Tropical Health Matters

Arsenio Manhice from Mozambique reports on a program that will be launched shortly in the northern part of the country …

More than 100,000 people are covered by the Program of Communities against Malaria (PCM) to be launched in Pemba-Metuge in Cabo Delgado Province, northern Mozambique, on Monday, December 20.

The act will be directed by the provincial governor, Elisha Machava and will be attended by the Interim Director of USAID as well as representatives of Mozambique and the Aga Khan Foundation of Advancement Organization supporting the initiative.

Among the population of the nine communities of the province, estimated at about 396 000 people, about 87 000 and 500 children under five and pregnant women and 21 000 and 700 people living with HIV and AIDS will benefit from the program in allusion.

The PCM is a partnership between the U.S. President’s Malaria Initiative (PMI) with Mozambique Aga Khan Foundation (AKF Mozambique), the Progress Organization and the Ministry of Health (MOH). This program will run for three years and will be implemented in nine districts of Cabo Delgado Province.

The districts were selected based on their health indicators, malaria, poverty, lack of community interventions and firm long term commitment, the AKF and Progress, to develop these areas.

The purpose of PCM is to reduce morbidity and mortality caused by malaria in Mozambique, particularly among pregnant women, children under five and other vulnerable groups of population in the districts of Quissanga, Meluco, Ibo, Pemba Metuge, Macomia, Mueda, Nangade, and Muidumbe Ancuabe.

The program was designed in collaboration with all key stakeholders and specifically aims “to broaden the scope and coverage of existing interventions, while making the local capacity for sustained control of malaria” in Mozambique

The total program cost is $ 1,625,997 (one million, six hundred twenty-five thousand, nine hundred ninety-seven U.S. dollars), of which USAID provided $ 1,482,502 (one million four hundred and eighty-two thousand, five hundred and two U.S. dollars), and will be co-financed by U.S. $ 143,495 (one hundred forty-three thousand, four hundred ninety-five U.S. dollars) of nongovernmental funds.

The burden of malaria is made worse when medicines consumed to treat the disease are either fake/counterfeit or substandard. This may result from intentional and illegal processes or as a result of poor shipping and storage procedures that reduce efficacy or allow expiration. Over 15% of drugs sold may be fakes.

Two recent initiatives hope to prevent the consumption of counterfeit malaria drugs.  JustMeans.com reports on a way to empower consumers in detecting fakes in Ghana and Nigeria. “Ghanaian social enterprise MPedigree and Hewlett Packard have launched a lifesaving service that will combat counterfeit pharmaceuticals by enabling people in Ghana and Nigeria to verify the authenticity of their malaria medication via text message.”

A scratch-off code found on the medicine packaging can be texted to a free number to verify the drug’s authenticity. Local pharmaceutical companies are actively involved in the process.

A second approach is being made possible through pilot activities of the Affordable Medicines Facility for malaria (AMFm), which is being managed by the Global Fund. AMFm intends to make appropriate approved malaria medicines available in public and private settings at prices comparable to the old first-line drugs, chloroquine and sulphadoxine-pyrimethamine. This will hopefully drive unapproved and potentially fake medicines from the market.

In Nigeria, “the official take off of the (AMFm) project in January … appears set to halt malaria related deaths from its communities by making available high quality, affordable and effective Artemisinine-based Combination Therapy (ACT) through the public, private, non-profit and for-profit organizations to all its citizens.” ACTs, which are normally quite expensive, will become more accessible.

As malaria elimination efforts become more effective. Timely surveillance and treatment will become even more important. Other tools like the use of minilabs can help. All efforts must be focused on maintaining the quality of our malaria drug supplies in order to reduce morbidity and achieve the Millennium Development Goals.

Arsenio Manhice, a journalist from Mozambique, provides us an update on malaria research at a leading institute in his country. A version of this report appeared in Portuguese in the newspaper “notícias“:

A series of scientific initiatives are underway at the Center for Research in Health Manhica (CISM) aiming to provide solutions to tackle the problem of resistance to drugs and insecticides used against malaria.

According to Eusébio Macete, Director of the biomedical research institute, among other initiatives, scientists are collecting mosquitoes that transmit the malaria parasite. The exercise includes an analysis of the different episodes of illness in people who arrive at clinics in the district of Manhica.

“We hope to have a block of information that can monitor the trend of malaria in its most complex context. That is why we consider the clinical aspects and impact of various measures are being introduced to control the disease as spraying, use of mosquito nets and medication,” the Director said.

