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Monthly Archive for "September 2010"

Efficacy &Health Systems &Procurement Supply Management Bill Brieger | 26 Sep 2010

What if available malaria tools actually reached people?

Tachi Yamada of the Gates Foundation told Discover Magazine (October 2010) that, “… childhood deaths … could fall by half by 2025 if we could deliver existing vaccines, malaria treatment, and today’s other lifesaving tools with 90% penetration to those at risk.” During the push towards Universal Coverage, it is good to ask whether we can really reach people with our existing tools.

efficacy-to-effectiveness-sm.jpgThe INDEPTH Effectiveness and Safety Studies (INESS) offers a conceptual model as to what happens when a when efforts are made to ensure that a highly efficacious tool – malaria medicines, LLINs – actually reaches people. This ultimately impacts on the effectiveness of the tool. Thus a drug that is 95% efficacious, may be less than 50% effective if the right people do not take it at the tight time.

First people need access to the tool – in the INESS case ACTs. We must deal with all the procurement and supply chain management issues that determine whether the medicines will reach the sick people in good condition beyond the end of the tarmac road.  Then targeting must be considered – do the right people get the medicines? Next the health workers themselves must comply with treatment guidelines, and finally, if the person with malaria gets his/her drugs, will he/she adhere to the treatment regimen?

Peter Moszynski in the British Medical Journal also expresses concern about the access and compliance issues:

Despite the widespread availability of effective new (malaria) drugs and diagnostic tools … major problems remain. Issues such as misdiagnosis and overprescription of treatments, counterfeit drugs, problems in supply and delivery, and emerging resistance to drugs “all hamper effective treatment.” A lack of awareness among donors and the public of some these basic problems “threaten the success of global malaria control efforts.“

Beatrice Wasunna, et al. addressed the provider compliance issue when they found that, “In-service training and provision of job aids alone may not be adequate to improve the prescribing, dispensing and counseling tasks necessary to change malaria case-management practices and the inclusion of supervision and post-training follow-up should be considered in future clinical practice change initiatives.”

Many resources are flowing through health systems right now, especially with the pressure to achieve Universal Coverage and the enthusiasm generated by the MDG Summit. Can we ensure that the health systems in place can bring the effectiveness of these tools closer to their actual scientifically tested efficacy?

ITNs &Monitoring Bill Brieger | 24 Sep 2010

Tracking Trends toward MDGs

The Center for Global Development developed a Millennium Development Goal trends report to coincide with the MDG Summit this week. The Report explains that …

The MDG Progress Index includes only 8 of the 60 progress indicators tracked and reported by the United Nations (see appendix I for complete list). We selected these 8 core indicators due to their (1) accuracy in capturing the original Millennium Declaration goals; (2) data availability; and (3) usage in the development literature.

The authors “… excluded … five malaria indicators because of the lack of available data – especially for baseline years.” Ideally the baselines should have been around 1990.  It was not until around the time that the Roll Back Malaria Partnership was formed that there was agreement on malaria indicators to be tracked and their actual measurement was done.

One of the excluded indicators was, “Proportion of children under 5 sleeping under insecticide-treated bednets.” Out of interest we examined DHS reports from three countries where ITN use was reported – Ghana, Nigeria and Zambia – as seen in the charts below with 2002/03 and 2008 information available.




These three countries present very different pictures, but none were approaching the 2010 RBM target of 80% coverage during their 2008 surveys.  Nigeria with the highest burden in sub-Saharan Africa was the farthest and had made the least progress. Zambia is said to be among the best performing countries and yet it was just a little over halfway to the 2010 target in 2008.

Maybe the move toward Universal Coverage will produce some major jumps in these indicators. But already some countries like Ghana have had to re-evaluate the feasibility of the 31 December 2010 Universal Coverage target due to net procurement challenges. Ghana now is aiming for 2011 to ensure there is at least one LLIN for every two people.

We may not have perfect data to track all MDG indicators, but we should use what is available to aid the planning and decision making to reach targets and sustain them.

Social Factors &Universal Coverage Bill Brieger | 23 Sep 2010

What are the indicators to monitor toward MDGs

There is hope among world leaders that the Millennium Development Goal of reducing malaria deaths to near zero is now likely to happen. Ray Chambers, the UN Special Envoy for Malaria is quoted as saying …

“Today, enough nets are in place to protect 75 percent of those at risk, and we will reach universal coverage by December 31, 2010, an astounding testimony to the power and efficacy of the unified global campaign. These nets have reached nearly 500 million people in the last two years alone, and their impact on saving lives is profound – current levels of intervention are saving 200,000 lives per year. We are on track to meet the Secretary-General’s goal of ending malaria deaths by 2015, and our work won’t be finished until we do.”

