Posts or Comments 19 June 2024

Monthly Archive for "March 2010"

IPTp Bill Brieger | 27 Mar 2010

IPTp – are controversies preventing prevention?

According to WHO, “Malaria in pregnancy increases the risk of maternal anaemia, stillbirth, spontaneous abortion, low birth weight and neonatal death.” We have interventions to help, but are we giving them our full support?Intermittent preventive treatment for malaria among pregnant women (IPTp) using the drug Sulfadoxine-pyrimethamine (SP) has been in use in antenatal clinics in Africa for over a decade. Even so, controversies remain that may deprive pregnant women of malaria protection at a time when they are most vulnerable. These controversies include questions of parasite resistance to SP and appropriate venues for administration of IPTp.

Currently WHO recommends a minimum of two doses of IPTp during pregnancy, but because of questions raised about parasite resistance to SP, WHO convened a Technical Expert Group* that concluded …

  1. Even though the IPTp policy was recommended and adopted in 1998 based on limited data, subsequent evidence has confirmed that IPTp is a useful intervention
  2. Given the possible detrimental effect that increasing SP resistance would have on the benefits and cost-effectiveness of SP-IPTp, there is uncertainty as to how long this intervention with SP will remain useful.
  3. Currently available SP efficacy data are insufficient to make specific and meaningful changes to current WHO recommendations on SP-IPTp. SP efficacy as currently measured in children cannot be extrapolated directly to the efficacy of IPTp. Therefore, in the absence of new data, the recommendation be streamlined to state that all countries in stable malaria transmission situations should deploy and scale up the strategy of SP-IPTp, until relevant data on its effectiveness under current conditions becomes available for WHO to review this recommendation.

Rwanda has already stopped using IPTp because of fears of SP resistance, although its neighbors have not made this move. The challenge of not providing IPTp is ensuring that two additional key interventions are in place, 1) provision of insecticide treated nets in the first trimester and 2) availability of prompt parasitological diagnosis and artemisinin-based combination therapy in antenatal clinics. iptp-mozambique.jpg

Unfortunately, countries are not achieving adequate coverage of these additional interventions to help pregnant women. It does not make sense to throw out an intervention like IPTp when we are so far from achieving RBM targets for protecting pregnant women. At present the effect of SP resistance may be more of reducing the duration of protection – not a reason to completely abandon IPTp until we have an alternative.

In the meantime people are raising questions about most of delivering IPTp.  Recently Ndyomugyenyia and Katamanywa reported from Uganda that ANC attendance does not guarantee that pregnant will get a full course of IPTp.  Problems of staff training and procurement and supply distribution may be in play.  Also there are concerns that although most women in Africa attend ANC sometime, they may not do so early enough and at the right intervals to successful complete two IPTp doses.

These ANC attendance concerns have given rise to community approaches. A basic community mobilization approach had positive effects in attendance and coverage in Burkina Faso. A Ugandan intervention showed that provision of SP by volunteer community agents could increase IPTp coverage.  While community volunteers did help increase coverage in Malawi, researchers there found that ANC attendance decreased in communities where volunteers were used. An ongoing study in Nigeria is testing community IPTp delivery that is strongly linked into ANC service provision (see abstract #632 at link).

Even if we can harness and improve the resources at antenatal clinics to achieve malaria prevention targets, we have problems in the wider environment. In most countries, contrary to official pronouncements, SP is still being sold to treat malaria in private pharmacies and shops. This inappropriate usage of SP will in fact contribute to increasing parasite resistance and decreasing efficacy of IPTp.  Until countries can get proper control on their drug supplies, IPTp and even appropriate treatment generally, will be threatened.

The lack of concern about protecting SP leads one to wonder whether endemic countries and donors are really concerned about protecting pregnant women from malaria and are just using SP controversies to continue their neglect of this vulnerable group.


*Technical Expert Group meeting on intermittent preventive treatment in pregnancy (IPTp) WHO HEADQUARTERS, GENEVA, 11–13 JULY 2007.

ITNs &Universal Coverage Bill Brieger | 16 Mar 2010

Universal Coverage 2010 – but how long will it last

The push is in high gear to ensure Universal Coverage of malaria interventions, especially long lasting insecticide-treated nets, by the end of 2010. Nigeria may have the biggest task – aiming to distribute over 60 million LLINs, but all endemic countries are facing the challenge.

The RBM partnership assisted countries conduct a gap analysis last year – known as the road map – in order to identify any funding and/or supply shortfalls. Through this we can see that concerted effort by partners is needed so that universal coverage can become a reality. Examples of the gaps facing universal coverage follow:

  • Mozambique – 4.5 million nets
  • Botswana – 0.35 million nets
  • Angola – 3.4 million nets
  • Kenya – 12 million nets
  • Burkina Faso – 1 million nets

Let us assume that partners will pull together and nets will be found.  Will the aim of universal coverage thereby be achieved by 2015? One issue that may have been neglected is how long lasting are ling lasting nets?