For the purpose of study and possible solutions, the researchers began to distribute mosquito nets in the province of Sofala. Districts were chosen Inhaminga, Mwanza, Nhamatanda and Gorongosa.

This is a joint initiative between the Centre for Health Research Manhiça, US President’s Malaria Initiative (PMI) of the United States, PSI and the National Malaria Control Program. PSI is involved in the local distribution of mosquito nets.

In Manhica CISM will monitor the transmission of malaria to know how it varies. “We do what are called cross-sectional studies that look at aspects such as the number of people who were infected and number of mosquito nets, houses fumigated and malaria cases registered in hospitals,” the Director said. It is an annual activity.

Studying malaria in pregnant women is another component of research that is being seen by scientists. This arises because one of the guidelines of the National Malaria Control is using intermittent preventive treatment with sulphadoxine-pyrimethamine (SP).

Due to the resistance of parasites to SP in other countries, the CISM is preparing a new alternative to save pregnant women. The initiative is from Mozambique and four other African countries. Having started in March 2009, the study ends in the middle of next year. “The goal is to see if mefloquine might have the same effect as SP in terms of preventing malaria in pregnancy.”

New solutions are not enough. Macete encourages people to use the tools to combat malaria are available. “Certainly there is a complexity that is the durability of the nets during the rainy season. The technicians who do the spraying must find the balance needed for example to do more patrols and use insecticides that last longer,” the Director stressed.

For now, the scientist believes that much work must be done to adjust the conditions of the country versus the available financial resources, characteristics of transmitters and type of insecticides available in the market.

In today’s guest report, Michelle Wallon from Jhpiego’s Zambia office discusses the challenges of maintaining stocks of sulphadoxine-pyrimethamine (SP) for use in Intermittent Preventive Treatment for pregnant women (IPTp) that arose during recent Roll Back Malaria meetings in Livingstone and Lusaka:

The effects of malaria in pregnancy are many and the interventions, simple.  Intermittent Preventive Treatment (IPTp), insecticide-treated bed nets, and timely case management can reduce effects including maternal anemia, low birth weight, and maternal and fetal mortality. Yet, when speaking to clinicians and public health experts across Africa about prevention and control of malaria in pregnancy (MIP), there is a common theme – stock-outs of SP, the drug used for IPTp, commonly inhibit the effectiveness of MIP interventions.

IPTp is relatively straight-forward and SP, is an inexpensive drug.  Furthermore, at the time that the IPTp recommendations were adopted via the Abuja Declaration in 2000, many countries were still procuring SP as the first-line treatment for the general population (For example, Nigeria did not officially switch to ACTs as firstline malaria drugs until 2005).

SP supplies were abundant when it was still recommended as treatment. What then is the problem now?

Although SP stock-outs are formally documented in only a few African countries, including Zambia, Tanzania, and Malawi, the problem can be inferred by most of the recent Demographic and Health Survey and Malaria Indicator Survey reports (e.g. Liberia, Nigeria, Uganda, Senegal) showing low coverage of the recommended two doses of IPTp. MIP experts readily and repeatedly identify a handful of culprits for the SP stock-out phenomenon.

One set of problems surrounds continued and irrational use of SP for treatment in RDT-negative cases in the general population that siphon off SP supplies from MIP services. These stem from …
• Provider mistrust of RDTs coupled with policies that ACTs be provided only after positive diagnosis via RDT or microscopy
• Real or perceived high incidences of malaria
• Strong correlation in the community between fever and malaria with high expectations for malaria treatment
• Weak clinical skills in the appropriate diagnosis and management of fever
• Lack of skilled providers and high client loads

Inaccurate SP quantification based on population rather than consumption data and/or quantification failing to account for irrational use also create stock problems. Weak logistics systems with bottlenecks between central-level drug stores and receiving facilities result in stock-outs of both SP and ACTs.

These problems are not new and neither are the solutions.  MIP has a potential advantage in that it falls under both reproductive health and national malaria control programs, and yet the persistence of SP stock-outs indicates that this is often used less as an opportunity for collaboration than as an excuse to pass the buck.

As the public health community moves towards more integrated programming, we must seize the opportunity to bridge the programmatic gap.

The Uganda Malaria Indicator Survey for 2009 is now available for reading. The report helpfully provides charts that distinguish levels of key indicators from the 2006 Uganda Demographic and Health Survey with the current data. While there has been clear progress, most indicators fall below the 80% targets set by the Roll Back Malaria Partnership for 2010.