Having nets ‘in place’ and having nets used are two different indicators of success. ‘Nets in place’ will not achieve the MDG for malaria unless nets are used. Numerous surveys have been mentioned in our previous postings showing that even when nets are ‘in place’ in homes, they are not always used by the most vulnerable members of the household.

Another concern is that even if nets are ‘in place’ by the end of 2010, we may not achieve the MDG of near zero malaria deaths. LLINs are known to wear out after 2-3 years of normal use. Unless there are plans for net massive replacement efforts around 2013, we may see slippage in attaining and sustaining the goal.

A major weakness of past public health programming has been providing people with technologically sound and useful interventions without taking into full account the social, cultural and behavioral factors that influence acceptance and use of the interventions.  In order to continue to save lives with nets and other malaria interventions, we must strengthen the social and behavioral components of programming now and not wait until 2015 to see if we actually saved lives or not.

Development &Funding Bill Brieger | 22 Sep 2010

MDGs – an electrifying experience

The UN Millennium Development Goals Summit is underway in New York. The New York Times reports on one aspect of development, guaranteeing regular supplies of electricity. For example …

In Nigeria, a major oil exporter with a population of about 155 million people, 76 million do not have electricity, (Fatih Birol) said. “If only 0.4 percent of their oil and gas revenues were invested in power production, they would solve the problem,” he said, “so it’s not just a question of money, it’s how the money is managed.”

lscn4010b.JPGElectricity is not the only issue that requires greater investment.  African countries have also been asked to designate 15% of their national budget for health, but as the New Vision explained, “UGANDA cannot allocate 15% of the national budget to health as agreed by the African Union (AU), a government minister has said.”

We need to recognize that all MDGs are interrelated. Malaria and electricity, for example, have connections.

  • Rapid Diagnostic Tests need to be stored at cool temperatures at national, regional and district health stores, and so air conditioners and fans are needed
  • When villages are electrified people can close doors to mosquitoes at night and use fans – and with light, children can read their school books on how to prevent diseases like malaria
  • Electricity ensures that laboratories run more efficiently and computers are able to analyze monitoring and evaluation data for enhance decision making
  • When schools of nursing, medicine, etc. have electricity, students can learn about malaria using the latest technology and access the internet to gain more knowledge on the disease

These direct and indirect connections between malaria and electricity demonstrate that endemic countries need to invest their resources to control and eliminate the disease. The MDGs are not something that stop in 2015. The projected gains in health and development status must be sustained beyond 2015 if malaria is to be eliminated – hopefully the political will to invest in health will be sustained, too.

Epidemiology &Eradication Bill Brieger | 18 Sep 2010

Monkey Business – sharing disease

Humans and monkeys have shared and competed in the same environments, though not always to the benefit of monkeys.  In an interesting form of retribution for killing and eating monkeys, humans may have acquired the simian immunodeficiency virus (SIV) which mutated into HIV.

Although the earliest evidence of HIV was traced to about 60 years ago, a new study in Science as reported by the New York Times, suggests that monkeys may have harbored SIV for over 30,000 years. The Times notes that scientists have questioned …

What happened in Africa in the early 20th century that let a mild monkey disease move into humans, mutate to become highly transmissible and then explode into one of history’s great killers, one that has claimed 25 million lives so far? Among the theories different researchers have put forward are the growth of African cities and the proliferation of cheap syringes.

HIV is not the only health problem humans and monkeys share. Erma Sulistyaningsih and colleagues are among the most recent to address the problem of Plasmodium knowlesi, acquired from monkeys when tourists among others visit forests as a possible fifth form of human malaria in southeastern Asia including Indonesia, Malaysia, Vietnam,  the Philippines and recently in Myanmar.

There is also … “the theory of P. vivax originating in macaques in Southeast Asia and the close relationship to other primate malaria parasites.” Studies in Brazil also show that monkeys could serve as reservoirs for P vivax.

Researchers have also been exploring the “co-speciation hypothesis” in the relationship between P. reichenowi in chimpanzees and P. falciparum in humans. Hughes and Verra concluded that, “The available data are thus most consistent with the hypothesis that P. reichenowi (in the strict sense) and P. falciparum co-speciated with their hosts about 5–7 million years ago.”

Then last year Medical News Today reported that, “Researchers based in Gabon and France report the discovery of a new malaria agent infecting chimpanzees in Central Africa. This new species, named Plasmodium gaboni, is a close relative of the most virulent human agent P. falciparum.”

