Posts or Comments 19 June 2024

Monthly Archive for "July 2010"

ITNs &Migration Bill Brieger | 31 Jul 2010

Nets, Mobility and Universal Coverage

alma-countdown.jpgThe recent meeting of the African Leaders Malaria Alliance (Alma) as part of the African Union summit reconfirmed commitment to achieving universal coverage with long lasting insecticide-treated nets by the end of 2011. The President of Tanzania and Chairman of Alma, writing in The Guardian, explains that, “Successes in malaria control have been substantial. Mosquito-net coverage in 20 African countries is at least five times higher today than in 2000, leading to significantly fewer cases of disease and death.”

While some places like Zanzibar in Tanzania and Rwanda have made serious incursions in malaria morbidity and mortality by concerted efforts at LLIN and malaria medicine distribution, others are facing challenges to meeting the 31 December 2010 goal. Nigeria has completed its mass distribution in only about one-third of its states, and Burkina Faso is still awaiting shipments of the LLINs.

Even when the nets arrive and are distributed, we still need to be vigilant.  Aside from hanging up the nets and sleeping under them in one’s normal place of residence, we also need to be concerned about population movement.

Researchers from the University of Michigan found that, “The greatest risk factor for a child living in an urban area in Kenya was whether the child spent at least one night a month in a rural area. Those children were nine times more likely to contract malaria.”

Movement between rural and urban areas in Africa is quite normal as extended family members are divided between the two areas. Although urban areas are often more hostile to anopheles mosquito breeding and have variable malaria micro-environments, urban residents definitely get exposed to malaria-bearing mosquitoes when they return ‘home’ to the rural village for ceremonies and holidays. It is not uncommon to send children to stay with village grandparents during school breaks and vacations.

These children would not have acquired any malaria immunity in the city. Travel history is an important part of investigations when these children are back in the city and become sick.

The question arises – are there enough LLINs in the villages to accommodate these temporary visitors and protect them from malaria?

filter-use-at-home-2.jpgGuinea worm elimination efforts faced similar problems – people may have a well or a cloth filter at their main residence in the village but not at their farm hamlet/settlement. Were they to expected to carry their filters back and forth, possibly leaving from family members exposed to infested water supplies at one location or another, or be given at least two filters – one for each residence? Likewise, can we expect people to carry their nets around?

These may seem like insignificant questions when countries are still grappling with just getting and distributing enough LLINs to achieve universal coverage in the next 153 days, but ultimately for elimination to succeed, every case counts, and every preventive effort must be made.

Diagnosis Bill Brieger | 26 Jul 2010

When negative is positive

rdt-algorithm-color2.jpgThe need for rapid diagnostic tests (RDTs) for malaria case management has never been more clear since of the publication by Gething et al. that only 43% of febrile episodes in malaria endemic countries are actually malaria. They did find that fever is a better indicator of malaria in areas of higher transmission, but in no situation can a clinician be confident that fever equates automatically with malaria.

Unfortunately, that confidence is more the rule than the exception.  In Burkina Faso, for example, health workers are taught to use the algorithm to the right in diagnosing malaria in patients greater that 5 years of age (at present there are not enough RDTs to use on children below 5 years).

In reality, health workers still provide artemisinin-based combination therapy (ACT) antimalarial drugs to most people who present with the classical symptoms of fever and headache.  Even when RDTs are used, negative tests are frequently treated with ACTs.

Health workers explain that during their training they were told that a negative test does not mean the person does not have malaria. While this is true to a very small extent, RDTs in current use are more that 90% accurate if stored and used properly. Gething’s results should cause health workers to think harder.

Earlier this month Bisoffi and colleagues reported that …

According to microscopy, in the rainy season versus the dry season, the prevalence of malaria infection in patients presenting at primary health care centres was three times higher in febrile patients and twice in non-febrile patients. In the dry season, only a small proportion of fevers were attributable to malaria.

dscn8925a.JPGThe Burkina Faso research found seasonal variations in the sensitivity and specificity of the RDTs, but concluded for adult patients that, “RDTs appear to be most useful during the low transmission season: a negative test safely excludes malaria and would avoid most unnecessary treatments, if prescribers are convinced to rely on the negative result.” Health workers need to hear this information.

