Posts or Comments 17 June 2024

Monthly Archive for "October 2009"

Integration Bill Brieger | 27 Oct 2009

Why Pneumonia Matters (Guest Blog)

world-pneumonia-day-logo.gifA big thanks to Bill for inviting me over to Malaria Matters.

In less than a week, child health advocates around the world will commemorate the first ever World Pneumonia Day. November 2nd will be bring greater attention—through conferences and events spanning 6 continents—to this disease, which takes the lives of 2 million children every year.

As Bill has written in Malaria Matters on previous occasions, we need integrated approaches to pneumonia and malaria control, especially as both killers often present as febrile illness in young children. A misdiagnosis can lead to inappropriate treatment, wasting valuable time, and putting the child’s life at risk. Integrating control efforts can include training community health workers to distinguish the two diseases, distributing bed nets during immunization days, promoting breastfeeding and adequate nutrition, and educating mothers on the danger signs of both diseases.

Why then, am I promoting World Pneumonia Day and not World Pneumonia and Malaria Day?

Besides a question of verbosity, the lack of awareness and funding for pneumonia is a serious threat to child survival. Less than 5% of Americans surveyed identified pneumonia as the leading cause of child death. And although pneumonia is responsible for nearly 20% of all deaths in young children, it receives only 1.3% of R&D funding for neglected diseases.

As Bill effectively argued, we need to make the pie of child health resources bigger, not compete for a bigger slice. My hope is that World Pneumonia Day will raise awareness and additional funds for the fight for child survival.

There are three simple things you can do to support World Pneumonia Day

  1. Take our online pledge. Add your voice to the growing call for action against pneumonia
  2. Wear blue jeans on November 2nd. Bring attention to this neglected disease by wearing your favorite pair to the office.
  3. Email Congress. Urge your Representative to co-sponsor the Newborn, Child and Mother Survival Act.

It’s not a question of stopping malaria or pneumonia. We have to do both.

Dr. Orin Levine, Executive Director of PneumoADIP

Community &Environment &Eradication &Migration Bill Brieger | 25 Oct 2009

Malaria in Guyana – Community Dynamics

The Americas have the lowest rates of malaria among the major endemic areas of the world. So when concerns are raised that Guyana may not be able to keep its total cases in 2009 below 10,000, countries like Nigeria, Tanzania and DRC may wonder what the fuss is all about. We must remember therefore, that for malaria eradication to succeed, the disease must be eliminated in EACH endmic country, no matter how few the number of current cases appears to be.

Success in Guyana has been mixed, with great reduction in some target communities, but now “There are areas in the country which did not have a problem now, but are not recording measurable and or moderate levels of malaria.” In the Omai area, “hundreds of small miners have appeared on the scene.” They are not paying attention to environmental control, but instead are responding to the increasing price of gold on the world market.

guyana-regions-and.jpgGuyana has received Global Fund grants from Round 3 and 7 for malaria control. Though the country has around three-quarters of a million people, the proposals focused on the more endemic regions. For example, Regions 7 and 8 are populated mostly by a little over 20,000 Native American peoples. These regions have also been inundated by another 20,000 informal miners and loggers.

The GFATM performance report on case management in the Round 3 grant shows that while appropriate malaria drugs are available in all target communities, actual appropriate treatment of vivax and falciparum malaria hovers around only 60% of cases. (Round 7 was signed only in May 2009 so a detailed progress report is not yet available.)

Community participation indicators also show high marks, but then one needs to consider that the non-indigenous miners and loggers may not really be part of a community.

The 2006 Multiple Indicator Cluster Survey found that sleeping under bednets by children under five years of age increased from 6.5% to 70% between 2000 and 2006. Of course this leaves open the question of whether adult migrant miners are using nets and are harboring the disease. Palmer and colleagues describe one typical mining camp in this region –

The mining camp … was approximately 400 km inland from Georgetown, the capital of Guyana, in the heart of the Amazon region of the country. It was typical of many of the mining camps in the jungle. Men sleep in rows of 20 to 40 hammocks strung underneath a large tarp-like covering. The tarp coverings are not enclosed, but the men usually sleep under mosquito netting, as malaria infection is a constant problem.

If Guyana is to meet its 2012 target of only 8,000 annual cases of malaria some serious thinking is needed about strategies to reach the diverse populations in the endemic regions.  The indigenous peoples have their community structures, and it appears that these have been reached.

The challenge then is to distinguish the other residents of these endemic regions and organize malaria control activities that will be appropriate to their social context, recognizing at the same time that their mining practices may be detrimental to the environment and the elimination of malaria.

Epidemiology &Migration &Resistance Bill Brieger | 24 Oct 2009

When Parasites Travel

Mobile population importation of drug-resistant infections and diseases is a focus of the November 2009 issue of Emerging Infectious Diseases. In that issue, MacPherson and colleagues cite, “Many examples of imported multidrug-resistant (MDR) infectious diseases are associated with migrant populations, e.g., MDR Plasmodium falciparum malaria in immigrants, tourists, and returned foreign-born travelers.”

Parasites travel –

  • According to Monge-Maillo, malaria accounted for nearly 10% “of 2,198 immigrants referred to the Tropical Medicine Unit of Ramón y Cajal Hospital over a 20-year period” in Spain.
  • CDC received reports of 1,324 cases of malaria, including four fatal cases, with an onset of symptoms in 2004 among persons in the United States or one of its territories. This number represents an increase of 3.6% from the 1,278 cases reported for 2003,” as reported in MMWR by Skarbinski and colleagues.
  • In the Netherlands 5043 laboratory cases of imported malaria were confirmed between 2000 and 2003 according to Klein and Bosman.

fly_dscn0185.JPGThe problem is worse when drug-resistant parasites travel. Chan and co-researchers have been examining archival human sera “to explore the origin and evolution of Plasmodium falciparum chloroquine resistance in the Pacific.”

