Posts or Comments 18 July 2024

Monthly Archive for "September 2013"

Elimination &Health Systems Bill Brieger | 30 Sep 2013

Will we eliminate malaria programs before we eliminate malaria?

DSCN3623 smAs malaria cases dwindle and we approach elimination, will malaria programs be integrated into broader disease control efforts? Integration is all the rage, but what does it mean for disease eradication efforts?

The arguments for and against vertical versus horizontal, siloed versus integrated programming sometimes misses the point when it comes to disease eradication.  Eradication is by nature a time-bound and focused activity.  Without a clear, reasonable target date, eradication will not happen, but disease control will linger until some financial or other event causes us to drop the ball completely and cases start rising again. This might sound familiar to those who were around for the malaria eradication efforts that floundered in the 1960s.

We may have been premature to start talking about malaria eradication a few years ago, but the discussion is needed about the state of malaria programming as pre-elimination and elimination are being reached in many countries. We must begin looking around for the resources for that last push toward eradication.  In the absence of a dedicated malaria eradication effort – a vertical program if you will – will be be able to organize the efforts needed for the final step?

filter use at home 2Let’s draw some lessons from guinea worm.  From the start in the 1980s programs were established that were called National Guinea Worm Eradication Programs, not guinea worm programs or guinea worm control programs, but eradication programs.  A specific date was set – 1995, and in most cases a dedicated team of people went to work on a well defined set of interventions from the national to regional to district to community levels.

Where the guinea worm effort faltered was when countries tried to ‘integrate’ it with other disease control or primary health care services. Work became unfocused and ten or more years were added to what should have been a straight-forward march to elimination in these countries by 1995.  What this meant in Nigeria was that the pace slowed, but at least was continual, and now 18 years after the original target date was finally declared free of the disease. In Ghana, with guinea worm hidden amongst the duties of pluripotent district disease control officers, cases began to rise again.

Already some countries that are in a high level of control and witnessing major drops in incidence and mortality have combined their malaria programs into a broader disease control unit or department.   There are hints that donors may wish to focus more on high burden areas for major scale-up and control.  All partners must be willing to ensure that both the funds/resources as well as the organizational infrastructure (systems) are in place to guarantee elimination in each endemic country.

Human Resources &MIM2013 Bill Brieger | 29 Sep 2013

Human Resources for Malaria

Two major international meetings are coming up in the next two months. One if the Multilateral Initiative for Malaria’s 6th Pan-African Malaria Conference (MIM2013) and the Third Global Forum on Human Resources for Health.  Neither apparently cross-reference the other.  None of the Plenary Sessions or Symposiums at MIM2013 explicitly address the crucial need of appropriate human resources to eliminate malaria, though we are sure it will be woven in to several presentations.

Nigeria CDD performs RDT in Upenekang Community Ibeno LGA Akwa Ibom State 2One of the most prominent focal points for malaria human resources arises from the effort to expand integrated Community Case Management (iCCM). The American Journal of Tropical Medicine and Hygiene features a special supplement launched at its 2012 annual Conference on iCCM.  The most interesting aspect of the iCCM movement is the innovative task shifting that is occurring to bring malaria and other disease solutions to the grassroots through a variety of auxiliary health workers and community volunteers. It has become clear that malaria treatment coverage cannot meet targets  – either the 2010 Roll Back Malaria goal or 80%, let alone the push toward universal coverage – without involving non-formal providers such as volunteer community health workers (CHWs) as well as patent medicine shop staff.

But finding human resources for treatment tasks is only the tip of the iceberg.  A variety of health workers are needed for malaria work in the areas of entomology/vector control, health information systems/surveillance, and laboratory/diagnosis, to name three.

The Global Health Workforce Alliance did issue a report in 2011 that questioned the ability of countries to meet Millennium Development Goal number 6 – reducing the inpact of HIV, TB, Malaria and other endemic diseases. Issues such as the distribution of health workers in a country were raised – especially the challenge of meeting the needs of rural areas where malaria is more common.

