Posts or Comments 18 July 2024

Monthly Archive for "October 2010"

Eradication &Surveillance Bill Brieger | 31 Oct 2010

thoughts on elimination

Sarah Boseley of the Guardian has opined that, “not to say that elimination should no longer be contemplated. It’s just more possible in some countries than in others.” Some comments we added to her blog follow:

When Melinda Gates used the ‘E’ word, she did add the caveat that eradication would not be in the immediate future, and as we have learned, the Gates Foundation has invested a lot in vaccine research.  Even with the addition of a vaccine, malaria elimination will continue to require multiple tools adapted and adopted according to the epidemiological situation of the area. Surveillance will continue to be the foundation tool for any effort to eliminate a disease.

The overall question of when can we start seriously talking about elimination requires a quick look back in history. Medical News Today in reviewing Feachem’s recent Lancet article, notes that, “Up to 1945, about 178 nations had endemic malaria. Since then 79 countries have eradicated the disease.” (Technically they have eliminated malaria since eradication only occurs when elimination country-by-country has occurred worldwide).  So 44% achievement in elimination over 65 years means _____ (your guess – fill in the blank).
There has been massive scale-up of malaria control activities over the past 5 years, but even with this, ensuring that an insecticide treated nets are inside a household does not guarantee that people will use them according to recent Demographic and Health Surveys and Malaria Indicator Surveys.

The danger of targeting a specific year is that once that year passes, donors and the public lose interest.  This is why it might be logical in the near term to ensure that appropriate malaria control and elimination activities are integrated into basic and universal primary health care services – which hopefully will not go out of style.

Surveillance Bill Brieger | 29 Oct 2010

Is malaria a neglected disease?

paho_logo_malaria2010.jpgThe answer to this question depends on context.  The tropical area with the lowest burden of malaria is in the Americas. The World Malaria Report of 2009 notes that while 21 countries in the region are endemic for malaria, “The number of cases reported in the Region decreased from 1.14 million in 2000 to 572,000 in 2008 (out of 243 million estimated cases worldwide).

Twelve countries in the Americas have seen reductions greater than 50% and four are in the elimination or pre-elimination phases.

As the number of cases reduces, neglect is surely possible. This may be why an announcement for Malaria Day in the Americas appeared on the website of End the Neglect. Malaria Day became a fixture in the Americas in 2005 when targets were set “to achieve a reduction of the malaria burden by at least 50% by 2010 and 75% by 2015.”

A recent editorial in the Lancet on NTDs warns that, “With more people getting treated, the need to monitor and assess changes in disease epidemiology, transmission, and treatment compliance remains a challenge. Monitoring and evaluation is crucial to modify strategies as needed, and to ensure that the best tools are in place for prevention, control, and even eradication of some diseases.”

The World Malaria Report (2009) observes that, “the Region of the Americas (has) updated information from household surveys and other information on the number of cases detected by surveillance systems.” Maintenance of such as system is crucial so that malaria will not become neglected in the region. This effort should also serve as a lesson to other countries that are nearing malaria elimination … surveillance cannot stop until we are free of malaria.

Development &Funding &Mortality Bill Brieger | 28 Oct 2010

Does Development Aid Work?

David Reiff, in reviewing the book Famine and Foreigners: Ethiopia Since Live Aid by Peter Gill, quoted William Easterly, who argues “not only that much aid is wasted—about this optimists and skeptics largely agree—but that, after five decades, outside aid, whether given by governments or by the increasingly important philanthropic sector … has done little to alleviate the condition of the world’s poor.”

angola-children-get-nets-an-child-welfare-clinic-sm.JPGThis view provides an interesting contract to a review by Steketee and Campbell entitled “Impact of national malaria control scale-up programmes in Africa: magnitude and attribution of effects.” These two authors report on studies occurring up to the end of 2009, that identified a three-fold increase in ITN household ownership (34 studies) and in malaria-endemic countries in Africa, with at least two estimates – pre-2005 and post-2005 when massive scale-up started.

