Posts or Comments 18 July 2024

Monthly Archive for "April 2011"

Community &Treatment Bill Brieger | 24 Apr 2011

Achieving Progress and Impact – only with the community as partner

world_malaria_day_en.gifWorld Malaria Day 2011 celebrates “Achieving Progress and Impact.” Major increases in intervention coverage and reductions in morbidity and mortality have been documented. Yet we are still a long way to go in achieving targets, especially for protecting pregnant women and treating vulnerable children.

In 2011 key interventions like prompt and appropriate diagnosis and treatment still do not reach all endemic communities. In several countries the health services still do not trust community members, and this is impeding progress, let alone impact.

A common belief among health workers in some countries, from upper level Ministry officials to front line primary care staff, is that the community cannot be expected to handle malaria diagnosis with RDTs and treatment with ACTs. In these locations Roll Back Malaria has yet to roll back the medical model of malaria elimination and trust the affected populations to play a major role in providing their own care.

Years of experience with onchocerciasis control tells a story of initial skepticism that communities could handle ivermectin, and yet 16 years after the African Program for Onchocerciasis Control was launched, over 100,000 communities regularly control and direct their own ivermectin distribution.

Studies by the Tropical Disease Research Program of UNCP/World Bank/UNICEF/WHO have shown that these same communities can effectively develiver malaria control services (ITNs and ACTs) along with their ivermectin duties. 

In Rwanda village health workers are the major providers of malaria diagnosis and treatment using RDTs and ACTs.  It can be done if there is willingness to form working partnerships with communities.

dscn0254a.JPGThe problem goes beyond malaria case management.  Recently the Global Fund pointed out to a grant recipient that coverage targets could not be met without an active role of communities in malaria case management. Communities needed to do more than provide behavior change communication telling residents to trek dozens of kilometers to the nearest health facility for care. 

In fact the Global Fund learned that this country had no policy for community case management of any illness. The nature of such medicalized and inaccessible health care is to condemn thousands of malaria sufferers to death.

Community members can make a difference, as Jhpiego has found in Akwa Ibom State, Nigeria.  Through training and supervision, communities can effectively take charge of meeting their health needs.

Progress will come only when health officials recognize that they cannot achieve impact alone. They must actively involve communities in decision making, planning, service delivery and evaluation of malaria is ever to be eliminated.

Communication Bill Brieger | 20 Apr 2011

malaria in the clouds

Most people have seen “clouds” of words on web postings that highlight the main terms or key words of relevance to that page or entry. A program called Wordle can tranform webpages or documents into such clouds. Below is a Wordle-created cloud of recent postings on Malaria Matters. Such programs might help us communicate key words and concepts in a colorful form.


Peace/Conflict Bill Brieger | 12 Apr 2011

War and Malaria

Today marks the 150th anniversary of the start of the US Civil War. The most common number of deaths attributed to that war is 620,000, a number that surpasses mortality in all other US wars from independence to Vietnam. Ironically two-thirds of these deaths were from disease.

Reports have it that, ” Surgeons from both sides of the Civil War called malaria “ague”,”shakes”, or “intermittent fever”; the illness accounted for 20 percent of all sickness during the war.” This was at a time when people believed that, “… malaria was caused by poisonous vapors emanating from ponds and swamps. While many of the men noted in their diaries the swarms of mosquitoes that attacked during warmer months, and the ensuing sickness that enveloped the camp, they never put the two together.”

Concerning mortality, it was estimated that malaria was responsible for three out of five Federal casualties and two out of three Confederates during the US Civil War. Of course during thie period malaria was commonly misdiagnosed, but “it is estimated that malaria was responsible for killing a full quarter of all servicemen during this time.”

small-wdr-2011-report.jpgTo this day war and malaria are still unfortunate comrads.  A war in malaria endemic regions also disrupts health services for civilians, bring greater misery to the population.

According to the BBC, a new World Bank report questions the focus of aid that emphasizes helping after conflicts and civil wars rather than on preventing conflict in the first place. Violent areas today have a history of violence, and building up health and education infrastructure will not be a sustainable endeavor if the next civil war tears these down.

Peace prevents malaria.

Resistance &Treatment Bill Brieger | 07 Apr 2011

Resistance – a barrier to malaria elimination

whd2011_230x60_en.gifThe World Health Organization reminds us today that, “Antimicrobial resistance is not a new problem but one that is becoming more dangerous; urgent and consolidated efforts are needed to avoid regressing to the pre-antibiotic era.”  It is not just antibiotics that are in trouble, but other microbial agents including malaria drugs.

