Posts or Comments 25 February 2021

Monthly Archive for "July 2011"



Eradication &Monitoring Bill Brieger | 30 Jul 2011

How important are target dates?

If target dates were realistic, there would have been no more guinea worm in the world as of 1995. As it stands today

“Ghana appears to have broken Guinea worm transmission! With 7 consecutive months of zero cases reported since May 2010, and 14 months after reporting its last known uncontained case in October 2009, Ghana might have conquered Guinea worm disease! Surveillance continues while the Guinea Worm Eradication Program waits and watches. Currently, only four countries continue to report cases of Guinea worm disease: Southern Sudan, Mali, Ethiopia, and Chad.”

Sixteen years after the supposed eradication date approximatelt 376 cases were documented in the first four months of 2011.

Even the famous smallpox eradication effort could not achieve its targets until a paradigm shift occurred that changed intervention approaches from from maintaining high vaccine coverage to case containment that focused on outbreaks – vaccinating in a radius around cases until the disease disappeared.

Another set of goals – 80% coverage with key malaria interventions by the end of 2010 – has come and gone. The country with the largest burden of disease, Nigeria, was able to achieve around 67% of its insecticide treated bednet distribution target by 31 December 2011, let alone actual use by 80% of the population.  Nigeria is not alone in this situation.

The website, Global Atlanta, headlines that “U.S. Works to End Malaria by 2015”. While not technically true, the headline is followed by the actual goal – “The U.S. government is leading the way in ending malaria-related deaths by 2015, the head of the President’s Malaria Initiative said at a youth leadership conference organized by Usher’s New Look Foundation.”

nigeria-mdg5.jpgThe 2015 date refers to the Millennium Development Goals. Many countries find themselves lagging in in the interrelated MDGs (see picture). Our ability to reduce malaria mortality (if not morbidity) depends so much on health systems issues – procurement, supply, distribution, access, and use.

We have to be careful with public goal statements lest we create and then deflate expectations, with the unwanted side-effect of scaring away donors and national financial commitment.  Goals are a public relations tool – just be careful that they are realistic and don’t backfire.

Advocacy &Communication Bill Brieger | 25 Jul 2011

Ghana National Unity Games: Sports men and women become Malaria Ambassadors

wnning-team-certificate-final-sm.jpgBy Guest Writer  – Emmanuel Fiagbey, Country Director, Ghana Voices for a Malaria-free Future

The Johns Hopkins University Center for Communication Programs (JHU/CCP) Voices for a Malaria-free Future Project under its flagship program, United Against Malaria, and in collaboration with the National Malaria Control Program and other partners have presented special commemorative ceritificates and T’Shirts to the National Sports Authority here in Accra.

The Certificates signed by the Director General of the National sports Authority Mr. Worlanyo Agra will be presented to all 4,942 participants and their officials. They carry the messages:

“Be a member of the Winning Team- Sleep in treated mosquito nets every night; Take only ACTs any time you have malaria; Encourage pregnant women in your house to seek Antenatal care on time; and Keep Ghana Malaria-free for the next games.”

The over 600 T’Shirts which also carry the above messages will be presented to members of the finalist teams of all the team games including Football, Volleyball, Table tennis, Handball, Netball, Basket ball, and the winners of the first, second and third positions in all the athletics events.

sports-items-ghana-sm.jpgMr. Emmanuel Fiagbey, Country Director JHU/CCP Voices, in presenting the items called on all sports men and women as well as their officials to remain ambassadors in the fight against malaria. He charged them to continue to behave as models in their communities in ensuring that families make maximum use of their treated mosquito nets and no one uses any other medicine apart from ACTs in treating malaria when they fall sick of the disease.

The Director General of the National Sports Authority, Mr. Worlanyo Agra in receiving the items commended the ever growing partnership between the malaria program community and the National Sports Authority. “We would remain active members of the United Against Malaria partnership and continue to ensure that sporting activities at all levels, national, regional, district and community are used as grounds for educating our people on malaria prevention and correct treatment of the disease.

Whether you are a sports man or woman or not, mosquitoes do not know the difference and the malaria parasite they carry can kill any one of us any time if we fail to sleep in our nets or take the correct medicines”, he emphasized.

Communication &Monitoring &Procurement Supply Management Bill Brieger | 24 Jul 2011

Malaria and Mobiles – Hacking or Helping

Surprise – the latest in the Rupert Murdoch scandal concerns malaria.  Yesterday Metro Online headlined a story: “Cheryl Cole’s ‘phone hacked while she was suffering from malaria.'”  The claims are still at the level of rumors, and thus investigators are still “looking into claims that her voicemails were hacked while she was hospitalised.”