Another key finding of the scale-up review was child “mortality declines have been documented in the 18 to 36 months following intervention scale-up.” They concluded that while, “Several factors potentially have contributed to recent health improvement in African countries, but there is substantial evidence that achieving high malaria control intervention coverage, especially with ITNs and targeted IRS, has been the leading contributor to reduced child mortality.”

In contrast to the pessimism of the wider development Aid Community, Steketee and Campbell stress that, “The documented impact provides the evidence required to support a global commitment to the expansion and long-term investment in malaria control to sustain and increase the health impact that malaria control is producing in Africa.”

Reiff also refers to James Grant, the former Unicef Executive Director who “was as unyieldingly optimistic about human possibility as he was clear-eyed about the extent of human suffering among the bottom half of the world’s population.”  The fact that Grant’s “optimistic scenario for what could be achieved has not come to pass does not necessarily mean that Grant was wrong to say – as, were he alive today, he almost certainly would say – that there was every reason to believe that it could do so.”

The political factors described by Gill that have ‘created’ modern famines are also likely to affect development work as it relates to malaria. Ironically Ethiopia, the scene of this famine narrative is also one of the success stories in malaria control. Were he here today James Grant might look at the unfolding malaria story and find support for his optimistic views of development.

That said, the ultimate success of malaria control rests in free, open societies where equitable access to all malaria interventions is possible for all citizens.

Equity &Integration &Procurement Supply Management Bill Brieger | 27 Oct 2010

Health Posts – meeting rural needs

People living in rugged rural terrain often go without formal health services. The population may be remote and even migratory, as some herd cattle.

dscn0659a.JPGAngola is working to ensure that at minimum there are Health Posts staffed by trained nurses to provide services beyond the municipal/district headquarters. And since onchocerciasis is common in many of such areas, we are also talking about providing integrated disease control and health care ‘beyond the end of the road,’ as advocated by the African Program for Onchocerciasis Control.

Life for these nurses is not easy as there is usually just one staff member to run the post. Also this situation means that male nurses predominate – one reason why it is presumed that antenatal care may not be easy to provide.

dscn0699-sm.JPGA visit to such a health post recently showed that not only was the nurse enthusiastic, but that he could provide some of the basic components of antenatal care in all but name.

The post had a good supply of sulphadoxine-pyramethamine that is required for intermittent preventive treatment of malaria in pregnant women. There were other medicines and supplements routinely given pregnant women such as ferrous sulfate and de-worming drugs.  The nurse even had a fetal stethoscope.

Strengthening these rural outposts is a priority for malaria control and health equity. These rural populations do not even have access to medicine shops as found in some areas.

Regular supplies of nets, RDTs, ACTs and SP will guarantee that all parts of Africa can work toward reducing malaria deaths by 2015.

Health Rights &Resistance Bill Brieger | 15 Oct 2010

If Myanmar cannot control malaria, what of Burma?

Myanmar has operated only three Global Fund Grants in its history. The Round 3 Malaria grant was terminated at Phase 1 in 2007. Two million dollars was disbursed, but no results were found in the progress report at the Global Fund website. No explanatory notes were offered.

In the meantime, malaria continues unabated. Reports from a remote rural area observe that, “About half of the villagers in this remote corner of Kachin State are suffering from the mosquito-borne disease, but medical supplies provided by the Kachin Baptist Convention (KBC), a Christian group, ran out two weeks ago.”

The website explains that villagers are reluctant to complain because, “In military-ruled Myanmar, saying anything seen as critical of the authorities can have serious consequences.” Instead villagers wait as they lack money needed to reach clinics and thus, resort to indigenous treatments.

Reports from the KBC indicate that they only had the resources to assist about five percent of the Kachin population in the fight against malaria. The mission group complained that, “There are many people we can’t reach, and it’s getting worse. It’s linked to poverty. Most of them can’t even afford mosquito nets.”

