contamination of agricultural products. Pesticide contamination can have serious ramifications for trade and commerce for countries exporting agricultural products.” The organic farmers in Uganda question whether adequate control is possible.

IPTi Bill Brieger | 15 May 2008

IPTi still in limbo, doubts remain

Even after several years of intensive, multi-site research on intermittent preventive treatment for infants (IPTi) with sulfadoxine-pryimethamine (SP) we still seem no closer to making IPTi a public health intervention to strengthen our malaria control arsenal. In 2006 WHO’s Global Malaria Program indicated that, “Intermittent preventive treatment in infants (IPTi) is a new promising strategy under WHO evaluation.” Two years later, this evaluation period appears to continue.

img_3667_lowsm.jpgCochrane Reviews has published this month an update on IPT and chemoprophylaxis. The authors conclude that the “long-term deleterious effects, including the possibility that it may interfere with the development of children’s immunity to malaria, are unknown for either regimen. Further trials with long-term follow up are needed.” Interestingly they do quote one study from 2005 that reported: “Intermittent treatment produced a sustained reduction in the risk of clinical malaria extending well beyond the duration of the pharmacological effects of the drugs, excluding a so-called rebound effect and suggesting that such treatment could facilitate development of immunity against Plasmodium falciparum.”

More recently these researchers addressed interventions including IPTi and found evidence, “… that each of these measures may permit attenuated P. falciparum blood-stage infections, which do not cause clinical malaria but can act as an effective blood-stage ‘vaccine’.” This paints a more positive picture than the Cochrane review, though the need for more research looking specifically at immunity would be valuable.

IPT is what the name says – intermittent. It would be given possibly three times a year coinciding with immunization contacts. There would therefore still be opportunities for ‘attenuated infections’ as mentioned above that could actually boost immunity.

It is time that decisions are made concerning IPTi. If more research is needed, malaria partners need to say so and fund it now. If more study is not needed, it is time to roll out another life saving malaria control intervention.

Drug Quality Bill Brieger | 07 May 2008

Can the commercial private sector be brought on board?

Whether through formal or informal channels, many people in Africa get their malaria drugs from the commercial sector comprised of private clinics, retail pharmacies, the ubiquitous drug shops or even hawkers in the market. A few years ago, The Lancet reported that drug quality is often compromised simply by the conditions under which these medicines are kept. Now a study in PLoS One revisits the quality issue from two points of view – the actual content of the tablets and the appropriateness of medicines in stock.

The Lancet article (Taylor et al., 2001) reported that in Nigeria shops, “279 (48%) samples did not comply with set pharmacopoeial limits, and this proportion was uniform for the various types of drugs tested. Although some preparations contained no active ingredient, most had amounts just outside the pharmacopoeial limits. We identified samples with both too much and too little active drug content.”

The new study by Bate and colleagues tested “195 different packs of malaria drugs sold in six African cities (and) showed 35 per cent of them either did not contain high enough levels of active ingredient or did not dissolve properly.” World News Australia quoted Dr Bate who explained that, “”Our study shows that efforts to increase access to quality antimalarial drugs in Africa are increasingly important. Substandard drugs not only endanger lives today, but also jeopardise future malaria treatment strategies by accelerating parasite resistance.”

Concerning the specific medicines located and tested, Bate and colleagues found that, “38% of SP, 48% of amodiaquine, 24% of mefloquine, 31% of artesunate, 27% of artemether, 55% of dihydroartemisinin and 19% of artemether- lumefantrine fixed-dose combinations” failed testing by thin-layer chromatography (TLC), dissolution or both.

The actual availability for sale of certain drugs was also cause for concern. WHO has actively recommended against use of monotherapy artemisinin-based drugs to avoid the dangers of promoting resistance to this lifeline of malaria treatment. Specifically, WHO observes that 10 endemic countries never registered monotherapies, 13 have taken regulatory measures against artemisinin montherapy, while another 13 have stated their intentions to do so. Nigeria, one of the largest markets for malaria drugs, is not on this list.

