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Monthly Archive for "January 2010"

Peace/Conflict Bill Brieger | 30 Jan 2010

Invisible but Important: IDPs, Refugees and Malaria

Between 1998 and 2008 there were 30 malaria endemic African countries with ≥10,000 refugees and 18 countries with ≥10,000 internally displaced persons (IDPs) according to Paul Spiegel and colleagues. Speigel’s group examined whether these populations were accounted for in National Strategic Plans (NSPs) and approved Global Fund applications.

The results were not encouraging. 7th Space reports that, “For malaria, refugees were not included in 47% of NSPs compared with 44% for IDPs.” National plans and proposals were slightly more accommodating of refugees ans IDPs for HIV. Even when such populations were mentioned, the plans and proposals often did not include specific actions to reach them.

Spiegel reminds us that, “Infectious diseases and neonatal disorders remain the largest cause of excess mortality in conflict settings of low incomes and life expectancies.” Furthermore, the needs of these populations may be hidden when they do not live in designated camps.

Africa is not the only place where people affected by conflict are at great risk of malaria. Richards et al. found that, “Prevalence of plasmodium falciparum in conflict areas of eastern Burma is higher than rates reported among populations in neighboring Thailand, particularly among children. This population serves as a large reservoir of infection that contributes to a high disease burden within Burma and likely constitutes a source of infection for neighboring regions.”

Fürst and co-researchers looked at pre- and post-conflict settings in Côte d’Ivoire and found that, “… the inadequate sanitation infrastructure prior to the conflict further worsened, and the availability and use of protective measures against mosquito bites and accessibility to health care infrastructure deteriorated.”

Nigeria is one of the endemic countries that does not address IDPs or refugees in its 2009-2013 National Strategy or its most recent Round 8 Global Fund malaria grant. Nigeria is not without its IDPs, whether it is the constant threat in the Niger Delta, exemplified by today’s plan by militant groups to abandon their truce, or the recent tragedy of religious conflict in Jos, Plateau State, where over 200 people have been killed and over 3,000 have been forced to flee their homes.

From the foregoing we can see that IDPs, refugees and all those affected by conflict are at greater risk of malaria, and yet we are not adequately planning for this population.  Such neglect will only postpone the day when we can certify elimination of malaria in those countries affected by conflict.

ITNs &Universal Coverage Bill Brieger | 29 Jan 2010

Universal Coverage – much to accomplish in 2010

Bauchi is the next Nigerian state to experience the drive to universal coverage with over 60 million long-lasting insecticide-treated nets expected to be in place nationally by the end of 2010. Nearly 2 million nets are targeted for Bauchi alone.

dscn0216a.JPGAccording to a representative of the National Malaria Control Program, “preliminary report showed that over 15 million LLIN were distributed to beneficiaries between May and December, 2009 in nine states,” out of the 36 total (plus Abuja). This figure is down from the projected 12 states and 22 million nets slated for 2009. Thus, there is even greater logistical and management pressure to reach the remaining 75% of states/people by the end of 2010.

Nigeria is not the only country trying to catch up with net distribution to meet 2010 targets.  Burkina Faso is hoping to cover all households in a campaign in July. In addition, in December the UN Special Envoy’s office explained that Kenya “is facing a “critical” shortage of funding for 11 million nets that must be addressed.”

Sometimes efforts are delayed, as they have been in Burkina Faso and Akwa Ibom State Nigeria, when expected donor support and net supplies are not available when and as expected. The slower than anticipated progress in Nigeria occurs despite the fact that “World Bank, DfID, USAID, and UNICEF … the Global Fund and many other funding agencies, NGOs, and the private sector” have joined together in the effort.

A team of researchers from Burkina Faso and Germany has warned that, “Lack of coordination between donors and international health agencies is leading to the needless deaths of too many African children from malaria.” Even with donor support and coordination, one cannot afford to repeat a massive campaign twice, and so malaria program staff wait until they get the nets they need to reach everyone.