Other concerns about positive predictive value of RDT use in Burkina Faso, and people should read the article by Bisoffi, but the take home lesson is that a negative result can be trusted and is an important guide to using expensive stocks of ACTs more judiciously.

Advocacy Bill Brieger | 23 Jul 2010

Inspired by World Cup – United Against Malaria can do more

Guest Blog by: Bremen Leak

black-stars-united-against-malaria-sm.jpgVuvuzelas, makarapa, and malaria awareness. For those of us in South Africa for the 2010 FIFA World Cup, the celebration of football and sport was also a celebration of life and health.

The United Against Malaria campaign, of which Johns Hopkins Bloomberg School of Public Health is a founding partner, took its life-saving message to South Africa this month for an unforgettable event, FIFA’s grand finale concert. Thousands of people saw firsthand how “the beautiful game” is raising awareness of malaria.

With the spirit of the tournament still in the air, UAM continues to unite governments, companies, soccer federations, health organizations, sports stars, and celebrities to eradicate this deadly disease, using football as the vehicle.

Voices for a Malaria-free Future has played an active role since the campaign’s beginning. We helped develop the UAM brand and directed many of its strategies, partnerships, and initiatives.

We brought world-class soccer players like Kolo Touré of Côte d’Ivoire and Stephen Appiah of Ghana to the campaign and created public service announcements with Ghana’s Black Stars (see photo) and other football federation partners.

We won the support of political and business leaders, who have educated and protected countless constituents and served as UAM champions in their home countries and abroad.

And we have educated at-risk populations through malaria-themed sports journals, malaria control program resource guides, and UAM publicity bracelets that raise funds for life-saving mosquito nets in Africa.

We’re excited to be a part of this campaign and look forward to the future. Inspired by the World Cup, we know we can do more.

ITNs Bill Brieger | 16 Jul 2010

Creative Mis-Uses of LLINs

My colleague Bright Orji in Nigeria sent these pictures of creative net uses after the recent mass LLIN distribution. Malaria program managers are worried that people may not hang up the nets after receiving them. These are hung – but not in the right place. The first picture shows how nets cover a farmer’s nursery for young plants.


The next two pictures show a LLIN pen for goats.



The next net pictures shows World Cup fever in Nigeria but will not prevent malaria fever.



Finally, a village ‘super market’ is protected by LLINs


Nigeria DHS 2008 results as well as recent net campaign follow-up survey results have shown that even when households have nets, people do not sleep under them. Now we know why. Our health education/behavior change activities must improve if ownership can become net use.

Diagnosis &Monitoring &Treatment Bill Brieger | 11 Jul 2010

dengue, chikungunya, malaria and more

Not all fevers are malaria. This should not be an earth shaking statement, but national treatment guidelines in malaria endemic countries often stress presumptive treatment for malaria, especially when children present with fever. Irin explains that even the World Health Organization has been hard pressed to recommend otherwise when accurate parasitological diagnostic resources are unavailable.

The concern about over-diagnosis of malaria is hitting home though because the current first line treatment, artemisinin-based combination therapy (ACT) is quite expensive, and additionally, health experts are concerned that overuse or misuse of these drugs may foster parasite resistance. To make this point even stronger Peter Gething and colleagues found that, “Of the 183 million children with malaria symptoms treated by public health clinics in 2007, only 43 percent were diagnosed with malaria, but many more most likely received anti-malarial medication (IRIN News).”

ghana3907sm.JPGA variety of febrile illnesses, especially from mosquito-borne diseases, occur in the same community. A news report from Vapi, India states that, “During the (previous week), 13 cases of chikungunya, six of dengue and 25 of malaria have been reported from in and around Vapi with Nehru Street being the most affected. The outbreak of mosquito transmitted diseases has made the health officials in the district rush to the city to initiate measures for vector control.”