The authors of the Gabon study warn that, “The risk of transfer and emergence of this new species in humans must be now seriously considered given that it was found in two chimpanzees living in contact with humans and its close relatedness to the most virulent agent of malaria.” Similarly other researchers have expressed concern that, “Finally, our data and that of others indicated that chimpanzees and bonobos maintain malaria parasites, to which humans are susceptible, a factor of some relevance to the renewed efforts to eradicate malaria.”

Hence we see the lesson. In all our efforts to eliminate malaria, we do not want to monkey around with other possible reservoirs of infection.  Capacity to monitor our simian cousins is a key element in eventually ridding humans of the malaria parasite.

Advocacy &Eradication &Funding Bill Brieger | 15 Sep 2010

Does future eradication means lives lost now?

rbm-progress-report-3.jpgFirst the good news. Roll Back Malaria’s “Saving Lives with Malaria Control: Counting Down to the Millennium Development Goals” report provides encouragement when one reads that, “it is estimated that in the past 10 years, scaling up malaria prevention has saved the lives of nearly three quarters of a million children in 34 malaria-endemic African countries, 85% of these in the past 5 years alone.”

This is the latest report in RBM’s Progress Series and indicates that, “the results suggest that if current scale-up trends are maintained until 2015, another 1.14 million African children’s lives will be saved between 2011 and 2015.”

On the other hand, RBM warns that, “if funding were to cease in 2010 and prevention efforts were to fall, an estimated 476 000 additional children would die in that same period.” Is it possible that a greater focus on future eradication of malaria could distract from saving lives now and reaching the 2015 Millennium Development Goals?

The New York Times reported three years ago that, “challenging global health orthodoxy, Bill and Melinda Gates called for the eradication of malaria.” According to the Times, the Gateses labeled this call to action ‘audacious,’ while some partners called it ‘inspirational,’ ‘noble but quixotic’ and even ‘harmful.’

Now the Seattle Times reports that Bill and Melinda Gates are, “revamping the scientific agenda with their eyes on the controversial goal they set three years ago: driving malaria to extinction”

Justifying the focus, the Seattle Times indicated that, “Although total eradication of the disease may be as much as forty years away, it’s important to start work on drugs and vaccines that could take a decade or more to bring to the field, David Brandling-Bennett, leader of the Gates Foundation’s malaria programs.”

The implications of “The increased focus on the future means the Gates Foundation is ending its support for some efforts to lessen the disease’s current toll. Those include research to improve treatment of the severe infections that strike children and pregnant women, and that are responsible for most of the estimated 850,000 annual deaths from malaria,” according to the Seattle Times. Fears have arisen that this change by Gates, due to its financial influence, may pull resources away from other malaria research and program implementation efforts.

pledges-to-global-fund-august-2009.jpgOn the programming side, Gates has pledged 3% of the total Global Fund pledges as of August 2009, which is three-quarters of the funds pledged by all non-governmental organizations (foundations, corporations, etc.). While this is important, it is unlikely that even if Gates does not continue its support for programming, the bigger threat to major malaria funding sources – i.e. governments – is the current weak global economic environment.

We can all agree that Bill and Melinda Gates have influence. Currently they are using it to advocate to other wealthy individuals, corporations and foundations to contribute more toward charitable pursuits. In the area of malaria, they can also advocate with governments – both donor and endemic – to maintain and increase their financial support for malaria control and elimination. By then the new malaria tools deriving from Gates-supported research may be ready to carry elimination into eradication world-wide.

ITNs &Universal Coverage Bill Brieger | 13 Sep 2010

Universal LLIN Campaigns Integrated with Maternal Newborn and Child Health

Guest Blog by Tony Anammah, DELIVER PROJECT, Nigeria

image0179a.jpgThe Universal LLIN campaigns in Sokoto, Kebbi, Kaduna and Adamawa States had one thing in common – the LLINs were provided alongside other interventions like immunization (especially polio), nutrition screening, vitamin A supplementation, deworming and provision of ante natal care services.

A quick assessment of what transpired during the Child Health Week in these states showed that there was some level of success in integrating the interventions in the above metioned states. This success was in terms of the fact that communities were more willing to accept polio immunization because of the  ‘mosquito’ nets. The Immunization Plus Days (IPDs) actually provided a good structure for the delivery of these nets to households and the structure designed for the distribution of the nets (if it had been stand alone campaigns) was modified to incorporate all the interventions.