Training has a major role to play. When Jhpiego/MCHIP began a 3-year effort with USAID to improve malaria services in Burkina Faso in 2009, they found a need to provide in-service training on malaria for newly graduated nurses and midwives. An examination of the curricula of the various cadres and branches of the National School for Public Health (ENSP) found a paucity of malaria content, especially content that reflected current national malaria guidelines from the Ministry of Health. This led to work with the ENSP to set up a planning committee to update the malaria components of its curricula.

DSCN3798 Ghana smWHO has a variety of training materials on issues and cadres ranging from strengthening malaria laboratory workers, entomology and vector control staff, as well as the basic training of health workers involved in malaria case management.

In addition to issues of health worker number are the issues of retention and performance quality. Researchers in Kenya are undertaking a study that will test whether a pay-for-performance (P4P) will improve malaria case management. Pay incentives might aid retention as well as improve quality of care. We need more such efforts to tackle the coverage gaps in malaria service delivery.  This also means addressing the human resource gaps among malaria researchers in national institutes and universities in endemic countries.

We need to use every forum available to discuss human resources for malaria control, elimination and eradication. The scourge of malaria will linger as long as we lack the quantity and quality of human resources to fight the disease.

Advocacy &Communication &MIM2013 Bill Brieger | 27 Sep 2013

MIM Pan-African Malaria Conference is Coming

MIMThe main program for 6th MIM Pan-African Malaria Conference is available at the Medical Research Council website: We will be using #MIM2013 to share tweets. The conference runs from 6-11 October 2013 in Durban, South Africa. There will be a variety of presentation formats including Plenaty sessions, symposia, parallel scientific sessions and poster sessions/exhibits.  Many partners will be hosting special events.

Plenaries will highlight the current status of malaria intervention as well as look toward the future. In that vein several sessions address malaria elimination as for example …

  • Plenary Lecture VII by Prof Alan Magill “Strategies for realising malaria elimination and eventual eradication”
  • Plenary Lecture V by Dr Robert Newman“From a one-size-fits-all to a tailored approach for malaria control and elimination.”
  • Symposium 19: Targeting malaria elimination in Zanziba. Prof Anders Bjorkman
  • Symposium 58: Malaria eradication: identifying and targeting the residual parasite pool Mr Simon Kunene
  • Symposium 41: The final decade of malaria in Africa: planning for the endgame

There are sessions on case management issues ranging from severe malaria to better diagnostics. The role of the private sector is addressed. Vector biology and entomology are featured.

Not only will there be formal media coverage of events, including interviews with key players in malaria control and elimination, but the Roll Back Malaria partnership is mobilizing its Working Group members and partners to provide a full range of social media exposure for MIM events on Facebook, twitter and various blogs.  Keep your eyes on this page for the latest updates as news is being released.

Chronic/NCDs &Epidemiology &Mortality &Severe Malaria Bill Brieger | 19 Sep 2013

Are non-communicable diseases actually communicable?

Much of the discussion around global health and post-Millennium Development Goals focuses on non-communicable diseases (NCDs) including cardiovascular problems, diabetes, cancers and the the like.  While it is important to recognize that low income nations are not plagued with both communicable and non-communicable diseases, we do not want the greater focus on NCDs in richer countries to overshadow the problems of malaria, pneumonia, TB, diarrhea and other child killers in poorer countries.

dscn7742-chw-flipchart.jpgA major reason for us not to lose focus on communicable diseases was recently reported from the Wellcome Trust on research they have supported in Malawi. The researchers found that the malaria parasite, Plasmodium falciparum, is able to “cause inflammation in blood vessel walls, making them more sticky so that the infected red blood cells can cling to the sides. Being able to stick to the blood vessels in vital organs allows the parasite to hide away from the immune system, a process called sequestration. When it occurs in the brain it causes a more severe form of the disease called cerebral malaria, associated with seizures, coma and sometimes death.”

The researchers also surmised that if this complication does not kill people in childhood, the damage to blood vessel walls can have more long lasting effects. In particular they noted that, “Chronic changes to the blood vessels like these could an important contributing factor to cardiovascular disease later in life.”

