Posts or Comments 28 September 2021

Monthly Archive for "August 2009"



Diagnosis Bill Brieger | 31 Aug 2009

Trusting the Tests

USAID’s Essential Health Services Program in Angola – known as Serviços Essenciais de Saúde (SES) – has been developing sentinel surveillance sites at four locations so far.  These have able to document current practices in malaria diagnosis and treatment.

angola2-rdt-sm.JPGDuring a regular seminar among representatives of Municipality Health Department staff from Luanda Province in Angola SES raised the issue of Rapid Diagnostic Tests and their value in preventing over-use of expensive artemisinin-based combination therapy (ACT) medicines.  We also acknowledged that there were people who trusted their clinical judgement more than RDTs. Similar skeptics were also at our meeting.

We presented data from other countries that showed how clinical diagnosis of malaria resulted in an over-estimation of malaria cases by anywhere from 25% to 75% of the time.  This may depend on the age of the patient (more accurate in children below five years of age) and in areas of higher endemicity.  But regardless of the context, there were excess cases and wasted treatments when clinical diagnosis was used compared to laboratory diagnosis.

The data so far indicate that a similar problem exists in Angola. Unofficial results show that out of all clinically suspected cases of malaria in the four sentinel clinics only 34% of children below five years of age and 23% of older people had laboratory confirmed malaria parasites.  In contrast half of the children below 5 years and two-thirds of the others who were clinically suspected of having malaria were given ACTs, i.e. much more than the numbers with laboratory confirmed malaria.

If people question laboratory tests, what also of RDTs? One of the skeptical people in the room shared that all the RDT tests in their clinic had turned out negative, and based on his clinical experience, he was sure that many of the patients really had malaria. We called attention to a recent study that found very low prevalence in urban Luanda, making it challenging to identify parasites. He was still not convinced.

Finally participants from two other municipalities came to our rescue.  They agreed that initially all their results had been negative. Then they undertook training and follow-up supervision of all staff who would use RTDs. This resulted in identification of positive cases.  Their stories also confirmed experiences in Tanzania where such training was crucial.

As more countries move closer to elimination and malaria cases become rarer, the importance of correct diagnosis and surveillance will increase.  We must ensure not only that our RDTs are of high quality (see FIND Report), but also that those who combat malaria at the front lines have trust in our diagnostic tools.

Funding Bill Brieger | 28 Aug 2009

A Long Gestation – Global Fund Grant Signing

Round 8 of the Global Fund to Fight AIDS, TB and Malaria concluded with the award of 28 country grants for malaria back in November 2008.  Nine months later much of the $1,506,627,922 designated for Phase 1 of these grants remains in the bank since only six of the 28 recipients have signed the grant (see grant negotiation/signing in GFATM lifecycle below).

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The six whose gestation was less than the traditional human period of nine months include Bolivia, Burkina Faso, Ethiopia, Nigeria, Rwanda and Swaziland. These do count for 36.5% of the grand total, but some high burden countries are still gestating, even though help is available, as seen below:

  • Afghanistan
  • Brazil
  • Central African republic
  • Colombia
  • Comoros
  • Democratic Republic of the Congo
  • Congo
  • Cote d’Ivoire
  • Dominican Republic
  • Ecuador
  • Ghana
  • Haiti
  • Indonesia
  • Korea DPRK
  • Kyrgyz Republic
  • Papua New Guinea
  • Sri Lanka
  • Tajikistan
  • Tanzania
  • Uzbekistan
  • Zanzibar (Tanzania)
  • Zimbabwe

With pressure on for achieving universal coverage of malaria interventions prior to reaching the 2010 Roll Back Malaria targets, one would think countries would be more anxious to get their hands on this crucial malaria funding.  This money is unfortunately not gathering interest for the recipient countries while they wile away the time. Lets hope their grant signing gestation period does not extend into 2010, as that would be a sad delivery.