A year ago when Ms Cole’s bout with malaria hit the news, The News of the World was mentioned as a source. One online posting noted that Ms Cole, “is believed to have lost half a stone during her battle with malaria. A source told the News of the World that the Girls Aloud beauty is now just over 7 stone. The insider told the newspaper that medics have said that it could be six months before Cole is allowed to perform her strenuous dance routines.”

Similarly another website reported last year that, “A source told the News of the World: “We nearly lost her and the battle is far from over. She is so weak and this horrible illness has taken complete hold of her. ‘It got so bad she was literally only hours from death’s door. Thank goodness she was diagnosed in time.'”

cellphone-mango.JPGNow a year later MTV UK published that, “Cheryl’s lawyers are investigating claims by a former News of the World journalist, who stated that the Geordie’s voicemails were listened to “while she underwent treatment for malaria.”

Fortunately most use of mobile phone technology these days helps promote malaria control and elimination. In Nigeria for example, mobile phone SMS has been used to track bednet distribution.  A UNICEF spokesperson who is involved in promoting such innovations explained that …

In Africa, we are finding there are systemic failures in public health and supply in terms of getting reliable information quickly from the field. Ninety percent of the developing world has access to a cell phone, so we’re experimenting with the use of instant messaging to make a difference. We’re finding that we can train people in villages to be data collectors and help us by using cell phones to text information to central authorities; we and governments can then respond faster to specific needs. In some places, it takes months just to get a piece of paper from the field. Mobile phones and SMS technology can help surmount that hurdle.

Recently the Business Standard reported that, “The University of Glasgow has received a grant from the Bill & Melinda Gates Foundation to further help in the diagnosis of malaria. The $100,000 award would go towards developing a device which uses mobile-phone derived technology to detect and separate red blood cells infected with malaria parasites.”

A study by Caroline Asiimwe and colleagues in Uganda has shown SMS improves the timeliness in reporting of specific, time-sensitive information on RDT positivity rates and ACT stockouts at modest cost, while by-passing current bottlenecks in the flow of data. Likewise in Tanzania “A multinational computer, technology and IT consulting company, IBM, in partnership with Novartis and Vodafone, together with Roll Back Malaria and Tanzania’s Ministry of Health and Social Welfare have reaped from the technology dubbed ‘SMS for Life’. The system tracks movement and the supply of anti-malaria drugs in sub-Saharan Africa.”

People have argued that technology itself is ethically neutral – it is how people use it that has ethical ramifications. In the case of malaria hopefully we will see more uses that help save lives instead of illegally spying on and disrupting them.

ITNs Bill Brieger | 23 Jul 2011

Bednets – Universal Coverage or Universal Challenge

esther-lu-p3290235-sm.jpgWe have seen photos of challenging uses of long lasting insecticide treated nets (LLINs) from across malaria endemic countries.  Some donors may become indignant that their valuable, life-saving commodities are not being used as intended, or shall we say ‘misused’.

We must remember that use is in the eyes of the beholder.  We had similar challenges when distributing monofilament nylon water filters to prevent guinea worm. Many in the villages thought these were ideal for straining esther-lu-p3290234-sm.jpgcassava starch.  Innovations designed in one culture may not fit congruently into the life of another.

The various uses of LLINs reflect real perceived needs of the populations – a place to dry fish, a way to protect vegetables from pests, a beautiful wedding veil. So where does the problem lie. The attached photos by Esther Lu taken in the Karamajong NE District of Uganda add to our ‘net creativity’ portfolio.

esther-lu-p3280167-sm.jpgWe have seen over and over again that mass LLIN distribution campaigns are barely able to mobilize the resources to carry out the distribution, including getting enough nets to the right places at the right times. Not surprisingly few resources have been devoted to follow up and community-based health education by trusted community members.

So is misuse of nets a problem of recipients’ behavior or a problem of financing and planning by program managers?

Private Sector &Treatment Bill Brieger | 13 Jul 2011

Buying malaria medicines in Sokoto

Ideally these days in Nigeria one should be able to get supplies of the recommended artemisinin-based combination therapy (ACT) drugs in public outlets throughout the country. Major malaria partners/donors in Nigeria include the Global Fund to fight  AIDs, TB and Malaria (GFATM), the US President’s Malaria Initiative (PMI), the SuNMaP project of the UK’s Department for International Develoment (DfID) and the World Bank’s Malaria Booster Program.

question.JPGIn reality one finds shortages of medicines that drive consumers and patients to medicine shops in search of whatever is available, and importantly, affordable.  The pictures herein detail what we bought in two patent medicine shops, one urban and one rural, in Sokoto State.

