Posts or Comments 20 July 2024

Monthly Archive for "June 2009"

Agriculture &Environment Bill Brieger | 26 Jun 2009

Deforestation, Agriculture and Malaria

While there have been some doubts that climate change will cause more malaria, there is little doubt expressed that deforestation is one of the major contributors to the malaria problem.  Actually a link is found between deforestation and malaria.

Yasuoka and Levins looked at anophelene ecology changes in relation to deforestation. They learned that, “Although niche width of anopheline species was not associated with density changes, sun preference was significantly associated with an increase in density. This study suggests the possibility of predicting potential impacts of future deforestation on vector density by using information on types of planned agricultural development and the ecology of local anopheline species.”

dscn4558sm.JPGTheir review of reports from across the malaria-endemic parts of the would found that although the mechanisms that link malaria and deforestation are complex, there were clearly examples of direct effects on some anopheline species either because of habitat changes or because of land use changes, particularly agriculture.

Vittor and colleagues have recently examined deforestation and malaria in the Peruvian Amazon.  Their study concluded that, “Multivariate analysis identified seasonality, algae, water body size, presence of human populations, and the amount of forest and secondary growth as significant determinants of A. darlingi presence. We conclude that deforestation and associated ecologic alterations are conducive to A. darlingi larval presence, and thereby increase malaria risk.”

Ultimately the elimination of malaria will require our links with broader development and environment partners.

Community &Vaccine Bill Brieger | 19 Jun 2009

Malaria immunization involves more than an effective vaccine

On Wednesday the Globe and Mail reported on efforts of a malaria vaccine trial in the Kenyan coastal district of Kilifi.  The researchers are happy that the “vaccine reduced the risk of clinical episodes of malaria by 53 per cent over an eight-month period.”  According to GSK, “large-scale phase lll vaccine efficacy trials in seven African countries across 11 sites. If these trials confirm the safety and efficacy of the candidate vaccine, it could be filed for registration.”

The villagers in Kilifi may have other concerns. Zoe Alsop in the Globe and Mail outlines several of these:

  • the Caduseus medical symbol on project vehicles contains a snake, but this is a ‘demonic symbol’ to the villagers
  • as a research project, blood samples are taken, but villagers fear this is ‘a lot’ and may be used for evil purposes
  • villagers are generally skeptical because of “a long history of neglect and corruption in Kenya’s public health-care sector and government in general”
  • people do not fully understand the nature of research trials and believe the vaccine is already approved

dsc00765-sm2.JPGThe researchers are facing the practical problems of any drug trial in communities that do not have good experiences with or full understandings of the workings of western science.  ‘Meticulous explanations‘ may not be enough to overcome fears, and trust can be shattered when a person in a control group gets sick from the drug that was supposed to prevent or heal. The process of signing formal consent documents itself may cause suspicion.

Vaccine programs over the years have faced their own hurdles, even when the offered on a regular basis.  One only has to witness the enormous challenges that the polio vaccine effort confronted in the face of widespread community resistance in Nigeria.  Ordinary occurrences such as side effects like fever or redness/pain at the immunization site discourage people.

Then there are the unethical research practices like Pfizer’s testing of a meningitis antibiotic in Kano, Nigeria that result in death and widespread fears of any future effort to help people.

The malaria vaccine researchers have conducted the perfunctory meetings with village chiefs and village information sessions.  It is not clear if the team involved social scientists in advance to learn more about people’s views and experiences of malaria and vaccines and engage the community in full dialogue about these issues.  It is not too late, but a word to the wise for any health research or intervention program: learn from the people first before you can expect them to learn something new from you.  These villagers have lived in the community for generations and will be left behind when your program finished – show them some respect, and your own efforts will be rewarded.

Mosquitoes Bill Brieger | 16 Jun 2009

When spraying may not hit malaria

The Ghanaian Chronicle has reported on a good example of public-private partnership, in this case between the Ministry of Health and a Waste Management fiim. “ZOOMLION Ghana Limited, the country’s waste management experts, in collaboration with the Ministry of Health, has begun a mass mosquito spraying exercise in the Western Region, which would cover all the 17 districts.”