In 2002 Afghan refugees brought malaria into northwestern Pakistan. They experienced a 28% treatment failure rate when chemically substandard locally manufactured sulfadoxine-pyrimethamine was used for routine treatment. This is a potential way of producing drug resistance that could be carried back home by returning refugees

MacPherson and colleagues demand what they call, “Pharmaceutical security systems for standard and quality medicines,” in an effort to combat “commonly substandard or counterfeit” drugs in endemic countries.  Progress in eliminating malaria in Zanzibar, Rwanda and Zambia can easily be threatened if resistant parasites cross their borders. These parasites don’t need passports and visas.

Epidemiology &ITNs &Treatment Bill Brieger | 19 Oct 2009

Projecting ACT needs in Malaria Strategic Plans

expected-cases-of-malaria-in-burkina-faso.jpgA consensus has evolved that as malaria interventions become more widespread and successful, the need for Artemisinin-based Combination Therapy (ACT) medicines will decrease in endemic countries.  As a case in point, The RBM Needs Assessment produced by Burkina Faso in 2008 and used as a base for planning the Round 8 GFATM proposal projected a decline in the number of P. falciparum malaria cases and hence, a decrease in the need for ACT supplies.

While the attached chart shows a projected decrease in malaria cases starting in 2009, there is little evidence that LLIN distribution and use are adequate enough at present to produce such a drop.  Burkina Faso’s RBM Road Map shows that the most recent coverage is LLINs is 24% for children below 5 years of age and 28% for pregnant women.

Furthermore, the major distribution campaign to achieve universal coverage of LLINs in Burkina Faso is not slated to take off until July 2010 at the earliest.

Specifically, the Global Fund reports that, “The Global Fund has shown that where distribution of insecticide-treated bed nets (ITNs), spraying and treatment are scaled up to national population coverage, malaria cases and child mortality can be reduced by up to 50 percent.” It appears that in the countries cited, less than 80% coverage was able to achieve up to 50% reduction in cases over a couple years.

The major challenge though is how to ensure coverage/use after a big campaign, since actual use if often much less than proportions of households possessing nets. Then too, there is the challenge of promoting continued use. Lea Pare Toe and colleagues recently reported research findings on decreased motivation to use ITNs in Burkina Faso. Factors included –

  • Acceptance was moderated by the fact that mosquitoes not seen as only cause of malaria
  • Use of ITNs adversely affected by functional organization of the houses: e.g. if also cook in sleeping areas, see nets as fire hazard
  • Bednets not used when perceived benefits of reduction in mosquito nuisance and of malaria were considered not to be worth the inconvenience of daily use

Universal coverage is not a one-time event. It must be maintained for many years. There must be continuous supplies of nets for new people and to replace old nets.  If after 3-4 years coverage falls, severe cases and mortality will rise as populations would have lost immunity.

And finally, any reduction in ACT need and use depends on use and acceptance of RDTs.  As the chart above shows, we will have no shortage of fever illness episodes even as malaria reduces.  Unless we couple diagnosis AND treatment, ACTs will be wasted and shortages will arise, especially if we reduce our orders of ACTs before we are sure that universal net coverage effects have really begun.

Mosquitoes &Surveillance Bill Brieger | 03 Oct 2009

It takes a village to understand malaria transmission

Malaria researchers in Niger have been observing malaria transmission and mosquito populations in two villages over two years and discovered major differences even though the settlements are only 30 km apart. Finding a 10-fold difference in mosquito density, the authors conclude that, “The highly focal nature of malaria in the Sahel makes detailed representation necessary to evaluate village-level risks associated with hydrology-related vector population variability.”

kwaciri10.JPGOther factors affecting transmission differentials include seasonal availability of nutrients and predators. Ultimately the authors recommend, “Topography, vegetation, soil type differences as well as shallow groundwater behaviour must all be incorporated at appropriate scales in order to accurately evaluate malaria transmission at the village scale using coarse resolution climate models.” These issues should inform ‘malaria early warning systems’ at a more focused level, the village.

The researchers were concerned about, “The sudden appearance of widespread but temporary water pools gives rise to a rapid increase in mosquito populations clustered around human habitation, resulting in the highly focal malaria transmission that is a characteristic of Sahel villages.”  While these local variations are known, the problem arises when computer models lump together areas of tens to hundreds of kilometers in size together, missing the local differences that imply different control strategies.While the overall climate and vector behavior were not different, local hydrology was. The researchers specifically modeled differences in “local topography, distributed land cover type, and subsurface hydrology environment.”

Such differences in transmission dynamics have also been reported for urban malaria. For example, in Luanda, Angola transmission was more than four times greater in areas 15 km or more beyond the city core, compared with the central areas.  In Dakar, Senegal transmission was highly focal, and “no mean figures for transmission would provide a comprehensive picture of the situation; risk evaluations should be conducted on a local scale,” even for areas only a few kilometers apart. Urban agriculture provides another example of very focal transmission.

A the present moment when countries are focusing on large efforts to ‘scale up for impact’ the small scale or focal differences might be ignored. As we move along the pathway toward elimination, more focal surveillance and intervention will be essential for mopping up transmission and monitoring against reinfestation. Now is the time to build those surveillance systems so that countries and communities will not be caught unaware when malaria attempts to make a comeback some years hence.