The chart of the right shows that sleeping under any insecticide treated bed net the night prior to interview tripled for children under five years of age and quadrupled for pregnant women, the 2009 levels do not achieve RBM goals.  Even when one looks only at households that actually possess these treated nets, one finds that use is less than ideal.

The report provides some reasons for low net usage…

The most common reason cited for non-usage was that the net was not hung (58 percent of households), especially in North East region (99 percent). Sixteen percent reported that the net was not used because it was too hot, and 11 percent said the net had too many holes or was too old.

There were also wide variations in ownership and use across different parts of the country, meaning that program managers need to look more indepth at possible regional factors that discourage access to and use of nets.

The East African countries were among the pioneers to introduce intermittent preventive treatment with sulphadoxine-pyrimethamine for pregnant women.  Again we see that RBM targets are far from being met in Uganda, although progress over 2006 is evident.

• 16% of pregnant women got two doses in 2006
• 45% got one dose in 2009
• 32% got two doses in 2009
• 95% of pregnant women attended ANC with a skilled provider at least once in 2009

Clearly problems of procurement, supply and stock keeping and missed opportunities are preventing achievement of this goal.

The malaria case management picture was not cheering. Among children under five years of age with a reported fever in the two weeks before the survey …

• 60% took any antimalarial drug
• 23% of took an ACT
• 14% took ACT same or next day
• Chloroquine and SP were still being used

Uganda is not in a unique situation. Even countries benefiting from the Global Fund, the US President’s Malaria Initiative and other major partners like Unicef, DfID and the WOld Bank are having a challenging time with managing commodities, improving service quality and attracting clients to avail themselves of malaria services.

2010 ends in 17 days. How many places will have achieved the RBM 80% targets? More importantly, what can the international partnership do to meet the needs?

Transparency International’s latest poll on corruption across the world was reported by the BBC with the concern that people perceive their countries as more corrupt over time. One of the key institutions responsible for demanding bribes is the police.

BBC’s own poll on the topic found people talking about bribery as a problem more often that poverty, unemployment and other national problems. Although health care was not featured when the issue of to whom bribes were paid was raised, public institutions generally came under scrutiny.

A 2006 press release by Transparency International addressed health care bribes directly. Concerns ranged from direct loss of life when people were denied services to the problem of corruption that allows counterfiet drugs into a country, thus jeopardizing more lives.

Specifically Transparency International stated that, “Corruption is undermining progress towards the United Nations’ Millennium Development Goals, in particular the three related directly to health: reduced child mortality; improved maternal health; and the fight against HIV/AIDS, malaria and other diseases.”

The issue of bribery does not feature prominently in the health literature although it is a major problem threatening quality of care.  A multi-country research project on health worker and client relationships found that health workers were willing to talk about the problem:

… participants in many sites spoke openly about various forms of informal income generation engaged in by health workers. This took the form, for example, of insisting on ‘tips’ before people received treatment and alternative prescribing methods or alternative charging structures for treatment and prescriptions. This open discussion continued despite people saying that talking about it made them feel ‘ashamed’.

Jennifer Hunt in a study of bribery in health care in Uganda found examples in both public and private sectors. Interestingly bribery may be associated with worse quality health care, and bribes may be an attempt to improve this, but to little effect.

When researching a story on health insurance in Nigeria a reporter from the Daily Independent found that, “… off record (some respondents) were soon to confide that a few workers demand inducements before attending to patients. (One) also remarked that while some personnel at the PHCs (Primary Health Centers) do not ask for bribes, most patients are compelled to give them packages when they notice that those who did before them were better taken care of.”

While we have recently reported on large scale corruption involving major donor funds, it is the small scale bribes at the front line level that immediately affect life and death access to malaria and other health services. Can we expect the front line health worker to behave any better than the big national program manager or policy maker? What can we do to end the culture of corruption and achieve our malaria elimination goals?

Scientific American is known for making the latest scientific advances – from dark matter to disease management – accessible to a wide audience.  An article in the November 2010 issue on malaria vaccine progress is generally a good example. The following passage though, may simplify the history of eradication a bit too much.

In the 1960s an enormous campaign wiped out the disease in many parts of the world and drove down its number in others. But that success ultimately bred its own end. As malaria became perceived as less of a threat, global health agencies became complacent; their chief tool, DDT, was found to be toxic to birds, and they largely abandoned their efforts. Malaria numbers roared back more fiercely than before.