The question arises as to whether this will really have any effect on malaria.  According to an official from the company, “This is part of a nationwide routine spraying exercise, which targets public toilets, urinal sites, container sites, refuse evacuated sites, drains and ditches, stagnant water, market places and finally, disposal sites, which we intend to spray to be able to control diseases and vectors.”

The sites listed above may serve as breeding grounds for Culex, Aedes and Anopheles mosquitoes – and in fact the operation is dubbed the “Nationwide Mosquito Control Programme (NAMCOP).”  Anopheles like clean, usually sunlit and stagnant (i.e. not moving) sources of water for breeding, and this being the rainy season, such places may be found among those listed.

dscn2552a.JPGSince the program is aimed at larviciding, it will is challenged in the case of anopheles by the multitude of tiny water puddles over wide expanses of territory.  These may not even be stable with the heavy rains being experienced now. It is unlikely in 33 days during this season that all mosquito breeding in the region will come to a halt. The article notes the valuable employment opportunities offered by the exercise as jobs will be available on the 420 spray teams, but these teams might be better employed distributing insecticide treated bednets throughout the region to guarantee universal coverage.

In the long term there are important lessons to learn from Aedes control in Latin America. Communies have played a major role in reducing the breeding of Aedes aegypti mosquitoes and dengue fever in Cuba, Argentina and Honduras, for example. Communities can maintain efforts over time, which is needed for sustained vector control.

While there are more resources for malaria control today than ever, they are not enough to achive elimination.  We should focus our efforts for now on the few key interventions that are known to work.

Health Systems Bill Brieger | 15 Jun 2009

Sick Systems – can we achieve RBM and MDG Goals?

The Magazine of the East African has featured a story on “Ailing Reforms,” after reviewing an evaluation of World Bank Efforts to improve health, nutrition and population (HNP) programs. “According to the watchdog, Independent Evaluation Group, while two-thirds of the Bank’s health projects between 1997 and 2007 achieved their development objectives, one-third, mostly in Africa, did not. ‘Overly complicated project designs and weak government capacity contributed to low outcomes,’ Martha Ainsworth, lead author of the report, told the media.”One example of reform, user fees to aid in cost recovery, were found not to have the desired effect.  We have seen this with Antenatal Care in Nigeria’s southeastern Akwa Ibom State where card fees at local government clinics have resulted in less than 20% of pregnant women seeking care, and consequently services to prevent malaria in pregnancy, at these facilities, despite the good compliment of well trained staff.

According to the Evaluation Group, “Contributing factors have been the increasing complexity of HNP operations, particularly in Africa but also in health-reform support to middle-income countries; inadequate risk assessment and mitigation; and weak monitoring and evaluation.” In particular, “Accountability of projects for delivering health results to the poor has been weak.”

The Evaluation Group’s report also offers an important lesson in health system capacity. “In an environment of scarce human resource capacity within the health system, care must be taken to balance the allocation of resources across health programs and budget lines, to ensure that large earmarked funds for specific diseases do not result in lower efficiencies or reduced care elsewhere in the health system.”

Two health systems experts with WHO, Kirigia and Barry, offer further insight into the challenges. They offer the following conclusions:

Effective public health interventions are available to curb the heavy disease burden in Africa. Unfortunately, health systems are too weak to efficiently and equitably deliver those interventions to people who need them, when and where needed. Fortunately, the health policy-makers know what actions ought to be implemented to strengthen health systems. However, it might not be possible to adequately implement those actions without a concerted and coordinated fight against corruption, sustained domestic and external investment in social sectors (e.g. health, education, water, sanitation), and enabling macroeconomic and political (i.e. internally secure) environment.

Kirigia and colleagues also shed light on why user fees may not work in their study of health financing in the African Region. They reported in the East African Medical Journal (2006 Sep; 83(9 Suppl): S1-28) that, “direct out-of-pocket expenditures constituted over 50% of the private health expenditure in 38 countries.” No wonder people don’t want to pay more in user fees!