While adequate numbers of nets will likely be in place by 31 December 2010, the battle will not be over. The UN Special Envoy “emphasized that global efforts should focus not only on solving the malaria problem in the short term, but also on sustaining prevention and treatment so that it won’t once again spiral out of control.” He explained that even when we succeed in distributing the needed nets, we must remain on top of the efforts – the achievement will only occur when people actually sleep under the nets regularly.

Researchers from Burkina Faso give us pause to reflect when they reported on “Decreased motivation in the use of insecticide-treated nets in a malaria endemic area in Burkina Faso.”  Continued outreach efforts to encourage people to sleep under their nets every night for years to come may prove more challenging that distributing millions of nets by the end of 2010.

Procurement Supply Management Bill Brieger | 26 Jan 2010

Fueling malaria control

Nigeria with at least 140 million citizens living in high malaria transmission areas appears to have the highest burden of the disease in the world.  Global progress towards malaria elimination depends on Nigeria’s progress.  Yet the 2008 Nigeria Demographic and Health Survey (DHS) shows indicators falling below the targets set for 2005, and therefore well below what was hoped for in 2010 (80% coverage of malaria interventions).

  • 16.9% of households have at least one bednet of any kind (16.3% are ITNs)
  • 11.9% of children aged <5years had slept under any net (5.5% under ITNs)
  • 11.8% of pregnant women had slept under any net (4.8% under ITNs)
  • 4.9% of pregnant women had received 2 doses of IPT
  • 33.2% of children with suspected malaria took an anti-malarial drug (15.2% got that treatment the same day; 2.4% got an ACT)

Nigeria certainly does not lack resources for malaria control, either from its extensive earnings from the oil industry or from international programs like the Global Fund.  What then explains the difficulty in achieving malaria targets?

One possible reason can be found in a This Day newspaper whose editorial

Like a monster that cannot be tamed fuel scarcity in Nigeria seems to have come to stay. What makes this national disaster and embarrassment even more unfortunate is government’s glaring inability to tackle a most basic need of the country. No doubt, this ignoble path, if not arrested, would lead the nation to more desperate social and economic consequences.

petrol-queue.JPGSeveral reasons are proffered for the fuel dilema, but in the end, according to the editorial, “… this country does not have to remain a theatre of winding queues and protracted traffic jams at filling stations. Neither do its citizens deserve to live fuel scarcity – induced mediocre lives. In the absence of respectable energy sources, people have continued to be subjected to all kinds of trauma.”

Part of the trauma is lack of malaria commodities – nets, medicines – at the front line where children are dying from the disease. Supply chains, whether in the public or private sector are threatened, and prices increase with scarcity. Provision of supervision and technical assistance from national to state to local government to front line health facility and return of timely data in the other direction is thwarted when there is no fuel.

Nigeria may not be able to eliminate malaria until it can eliminate fuel shortages.

Advocacy &Morbidity Bill Brieger | 25 Jan 2010

When the media goes home

The malaria threat to Haiti may not be as immediate as the terrible injuries and potential infections from inadequate water and waste disposal. Malaria will be lurking – but will anyone be paying attention when it arises?

Anderson Cooper of CNN was quoted in the New York Times as saying “We all know what’s going to happen. People are just going to lose interest in this as a story. They’re going to stop watching.” Already today the BBC has only one small headline on its world news homepage referring to Haiti and one feature piece far at the bottom of the page.

newspapers-in-kenya.JPGMore importantly, according to the Times, the major news organizations also have ‘money worries’ about the extensive coverage. The costs of coverage, and the boost it gives to donor organization efforts to raise funds, were outlined by the Times as follows: “News outlets rushed to charter airplanes and snap up extra seats on aid flights, but that was the easy part. Upon arrival, they had to establish supply lines, mostly through the neighboring Dominican Republic.”

