Tropical Health Matters

World Malaria Day 2014 was observed at the Johns Hopkins Bloomberg School of Public Health on Friday 25 April. 21 posters were presented. Below is the abstract of a poster presented by Antonio M. Quispe (aquispe@jhu.edu) and Josiah L. Kephart of the U.S. Naval Medical Research Unit Six (NAMRU-6), Lima, Peru and Johns Hopkins Bloomberg School of Public Health, Baltimore.

After a decade of decline, malaria prevalence in the Peruvian Amazon quadrupled from 2010 to 2013.(1) The most plausible explanation for this reemergence is administrative, as a concurrent dengue outbreak has forced authorities to reallocate their resources away from malaria and towards dengue. The current surveillance system provides epidemiological analysis on a macro level only, limiting decision-makers ability to efficiently distribute resources towards both diseases simultaneously by targeting outbreaks on a micro level and in a timely manner.

We have developed the Free Surveillance Application (FREESAPP), an online application that facilitates epidemiologic analysis and cost-effectiveness decision trees using data already collected by the malaria surveillance system. By leveraging free and publicly available software (Google Docs, R, etc.), the app provides public health decision-makers with the ability to transform weekly epidemiological reports into exploratory analysis, monitor epidemiologic thresholds, and assess the cost-effectiveness of deploying various control methods.

FREESAPP enables users to visually contrast malaria incidence rates with   epidemiological thresholds. When the weekly epidemiologic report is uploaded, the visualization will automatically update, providing a signi?cant time-advantage over the current system of annual   reporting. These comparisons can be also performed across reporting levels, from the regional   to individual health center levels (Fig 1).

The app facilitates follow-up analysis through the ability to combine or adjust for various relevant covariates (incident rate, population size, P. vivax proportion, time, etc.) using several display options (bubble, bar, and line charts) and offering a variety of mathematical transformations (linear and logarithmic) (Fig 2).

FREESAPP allows decision makers to get a sense of the relative costs of deploying a team of health workers to perform either active case detection (ACD) or reactive case detection (RCD) in responses to an outbreak or malaria elimination effort within a particular community. ACD targets the malaria burden (symptomatic cases only) by searching for malaria cases among the entire population at risk, while RCD targets the malaria reservoir (both symptomatic and asymptomatic cases) by focusing on malaria infections within high-risk sub-populations.(2) To compare these methods, we have developed a decision tree that assists in the decision-making process of the optimal strategy for outbreak responses and malaria elimination initiatives, adapting the model developed by Shillcut et al.(3)

By utilizing publicly available software, FREESAPP can provide public health decision-makers with valuable insight into malaria outbreaks and cost-efficient responses. Present malaria and dengue control efforts in Peru are limited by a lack of access to timely epidemiological analysis across all health-system levels. FREESAPP offers valuable and accessible tools to improve public health leaders’ ability to leverage data from existing surveillance systems of malaria and other infectious diseases to implement efficient and effective interventions.

References

1. WHO. Global Malaria Report 2013. Geneva: World Health Organization, 2013.
2. Moonen B et al. Operational strategies to achieve and maintain malaria elimination. Lancet. 2010; 376(9752): 1592-603
3. Shillcutt S et al. Cost-effectiveness of malaria diagnostic methods in sub-Saharan Africa in an era of combination therapy. Bull World Health Organ. 2008;86(2):101?10

World Malaria Day 2014 was observed at the Johns Hopkins Bloomberg School of Public Health on Friday 25 April. 21 posters were presented. Below is the abstract of a poster presented by Suzanne Van Hull of Catholic Relief Services.

Catholic Relief Services (CRS) and the Ministry of Health and Sanitation (MoHS) of Sierra Leone (SL) are co-implementing nationwide malaria prevention and treatment activities funded by the Global Fund to fight AIDS, Tuberculosis and Malaria. In order to track progress and impact, CRS and partners led the implementation of a malaria indicator survey (MIS) in early 2013 covering a nationally-representative sample of 6,720 households, inclusive of blood testing to determine prevalence of anemia and malaria. In early 2012, CRS also had the experience of using mobile technology for a Knowledge Attitude and Practices (KAP) study.