In Ghana a study collected 255 LLINs 38 months after distribution.  Some key findings were

  • An average of 40 holes of varying sizes per net
  • Half had seam failure
  • Only 15% retained full insecticide strength

dscn0216a.JPGLikewise, LLIN maintenance behavior was observed in Laos after 2–3 years of use, and “About 40% of the observed nets had holes/were torn.” Two years after LLINs were distributed as part of an immunization campaign in Togo, 200 nets were analyzed. Apparently 9% were not being used and one-third had unacceptable concentration levels of deltamethrin.

Finally in Uganda washing of LLINs did not appear excessive as in some reports, and so loss of insecticide was possibly attributed to “time which has to be seen as a proxy variable for regular use or handling of the net or exposure to environmental factors.”

The implication is that even if we fill the gaps and achieve universal coverage by December 31, 2010, will we be able to achieve the aims of reduced morbidity and mortality by 2015?  The challenge is more than catch up and keep up. We may in fact need millions and millions of replacement LLINs by 2013.

Migration &Partnership Bill Brieger | 14 Mar 2010

Maasai and Malaria

The nomadic Maasai people of East Africa are certainly not immune to malaria. Research by Bussmann and colleagues shows a wealth of ethnomedical responses to the problem and points out that, “The Maasai pastoralists of Kenya and Tanzania use a large part of the plants in their environment for many uses in daily life.” Specifically, they reported that …

“Although malaria treatment is often available at health centers, the traditional use of herbs for the treatment of ‘malaria and fever’ is still common. The cures mostly involve the ingestion of purgative plant extracts, obtained by boiling plant material. In the Sekenani valley the most important species used to treat malaria were Achyranthes aspera, Warburgia salutaris, Combretum molle, Olea europaea, Sporobolus stapfianus, Teclea nobilis, Toddalia asiatica and Cissus quinquangularis.”

dscn6644sm.JPGLikewise Koch and co-researchers learned from three Maasai healers the names of 21 indigenous herbs used to treat malaria. “Of the species tested, over half were antiplasmodial, and all but one displayed selectivity for the malaria parasite Plasmodium falciparum.”

A new NGO, Maasailand Health Project (MLHP) based in Washington State, USA, is trying to bring current anti-malaria technologies to a Maasai community in Tanzania. The project focuses on six boma or villages in an approximately 200 square mile area in which nearly 500 people live. MLHP’s “first shipment of 100 nets, 50 blood test kits, 30 treatments of medication, and training,” took place last month.

The group has been in touch with USAID and the Tanzanian Ministry of Health, so hopefully this effort can be integrated with the overall national malaria control program and thus be sustained. Integration of programming for nomadic people is crucial since none of the currently operating Global Fund malaria grants in either Tanzania or Kenya explicitly mention outreach to the Maasai.  The US President’s Malaria Initiative Malaria Operations Plans for both countries are also silent on the needs of the pastoralists.

Unfortunately Kenya’s unsuccessful Global Fund Round 9 malaria proposal intended to involve the Maasai Pastoralist Development Foundation. “This organization has an extensive community network which will be mobilized as part of BCC-Community Outreach. Its capacity will be built through the dual track PR as part of Community Systems Strengthening.”

National and cross-border malaria control efforts need to plan for and finance efforts to protect nomadic, migratory and minority populations from malaria. Without attention to the needs of these populations, malaria cannot be eliminated.

Mosquitoes &Partnership Bill Brieger | 11 Mar 2010

Breweries should become malaria partners

PLoS One has just published a study from Burkina Faso entitled, “Beer Consumption Increases Human Attractiveness to Malaria Mosquitoes.” Beer and water consumers were compared and “Water consumption had no effect on human attractiveness to An. gambiae mosquitoes, but beer consumption increased volunteer attractiveness.”

african-beers-sm.jpgSpecifically, “Body odours of volunteers who consumed beer increased mosquito activation (proportion of mosquitoes engaging in take-off and up-wind flight) and orientation (proportion of mosquitoes flying towards volunteers’ odours).”  The authors therefore concluded that, “beer consumption is a risk factor for malaria and needs to be integrated into public health policies for the design of control measures.”

This is not the first study to look at what attracts mosquitoes to human beings. For example in 2003 Mukabana and colleagues found that “… mosquitoes preferred certain individuals despite being presented with emanations of three persons simultaneously.”