Nigeria appears to be taking a passive approach to artemisinin monotherapies – letting the registration of those already approved lapse. Visits to medicine shops from Abuja to Uyo confirm that this policy does not result in the quick removal of the medicines. Since artemisinin drugs have a shelf life of less than two years, another passive approach would have been to simply disallow further import and let existing stocks run out, but the approach based on lapsing registration allows continued imports.

sp-and-monotherapy.jpgAnother concern about the drugs found in Bate’s study and in visits to Nigerian shops is the continued presence of sulfadoxine- pyrimethamine (SP) for sale as a treatment drug. Since SP is currently the only drug approved for IPTp and since SP continues to experience growing resistance in children, the wise decision in theory has been to withdraw SP from the market and from treatment generally and reserve it only for IPTp in antenatal care clinics.

Promulgations and policies either by global organizations or national bodies do little to help control malaria if there is no functional regulatory enforcement in place. We will quickly lose more malaria control tools – pushing the hope for eradication even farther into the future.

Health Systems &Peace/Conflict Bill Brieger | 06 May 2008

CDC and KEMRI take stock after Kenya violence

Even if adequate stocks of ITNs/LLINs were available for ALL people in malaria endemic communities, as the UN hopes … Even if there were supplies of ACTs to treat ALL people who suffer from malaria … even when effective vaccines become available … if human beings themselves continue to disrupt countries and health services (what the New York Times has termed “self-inflicted wounds”) – within and across borders – malaria will not be eradicated.

In a letter to the editor of the American Journal of Tropical Medicine and Hygiene colleagues from the US Centers for Disease Control and Prevention (CDC) and the Kenya Medical Research Institute (KEMRI) take stock of the health care situation as Kenya tries to return to normal after months of violence sparked by the national elections in December.

“It is possible that the health impact of Kenyas chaos could ’ linger well beyond a political rapprochement. We may see increases in mental illness, substance abuse, and unemployment in response to the violence, which may lead to new public health challenges for the country. Disruptions in food supply, immunizations, medications, and health services could affect people’s health for months, and perhaps years, to come. For example, the national malaria control program, which had made notable progress over the past 5 years, now faces the challenge of delivering life-saving antimalarial drugs and long-lasting insecticide-treated bednets in a country where the roads are far less secure. Gains in HIV care and prevention may also have been compromised. An undisrupted supply of drugs and reliable access to clinical care are essential for the health of the 180,000 HIV-infected people receiving antiretroviral therapy. The influx of tens of thousands of internally displaced people to areas of the country already struggling with ongoing public health challenges, such as malaria and HIV, could place an unsustainable weight of health needs on an already fragile public health infrastructure. In addition, future research collaborations and their associated gains in capacity building for the country could be limited by reluctance of research partners to locate projects in Kenya.”

The New York Times today also reports on the post-election situation and efforts to begin national and community healing in Kenya. The Kenyan government, facing an economic and food crisis arising from the conflict, is encouraging people to return to their farms, even in ethnically conflicted areas, with promises of food, tool, new houses and cash. “To make its plan work, the government has said, there must be genuine ethnic reconciliation,” which is the real challenge. Political jockeying and an over-bloated cabinet do not help, according to the NY Times.

As CDC/KEMRI staff remind us, 30 years of collaboration for improving the health of Kenyans can be nearly destroyed in a few days. Clearly conflict prevention and resolution need to be considered among the key strategies for eliminating malaria from the world.