The link between malaria and Endemic Burkitt lymphoma (eBL) continues to be explored. Recently adding to this long history of eBL research, Peter Aka and colleagues reported that. “Anti–HRP-II (Plasmodium falciparum histidine-rich protein-II) antibodies suggest that recent malaria infection triggers the onset of eBL.”

In a review of intrauterine growth retardation (IUGR) Demicheva and Crispi observed that, “Several clinical and experimental studies showed that IUGR fetuses present signs of cardiac dysfunction in utero that persist postnatally and may condition higher cardiovascular risk later in life.” In endemic regions, malaria in pregnancy is a major cause of IUGR and thus low birth weight.

Preventing malaria therefore saves lives now and in the future. Ignoring malaria now adds greater burdens to the health system and national productivity tomorrow. We need to maintain our investments in malaria both globally and in and by endemic countries themselves.

Elimination &Funding &Surveillance Bill Brieger | 01 Sep 2013

Eliminate Malaria, Not Malaria Funding

As countries begin to see the benefits of sustained malaria intervention, they worry that they may be punished by donor agencies for their success. For example, The Tanzania Daily News reports that, “HEALTH officials in Zanzibar have said that the Islands are likely to experience problems in the fight against Malaria should major donors, including Global Fund and the United States government pull out from financing the project.”

dscn9801a.jpgZanzibar is nearing pre-elimintion malaria transmission levels but is dependent on donor funding to maintain progress. The Daily News specifies that, “The US through its President’s Malaria Initiatives (PMI) remains the leading financier with 56 per cent of the funds received for the malaria campaign. Global Fund is 40 per cent, WHO and UNICEF two per cent; other donors 1.97 per cent; and Zanzibar government is 0.03 per cent.”

Health officials did clarify the actual situation by saying that, “We are happy that PMI has not shown any indication to pull out, but we must prepare ourselves and look for alternative financiers should the US stop supporting Malaria programme.” A look at the latest grant progress report for Zanzibar at the Global Fund website had only a report from August 2012 for Round 8 Malaria Grant that was made near the end of Phase 1 of the grant.

It is not clear if Phase 2 of the Global Fund grant has been or will be funded, but we know that the GFATM has been going through financial difficulties and changes.  This is likely why Zanzibar health managers are worried. The last grant rating was files back in 2011 and gave the program a ‘B2’ rating which is cause for caution and possibly hints at reasons why Phase 2 is in limbo.

PMI reports that donor support and Zanzibari leadership, “has resulted in a dramatic decrease in malaria prevalence in Zanzibar. However, persistence of malaria transmission in surrounding areas (Tanzania mainland and Kenya) leaves the island vulnerable to sudden outbreaks and the re-establishment of ongoing, perennial malaria transmission.” Even though Zanzibar is an island, it is still vulnerable, and any withdrawal of support would negate and reverse gains made. For example, PMI explains that Zanzibar is a place where “Malaria Early Epidemic Detection System (MEEDS) … an innovative mHealth system” is being tested.

Pre-elimination not only requires sustaining existing interventions, but also implementing new ones like MEEDS in order to maintain necessary surveillance that will ultimately document whether malaria elimination has succeeded. As PMI notes, “MEEDS and Coconut Surveillance are helping Zanzibar to identify and treat many otherwise undiagnosed malaria cases, identifying hot spots and transmission patterns, and responding rapidly to new outbreaks. These mHealth applications are helping Zanzibar to sustain the remarkable gains it has made against this dangerous and debilitating disease.”

Also, “maintaining and continuing to reduce malaria transmission will require ongoing education for both health care providers and residents to reinforce the importance of using preventive measures,” as the public and health workers perceive the drop in prevalence according to Bauch and colleagues. Malaria prevalence in Zanzibar has been less that 1% for over 6 years, and we need to continue to reduce it.

Interventions in the final phases of malaria elimination may not be as dramatic or visible as distributing millions of insecticide treated bednets, but they are just as essential.  We need to maintain support in all endemic countries until we see malaria elimination through to its conclusion. Otherwise years of intervention will be wasted, and new lives will be lost.