A year later BBC reported on another study the found that, “A key chemical found in
sweat is what draws the mosquito that spreads malaria in Africa to bite its human victims.” The researchers from Yale and Vanderbilt indicated that, “The chemical, or odorant, in sweat responsible for this attraction is called 4-methylphenol.”

Researchers from the University of Florida also explained that, “… the process of attraction begins long before the landing. Mosquitoes can smell their dinner from an impressive distance of up to 50 meters … This doesn’t bode well for people who emit large quantities of carbon dioxide.”

So back to beer drinking – the smells and chemical attractants emitted by the beer drinkers put them at risk. What can be done?  During these days of counting malaria out we need all the partners we can get.  We ask whether breweries are contributing their fair share to protecting their customers and the customers’ families from mosquitoes? Shouldn’t breweries contribute a certain portion of the price of each bottle to the national malaria control program or an appropriate NGO?

Breweries are known for having contests and give aways at local pubs in order to increase sales – instead of giving away caps and t-shirts with the beer logos, maybe they should now give out insecticide treated bednets with their logos.  The role for corporate responsibility by the breweries could not be more clear.

Equity &Malaria in Pregnancy Bill Brieger | 07 Mar 2010

International Women’s Day … and malaria

For 99 years International Women’s Day (8 March) has been “a global day celebrating the economic, political and social achievements of women past, present and future.” According to the UN Special Envoy for Malaria, Ray Chambers

The disease strikes infants, children under five and pregnant women in astonishing disproportion, as these segments of the population account for 90 percent of malaria deaths. Given the dual role of women as both victim and primary protector of victims, malaria clearly belongs under the umbrella of traditional women’s health issues.

dscn7760sm.JPGThe protective role of women in the fight against malaria extends beyond the household. In endemic most countries the majority of front line health workers who treat malaria patients and give out bednets are women.  Women also play a major community role when they volunteer as village health workers and bring malaria treatment and prevention to the grassroots as seen in Ethiopia‘s “scheme to train thousands of young women in malaria fighting tactics.”

Although women may not have equal numbers of positions compared to men when it comes to malaria policy making and program management, it was impressive at the November meeting of the RBM Harmonization Working Group to be addressed by the women who were directors of the national malaria control programs of Kenya, Nigeria and Ghana.

The World Gender Gap Report (2008) considers economic opportunity and participation, educational attainment, political empowerment, and health and survival of women in each country.  130 countries were scored, and at ten of the lower 30 on the list are endemic for malaria compared to only 3 in the top 30. This does not mean that malaria per se creates inequality, but may have a harder time accessing malaria prevention and treatment where gender equality is highest.

Provision of Intermittent Preventive Treatment for pregnant women (IPTp) during antenatal care is an example of neglected services for women. The World Malaria Report roughly estimates that no around 20% of pregnant women in areas of stable malaria transmission in Africa received the minimum two doses of IPTp even though the target for 2005 was 60%.  The RBM website’s country facts show that coverage with two doses can be as low as 3% in Angola and 5% in the Democratic Republic of the Congo. Only one country appears to have broken the 60% ceiling, Zambia.

Countries need to step up and close the gender gap in malaria services. Resources are available from Jhpiego to help countries assess their current malaria in pregnancy program implementation status, update their malaria policies to reflect the needs of women and train health workers to deliver better malaria services to women.

Monitoring Bill Brieger | 05 Mar 2010

Timely Data to Count

Since this year’s World Malaria Day continues last year’s emphasis on ‘counting malaria out’, we need to think about the availability of timely data to know if progress is being made toward universal coverage. The best bet for reliable and comprehensive information on coverage has often been the Malariaa Indicator Surveys. The challenge is that such national surveys are expensive, take time to analyze and do not give us the needed snapshot to help direct and redirect intervention.

Angola is a case in point. The last MIS was done in 2006. All coverage indicators – ITN use, ACT access and consumption and IPTp distribution were low. Since that time major donor input from the US President’s Malaria Initiative and Global Fund have help speed up intervention. We know challenges exist, especially from a logistical point of view, in getting services and commodities out to people, but at this point we cannot easily pinpoint areas that are in most need.

Another MIS is being planned for late 2010 or early 2011 in Angola, and this will certainly let us know how close we came to universal coverage. We know from experience that distribution of a commodity alone does not guarantee its use, but for the present we may have to rely on such distribution data as a proxy until the impact indicators can be measured.

Also it would help if all donors required and provided simply surveys as part of their grants – whether they be an oil company or a bilateral agency.  At least one could thereby learn more quickly on a province or district level what is working or not.

We cannot eliminate malaria unless we take counting seriously – in short without counting we will never know if we have reached our targets.

PS – we have been offline for the past couple weeks while our website is ‘migrating’ within the JHU system. We are still testing the result, hence this quick posting.