First, even though testing of chloroquine (CQ) for the past 10 years has shown it lacks efficacy, and in fact only ACTs are recommended first-line treatment, we found CQ in both tablet form as well as syrup for children.  Of equal concern is the sale of syrups, which in and of themselves are unstable in the environment.

That said, each of the CQ medicines was duly registered by the National Agency for Food and Drug Administration and Control (NAFDAC). This demonstrates a lack of communication between NAFDAC, one arm of the Federal Ministry of Health, and the National Malaria Control Program, another arm of the same ministry.

The ‘questionable’ products also include Artesunate, a monotherapy drug. It has only artesunate, not a combination, a situation deplored by the World Health Organizations, who explains that use of monotherapy leads down the road to resistance, and we have little in the pipeline to replace the artemisinin derivatives.  This product is registered by NAFDAC, who had promised to not renew licenses for such drugs, and in addition this packet is set to expire in a few months.
sp.JPGWe found numerous brands of sulfadoxine-pyrimethamine (SP).  According to national malaria drug and treatment policies, SP should also not be used for first-line treatment due to increasing parasite resistance. SP should therefore be reserved only for use as Intermittent Preventive Treatment in pregnant women (IPTp).  This use is clearly stated on the Melofan packet, though we are not sure that the NMCP has given permission for such labeling. The key reason for this is that SP for IPTp should not be taken as self-treatment, but integrated into a comprehensive antenatal care program.

Finally we did find ACTs.  The card showing Coartem (artemether-lumefantrine – AL) was the only one of the four different age-specific Coartem packagings seen in the shops.  Supposedly this Coartem was being made available in shops at subsidized rates through the Affordable Medicines Facility malaria (AMFm) administered through GFATM.  Normally drugs for this program have different packaging than seen here, which is the normal format for medicines supplied for the public sector from donor programs.

We bought this Coartem pack for $1.33, which was more than the going price for AMFm drugs. The shopkeeper said she also previously had some artesunate-amodiaquine (AA), another ACT in stock, but this had sold out.
act.JPGAlso seen in the ACT picture is an empty carton of AL provided through private wholesalers as part of the AMFm program as evidenced by the small green leaf logo.  The medicine seller with this empty box informed us that he bought many of these cartons and shared with fellow medicine dealers. Unfortunately they did not pay him back and he has been unable to order more. He was excited that these were purchased from the wholesaler for only 50 Naira (about 33 US Cents) compared to proces of several dollars under normal commercial arrangements. Not shown was a bottle of AL suspension that could be reconstituted with water for child use.

We have been rolling back malaria since at least 1998. Nigeria changed its malaria drug policy to ACTs in 2005. Based on the Abuja Declaration of 2000, we should be seeing near universal coverage of malaria illness episodes with ACT drugs by now. There are not gaps in the system – there are wide crevasses.

Malaria in Pregnancy Bill Brieger | 09 Jul 2011

Family Planning and Malaria

fpconf_logo.jpgPreparations are underway for the 2011 International Conference on Family Planning in Dakar later this year. Although the date is some months away, the organizers are encouraging potential participants and interested persons to become engaged in online discussion forums. An issue we would like to explore here is whether there is any connection between malaria and family planning.

One positive connection is child survival. Researchers in Ethiopia report that, “Immunization, breastfeeding and low parity mothers were independently found to be protective from childhood death. Strengthening the child survival initiatives, namely universal child immunization, family planning and breast feeding — is strongly recommended.” These characteristics were positively associated with reduced deaths from pneumonia, malaria and diarrhea.  Clearly the reduced parity component can be achieved in part through successful family planning.

Connections may come through health systems strengthening. Experiences from the Lao Peoples’ Republic show that, “Synergies of Global Fund support with the health system include improved access to services, institutional strengthening and capacity building …” For example opportunities to enhance community service delivery for malaria could also be used to extend family planning services. Thus, sometimes malaria activities are integrated into successful reproductive health services, and at other times the reverse happens, or one finds malaria, family planning and other services handled under one roof as seen in Senegal or eastern Burma.

A great concern is that malaria is dangerous in pregnancy. Any way to space pregnancies or limit the number of times women face the risk of malaria in pregnancy, can save mothers from malaria deaths directly or indirectly from malaria-induced anemia. We encourage dialogue among all partners in maternal and reproductive health and malaria control leading up to the November conference.