Pharmacovigilence &Resistance &Treatment Bill Brieger | 23 Aug 2009

Enhancing artemisinin production – on a fast track

With reports from Southeast Asia of resistance by malaria parasites to artemisinin-based drugs, the race is on to guarantee adequate supplies of these medicines for appropriate treatment in the most endemic areas of the world.  As PBS phrases it, resistance “now threatens to outfox medicine’s last line of effective drugs.”

According to WHO this could reverse the “Huge strides have been made in the past 10 years to reduce the burden of malaria, one of the world’s major killer diseases.” The challenge, as WHO makes clear, includes providing adequate supplies of artemisinin-based combination therapy (ACT), which are used only on parasitologically confirmed cases of malaria and with guarantees that the full, correct does is consumed.

artemisia-annua-bbc2.jpgAs a natural product, artemisinin has not been easy to produce and store in quantities needed for large scale control programs.  The BBC recently posted an video on efforts to grow Artemisia annua with enhanced artemisinin content. The video explains techniques that were used to breed the plant far more quickly than traditional methods using “fast track molecular methods.” The new plants are being disseminated for field testing to parts of the world where the plant is being grown commercially.

Keeping ahead of resistance requires not only better and faster supplies of ACTs to the front line.  There is also need for drug response surveillance, health education on correct treatment practices and continued vector control efforts.

We should also remember another approach to artemisinin production. A group at the University of California, Berkeley, “has been refining their method of engineering E. coli and yeast to produce a chemical precursor of artemisinin – the most effective malaria treatment available. Artemisinin is sorely needed in the developing world, but too expensive to produce to be affordable.” Not only could such approaches yield more affordable medicines, but could also eventually engineer a form of medicine for which parasites are not resistant

The race is on – will we be able to disseminate enough ACT supplies to make a major dent in malaria morbidity, mortality and especially prevalence before resistant parasites win their own race across the continents from Asia to Africa has happened with chloroquine and sulfadoxine-pyrimethamine?

The biggest threat may not be drug resistance or insecticide resistance but bureaucratic resistance that threatens timely scale-up and sustained implementation of our available interventions, which are the precursors to malaria elimination.

Funding &Partnership Bill Brieger | 12 Aug 2009

Global Fund – Donors Needed

Reuters reports that the Global Fund has been seeking a wider donor base. Looking toward the wider G20 membership, “Michel Kazatchkine, executive director of the Global Fund to fight HIV/AIDS, TB and Malaria (GFATM), said in an interview that nations such as China, Mexico, Brazil and South Africa may now be in a position to offer a hand to poorer countries that need help.”

gfatm-pledges.JPGThe search for more funding is spurred not only by the economic problems facing the core G8 donors, but by the fact that the other G20 members themselves have larger economies now and should share in supporting global efforts to curb these diseases. With the Global Fund facing a US$ 3-4 billion shortfall, involving more donor partners is essential.

The chart at the left shows country donors to the Global Fund and is derived from GFATM data available on their website.  One can see that the G8 makes up the bulk of pledges (77%) and payments (76%) at present.  The European Union itself, plus 15 other non-G8 members provide 20% of pledges and 21% of payments since inception.

Only seven of eleven G20 members who are neither G8 and EU were mentioned by name (Australia, Brazil, China, India, Republic of Korea, Mexico, Saudi Arabia), and that group pledged and contributed only about one percent of the total country donations to the GFATM since inception.  The remaining four G20 members may have contributed and their amounts were grouped under ‘other’.

Kazatchkine observed that G20 members are taking on a greater international political role, and believes they should also take on greater health and development roles.  He explained that, “I really think it is time for the G20, which is 85 percent of the world’s economy, to come into the circle of donors. The Global Fund has to expand. China is an obvious example, I know South Korea is quite prepared to come in as a donor.”

Kazatchkine reminds us that HIV, malaria and TB are not in recession, so the G20 countries, many of whom are endemic for the three diseases, should not let economics be an excuse for shirking their expected contributions toward controlling these diseases.