One of the key reasons malaria eradication failed in the 1950s and ’60s was weak health systems that could not cope with the demands of sustained spraying operations.  Lack of financial, human resource, and political commitments to health systems can doom disease control efforts. Fifty years later, even though we have more malaria control options, we are again confronted with health systems challenges. Donors that don’t address and fund systems issues together with disease control priorities are only asking history to repeat itself.

Agriculture &Resistance Bill Brieger | 08 Jun 2009

Artemisinin – production, resistance, change

The fate of artemisinin in malaria control may be affected from the plant source to the parasites in humans according to two recent web postings.  Some challenges may result from people willing to change quickly, while others may be slow to react.

Sociolingo Africa has provided an update on artemisinin production in Uganda.  The situation of decreasing prices amid increasing demand was seen as puzzling.  The farmers who had begun cash crop production of artemisinin were now seeing ‘leaves rotting in the fields’ and were being encouraged to grow “Davana; Chillies; Fennel; Jasmine Rose; Ginger; Vettiver; Basil; and many more others, most of which are used in the production of essential oils and perfumes” by the Indian companies that were in fact guiding the Ugandan production of artemisinin.

It is possible, considering any commodity market, that diversification is a wise move on the part of the company.  Clearly there are efforts afoot (e.g. AMFm, Clinton Foundation) to reduce to cost that consumers pay in order to make the artemisinin-based combination therapy (ACT) drugs available thus, creating possibly more downward pressure on pricing.

In the early days of ACT promotion prices of the drug were said to be high because of the uncertainties in the procurement processes of endemic countries.  International mechanisms by organizations such as the Global Fund and WHO to coordinate this process while also increasing the supply to reach coverage targets also mean that production could confidently increase while prices of the final product could reduce.

So back to Uganda – there is likely now greater competition among producers of artemisinin in many countries – including the Ugandan farmers – in line with increasing demand projections. These farmers changed in reponse to the companies’ projections. At least in this case if substitute crops are provided, they may not suffer too much, but the fate of such farmers in other endemic countries such as Kenya where artemisinin farming has been introduced may not be so clear.

On the other side of the continent there are worries about parasite resistance to artemisinin.  In Nigeria ASNS News notes that, “Dr. Paul Orhi, Director General of NAFDAC (National Agency for Food and Drug Administration and Control), is quoted in the local press that the main reason for (growing emergence of resistance) was because people were not taking proper doses and that they still use monotherapy instead of combining two drugs appropriately.”

While it may take time for the resistance to spread from Southeast Asia where it has recently been documented, the Nigerian concern is real.  The irony is that there does not need to be worry about monotherapy if NAFDAC were to be bold and withdraw the registration of the numerous artesunate monotherapies currently on the market in Nigeria.

The current policy of NAFDAC is to allow those monotherapy drugs already registered to stay on the market until their registrations expire – some as late as 2012.  If NAFDAC were bold enough to change now and withdraw those registrations, its Director General would have less to worry about.  Proper training of health and pharmacy workers in both public, private and commercial sectors to counsel those receiving ACTs on the proper regimen would also reduce his worry about improper dosing.

Timely and appropriate change is needed to protect and increase the malaria drug supplies we have now, while research continues to find new medicines as the need will most certainly arise.

Advocacy &Eradication Bill Brieger | 07 Jun 2009

Measles elimination – Malaria lessons

Measles still kills nearly 800,000 children annually, but some regions of the World, according to de Quadros (2004) have made major strides in eliminating the disease. What does this process teach us about eliminating and eventually eradicating both diseases? de Quadros explains that –

The 24th Pan American Sanitary Conference in 1994 established a goal of eradicating measles from the Americas. Progress to date has been remarkable and the disease is no longer endemic in the Americas, with most countries having documented interruption of transmission. As of November 2003, 12 months had elapsed since the last indigenous case was detected in Venezuela. This experience shows that measles transmission can be interrupted, and that this can be sustained over a long period of time.