News executives acknowledge that the media can move in and out of Haiti quickly, but efforts to scale back are already in evidence. One network reported on running out of water for its staff twice.  Overall it was estimated that each news organization would be spending $US 1.5 million on its Haiti coverage.

Well recognized media figures like Dr. Sanjay Gupta have been serving an advocacy role encouraging potential partners to reach difficult areas and provide better quality services.  The Times recognizes the importance of the visual element in this advocacy process.  Will scaled back coverage reduce this advocacy avenue?

Over 150,000 people have been confirmed dead so far in Haiti, and final estimates reach as high as 200,000.  The World Malaria Report still estimates over 800,000 malaria deaths world wide annually. These deaths may not occur in as dramatic a fashion as a natural disaster, but they add up and are still disastrous to families and nations.

The media has been an essential partner in highlighting malaria interventions and progress at all levels, especially as we count down to universal coverage.  We need all partners to ensure that the media spotlight remains on malaria, and especially right now on malaria in Haiti.

As morbidity reduces and we get closer to malaria elimination, this task may become harder – but media advocacy will be needed up to the very end to ensure adequate funding to maintain surveillance and certify elimination even when malaria seems less pressing.

Drug Development &Eradication Bill Brieger | 21 Jan 2010

Open Source for Malaria Drug Development

Malaria Journal has launched a new series on malaria elimination in which the Journal’s editorial notes that, “The challenges remain formidable, but efforts must focus at all levels from developing better tools to how existing and future tools can be strategically combined for maximum synergistic effectiveness when integrated into different health and social systems prevailing in endemic areas.”

dscn7285sm.JPGGlaxoSmithKline (GSK)yesterday annnounced one way to help develop better malaria control tools. At the Council on Foreign Relations Andrew Witty announced the ‘open innovation’ strategy focusing on neglected diseases and malaria and explained that …

we have spent the last 12 months screening two million molecules in our compound library for reactions to the malaria parasite P. falciparum, the deadliest form of malaria found primarily in sub-Saharan Africa. This exercise has yielded more than 13,500 ‘hits’ that inhibited the parasite.

Apparently GSK itself has 5 or 6 in advanced phases of development. With this open sourcing, researchers, NGOs, governments and manufacturers in endemic countries can continue the work of drug development on the many other open source chemicals.  For HIV drugs GSK already has local manufacturers producing its products without charging royalties.

These activities build on GSK’s commitment, announced in February 2009, “to searching for new treatments for many of the diseases that affect millions of people in some of the world’s least well off nations. We have a heritage and expertise in researching and developing new medicines and vaccines, and we are directing our scientific resources into this important area.”

Hopefully such openness will spur local and appropriate solutions to disease control. Andrew Witty also encouraged other pharmaceutical companies to join in this process. With the early signs of artemisinin resistance on the horizon, new malaria drug research and development will always be needed until eradication is finally certified in the future.

PS – GSK contributes Albendazole for free to compliment donations of Mectizan by Merck for the lymphatic filariasis elimination program.

Advocacy &Funding Bill Brieger | 20 Jan 2010

Advocacy for the Next Phase of Malaria Control

We move into 2010 with the hopes that scale up for impact (SUFI) will achieve universal coverage of malaria interventions. The next several years will require sustained and consolidated effort if the MDG of reducing malaria mortality by 50% can be achieved.

The World Malaria Report of 2009 already shows us what is possible. Ten countries/areas have achieved a greater that 50% reduction since Roll Back malaria was inaugurated.  As we move to the harder to reach populations, not only will sustained action be needed, but increased funding and leadership will be needed.

It is in this context that the Malaria Round Table, supported by the Global Health Counci, met today to strategize on the current malaria programming and funding landscape and determine how advocacy efforts should move forward through sustained control into pre-elimination of the disease

The meeting was organized by the VOICES advocacy program and hosted by VOICES partner Fleishman Hillard. Over 30 members of the Round Table assembled to review their advocacy messaged first drafted in 2006 and craft new messages for the current situation that reflects hope and concern. Hope arises from the progress made in those areas with concerted and continual investment in malaria control. Concern is based on the world’s current economic malaise.