Myanmar does have an unsigned Round 9 malaria Global Fund grant pending. One wonders whether performance would be any better than Round 3.

Myanmar is part of the broader Mekong area where fears of malaria drug resistance are a constant concern. IRIN reports that, “Mekong countries of Cambodia, China, Lao PDR, Myanmar, Thailand and Vietnam, show (malaria drug) tolerance … with the drug proving less effective and taking longer than previously to kill the parasite.”

IRIN noted that, “… studies in Myanmar had shown that parasites were still detected in some cases after treatment, taking more than a benchmark three days to be cleared …  This is an indication that there is resistance .” Furthermore, “only around 500,000 ACT courses are available annually – a fraction of what is needed to treat an estimated 8.5 million malaria cases.”
wikimedia-commons-myanmar.jpgAccess to malaria treatment and prevention is not a unique problem. IRIN reminds us that in the wake of a major tropical cyclone in 2008 the Myanmar population in affected areas was threatened with malnutrition and diseases due to lack of adequate access to food and medicine. This health neglect is endemic.

Will new elections help? BBC reports that a group of 15 nations, “known as the Friends of Burma, called for inclusive, participatory and transparent elections. Afterwards the secretary general said he had expressed concern that conditions in Burma do not measure up to what is needed for an inclusive political process.”

Without an inclusive political culture can the political will and accountability exist to control and eventually eliminate malaria? This is not just an issue for the poor and suffering within Myanmar since practices there enhance malaria drug resistance in the region and ultimately the world.  If Myanmar cannot control malaria, one wonders if Burma could.

Eradication Bill Brieger | 11 Oct 2010

Is eradication really forever?

Spain has reported a case of indigenously transmitted malariaP. vivax. Although there are up to 500 ‘imported’ cases annually, it is believed that the local vector, Anopheles atroparvus, was responsible.

The last such case in Spain occurred in 1961. “Malaria was officially declared eradicated in Spain in 1964,” according to the Examiner. Technically the term for removing malaria from one country is elimination, while eradication is reserved for worldwide cessation of transmission, but whatever one calls it, the situation in Spain shows that we cannot be complacent once we think malaria might be gone from a country.

A similar experience occurred in Virginia in the USA in 2002. “Two cases of Plasmodium vivax malaria near the US capital seem to have been acquired locally from indigenous malaria carrying mosquitoes breeding in the area, not from malaria carrying mosquitoes escaping from Dulles international airport.”

Malaria shows a penchant for moving with its human hosts. In observance of the 400th anniversary of the settlement of Jamestown in the USA, National Geographic Magazine (2007) made the claim that, “Colonists carried the plasmodium (vivax) parasite to Virginia in their blood. Mosquitoes along the Chesapeake were ‘infected’ by the settlers and spread the parasite to other humans.”

botdistributiongrad.jpgMany countries on the frontline of malaria elimination such as Botswana and Namibia should be concerned. First more attention is being paid to high burden countries than those close to elimination. Secondly, opportunities to learn how to achieve elimination are not receiving donor attention. This attention needs to include strategies for keeping malaria out once elimination has been declared.

For example, in its Roadmap to universal coverage Botswana documents …

  • No specific govt allocation towards LLINS
  • National requirement for universal coverage is 400,000
  • Need to re-orient the program towards pre-elimination
  • Inadequate resources for malaria focal persons

Malaria is a moving target. Are we ready to keep up the chase?

Efficacy &Migration &Resistance &Surveillance Bill Brieger | 10 Oct 2010

Will malaria parasites defy elimination?

Three new articles in Malaria Journal plus a news release from the Commonwealth Games in India remind us that like any other organism, the malaria parasite will fight for survival.

Yvonne Lim and colleagues document a rare case of P. ovale imported into Malaysia. They note that local vectors are capable of transmitting this parasite as well as an “exponential increase in the number of visitors from P. ovale endemic regions.”