Integration &Mosquitoes Bill Brieger | 08 Jul 2011

Ivermectin against malaria: novel idea, but can it be scaled

Several news sources have picked up on a new article in the American Journal of Tropical Medicine and Hygiene that reported when communities take annual ivermectin doses for controlling onchocerciasis and lymphatic filariasis, they may also be protecting themselves or their neighbors from malaria. Specifically the researcheds reported that ivermectin Mass Drug Administration (DA) “reduced the proportion of Plasmodium falciparum infectious Anopheles gambiae sensu stricto (s.s.) in treated villages in southeastern Senegal.”

The process works the same way that ivermectin treats head lice in that when insects take a bloodmeal from someone who has swallowed the drug, the medicine kills the insect. Sarah Boseley points out that some of the attractions of ivermectin are that it has been safely used in humans for 30 years and that it is inexpensive.

The Merck company has been supplying ivermectin (under its brand name Mectizan) free through the Mectizan Donation Program (MDP) to the African Program for Onchocerciasis Control for 16 years.  Over time coverage has reached over 100,000 villages in 18 African countries. Annual distribution in Africa contrasts with more frequent distribution in the smaller focal transmission points in Latin America where the diseases has almost been completely eliminated.

MDP reports that, “Currently, more than 70 million treatments are approved for onchocerciasis in Africa and Latin America and 80 million for lymphatic filariasis in Africa and Yemen each year.” That is a lot of free medicine and one of the largest and far reaching corporate social responsibility programs known.

Back to Senegal – the researchers found that the effect of ivermectin on mosquitoes lasted up to two weeks. They also raise the question of whether more frequent ivermectin distribution in onchocerciasis or filariasis MDA communities during the main malaria transmission season would be feasible.  Possibly a small scale operations research proposal could be submitted to the Mectizan Expert Committee.

cdi_report_08.jpgOf importance is the fact that the Community Directed Treatment with Ivermectin (CDTI) approach utilized by APOC projects has been tested and found quite accommodating to the addition of other Community Directed Interventions (CDI) such as community case management of malaria, ITN delivery and use monitoring and Vitamin A distribution among other basic health services.

The availability of tens of millions of exra ivermectin doese in communities where MDA is already occurring is unknown at present, let alone the feasibility of starting free ivermectin in malarious areas that have no onchocerciasis or filariasis.  In addition, for onchocerciasis, the idea time for distribution is before the rainy season so that microfilariae loads are seriously reduced before the black fly vectors emerge. This timing may not benefit malaria control fully.

Regardless of the unknowns, it is encouraging that people are thinking of synergistic ways to control the various endemic diseases that inflict suffering on poor communities.

Funding Bill Brieger | 07 Jul 2011

Malaria – donor support up 3000 percent, what of national commitment

Dr Coll-Seck, the Executive Director of the Roll Back Malaria Partnership reminds us that, “Since the moment when advocacy efforts shifted malaria from a neglected disease to global health priority, the results were tangible …

  • a 30-fold jump in international funding
  • increased commitment by African leaders
  • a rapid expansion of research and development, and
  • the creation of new alliances addressing malaria

This update is telling in what is not said. What is the financial value of the “increased commitment by African leader”?

Dr Coll-Seck adds that, “Change has been most dramatic in Africa, where enough insecticide-treated mosquito nets have been delivered to cover 76 percent of people at risk and 11 countries have reduced malaria cases and deaths by more than 50 percent,” but also cautions that, “these gains are as fragile as they are impressive.”

One of the factors that make these gains fragile has been the ‘fragile’ performance of some national Global Fund Principal Recipients in using their hugely increased donor support.  The Global Fund’s Office of the Inspector General has issued a plethora of abuse reports over recent months about misuse and fraud – Mali, Nigeria, Djibouti, Mauritania and Zambia to name some.

dscn2654sm.jpgEven when funds are not abused, they may not always be put to the best use. Uganda plans a outreach effort to make malaria interventions available at the village level. The plan includes, “plan, a batch of 110,000 bicycles, 110,000 T-shirts and 110,000 medicine kits will be disbursed to every district to be used by the village health workers. The project will cost the government 6 million dollars.”  Support for village volunteers is crucial, but if volunteers are selected from the smallest community unit/settlement/hamlet, they will not need bicycles to move around.  If supplies are made available at a nearby central point, they will not have to travel far.