In the malaria community we are also worried about insecticide resistance.  Growing resistance to DDT was one of the reasons that earlier efforts to eradicate the disease were not globally successful.

WHO explains clearly that human behavior (patients, providers, health service managers and drug manufacturers) plays a big role in developing antimicrobial resistance:

Antimicrobial resistance is facilitated by the inappropriate use of medicines, for example, when taking substandard doses or not finishing a prescribed course of treatment. Low-quality medicines, wrong prescriptions and poor infection control also encourage the development and spread of drug resistance. Lack of government commitment to address these issues, poor surveillance and a diminishing arsenal of tools to diagnose, treat and prevent also hinder the control of drug resistance.

Scientific American this month has two timely articles on antibiotic resistance that also highlight how human behavior exacerbates the problem.  Agricultural use of antibiotics is one major problem. Another revolves around infection prevention procedures (or the lack thereof) in hospitals.

The use of combination drug treatments was expected to slow or prevent the emergence of resistance to another class of anti-malaria drugs, but prior and continued use of monotherapy artesunate drugs in Southeast Asia has raised the specter of resistance developing there and spreading throughout the world following the patterns of chloroquine and sulphadoxine-pyrimethamine. The following steps are designed to help:

  • Treatment only with combination therapies where there is no demonstrable resistance for either component of the combination
  • Treatment based only on positive results of parasitological tests thus avoiding indiscriminant use of malaria drugs
  • Regular/frequent drug efficacy testing using WHO protocols
  • Pharmacovigilence/Surveillance

Donors and National Malaria Control Programs must recognize and fund surveillance activities as one of the central interventions in efforts to eliminate malaria. As this year’s World Health Day theme clearly states: no action today, no cure tomorrow.

Diagnosis &Treatment Bill Brieger | 03 Apr 2011

Making a Difference through Diagnosis

For many years after the launching of the Roll Back Malaria Partnership, the malaria community had been putting the cart before the horse.  As malaria drug policy changed to artemisinin-based combination therapy (ACT) rolled across the African continent in the wake of resistance to chloroquine and sulphadoxine-pyrimethamine, basic diagnostic criteria at the front line clinics still relied on clinical diagnosis, often through well accepted algorithms.

Health workers of all stripes from physicians to clinic aids trusted in their clinical judgement and prescribed ACTs in nearly all cases of febrile illness. This was justified to some extent by the deadly nature of malaria in small children.

Eventually two issues called into question the validity of algorithms and clinical judgement if malaria were to be eliminated.  First, if we actually went to scale in providing malaria treatment for all suspected cases of malaria, we might never find adequate funding to buy all the needed ACTs, which cost upwards to 10 times that of the predecessors.

Secondly, if we were ever to gain a true picture of the malaria situation as interventions were scaled up and prevalence decreased, we could no longer base our health information systems on clinical or suspected cases.

Rapid diagnostic tests (RDTs) were a long time in coming and in many places have still not reached the front lines. Even when RDTs become available, they have not always been used correctly.  Just last year we assessed RDT implementation in Burkina Faso, for example, and found most cases of paludism simple (uncomplicated malaria) were treated with ACTs without testing. The only encouraging note was that following the national sick child algorithm, cases with fever ANCDcough were treated as acute respiratory illness.

dscn9149-sm.JPGCascade training had been rolled out to teach health workers in Burkina Faso to use RDTs, but nearly expired unused RDT stocks were found in their clinics.  Not all RDTs were stored properly to protect against high tempaerature and humidity.

Even when RDTs were used, the existing clinic records systems did not provide a clear space to record RDT results. Some health workers were creative and addre red RDT+ and RDT- notations in their registers where space allowed.  Findings of this assessment are being used to improve training.

Now comes an encouraging study from Tanzania that shows health workers not only can learn to use RDTs correctly. The researchers also found reductions of ACT use in lower transmission areas where previously clinical judgement had resulted in high proportions of febrile patients receiving ACTs.

The Tanzania experience shows the neet for both clear government policies supporting RDT use and well supervised dissemination of these policies out to the front line clinic. Both Rwanda and Mozambique have shown that RDTs can even be effectively used beyond the clinic walls by community health workers. Accurate diagnosis is a key step in th elimination of malaria.