A Nigerian table tennis player at the Commonwealth Games in India withdrew after coming down with malaria. The Times of India implies that the illness may be a result of “The Capital’s dreaded mosquitoes.” Depending on when he arrived in India, Ekundayo Nasiru could have brought the disease with him. In either case the potential for importing and exporting malaria exists.

Now under way in several pilot countries, “The Affordable Medicines Facility-Malaria (AMFm) is a mechanism to increase access to quality assured ACT.” AMFm hopes that with approved and cheaper artemisinin-based combination therapy (ACT) drugs monotherapies will be driven from the market and the lifespan of ACTs will be prolonged, thus “reducing the likelihood of resistance to artemisinin.”

artequin-child2.jpgUnfortunately, another article in Malaria Journal reviews “Declining in clinical efficacy of artesunate-mefloquine combination has been documented in areas along the eastern border (Thai-Cambodian) of Thailand.” After identifying cases of recrudescence after treatment, the researchers concluded that …

Although pharmacokinetic (ethnic-related) factors including resistance of P. falciparum to mefloquine contribute to some treatment failure following treatment with a three-day combination regimen of artesunate-mefloquine, results suggest that artesunate resistance may be emerging at the Thai-Myanmar border.

These experiences show how important it is not only to document drug resistance and imported cases but also to help countries plan “Robust Malaria surveillance systems towards malaria pre-elimination and assessing Roadmaps achievements,” which is the theme of a meeting of the East Africa Regional Network (RBM) underway in Kigali. More technical assistance is needed in “strengthening Malaria surveillance in high and low burden countries,” if elimination goals are ever to be achieved.

Funding &Partnership &Procurement Supply Management Bill Brieger | 08 Oct 2010

GAPS – funding, oversight and participation

AIDSPAN has produced another valuable issue of the Global Fund Observer (GFO) that reports and analyzes the challenges of implementing Global Fund grants. Three of the main articles address serious gaps in various areas of programming.

The first gap is one of funding. As we discussed recently, even with an overall increase in pledges to the GFATM, the amounts are inadequate to achieve goals. The inability to raise funds at all level shows serious weaknesses in commitment and planning. AIDSPAN notes consequences of this such that for example …

In fact, though, this week’s pledges provide only $2.9 billion for Rounds 10, 11 and 12. The current estimate of the cost of Phase 1 of Round 10 is $2.0 billion. So the prospects for adequately funding Rounds 11 and 12, and Phase 2 of Round 10, are currently bleak, unless funds significantly in excess of this week’s pledges end up being raised.

dscn0330-community-health-nurse-officer-in-stma-chps-sm.JPGThe second gap is in oversight of procurement and supply management (PSM). “Deficiencies in the oversight of procurement and supply management (PSM) arrangements may be exposing Global Fund grants to unnecessary and unacceptable risks. This is one of the conclusions of an audit report released by the Fund’s Office of the Inspector General (OIG) in April 2010.”
Some of the main PSM deficiencies as summarized by GFO are –

  • weak forecasting of requirements for drugs and health product
  • weak technical specifications for procurement
  • absence of, or weak, procurement policies and procedures
  • poor inventory management
  • poor storage and transportation facilities at national and sub-national level
  • weak procurement planning resulting in frequent emergency procurements and
  • inadequate management information systems

The third major gap reported in the GFO is lack of civil society participation in County Coordinating Mechanisms (CCMs) for global fund grants. The article highlights the Civil Society Action Team’s recent report. This report documented the fact that while persons affected by the three diseases in theory have representation on CCMs, they often do not take part in the real decision making.

In particular, “civil society representatives often lack the capacity and expertise to fully engage in CCM processes and to properly represent their constituents.” Lack of participation threatens the relevance and acceptability of programs.
These gaps focus on weaknesses basic health systems management processes and competencies. It is not enough to point out these gaps. Serious efforts are needed to strengthen health systems. Unless these three gaps are closed, partner interest in pursuing the noble goals of disease control and elimination will be threatened.