Community &Coordination &Partnership Bill Brieger | 07 Aug 2009

Getting ready for World Pneumonia Day

Pneumonia, diarrhoeal diseases and malaria are the biggest killers of children in the tropics. Malaria is the recipient of major funding efforts from the World Bank, the Global Fund, US President’s Malaria Initiative, DfID, Unicef plus many other bilateral, corporate and NGO donors.  Efforts to place a spotlight on diarrhoeal diseases and prevent mortality using oral rehydration in the 1980s and ’90s never really took off.  Pneumonia likewise has been a neglected disease.

wpnd.pngThe fate of pneumonia may change this year. One reports that during this year’s “World Health Day, a group of organizations and activists launched an effort to encourage the United Nations to declare November 2nd as World Pneumonia Day. Pneumonia which is the leading killer of children around the world taking upwards of 2 million lives of children under 5 every year is rarely discussed in the media as a childhood killer and is often thought of only as a disease of the elderly.”

GAVI observes that, “Pneumonia has been overshadowed as a priority on the global health agenda, and rarely receives coverage in news media. World Pneumonia Day will help bring this health crisis to the public’s attention and will encourage policy makers and grass roots organizers alike to combat the disease.”

Likewise Save the Children says, “We’re thrilled that so many people and organizations want to join forces for World Pneumonia Day to reduce the impact of the largest killer of children. Through our efforts, we expect to change the lives of millions of young children and parents by making childhood pneumonia deaths a part of history.”

Attention to Pneumonia does not detract from efforts to control malaria.  In fact the attached maps from the Malaria Atlas Project (MAP) and pneumoADIP show that the two diseases share common ground in the tropics. What is needed is an integrated at the community and household level that empowers local people to prevent and control childhood diseases through such actions as prompt and appropriate home management, hand washing, bednet use and vaccination.

map-spatial-distribution-p-falciparum-2007a.jpg

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Coordination at the local level is the key to success. District health systems must be strengthened for us to realize the full potential that communities have to deliver the goods for child survival.

Advocacy &Development Bill Brieger | 05 Aug 2009

USAID rudderless? – implications for malaria

A front page headline in the Washington Post today worried that, “Leadership Vacancy Raises Fears About USAID’s Future.” Although the previous administration began the process of absorbing USAID into the State Department, it at least created the President’s Malaria Initiative, an inter-agency partnership housed within USAID that boosted USAID’s worldwide technical leadership in malaria control.

Leaving the USAID Directorship post vacant for over 6 months contradicts the State Department’s intentions to continue to pursue strong leadership in health and development. This is expecially true in the field of malaria that is facing some serious deadlines and targets in 2010.

Various excuses of this leadership lapse have been offered, according to the Post, including the new administration’s detailed vetting process that discourages potential candidates for the Directorship.  If the administration really believes, as it is quoted as believing, that development is an important part of diplomacy, then why does the vacancy persist?  It certainly gives room for fears that this administration may finish the job started by the previous one of swallowing US development efforts under the political aims of diplomacy, threatening the credibility and independence of US leadership in the health and development arena.

Health, and particularly malaria, do not feature much in the Post article, even though the Secretary of State’s first stop is Kenya, one of the key PMI countries. The State Department’s own briefing on the trip to Africa also does not emphasize health or mention malaria. If health has any role in the Secretary’s 11-country visit, it does not reflect in the travel diary on the State Department’s website which says, “Throughout her trip, the Secretary will reaffirm the commitment of the United States to building new partnerships to promote responsible governance, economic opportunity, and shared responsibility.” So are health and development really components of the current State Department’s diplomatic goals?

This is certainly not to say that such goals of the current visit are not important – resolution of Kenya’s discord over its presidential elections and peace in Somalia are urgent issues. The visit simply reasserts concerns expressed in the Post article that without strong leadership for USAID, the health and development agenda may get lost, and thereby, threaten the ability of the U.S. to contribute in a timely and meaningful manner to achieve the 2010 Roll Back Malaria targets.