measles-immu-cote-divoire-who2.jpgShort campaigns can interrupt transmission temporarily, but what is needed to sustain the interruption of transmission long enough to result in elimination – the total and continual lack of cases in a country/region – and ultimately in eradication – the total elimination of cases/transmission world-wide? The strategy in the Americas has included –

  • a one-time catch-up campaign, implemented during the low season for measles virus, targeting all children aged 1–14 years, to attempt to interrupt all chains of measles transmission.
  • maintain continued routine high vaccination coverage of the susceptible population at all times to keep up with new birth cohorts
  • a follow-up campaign should to be undertaken every five years among all children aged 1–4 years regardless of previous vaccination status
  • effective surveillance to detect measles transmission and respond accordingly

WHO points out that “The first country to adopt this strategy in the Americas was Cuba, which successfully interrupted measles transmission in the late 1980s.”  We are beginning to see malaria progress in other island situations such as Zanzibar and Bioku.

Unlike measles, malaria control has several tools at its disposal, but unlike measles, malaria has a vector, and hence the need for additional tools and their coordinated use.  No one is claiming that the immunization tool for measles is perfectly effective, but the consistent application of the strategy offered above has worked.

Likewise no one is claiming that any of the current malaria interventions is perfect, and no one expects the first vaccines to be 100% effective. What is the important lesson from the experiences in the Americas is the willingness to maintain both campaign and routine intervention over a period of time long enough to interrupt transmission and sustain that interruption. Do we have the same political and financial will to eliminate malaria?

de Quadros concludes that, “A world free of measles by 2015 is not a dream.” What date is in our dreams for eliminating malaria?

Community Bill Brieger | 06 Jun 2009

Community Directed Intervention – Need for Greater Understanding

In the past couple months I have presented information on the community directed intervention (CDI) approach at several meetings. The common question arises, “Can volunteers handle all those different interventions?”  This made me realize that the CDI approach, though well accepted in the onchocerciasis control community, may not be understood by others.

CDI was developed through field research in 1995 as a way of ensuring that the ‘people beyond the end of the road’ would be able to get annual ivermectin treatments to control onchocerciasis by reducing microfilariae loads and reducing the fertility of the adult female Onchocerca volvulus worms.  CDI was adopted as the official mechanism for ivermectin (Mectizan) distribution by the African Program for Onchocerciasis Control (APOC) when it was launched in 1996.

CDI means that the community takes responsibility for ivermectin distribution in terms of conducting a village census and maintaining a village register, deciding on distribution days, times and modalities, collecting the ivermectin from the nearest health facility, managing simple side effects and referring adverse events and finally submitting simple records of treatment. In the process the community may select one or more volunteer community directed distributors (CDDs) to handle the different tasks, but at the same time community members like chiefs, opinion leaders, and others such as traders and teachers, may equally help with tasks like mobilization to take the medicine, collecting the ivermectin from the health center and returning the tally sheets after distribution.

In short CDI is not specifically a ‘volunteer’ program. It is a program where the community takes responsibility and divides up the tasks. The community can decide to change its approach, select new CDDs, ask other community members to help, try new distribution mechanisms – e.g. change from a house-to-house format to a central place distribution event.  In short, the process is not and should not be dependent on an individual volunteer.

cdi_report_08.jpgRecently APOC and the UNICEF/UNDP/World Bank/WHO Tropical Disease Research Program (TDR) have documented that other health and development programs have taken advantage of the existence of CDI to promote activities ranging from immunization coverage to agriculture extension. Subsequently APOC/TDR have intentionally tested the addition of specific tasks to the CDI process and found that not only does the community approach guarantee better coverage of these additional services (home management of malaria, bed net use and vitamin A consumption), but those communities that add these services to their ivermectin CDI activities actually achieve better ivermectin coverage than communities without the additional interventions.