A serological-epidemiological household survey in Sudan after a yellow fever outbreak found, “serologic evidence of recent or prior chikungunya virus, dengue virus, West Nile virus, and Sindbis virus infections.”

Källander and colleagues stressed the challenges of clinical diagnosis to differentiate malaria and pneumonia and reported that, “Of 3671 Ugandan under-fives at 14 health centres, 30% had symptoms compatible both with malaria and pneumonia, necessitating dual treatment. Of 2944 ‘malaria’ cases, 37% also had ‘pneumonia’.”

Gething’s group did find that 72% of those febrile cases that actually were malaria were found in locations that had higher parasite prevalence. Possibly clinicians in more highly endemic areas can presume correctly more often that a fever is malaria, but this still does not stop the wastage of ACTs, which will continue until the parasitological testing gap is closed with adequate supplies of rapid diagnostic tests and microscopes (and the skills to use these).

Gething and colleagues stress the need for countries to develop appropriate strategies by adapting the statistical models they developed with more country based data. They sadly conclude that, “Unfortunately, inadequacies in national health management information systems across Africa are in part a cause of the present imperfections in essential  commodity demand and burden estimation.”

It would be even sadder if much of the treatment commodity supplies distributed in 2010 to achieve universal coverage of malaria interventions were wasted on non-malaria fevers.

Development Bill Brieger | 07 Jul 2010

United Nations Reports on MDG Progress

Five years remain to achieve the target of the Millennium Development Goals.  Malaria is considered within the wider context of development. So how do things look for achieving the target of 50% reduction in malaria mortality in the context of other MDG goals that might influence the success of malaria interventions?

The 2010 MDG progress report by the United Nations was released last month. Female education is one of the key factors that influences a family’s uptake of health innovations  and reductions in child mortality for example in Brazil and in Ghana. School enrollment has increased from 58% in 1999 to 76% in 2008 in Sub-Saharan Africa, a ways to go to reach universal education access. The following gaps have been found:

Household data from 42 countries show that rural children are twice as likely to be out of school as children living in urban areas. The data also show that the rural-urban gap is slightly wider for girls than for boys. But the biggest obstacle to education is poverty. Girls in the poorest 20 per cent of households have the least chance of getting an education: they are 3.5 times more likely to be out of school than girls in the richest households and four times more likely to be out of school as boys in the richest households.

mdg-report-2010-sm.jpgConcerning access of women to employment, which helps the family be able to afford malaria interventions, the UN says that, “Women are largely relegated to more vulnerable forms of employment.” Specifically, “Women are overrepresented in informal employment, with its lack of benefits and security.

Concerning the goal of reducing child mortality, or which malaria is an important contributor, the UN reports that “Child deaths are falling, but not quickly enough to reach the target.” In Sub-Saharan Africa, the most malaria endemic region of the world, the 2008 rate of child mortality is 144/1,000 live births, double that of the developing countries overall.  Worldwide malaria directly accounts for 8% of deaths among children under age five in 2008. Malaria in pregnancy contributes to low birth weight, which predisposes to many other causes of infant death.

The goal of improved maternal health shows progress in the area of increased attendance at antenatal care with a skilled health worker.  Even with improved ANC attendance we know that health systems challenges such as procurement and supply chain problems often mean stock-outs for IPTp and ITNs for pregnant women.

Goal 6 – reduction of disease burden – shows progress in world-wide production on ITNs, but even in the best circumstances, most recent surveys show no country in 2008 was close to attaining the 2010 target of 80% of children under five years of age, speeling under nets. Poverty is still a major factor associated with low net ownership and use or inability to get appropriate malaria treatment

Concerning environmental goals, the UN reports that, “The rate of deforestation shows signs of decreasing, but is still alarmingly high.” Recent reports from Brazil show that malaria increases with deforestation.