A combination of donor fatigue, financial crisis and recipient abuse does make the funding situation fragile. How can we guarantee resources to reach 2015 and beyond?

Coordination &Treatment Bill Brieger | 05 Jul 2011

Malaria Treatement: right hand, left hand

Nigeria adopted artemisinin-based combination therapy as its first line of malaria treatment in 2005. While it did not ban chloroquine, it has actively discouraged its use since efficacy studies across the country showed high levels of parasite resistance. Likewise Nigeria has tried to confine sulphadoxine-pyrimethamine (SP) for use at intermittent preventive treatment during pregnancy (IPTp), and discourage its use for case management.

Specifically the National Malaria Control Program (NMCP) recommends artemether-lumefantrine and artesunate-amodiaquine, for which there are only few WHO ‘prequalified’ producers, for first line treatment of uncomplicated malaria. Based on WHO recommendations the NMCP also recommends against artesunate monotherapies (i.e. medicines not containing a combination of drugs).
dscn2808sm.jpgOne is not surprised to find inappropriate malaria drugs in patent medicine shops around the country (see picture). Unfortunately the National Agency for Food and Drug Administration and Control approves drugs based more on safety than on appropriateness to control efforts.  Thus, the chloroquine found in shops will not kill you, but it will not cure your malaria either.

With this in mind it came as a shock to see local government clinics stocking chloroquine and artesunate monotherapies, among others.  These were in clinics that were being supplied by the National Health Insurance Scheme using Millennium Development Goals special funds to provide free treatment for pregnant women and children less than five years of age. This laudable goal of reaching the poor can be undermined when drugs with questionable therapeutic value are provided.

The NHIS drug list for malaria includes the following in various forms (tablets, syrups, suspensions, injections):

  • Artesunate
  • Chloroquine
  • SP+Meflaquine
  • Dyhydroartemisinin
  • Proguanil+Pyrimethamine
  • Quinine
  • SP
  • Mefloquine
  • Artemeter

While the SP in the list should ideally be used for antenatal clinic services, one is not sure this happens since several of the clinics visited had no stock of SP, but plenty of chloroquine syrup bottles – a formulation that is not very stable in these climates.

We encourage the NMCP to take stock of malaria drug stocks – basically, there are many national and international agencies supplying malaria medicines at national, state and local government level.  They should be brought together so that one coordinated national malaria drug policy is enacted. Only then will the public receive effective malaria treatment.

Mosquitoes Bill Brieger | 04 Jul 2011

Mosquito Mis-Match

dscn3027sm.jpgVisiting a clinic in Binji Local Government Area of Sokoto State Nigeria today we saw the attached poster.  In fact there were three copies posted on walls in the public waiting areas. It was not clear whether this poster was intended as a job aid (reminder) for the health staff or a public education poster. If the latter, there is too much happening on the poster for it to be a good BCC material.

The main concern about this poster is that it implies that all mosquitoes are responsible for malaria. The pictures in fact implicate other mosquitoes such as the culicine species and Aedes aegypti.  Covering pots and getting rid of old cans and bottles will prevent mosquito breeding, but more than likely will prevent yellow fever, not malaria.

Clearing dirty gutters can prevent breeding of culex and the various viral diseases they carry, but not malaria. Yes, we want people to prevent mosquito breeding generally, as there appear to be no ‘good’ mosquitoes, but promising that preventing breeding of non-anophelene species will prevent malaria is misinformation.

We can be straightforward with the public and say there are many types of mosquitoes, and they carry many different diseases. It helps to prevent the breeding of all, but as different ones breed in different places, we can not expect every action will result in the prevention of malaria. We also need to stress that not all fevers are malaria, and we need testing to ensure the right medicine is given, not ACTs for dengue or west nile virus (which are carried by the other mosquitoes – adding to the public’s confusion).
At present there are two major vector control measures recommended by the RBM community – insecticide treated bednets and indoor residual spraying.  A few places have been successful with limited larviciding, but since breeding sites are ubiquitous, this is an almost never ending activity.  Lets focus on what is feasible.

Finally we need to recall that when we talk to local people about mosquito breeding, they may not understand what we mean by mosquito larvae.  Among the Yoruba, for example, these larvae are called tanwiji and are thought to be a different animal from actual mosquitoes themselves.  People have been confused by attempts at BCC on larval control thinking that health workers are saying that swallowing the tanwiji causes malaria.

Again, for now lets make headway with our treated nets and appropriately targeted IRS.  If we can achieve those coverage targets, the 2015 Millennium Development Goals will be achievable.