In 2006 many stakeholders did not understand malaria and that it was a problem with solutions. Since then stakeholders have made major investments, and thus, in 2010 they need to make a commitment to taking malaria control to the next level – elimination.

Below are listed the messages that arose out of the meeting – an over-arching message and four sub-messages. We hope the broader malaria community will comment on these and in particular provide factual proof that will make the messages stronger.

Your comments are not only welcome, but are crucial in bring all malaria advocates together to ensure sustained effort and coverage so we can eliminate malaria.

Please review and comment on these messages …

Overarching Message

Your investments in malaria control are paying off and we must continue our success so that we can end this disease or we will lose the progress we have made to date in saving millions of lives.

Message 1

The investment has paid off and the global funding for prevention and treatment has saved millions of lives.

Message 2

The good news is that malaria control also frees up other resources, has a direct/ripple effect, improves economies, productivity, and other health priorities.

Message 3

Without continued investment, we could not only lose the gains we’ve made, but also could see the situation even worsen, which would cost even more in the future.

Message 4

We have a plan to get the job done, but we need sustained and increased funding for malaria prevention and treatment, research, and new tools.

Please post comments here AND send comments to

Drug Quality &Procurement Supply Management &Treatment Bill Brieger | 19 Jan 2010

Putting a gift horse in the mouth

The old saying goes, ‘don’t look a gift horse in the mouth.’ Equine experts can tell a lot about the age, health and travails of a horse by examining the teeth and mouth.  The admonition not to examine an animal that is a gift might arise from not wanting to embarrass the giver, and why worry anyway if you did not pay for the horse.

It may me another matter when the intended gift is to be swallowed.

duo_cotecxin.jpgNews reports record that, “The Chinese government on Monday (18 January 2010) donated over 244,000 doses of anti-malarial drugs to the Uganda in a bid to fight the deadly disease that kills over 320 people daily in the East African country.” The donation includes 144,000 doses of Arco and 100,000 doses of Duo-Cotexin.

Supplies of the same two drugs were also donated by China in April 2009. The two medicines apparently are not yet included in the country’s essential medicine list or listed as firstline treatments in the national malaria strategy/policy. “The drugs are, however, still awaiting pre-qualification from the World Health Organisation (WHO).”

Duo-Cotexin is a dihydroartemisinin plus piperaquine product (of which other brands include Artekin, Artecom, CV8) and is “given in a four-dose regimen that has proved highly effective and well tolerated in South East Asian trials.” ARCO is a combination of two drugs – Artemisin and Naphthoquine Phosphate. At present the only two combinations that have WHO pre-qualified products are Artemether+Lumefantrine (AL) and Amodiaquine+Artesunate (AA).  AL is the firstline treatment used in Uganda.

The two donated drugs apparently do offer a more convenient regimen than AL, which is taken for 3 days. “For Arco, its dose is swallowed once while Duo-Cotexin the tablets are swallowed once a day as prescribed by a doctor.”

The main concern is that when there are many different types of drugs on the shelves with different regimens, as is the case here, health workers and patients can get confused. There may also be different formulations for different age groups.

Granted, Uganda has not often had the luxury of too many malaria drugs, and shortages have been common. Thus, there may be the tendency not to look this gift horse (or medicine) in the mouth. Uganda, like most endemic countries, is definitely under pressure to scale up for impact this year.

We can only encourage the malaria partners in Uganda to practice pharmaco-vigilance with these donations and ensure thorough in-service education for health staff and patient education to promote adherence among clients.