Two specific issues from the foregoing do not paint the full picture. First, bird deaths did not stop malaria eradication, though the toxicity issue is true in its own context. The real end of DDT was bred by mosquitoes developing resistance to the pesticide, which was discerned even before the campaign reached its height. The Lancet in reviewing Randal Packard’s book, The Making of a Tropical Disease, a Short History of Malaria, explained that …

It (the eradication campaign)was far too monodimensional, relied too much on DDT spraying, and neglected the palpable problem that the delivery infrastructure was not in place in too many parts of the malarious world. The emergence of widespread mosquito resistance to DDT, and parasite resistance to the cheap mainstay of therapy, chloroquine, compounded the difficulties.

Secondly, at least for colleagues in the US Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO), malaria research overall did not halt. Surely the funding levels were not as high as we see today, but persistent research provided us with new tools including insecticide treated bednets, artemisinin-based combination therapy, and nearly a dozen insecticides for indoor residual spraying, for which we are thankful.

True, these additional tools do not confer permanent immunity as a vaccine eventually should, but their implementation has driven down the number of malaria deaths in many countries, and when a vaccine comes along to strengthen the toolkit, we will be farther down the long road to elimination. The malaria lifecycle is complex, and health systems designed to deliver malaria interventions is equally complex (and challenging), which means we cannot  and should not expect a magic bullet in the near future.

As Randal Packard pointed out a key lesson from the first eradication campaign needs repetition, lest we again blame it all on the birds. Aside from developing insecticide resistance, there was clear indication that the health systems in the most highly endemic areas were not able to maintain continuous IRS application.

Health systems are stronger today, due in part to recognition by partners (international and internal) that malaria cannot be controlled, much less eliminated, without health system strengthening. It is these same health systems that will also be required to deliver the new malaria vaccines, so they better be strengthened before vaccines are rolled out.

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Another short note of concern about the Scientific American article – in a box entitled “Plan B: Vaccine Alternatives” we are correctly shown that the effort to eliminate malaria has other tools that must be sustained. Unfortunately the text refers to malaria as a ‘virus’, though elsewhere in the article the stress on ‘parasite’ prevails.

A few years ago, the Global Fund to Fight AIDS, TB and Malaria (GFATM) issued as evaluation report that among other things documented that among three types of agencies who had served as Principal Recipients (PR) of funds – government entities, international organizations (e.g. UNDP) and Non-governmental organizations – the latter had the best performance record on average.  Not long after, GFATM issued a directive that with all grant applications there must be at least one NGO nominated as PR.

No organization is perfect, but NGOs are known for being flexible and able to innovate and involve the grassroots, particularly the people who are living with the three diseases. In contrast, we outlined the challenges of big government bureaucracies and corruption a few days ago. Now it seems that the ‘disease’ of corruption is more widespread than expected.

Unfortunately it appears to be Mali’s turn in the spotlight now. A press release from GFATM yesterday announced that it had “suspended funding of two malaria grants in Mali with immediate effect and has terminated a third grant for tuberculosis (TB) after it found evidence of misappropriation and unjustified expenditure.” Ironically, one of the suspended PRs is an NGO.

An Associated Press story explained that, “The announcement came two days after Malian Health Minister Oumar Ibrahima Toure resigned without explanation on Sunday.” The story went on to announce that, “The fund said the $4 million appeared to have been skimmed through false invoices, fake bid documents and overcharging for goods and services,” and that 15 unnamed government officials had been arrested. The GFATM Executive Director was quoted as saying …

The Global Fund tolerates no fraud, and we take public action to stop it, recover lost money and establish new and trustworthy channels for resources so they can reach those in need.

The Associated Press story also explained that, “The poor, landlocked West African nation relies on international donors to fund its health system. In August another international body, the GAVI Alliance, which helps get vaccines to developing countries, also froze the funds it gives to Mali because of corruption fears.”

Apparently GFATM officials are in Bamako to rescue the funds and ensure that disease control services are not disrupted, especially in this year when countries are trying to achieve universal coverage. The GFATM press release also indicated that, “Management of the two suspended grants will be transferred to a new Principal Recipient.” A watchlist has been formed of grants requiring closer financial scrutiny including Cote d’Ivoire, Djibouti, Mali, Mauritania and Papua New Guinea.

GFATM is about to disburse its 10th Round of Funding. It is encouraging that over the past 10 rounds relatively few cases of outright embezzlement of GFATM monies and corruption have been documented, because the temptation is certainly large. Sometimes threatened suspension of grants arises simply from poor management and performance.  The fact that GFATM is setting up mechanisms for more accountability among grantees is a timely step.