Communication &Development Bill Brieger | 03 Aug 2009

Child Health Week – what can campaigns achieve

Professor Olikoye Ransom-Kuti was famous for promoting strengthening of primary health care services when he was Minister for Health in Nigeria twenty years ago.  When certain donors and partners wanted to push campaigns as the best way to achieve high coverage of childhood immunizations, the Professor resisted as best he could.  Ultimately he was proved correct – strengthening stable routine service delivery is tha main way to maintain coverage in the long run.

As Nigeria embarks on another series of campaigns known as Child Health Week, Nigeria Health Watch observes that, “We seem to be already very addicted to campaigns as a means of vaccinating our children rather than ongoing sustained routine programmes.” Specifically UNICEF reports that, “Executive Director, Ann M. Veneman and the Nigerian Health Minister, Professor Babatunde Osotimehin, launched the first ever National Health Week in Nigeria which will take place 1 to 8 August, 2009.”

Ideally “Over the course of the week, children, especially those in rural areas, will receive immunizations, deworming medicines, insecticide treated mosquito nets. Mothers will be counseled on key household practices like breast-feeding and basic hygiene.” Since there is a separate effort to provide universal coverage with mosquito nets in about half the states this year, it is not clear where additional nets will come from for this campaign, but we can hope that at minimum health education on malaria will feature.

But will coverage be achieved.  The Johns Hopkins University Center for Communication Programs (JHUCCP) found in 2007 that while nearly 83% of women in northern Nigeria had heard about immunizations through campaigns and the media, actual immunization coverage remained low. Various social and cognitive factors – father’s beliefs and approval, levels of social support influenced coverage.  These are factors that cannot easily be addressed by campaigns aimed at mothers.

When malaria interventions are tied to such campaigns, they too may suffer from the poor response attributable to beliefs and concerns about immunizations and fears of strangers moving around the community delivering these interventions. One would hope that strengthening routine services would also be a way to strengthen trust in the intentions and reliability of local health workers.

Interestingly UNICEF’s Executive Director, in commenting on the Child Health Week efforts also observed that, “Malnutrition is a silent emergency in Nigeria. Among children under age five, 29 percent are underweight. Nearly three million children are suffering from chronic malnutrition and more than one million from stunting. This is simply unacceptable.”  Nutrition is certainly not an issue that can be addressed by a week-long campaign.

A timely juxtaposition of news drew attention to this nutritional challenge in today’s Washington Post, which said, “The nation blessed with Africa’s largest oil reserves and some of its most fertile lands has a problem. It cannot feed its 140 million people, and relatively minor reductions in rainfall could set off a regional food catastrophe, experts say.” A change in weather patterns could be a deadly tipping point –

Today, about 90 percent of Nigeria’s agricultural output comes from inefficient small farms, according to the World Bank, and most farmers have little or no access to fertilizers, irrigation or other modern inputs. Most do not even grow enough food to feed their own families (according to the Post).

So as Nigeria Health Watch resigns itself to campaigns by saying, “BUT yes… if that is the only way to reach most of our children….so be it,” we can hope that policy makers become more attuned to the broader health systems and economic development requirements that will guarantee families access to routine malaria control services and regular food supplies.

Mortality &Peace/Conflict Bill Brieger | 02 Aug 2009

Is the neighborhood safe from malaria?

Major progress against malaria in Rwanda was reported in the Malaria Journal earlier this year. “In-patient malaria cases and deaths in children < 5 years old in Rwanda fell by 55% and 67%, respectively." This is attributed to major scale up of interventions as follows:

In Rwanda, the Ministry of Health (MOH) introduced LLIN and ACT nationwide within a two-month period, September to October 2006. In September 2006, the MOH conducted a mass distribution of 1.96 million LLIN to children < 5 years, integrated with measles vaccination. (In comparison, Rwanda's population was around 9.5 million in 2006.) During a household survey 8 months after this campaign, LLIN use in children < 5 years old was 60% (unpublished MOH Malaria Indicator Survey, 2007). ACT was introduced nationwide quickly in October 2006 to public-sector health facilities throughout the country.