Advocacy &Communication Bill Brieger | 18 Jan 2010

Can Musicians Stop Malaria?

dscn3539sm.JPGJenerali Ulimwengu in the East African on Saturday talked about the efforts of Tanzania’s musicians to get involved in fighting malaria and commented cleverly that, “Let’s welcome our artistes as they remind us that ‘malaria is unacceptable,’ but the government should take up its responsibility and lead the nation in creating a mosquito-free country. Else, those beautiful sounds of our Lady JDs will only serve us as lullabies while our lady insects are hard at work.”

Lady JD is among 18 musicians/singers to join in what the Tanzania Daily News calls the “biggest ever musical collaboration among top local artists.” The music video in question “is blended with soothing voices and hip hop lyrics. President Kikwete sporting very casual attire appears in the video, urging everyone in the country to stand up and play a part in eradicating malaria.”

So how is such a video supposed to combat malaria? According to the Tanzania Daily News …

‘Malaria Haikubaliki’ is an initiative urging Tanzanians to think differently about the disease with an objective of increasing practices to prevent malaria such as consistently sleeping under an insecticide-treated mosquito, detecting and treating malaria early and ensuring antenatal care for pregnant women.

This experience harks back to the Africa Live Concert in 2005.  In addition to malaria-themed songs (see singers on YouTube), the concert featured “Information booths were set up at the stadium explaining how malaria is transmitted and how to use mosquito nets sprayed with insecticide to avoid infection.” An example of the songs comes from Youssou N’Dour (Senegal) –

Roll back malaria,
fight malaria, it’s so serious, clean up your area,
Roll back malaria,
don’t give them chances, not even places, to make a bite,
Roll back malaria,
fight malaria, it’s so serious, clean up your area,
Roll back malaria,
don’t give them places, not even chances, to make a bite …

In addition to responding to the messages in the songs, the audience and subsequent viewers on the web were encouraged to, “… make a financial contribution to the Roll Back Malaria cause can do so through the U.N. Foundation.”

It is not quite clear how these well staged efforts contribute to malaria fundraising or malaria behavior change.  Famous people feel good when they can make a visible statement about a health or development problem, and maybe the general public is inspired by celebrities to ‘do what I say.’ Evaluation of the effect of such efforts is certainly not easy.

In the end, while we sing our songs against malaria, we must go back to Jenerali Ulimwengu’s thoughts – if governments and donors do not supply the nets, medicines and insecticides all the way down to the grassroots, the ‘lady insects’ (female anopheles mosquitoes to be a little more accurate), will win the day.

Emergency Bill Brieger | 16 Jan 2010

Haiti – will malaria be added to all the problems?

According to the WHO’s Weekly Epidemiological Record (2008), “Hispaniola is the only Caribbean island where malaria persists” in endemic form.  From that base, “Hispaniola has been the source of outbreaks of Plasmodium falciparum malaria in the Bahamas and Jamaica.” Current estimates from WHO are for “eliminating … malaria from
Hispaniola by 2016–2017.”

haiti-damage-un-photo.jpgWhat are the implications for malaria transmission from the horrendous earthquake that has devastated the Port au Prince area?

Randall and Tirrell report that, “SURVIVORS of the Haiti earthquake face deadly outbreaks of diarrhoea, measles and malaria after the country’s already fragile water and health systems were destroyed.” The destruction of general as well as health infrastructure and the loss of life in the health workforce will have long term consequences in the ability of the country to respond to infectious diseases now and for a long time to come.

According to the Global Fund, “The current malaria situation is not well known in the country because of the inexistence, since 1988, of a structured and operational control program at both the central and peripheral levels. Still malaria has long been documented in Haiti as a significant public health problem. Haiti is the only island in the Caribbean region (Hispaniola – Dominican Republic and Haiti) where malaria is endemic.”

In addition, The World Malaria Report 2009, states that, “As of 2008, French Guiana, Guatemala and Haiti were the only countries yet to adopt the policy of using ACT for treatment of P. falciparum malaria.” The WMR also documents that half of Haiti’s population is at high risk from malaria and the remainder at low risk.