Fieldworkers used Apple 3GS iPhones for both surveys to collect data via the iFormBuilder platform, a web-based, software-as-services application with a companion app for the mobile devices allowing for timely data collection, monitoring, and analysis.

This was the first time that iPhones were used for a MIS, and lessons learned include: allowing at least four months to transform paper-based questionnaires into electronic format, giving the program enough time for pre-testing the tool and training data collectors/biomarkers/laboratory technicians, and involving key malaria stakeholders to ensure a nationally-led survey. Global Positioning Systems enabled the MoHS to make in-depth analyses on malaria trends based on geographic locations.

Overall the benefits of an electronic versus a paper-based MIS questionnaire outweighed the challenges. The iPhone technology eliminated the need for paper transcribing, allowing for quicker data tabulation, real-time identification of mistakes, faster interviewing through skip patterns, and a close-to-clean dataset by the end of data collection saving time and money.

Survey results will be used to set evidence-based targets for all partners’ future malaria activities, especially the next 3 years of GF-supported malaria grants

World Malaria Day 2014 was observed at the Johns Hopkins Bloomberg School of Public Health. Admiral Tim Ziemer, the Coordinator of the US President’s Malaria Initiative was keynote speaker. Other speakers from the NGO and faith based organization community also talked about the importance of partnership in fighting a disease that still claims 600,000 lives annually.  In addition 21 posters were presented.

Below is the abstract of one poster representing our work with USAID’s Targeted States High Impact Project in Nigeria.

Malaria and febrile illness care seeking in Bauchi State, Nigeria: context for improving case management at the primary level

Seeking of appropriate and quality care for childhood illnesses is a major challenge in much of Africa including Bauchi State, Nigeria. In advance of an intervention to improve available care in the most common points of service (POS), government primary health care centers (PHCs) and patent medicine vendors (PMV), a survey was done of child caregivers in four districts concerning responses to febrile illness, suspected malaria, acute respiratory disease and diarrhea. The ethical review committee in the Bauchi State Ministry of Health approved of the study.

A total of 3077 children below the age of five were identified in the households sampled. Their mothers, fathers or other caregivers consented and were interviewed. Among the children 74% had any Illness, 57% had fever, 26% had cough, and 15% had diarrhoea. Only 8.7% of 1186 febrile children had their blood tested.

Care seeking from PMVs varied from 45% with fever, 40% with cough to 36% with diarrhoea. Care from public sector POS varied from 26-33%. Treatment that might be considered ‘appropriate’ for each also varied with 30% receiving antimalarial drugs for suspected malaria, 20% getting oral rehydration solution for diarrhoea and 50% being given an antibiotic for a suspected acute respiratory illness.

The results show that providing quality integrated case management with appropriate commodities through PHCs and PMVs can improve the illness care of a majority of children in Bauchi State, and interventions are currently being planned to do this.

Poster by … William R. Brieger, MPH, CHES, DrPH ¹, Bright Orji, MPH ², Masduk Abdulkarim ³, (1) International Health, Bloomberg School of Public Health, The John Hopkins University, 615 N Wolfe St, Baltimore, MD 21205 (and Jhpiego). (2) Jhpiego, Thames St, Baltimore, MD 21231`. (3) Targeted States High Impact Project USAID Nigeria, Bauchi, Nigeria.

According to the UN Food and Agriculture Organization (FAO), about six years ago following a global food crisis, a United Nations high-level task force called for a paradigm shift in urban planning, to one that encourages urban and peri-urban food production. By including urban agriculture in urban land use considerations, planners hoped to achieve benefits ranging from improved food security, economic development to greener environments.

FAO recognizes that there are complex political issues involved in meeting the vision of promoting urban agriculture, including basic access to land, water and other resources, before the benefits can be realized. The issue is further complicated by malaria in some urban environments.

Prathiba De Silva and John Marshall observed that, “Malaria transmission in urban and periurban areas is highly focused around vector breeding sites, which tend to be more numerous in areas of lower socioeconomic status. Control strategies should therefore adopt an element of spatial targeting rather than targeting a wide urban area uniformly. Vector breeding sites are common in areas with slum-like conditions and in areas where urban agriculture is practiced.”

