Posts or Comments 14 April 2024

Monthly Archive for "October 2011"

Health Information &Treatment Bill Brieger | 27 Oct 2011

Cambodia DHS lacks adequate attention to malaria

cambodia-dhs-2010-cover-sm.jpgThe Cambodia Demographic and Health Survey 2010 report is now available for download.

Surprisingly little information is available about malaria.  The following narrative on ‘fever’ was provided:

“Less than 1 percent of children with fever received antimalarial drugs, whereas 44 percent received antibiotic drugs. Use of antibiotic drugs was more common in urban areas (52 percent) than in rural areas (43 percent) and more common among mothers with at least a secondary education (54 percent) than among mothers with no schooling (39 percent). Mothers in Prey Veng (85 percent) and those in Kampong Chhnang and Kampong Speu (79 percent in both) were most likely to use antibiotic drugs to treat fever.”

We note that Cambodia is a place where artimisinin resistance has been suspected and yet these DHS results do not diagnose malaria with RDTs as is done in other DHS and MIS surveys. Therefore, appropriate treatment cannot be ascertained from the results. This is made more complicated by the following list of appropriate and inappropriate medicines in the survey instrument that were lumped together under the title “antimalarials”: SP/FANSIDAR, CHLOROQUINE, QUININE, MALARINE, A+M, MEFLOQUINE, ARTEMISININ, ARTESUNATE TABLET, ARTESUNATE SUPPOSITORY, ARTEKINE, COTEXIN.

While the report mentions…

“Iron and folic acid supplementation and antimalarial prophylaxis for pregnant women, promotion of the use of insecticide-treated bednets by pregnant women and children under 5, and six-month deworming for children are some important measures used to reduce anemia revalence among vulnerable groups…”

… it does not report on bednet use.

RBM partners are trying to take the problem of malaria in Asia seriously. They would be assisted by better data on the malaria situation in countries like Cambodia.

Funding &Partnership Bill Brieger | 27 Oct 2011

Challenges in signing Global Fund Grants

Our colleagues at the West Africa Regional Network (WARN) of the Roll Back Malaria Partnership have been deliberating on the challenges facing countries in signing their Global Fund Grant Agreements. Many people do not realize that even when the GFATM Board approves a grant proposal, the grant does not become effective until a country prepares plans for implementation.  Only after such are approved, is the grant signed.  Below are observations and concerns from the WARN Secretariat.

Only two countries in West Africa were able to sign round 10 (Sierra Leone and Cap Verde). WARN noted that the countries that did not sign Round 10 or phase 2 of their grant registered significant delays due to:

  • Lack of understanding regarding the conditionality to be fulfilled before the signing
  • Cumbersome administrative procedures and communication bottlenecks between the countries and the Global Fund during negotiations

WARN Recommendations to the countries, Partners and PRs:

  • Secure the support of the network of partners all throughout the negotiations process
  • Involve local partners and WARN in the final grant negotiations with the Global Fund

WARN Recommendations to the Global Fund:

  • Send a team to the relevant countries to explain conditionality and make proposals for immediately resolving problems encountered
  • Send clearly stated correspondences to the countries and RBM partners indicating the planned date or period for the signing, failing which, the Portfolio Manager should provide the countries with explanations for the delay in the signing

It is likely that WARN is not the only region experiencing these problems.  As international funding support for malaria programs is threatened, Global Fund needs to ensure that whatever is available reaches those in need in a timely manner.

Environment &Epidemiology Bill Brieger | 17 Oct 2011

Malaria Transmission: are we out of the woods?

Human activity is leading to deforestation in central Africa and bringing hunters and people in closer contact with our primate cousins and their collection of pathogens.  The Global Viral Forecasting Initiative is carefully studying these contacts between humans and other vertebrates in an effort to identify possible new viral epidemics. In the process they have also made observations about the origins of human malaria and the potential for transmission of primate plasmodium infections to people.

While transmission of malaria species between humans and other primates has been documented in South America and Africa, Southeast Asia has received the most attention.  In fact, the question is being raised as to whether P. knowlesi is becoming the fifth human malaria parasite. If new infections as well as new species are arising from the primate world, this has grave implications for efforts to eliminate malaria worldwide.

A recent study from Vietnam found that, “showed P. knowlesi infections in 32 (26%) persons with malaria (n = 125) and in 31 (43%) sporozoite-positive An. dirus mosquitoes (n = 73). The authors observed and warned that …

P. knowlesi–co-infected patients were largely asymptomatic and were concentrated among ethnic minority families who commonly spend nights in the forest. P. knowlesi carriers were significantly younger than those infected with other malaria parasite species. These results imply that even if human malaria could be eliminated, forests that harbor An. dirus mosquitoes and macaque monkeys will remain a reservoir for the zoonotic transmission of P. knowlesi.

In another study researchers confirmed P. knowlesi in humans in Cambodia. This is worrisome especially since Cambodia is one of the locations where resistance to artemisinin-based medicines is rising.

gametocytes-of-p-knowlesi-in-a-giemsa-stained-thin-blood-smear-from-a-patient-that-traveled-to-the-philippines.jpgLikewise, researchers in Malaysia reported that, “P. knowlesi is a major cause of severe and fatal malaria in Sabah. Artemisinin derivatives rapidly clear parasitemia and are efficacious in treating uncomplicated and severe knowlesi malaria.”  Gametocytes of P. knowlesi in a Giemsa-stained thin blood smear from a patient that traveled to the Philippines can be seen in the attached photo from CDC.

Simian reservoirs of malaria throughout Southeast Asia pose a major challenge for control efforts.  Tackling this problem in the forest habitats where people come into contact with monkeys will be daunting – we are not out of the woods yet for malaria elimination.

Communication &Malaria in Pregnancy &Surveillance Bill Brieger | 13 Oct 2011

Keeping up with malaria … including in Rwanda

During the past month we have posted few blog entries due to a heavy travel schedule.  That said, we have maintained malaria communication through our three other venues. If you are not aware of these news and update options, please check out and follow these links …

malaria-rwanda-2007-and-2010.jpgPart of recent travel includes Rwanda where we are working with the Ministry of Health and the US President’s Malaria Initiative to design and implement a malaria in pregnancy (MIP) survey.  As seen in the attached chart, Rwanda is making great progress in moving toward pre-elimination with string emphasis on community case management and ITN promotion.

Normally in low and/or unstable transmission areas, intermittent preventive treatment for malaria in pregnant women is not practiced. That does not mean that pregnant women are not at risk. The results of the MIP prevalence study will help the Ministry and other partners decide on appropriate ways to protect pregnant women as we move closer to malaria elimination.

Finally as Rwanda makes progress, there is concern about malaria in the neighboring countries.  Efforts like this MIP study can become part of a larger surveillance activity to monitor the potential for imported malaria in the future.