Funding Bill Brieger | 06 Oct 2010

Swimming Upstream

Eric Goosby of the President’s Emergency Plan for AIDS Relief, or PEPFAR, has likened the effort to get more funding for HIV/AIDS control in the current economic climate as “swimming upstream.”

Even so, The Global Fund reported that the United States pledged “US$4 Billion to The Global Fund to Fight AIDS, Tuberculosis and Malaria for the period 2011-2013. The pledge is the largest ever by a donor to The Global Fund and represents one of the largest increases by an individual donor country to the Global Fund for this replenishment period.”
The increases did not satisfy all. The New York Times reports that, “AIDS activists vented open frustration, both with the overall result and the American contribution.” The challenge remains that even with heightened funding, the actual amount was just barely able to “reach even its lowest ‘austerity level’ fund-raising target of $13 billion — the amount (The Global Fund) had said it needed just to keep putting patients on treatment at current rates,” according to the Times. This echoes recent reports of inadequate funding to meet malaria targets.

On a positive note, contributions by corporate partners are increasing. The Global Fund announced that, “Chevron Corporation (NYSE:CVX) today announced that it will commit an additional $25 million to The Global Fund to Fight AIDS, Tuberculosis and Malaria, raising its 6-year investment in the organization to $55 million. This is now the largest contribution from a single corporation.”

Finally, Dr Goosby explained that …

The battles against malaria and tuberculosis will also suffer, but the effect on AIDS is easier to measure. Malaria waxes and wanes with hot weather and local spraying. The TB epidemic echoes the AIDS epidemic because so many people have both, but TB can be cured in six months, which shrinks case counts rapidly.

When the Abuja targets for Rolling Back Malaria were enthusiastically set ten years ago people did not perceive that finance would be a major problem. Even at the subsequent ATM conference in Abuja in 2006 there was more emphasis on capacity building to deliver interventions.  People argue that the global financial crisis could have been predicted, but that does not help us meet current disease control promises and shortfalls.

New donors are needed – greater corporate participation will help as will increased contributions by upcoming economic power like China who pledged $US14 Million.  Also greater commitments by endemic countries themselves will be needed to sustain efforts.

Funding Bill Brieger | 03 Oct 2010

Malaria Investments at Risk

While Robert Snow and colleagues have some good news to report – an increase in malaria funding by 166% since 2007 – the overall message of their article in The Lancet is that we are well below financial targets to maintain the level of malaria control expected for achieving RBM’s 2010 goals.  This is particularly true in countries where P. vivax predominates.

This “60% global shortfall in funds for malaria control” combined with less than effective roll out of malaria interventions, as we recently discussed, bodes ill for achieving MDGs.

According to The Lancet article a major part of the problem is not adequately targeting the poorest countries and sustainability of funding: “More efficient targeting of financial resources against biological need and national income should create a more equitable investment portfolio that with increased commitments will guarantee sustained financing of control in countries most at risk and least able to support themselves.”

The BBC quotes the authors as saying that not only does the funding shortfall increase the risk on malaria resurgence, but could also mean that the nearly $10 billion invested since 2002 would be in vain.

Why would be take the risk of turning this second international push toward malaria elimination into a repeat of the first eradication effort? Aside from the overall inadequacy of funding, the issue of targeting countries is crucial.  Do existing funding mechanisms ensure that support for malaria control and elimination actually goes where there is most need, and are endemic countries themselves contributing as much as possible to support and sustain these efforts?

pathway-to-elimination-figure2-10a.gifGlobal Fund monies flow to countries that can write the best proposals, not necessarily those in most need. US government support for malaria then ties in with existing donor support like the Global Fund in order to add that extra push for achieving targets. Neither of these efforts begin from the question of where is there the most need.

On top of this, though lip-service is given to health systems strengthening, it has not received priority attention by countries, such that we are faced with procurement, supply and implementation challenges that threaten what funding is available.

It is time for the Roll Back Malaria Partnership to rethink how best to support progress along the pathway to elimination and not just let the funding chips fall where they may. Lets put the country road maps to good use.