We have come too far along the pathway toward malaria elimination to be derailed by corruption.

Polio eradication efforts are pushing toward the end. The New York Times, in discussing setbacks in the mostly successful eradication effort such as outbreaks in Tajikistan and emergence of a mutated attenuated vaccine virus that has caused some cases, stressed the importance of ‘more aggressive’ campaigns with the oral virus.

Timing is crucial for any eradication effort, since a disease can get an upper hand again if efforts stall. An example of the aggressive and timely response is a donation by Rotary International of $500,000.00 immediately to UNICEF & WHO in equal parts to contain the current outbreak in DRC and take preventive measures.

The economic benefits of achieving eradication are spelled out in an article in the current issue of Vaccine. The study estimates net benefits of at least US$40-50 billion if transmission of wild polioviruses is interrupted within the next five years and $17-90 billion in benefits from add-on campaigns such as the life saving effects of delivering vitamin A supplements. Awareness of these benefits should add further impetus to wrapping up of the polio eradication program.

Annually, we are now numbering polio cases in the hundreds and guinea worm cases in the dozens, while still malaria numbers in the millions. We are only at the beginning of the road to an effective malaria vaccine. While researchers and program managers worry about whether vaccine efficacy will be proven in ongoing phase 3 clinical trials in sub-Saharan Africa, Rebecca Voelker has pointed out an equally serious problem, developing and implementing an effective malaria vaccine delivery system.

Regulatory approval is just the first step, according to Voelker.  A functional procurement and supply management (PSM) system is needed to ensure that the malaria vaccines get to the point of delivery. Plans are needed to ensure social acceptability and timely uptake.

Malaria programs have an advantage over polio in that there are several different technologies available from which appropriate package of national and local interventions can be planned. Still, we face PSM challenges with the nets and medicines. Hopefully effective malaria vaccines will come along soon, and that as delivery systems are strengthened for nets and medicines, these too, can smooth the way for introduction of the malaria vaccines.

… and of course, we should learn lessons from the global polio vaccination effort, such as the fact that the last stages of an eradication campaign require constant vigilance.

Guest Posting by Bremen Leak, Voices for a Malaria-Free Future, Bamako Office Johns Hopkins University – Center for Communication Programs

The 2010 FIFA World Cup South Africa may be over, but Africa is still fanatic about football.

That’s why the United Against Malaria partnership—forged ahead of the World Cup to raise awareness about malaria through football—continues to fill stadia and airwaves across the continent with critical messages about malaria prevention and treatment. Today it’s the humanitarian face of the CECAFA (short for the Counsel of Eastern and Central African Football Associations), organizer of Africa’s oldest football tournament and the year’s biggest football competition since the World Cup.

A 12-team tournament lasting 16 days, the CECAFA Challenge Cup has drawn as many as 60,000 fans per game since its started on Nov. 27 in Dar es Salaam, Tanzania. These fans are primarily men, considered the decision-makers and breadwinners of Tanzania.

To reach this key demographic, Voices for a Malaria-Free Future, through Johns Hopkins Bloomberg School of Public Health—a founding partner of UAM, has joined forces with CECAFA and local beverage maker Tusker to bring attention to the region’s deadly malaria statistics, one football game at a time.

In Tanzania, for example, malaria claims some 80,000 lives each year—almost one in ten of all malaria-related deaths in Africa. In the long run, those deaths rob football clubs of talent, vitality, and World Cup victory, which is why CECAFA’s chair, Leodegar Tenga, announced last week that CECAFA and UAM “shall be partners forever, until we eradicate malaria.” As a result, five additional CECAFA football federations have since joined the campaign.

The official support of CECAFA and the tireless efforts of Tenga have helped UAM continue to educate fans, inform the media, and engage business and political leaders. As the opening ceremony began, Tanzanian President Jakaya Kikwete joined Tenga on the field to greet the UAM ball boys during the opening ceremony.

Throughout the tournament, UAM banners will fly on the field and in the parking lot. Players, ball boys, team escorts, and officials will wear UAM T-shirts or uniforms. And all printed programs will feature simple messages labeled “winning moves to beat malaria, protect your family, stay healthy, and save money.” These include sleeping under a long-lasting insecticide-treated net every night, visiting a health center for malaria testing and treatment when sick, and encouraging pregnant women to seek antenatal care.

More information on UAM and CECAFA may be found online at www.unitedagainstmalaria.org and www.cecafa.net