In another study Christophe Antonio-Nkondjio and colleagues concluded that, “The data confirm high selection pressure on mosquitoes originating from urban areas and suggest urban agriculture rather than pollution as the major factor driving resistance to insecticide.” Similarly, Seidahmed et al. observed

— Urban gardens along the banks of the Niger River in Bamako, Mali —

different urban agriculture land use patterns between urban and peri-urban areas as well as differences in insecticide resistance.

These studies suggest that urban planners not only need to consider urban agriculture in land use planning but also need a strong working relationship with public health authorities. Both need to work on pesticide use issues. Green cities can be places that help feed their populations, but they can also be places that a strong focus on local land use can be used to prevent malaria.

n 2012 the World Health Organization’s Global Malaria Program reconfirmed the use of intermittent preventive treatment for pregnant women (IPTp) using sulfadoxine-pyrimethamine (SP). IPTp now may be given at each antenatal care (ANC) visit after the first trimester as long as it is a month since the last dose.

Countries have been moving forward in reviewing and adapting/adopting this guidance where appropriate. One of the key challenges countries have faced is what to do about folic acid, which is given concurrently with IPTp as part of focused ANC. Specifically the guidance states … WHO recommends the administration of folic acid at a dose of 0.4 mg daily; this dose may be safely used in conjunction with SP. Folic acid at a daily dose equal or above 5 mg should not be given together with SP as this counteracts its efficacy as an antimalarial.

This new low dose formulation of folic acid requires accessible and affordable supplies made available through a country’s pharmaceutical procurement system. Manufacturers would need to adjust, and national food and drug approval agencies would need to register the product(s).

All this worry may in fact be a case of closing the barn door after the horses have escaped. Since in many countries women do not register for antenatal care until well into their second trimester, the benefits of folic acid supplementation may in fact me missed. A broader view of the health and nutrition of women of reproductive age is needed, not just the narrow focus of giving folic acid as part of ANC.

The online encyclopedia of Medline explains that “There is good evidence that folic acid can help reduce the risk of certain birth defects (spina bifida and anencephaly). Women who are pregnant or planning to become pregnant should take at least 400 micrograms (mcg) of a folic acid supplement every day.” Let’s look at the term “planning to become pregnant.” This means that women of reproductive age (WRA) who are interested in having children need to ensure that taking folic acid. Since many pregnancies are not “planned” this means folic acid should be a regular part of their lives.

How can this be achieved? First, while it may not be practical, WRA could take regular folic acid tablets. A variety of health and social programs, including secondary schools for those who attend, may be venues to try distribution of supplements. Secondly there are food sources, and thirdly there could be fortification of commercial foods with folic acid.

Again the Medline encyclopedia informs us that, “Folate occurs naturally in the following foods: dark green leafy vegetables, dried beans and peas (legumes), and citrus fruits and juices.” These items are often available in malaria endemic countries and part of a normal diet. Of course, as the American Journal of Clinical Nutrition points out, “Naturally occurring seasonal variations in food consumption patterns have a profound effect” on the availability, cost and use of these food sources.

While commercial food fortification is common in industrialized countries, IRIN also points out that, “use local manufacturers and commercial distribution systems to reach undernourished children in Nigeria, Ghana and Tanzania. All three countries have mandatory fortification of wheat flour with iron and zinc.” Why not add folic acid? Researchers in Kenya found that “Locally available indigenous foods can be used in the formulation of acceptable, low-cost, shelf-stable, nutritious supplementary foods for vulnerable groups,” including folic acid fortification.

We should now focus our attention of the folic acid needs of WRA generally. We must plan for the three possible interventions mentioned above as appropriate to each country and as an ongoing effort to ensure women’s overall health and nutrition. If we succeed, women in malaria endemic countries will enter pregnancy with a strong foundation of folic acid supplementation and not have to depend solely on tablets during the short window when they attend ANC.