Epidemiology &Resistance Bill Brieger | 05 May 2008

Malaria warnings from the east

Two news items require greater world-wide attention if current malaria control tools are to remain effective. asks the question, is “Monkey malaria the next bird flu?” The article reports that Dr. McCutchen, “An expert at the NIH, has highlighted the threat of an emergent highly virulent form of malaria, questioning whether the disease has made the jump from animal to man.”

macaque-4509sm.jpgThe news story further states that, “Although at least ten species of Plasmodium can infect humans, only four forms of specifically human malaria are believed to exist. In the case of these four established human malaria types, the parasite is transmissible from one human to another, and a stable transmission cycle is established in the absence of any other vertebrate host. Now Dr McCutchan has raised the question – has a monkey malaria made that switch and become the fifth human malaria?” The full article appears in Future Microbiology and focuses on Borneo.

Dr McCutchan explained that interest was generated because of the severity of the infections and that, “The study of P. knowlesi is extremely significant regardless of whether it has entered humans permanently or represents a zoonosis. In either case, we face a health problem of potentially widespread significance and one that will present new problems for malaria control.”

Two other recent studies have documented the transmission of Plasmodium knowlesi to humans in the Philippines and Singapore. Research by Luchavez et al. (2008) extends the geographic range of known human P. knowlesi infections from Thailand, Myanmar, peninsular Malaysia, and Malaysian Borneo to Palawan Island in the Philippines. Their “report documents autochthonous human cases in the country. Major progress in malaria control has been achieved in many malarious areas in the Philippines. However, P. knowlesi forms a previously unrecognized pool of infections that may be maintained in forested areas through its presence in a simian reservoir, despite control efforts in the human population.”

Ng et al. (2008) in the Singapore example note that the case was originally misdiagnosed as Dengue, which is endemic in the region. They were fortunate that the infection responded to chloroquine.

Finally, another malaria control challenge was reported by Wongsrichanalai and Meshnick (2008) in the form of growing resistance to artesunate-mefloquine on the Cambodia-Thailand border. They suggest that, “These ACT failures might be caused by high-level mefl oquine resistance because mefloquine was used for monotherapy long before the introduction of ACT. This observation raises 2 questions. First, how can existing P. falciparum–resistant strains be controlled? Second, how can the evolution of new ACT- resistant strains be avoided elsewhere, e.g., in Africa?”

Not only does malaria not respect political borders, but now it seems, not even the ‘borders’ between species.

Advocacy &Partnership Bill Brieger | 03 May 2008

Malaria Border Patrol

As with any annual observance, concern expressed on just one day a year will not solve a problem. Here are two recent updates on cross-border malaria issues in keeping with this year’s World Malaria Day theme.

Even frosty relations across borders do not stop malaria, and so according to the Associated Press, “South Korea plans to donate more than US$1 million worth of anti-malaria supplies to North Korea. The Unification Ministry said Friday the donation will be made through the World Health Organization to buy medicine and diagnosis equipment. Yonhap news agency said North Korea’s malaria cases declined to about 7,500 last year from some 300,000 in 2001. The donation comes amid a freeze in the two Koreas’ relations.”

For South Korea, this is not just a philanthropic gesture. reports that, “Soldiers guarding the border were previously the main victims but now an equal number of civilians are being infected, said Seoul National University team leader Chae Jong-Il, a parasitology professor.” AFP also observed that a “Seoul research team warned this week that the mosquito-borne disease is spreading from North Korea and beginning to take root in South Korea.”

zambezi.jpgAnother cross border venture is the Zambezi River of Life Expedition. After passing through Angola, Botswana, Namibia and Zambia, the torch of the expedition is being passed to Zimbabwe. The Herald (Harare) reports that, “ZIMBABWE has taken over from Zambia the Sadc roll back malaria campaign programme code named the Zambezi River of Life Expedition aimed at intensifying the fight against the disease.”

The Zambezi Expedition is not only raising awareness but encouraging action. A Zimbabwean Ministry of Health official was quoted saying that, “Sixty percent of our population use nets and we want to reach the 100 percent mark. There is also need for community participation to complement efforts from the Government and stakeholders in this fight against malaria.”

These are practical examples of cross-border cooperation needed to eliminate malaria. Readers are encouraged to share other examples.

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