The project did find that not every task is appropriate for CDI. For example, efforts to carry out Directly Observed Therapy Short-course for Tuberculosis were not possible in five of the seven research sites because of health worker resistance and community perceptions of stigma.  Alternatively recent study has found that CDI can be used to provide intermittent preventive treatment for malaria in pregnancy because the CDDs and the community can be effectively linked to the nearest health center for ogistical and technical support.  Additionally a new report from APOC documents how the CDI approach can strengthen health systems.

APOC’s strategy of community-directed treatment has brought continent-wide success for onchocerciasis control in Africa while other health initiatives have floundered. This report explores how community-directed treatment is helping to supplement and reinforce health systems, while empowering communities to control disease.

Finally CDI works best when it is introduced at the most basic unit of community.  A town may be too large. In southeastern Nigeria, for example, towns are composed of several villages and each village contains several kin groups or clans (extended families of 100-200 people). These kin groups are the best level to implement CDI because even when volunteers are selected, they are accountable to close friends and relatives whom they would be helping anyway.

So to borrow from a former US President – don’t ask what community volunteers can do for you, ask what you and your whole community can do for each other.

Pharmacovigilence &Treatment Bill Brieger | 02 Jun 2009

Guarding malaria drug quality in Nigeria – from port to store

The Nigerian Tribune reports today that, “A clearing agent(names withheld) has been apprehended by the National Agency for Food, Drug Administration and Control (NAFDAC) over his involvement in the importation of fake malaria drugs (Maloxine and Amalar tablets) worth N32.1million.”

maloxine-and-amalar.jpgThe fake products were produced in China but labelled “Made in India,” according to NAFDAC.  Their lab tests showed that these supposed sulphadoxine-pyrimethamine (SP) products lacked the pyrimethamine.  The Tribune quoted the NAFDAC boss as saying that, “the seizure was significant in view of the emergence of resistance strain of malaria parasites, saying the use of the fake drugs might lead to treatment failure, anaemia and death if no effective drug was given after.”

Ironically, these two SP products should not be imported for treatment, since studies dating back five or more years have shown a growing SP resistance. At present the national malaria drug policy recommends only artemisinin-based combination therapy (ACT) for treatment, while reserving SP for intermittent preventive treatment in pregnancy.  The fact that people are still demanding SP products for treatment shows lack of success in educating providers and consumers about the correct medicines as published in 2005 within the drug policy.

At the other end of the malaria drug spectrum, the Registrar of the Pharmacists Council of Nigeria (PCN) worried that unless patent medicine shops are “fully registered and regulated, the health of the people in the state will continue to be in jeopardy.” The PCN Director said that, “training (of PCN staff), which began in 2004 was informed by the council’s desire to train and retrain its staff on transmission, storage and general management of vital records.” It is not clear when and if PCN actually intends to offer training for the medicine shop owners and clerks.

The Tribune also reports that in an effort to comfort parents whose infants are experiencing what they perceive as ‘teething problems’, makers of commercially sold teething mixtures will include “very low doses of anti-malaria, especially those produced here in Nigeria or in the tropics. They also have pain relievers. However, we do know that malaria is not treated or prevented that way in children.” Since these mixtures may not be registered to treat disease, they may not be adequately regulated – and not surprisingly have led to the deaths of many children recently.

A scoping study by Nigerian researchers from the University of Ibadan has shown that patent medicine vendors (OMV) do need more education on the products that they sell – especially a full orientation on the current national malaria drug policies.  They continue to sell the more of the old first-line drugs, chloroquine and SP, instead of the recommended ATCs in large part because their customers cannot afford the new medicines. The researchers have recently called together key policy makers and donor partners to address the PMV question and find ways to improve their practices. We look forward to learning what was achieved.

In the meantime, Nigeria is among the first applicants to the new Affordable Medicines Facility – malaria (AMFm). AMFm “enable countries to increase the provision of affordable ACTs through the public, private and NGO sectors.” AMFm also “will reduce the manufacturer sales price of ACTs to public, private and not-for-profit sector buyers.” This will be an ideal way to ensure that quality ACTs are available to the public at a price they can afford from whichever outlet is most convenient.  AMFm will not succeed though without proper education and training of all providers, including PMVs and the public at large.