Rwanda’s neighbors are not so lucky. In addition to driving out malaria, Rwanda had, as a result of the civil strife and genocide in 1994, also driven out many rebels.  These rebels are wreaking havoc with the lives of villagers in eastern Democratic Republic of the Congo (DRC).  Hundreds of thousands of Congolese have been displaced and according to The Lancet …

… live in squalid camps where they depend on handouts from charity organisations. But food and medical supplies are in short supply in these camps, and security cannot be assured as armed men have been attacking residents. Often, the fighters block medical and humanitarian workers’ access to communities. Health units are routinely being looted, and many report that they are running out of supplies.

The International Rescue Committee (IRC) estimates 5 million Congolese have died as a result of continued cross-border and internal fighting with these rebels, who drive civilians from their homes, “arguably making DR Congo the world’s deadliest crisis since World War II.”

The Washington Post explains that is not war that is directly killing people. “In eastern Congo, people die from malaria and diarrhea, from untreated infections and measles, from falling off rickety bridges and slipping down slopes, from hunger and from drinking dirty water in the hope of surviving one more day.” These include not just people in camps but people hiding in the forest, driven from home with only the clothes on their backs.

The Washington Post also reports on a survey that estimates DRC’s death rate “to be 57 percent higher than the average for sub-Saharan Africa. The rate in eastern Congo was 85 percent higher.Congo’s death rate was estimated to be 57 percent higher than the average for sub-Saharan Africa. The rate in eastern Congo was 85 percent higher.”

Infections and neonatal conditions account for over half of deaths in DRC while malaria (or fever) is responsible for around 26%. An IRC survey for 2006-07 documents that, “Based on our findings, fever/malaria is the No. 1 killer in DR Congo.”

It is difficult to celebrate Rwanda’s successes against malaria when right across the border Congolese are dying from malaria through the actions of Rwandan rebels. Malaria truly is a disease without borders.

Malaria in Pregnancy &Mortality Bill Brieger | 01 Aug 2009

Reverse the neglect of maternal mortality

Nicholas Kristof of the New York Times has often written on the shameful problem of maternal mortality. A few days ago he proffered a solution to the problem that goes beyond health system fixes.  Specifically women’s issues need political attention, and to do that, women need to be more involved in governance.

Kristof observed the U.S. experience that “after women’s suffrage became a reality, maternal mortality fell sharply. It seems that when women were accepted fully into the political system, then resources were also made available in the health system and they, less marginalized, were able to take advantage of them.” In countries with high maternal mortality, the right to vote is not enough, especially when voting may not actually determine political outcomes.

Malaria, of course, is responsible for an important portion of maternal mortality, whether directly through severe episodes when women have reduced immunity, or through anemia caused by the infection.  As we have often observed, of the main components of malaria control and elimination efforts, malaria in pregnancy (MIP) is the weakest leg of the stool.  Until national malaria programs, with pressure from malaria partners, make MIP control an equal priority with bednet distribution and treatment of small children, the destructive work of the disease will continue.

_38913701_elections1999_ap203b2.jpgKristof wishes that groups promoting Safe Motherhood initiatives will “hopefully … get strong backing from the Obama administration.” Not only are pregnant women with malaria at risk themselves, but their newborn children would have suffered from growth retardation in utero and being born of low birth weight, would be more likely to die before they can benefit from bednets and artemisinin-based combination therapy.

Not only do women in malaria endemic countries need to vote, the people they vote for need the political will to reduce maternal mortality by all means including preventing malaria in pregnancy.