Prior to the catastrophe Haiti’s Round 3 Global Fund project was reportedly on track in terms of malaria treatment and bednet distribution, although chloroquine is listed as the treatment drug. Health and Management Information Systems including surveillance activities were still in need of strengthening.

Researchers from the US Centers for Disease Control and Prevention have shown highly “focal and seasonal distribution of malaria in Haiti,” with rural areas and rainy season periods producing more of the disease. Sub-Urban areas are increasingly at risk. For example, “Historically, malaria transmission peaks in November, December, or January in central Haiti.”

We can conclude that those right in the densely populated (and heavily damaged) parts of Port au Prince may not be at immediate risk from malaria, but as people move out from the city center to seek shelter and services, more people will be susceptible.

Haiti has yet to receive its Round 8 Global Fund money and the Round 3 grant is basically finished. We hope that donors trying to provide aid in this emergency will not forget to bring malaria drugs and insecticide-treated nets.

Malaria in Pregnancy Bill Brieger | 16 Jan 2010

Malaria in pregnancy as we move toward elimination

dscn4965sm.JPGOver the past decade countries in stable falciparum malaria transmission areas adopted the use of intermittent preventive treatment of malaria in pregnancy (IPTp) using the drug sulfadoxine-pyrimethamine (SP). At present only two of these locations are pulling back or considering stopping IPTp.

Both Rwanda and Zanzibar in the United Republic of Tanzania may no longer need IPTp because successful malaria control interventions have brought transmission down.  Rwanda specifically stopped using IPTp, while Zanzibar is still considering the implications of changing policy until more evidence is available.

Currently in areas of unstable, seasonal or epidemic malaria where it is unlikely that adults would have developed partial immunity and carry asymptomatic disease, IPTp has not generally been used. Instead prompt laboratory diagnosis (including RDTs) and appropriate treatment have been recommended for addressing malaria in pregnancy.

Just because the transmission picture changes as we successfully move toward sustained control and pre-elimination, does not mean pregnant women are not at risk of malaria. In fact as high transmission areas begin begin to resemble the unstable transmission zones, all people will be at greater risk of severe malaria.

Recent articles show that this risk to pregnant women extends to their offspring. Aribodor and colleagues in Nigeria documented again that not only does placental malaria result in significantly lower birth weight than that of children born to mothers without infection, but that low birth weight (LBW), defined as less than 2,500 g, was more common among those born to mothers with placental malaria. Low birth weight is an important risk factor in neonatal and infant mortality.

Walther et al. looked beyond the actual birth of the child and found that regardless of whether the child was born with LBW, the fact that the mother had placental malaria had a “negative impact on the infant’s subsequent weight development that is independent of LBW, suggesting that the longer term effects of PM have been underestimated, even in areas where malaria transmission is declining.”

The question arises as we move toward lower transmission and elimination, but not immediately toward lower risk – what can we do to protect pregnant women in addition to providing them bednets?

Daniel Chandramohan at the 11th meeting of RBM’s Malaria in Pregnancy Working Group suggested Intermittent Screening and Treatment (IST) as an appropriate strategy which might consist of:

  • Screening for malaria (RDT or Microscopy) at first ANC visit
  • Treatment with a long acting antimalarial combination (e.g. DHA+PPQ, SP+AQ, SP+AZ, SP+MQ)
  • Further screening and treatment at 2nd and 3rd trimester (2 to 3 IST per pregnancy) plus passive case management

Lucy Smith and co-researchers found that pregnant women liked “both intermittent screening and treatment and intermittent preventive treatment appeared equally acceptable to pregnant women as strategies for the control of malaria in pregnancy,” valuing the addition of such services to routine Antenatal Care.

Finding appropriate ways of protecting pregnant women from malaria, as we move toward elimination, must remain a priority in all endemic countries.

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