The challenge was not if the communities will accept the nets or ensuring that the nets gets to all the communities. The major challenge is if the households will actually use the nets. This needs to be closely monitored and followed up. There was an end process monitoring after the campaigns but it will be interesting to know how well the households are using their nets some months later.

image0175a.jpgEven though there were some successes, there were a number of challenges. One of such challenge was that the time to plan for such an elaborate campaign to integrate all the interventions was evidently too short and there were clashes in programmes delivery strategies. There were some level of cooperation between the programme managers but at the same time, each manager was equally keen on delivering on their individual programme obejectives.

On the average, it can be said that there was some level of success but  it will be wonderful to see if this kind of attempt to integrate interventions can be sustained and lessons learnt incorporated into strategies. But most importantly, it must be ascertained if integrating these interventions has actually been beneficial to the fight to reduce mortality due to malaria.

Vaccine Bill Brieger | 08 Sep 2010

Vaccine without pain – a future for malaria control

During a discussion organized the Bill and Melinda Gates Foundation, Chris Wilson explained that vaccines are one of most efficient and effective interventions ever developed. Among the discussants was Tycho Speaker who is doing research on transdermal delivery systems using microneedle systems.

Dr Speaker is the primary contributor in developing TransDerm’s proprietary soluble microneedle technology, which is finding utility in skin therapeutics and skin-based vaccinations. This vaccine research has received specific funding for malaria prevention from the Bill and Melinda Gates Foundation under their Grand Challenges Explorations program.

phase-iii-rtss-trials-dave-poland-path-malaria-vaccine.jpgChris Wilson emphasized that, “We need to do better job to ensure vaccines reach people who need them and increase coverage.” The microneedle patch technology may be able to achieve this for malaria vaccines that are in the pipeline.

Normally such technology may take ten years from conceptualization to actual use in the population. Gates has given Dr Speaker’s group a preliminary one year grant to test the concept, and then there is the possibility for a second grant to develop the practical applications of the microneedle patch if the results are encouraging.

The patch actually resembles a bandaid. The microneedles penetrate the skin and dissolve so there is no medical sharps waste. The vaccine itself in made into a powdered form and is stable without the need for coldchain.  The speakers stressed the practicality – the patch vaccines could even be transported on motorcycle to peripheral health facilities that have no electricity.

The patches can be printed with a picture or pattern that appeals to children and parents to address the perennial vaccine problem of community acceptance.  Within 2-10 minutes the vaccine will be delivered.

The discussants concluded that a small increase in compliance can have enormous effect on the vaccination effort overall, especially when there is no pain. It’s good to know that researchers are not simply looking for an effective malaria vaccine, but also for delivery mechanisms that will make the vaccines more acceptable and actually used.

Private Sector &Procurement Supply Management Bill Brieger | 08 Sep 2010

Diversions – bumps in the road to malaria elimination

During visits to private pharmacies in 11 African cities from late 2007 to early 2010 Bate and colleagues purchased 894 samples of antimalarial medicines. Overall 6.5% of these medicines had evidence of being diverted from the public health system. This was only 4.2% of the older malaria therapies, but 27.8% of the 151 ACTs had come from the public sector.

global-fund-coartem-found-at-pharmacy-in-angola2.jpgThe ACT diversion problem was most noticeable in Nairobi, Lagos, Kampala, Luanda and Dar es Salaam.  The photo here shows ACTs we found in a small pharmacy shop down the street from a clinic in the suburbs of Luanda in 2008. Informal discussions in Luanda with donors also revealed major problems of theft from the ports. Specifically, the Boston Globe reported that, “According to an audit last year by the US President’s Malaria Initiative, about $640,000 worth of medicines sent to Angola vanished from airports and the government’s medicines warehouse.”

The authors are the first to admit that the study design is not perfect and that their sample size could have been larger, but the key issue is that they have actually documented the ‘leakage’ of these donated medicines from the people who need them. This moves the problem beyond the anecdotal level.

Medicines are not the only area where the diversion makes malaria commodities take a detour. Nets disappear, too.

Last year’s universal LLIN distribution in Kano State, Nigeria experienced some challenges in terms of reaching people and their retaining nets.  The goal was two nets per household, but a report by donors after the distribution found that 28% of households surveyed got only one. Seven percent of nets that reached households were also ‘lost’. So far there have been no mechanisms like the study by Bates and colleagues to trace nets into the private sector or elsewhere.

The main issue we see is that health systems need to be strengthened and public education needs to be improved – in this was diversions will be less likely and the public can serve as a watchdog for any malpractices and take an active role in rolling back malaria in their communities.


ps –

08 Sep 2010 17:37:32 GMT

Source: Reuters