The goal of partnership looks promising, but while “Aid continues to rise despite the financial crisis, … Africa is short-changed.”

The malaria statistics are certainly not new to us. What is helpful about the 2010 MDG report is that it shows us the context – development, poverty, education, equality – in which we are trying to achieve malaria control targets and makes us realize that an integrated approach is needed.

Eradication Bill Brieger | 05 Jul 2010

Eradication campaigns – past and present

The World Health Organization reminds us that …

2010 marks the 30th anniversary of the eradication of smallpox. Smallpox was officially declared eradicated in 1980 and is the first disease to have been fought on a global scale. This extraordinary achievement was accomplished through the collaboration of countries around the world.

A key point to keep in mind is that the final battle was fought in Africa and Asia where health systems were often weak.  The organizers adapted to this reality and in the end adopted a case containment strategy.  This entailed a move away from the resource intensive mass vaccination campaigns to focused vaccination within a radius of a detected case. Containment required a good surveillance system, but was helped by the easy recognition of the distinctive signs of a ‘case.’

gwcounter.jpgTwo other diseases are now on the verge of eradication, guinea worm and polio. WHO reports on guinea worm that, “There were only 3190 confirmed cases in 2009 compared with 25217 cases in 2006 and almost 3.5 million cases in 1986.”

So far in 2010 there are less than 600 reported cases. Guinea-worm disease is now endemic in only four countries in Africa: Ethiopia, Ghana, Mali and Sudan. The guinea worm effort also drew valuable lessons from the case containment strategy of smallpox.

At WHO’s Media Center, Veronica Riemer reports that …

Polio eradication is at a critical juncture. Only four countries in the world remain polio-endemic: Afghanistan, India, Nigeria and Pakistan. In Nigeria, case numbers have collapsed by more than 99% in the past year, from 312 cases to just three in 2010. In India, for the first time, the remaining endemic states of Uttar Pradesh and Bihar have not reported any wild poliovirus type 1 cases concurrently for more than six months. That’s the good news. The bad news is that Tajikistan, which had been polio-free since 1996, was reinfected with poliovirus from northern India in 2010. By mid June more than 200 children were paralysed.

casemap-201006-sm.gifSo far this year there have been 456 cases of wild polio virus detected; 1604 were counted in 2009. There still are a few cases being reported this year in Chad, Nigeria, Mauritania, Niger and Mali among 15 affected countries.

What can malaria elimination proponents learn from these experiences? At present malaria programs are generally at a mass intervention scale-up phase, though some places, notably in southern Africa, are getting close to elimination.

It is in these pre-elimination countries that we will begin to learn whether surveillance and containment activities used in other eradication efforts can be successful. Malaria does not have the relatively unmistakable signs of the smallpox rash, the emergent guinea worm or acute flaccid paralysis that makes surveillance and detection relatively easier for the other three diseases. Malaria is known to be confused by both community members and clinical staff for other febrile illnesses.

What we do share is that conflict or post-conflict countries are among the hot spots of the remaining cases of polio and guinea worm – as is also the case of malaria, and these areas have health systems challenges that make both mass intervention and focused surveillance systems difficult to operate.

We also worry as the number of cases wind down for polio and guinea worm that attention may wane and new cases spring up.  Guinea worm for example, has been lumped under the rubric of ‘neglected tropical diseases,’ which hopefully will not be a recipe for further neglect.

Unexpected outbreaks gave occurred with both guinea worm and polio because of human movement alone (the pond-bound cyclops that serve as intermediate host of guinea worm can be dealt with using temephos). With malaria both humans and vectors/mosquitoes are on the move.

This leads to another major difference. smallpox and polio have been attacked with one major tool – vaccines. Guinea worm could be solved with provision of safe water supplies or at least by filtering pond water through a piece of cloth. Malaria requires medicines and nets and sprays.

We have our work cut out for us. we can draw hope from the successes of other eradication campaigns, but also take lessons that the job requires perseverance until the last case is detected and controlled.