This year World Health Day (April 7^th) focuses on insect vectors of disease with the theme “small bite, big threat.” WHO explains that, “Mosquitoes, flies, ticks and bugs may be a threat to your health – and that of your family – at home and when travelling. This is the message of this year’s World Health Day.” Furthermore “Every year, more than 1 billion people are infected and more than 1 million die from vector-borne diseases.”

Wrong mosquito used in article about malaria

While we are happy about this world-wide attention to disease vectors in general, at Malaria Matters we are particularly concerned with the various anopheles mosquitoes that carry malaria parasites. Thus it is time to vent a little frustration with the media that visually sends the wrong message about mosquitoes and malaria.

First we can see a typical news story on our first screen shot that presents an article about malaria with a photo of Aedes aeqypti mosquitoes that carry dengue and yellow fever.  While one can agree that this black and white striped mosquito is a bit scarier and attention grabbing than a blander colored anopheles, it still gives wrong information and wrong ideas. The two mosquitoes have very different biting and breeding and patterns that lead to very different control interventions.

Granted, the general public might not distinguish among the various nuisances called mosquitoes, but at least professionals aiming to communicate information about malaria should research and present the correct graphics.  Fortunately we can rely on the US Centers for Disease Control and Prevention to help us distinguish our mosquitoes.

Another concern with the media is a stress on malaria control interventions that may not be the major focus of key international programs that are part of the Roll Back Malaria (RBM) Partnership.  RBM and partners set sights on three main malaria interventions at the onset – insecticide treated bed nets (ITNs), prompt and appropriate malaria case management, and intermittent preventive treatment (IPT) for pregnant women. WHO offers guidance on each of these interventions that donors like the Global Fund and the US President’s Malaria Initiative follow in making their funding decisions.

Malaria control has expanded cautiously from the three core interventions to include indoor residual spraying (IRS) in epidemiologically appropriate settings. Larviciding under restricted conditions is now included to round out an integrated vector control strategy. Also the concept of IPT was tested with infants and children and has now become the strategy of seasonal malaria chemoprevention (SMC) in countries of the Sahel. These additions have come after rigorous scientific testing and with an eye to the economic costs and benefits of supporting scale up.

Outdoor fogging is not a RBM malaria control strategy

Ironically, some media outlets and city councils get fixated on outdoor spraying or fogging (as seen in photo). This is NOT a RBM strategic intervention for a number of reasons. INDOOR residual spraying is designed specifically with the behavior of anopheles in mind because they do rest on the walls inside houses after biting and residual means the insecticidal effect lasts for some months. OUTDOOR fogging is hit and miss and dissipates.

So in conclusion we hope people will use today’s World Health Day focus on vector borne diseases to give a nod to the Pan-African Mosquito Control Association and to get to know their mosquitoes and mosquito interventions better.

The impact of the international response to Uganda’s any-gay laws is starting to be seen. IRIN estimates that 37% of Uganda’s annual health budget is dependent on development aid from outside. So far, “Project and budget support worth about US$140 million has been suspended or redirected by the World Bank, US and several European countries, including Sweden, the Netherlands, Norway and Denmark,” which represents about half or 20% of the health budget.

IRIN shares the concerns of a senior Ugandan official who explains that, “We have a crisis. The government has been forced to review its priorities and make readjustments as donors have withheld aid. We are seeing stagnation of social services and public investments. The civil servants have not been paid their salaries [in February].” Even AIDS activists are concerned about the humanitarian impact of such suspensions.

While the situation certainly bodes ill for people with AIDS, TB, malaria and other health problems, it more than demonstrates the difficulties when national health and development budgets are dependent on outside resources.  World Malaria Day for 2014 continues with the previous theme of investing in malaria. Clearly when countries won’t or can’t direct their own national resources to health, the population will suffer.

Even without the political strings attached to aid, aid is not sustainable in the long run. Industrialized countries, through bilateral and multilateral contributions and their citizens, through NGOs, not only grow fatigued, but also run short of funds.

Uganda is entering the realm of oil producing nations. Hopefully more resources will in fact be available, unless the country follows the example of other oil nations where more oil funds wind up in Swiss banks than in health and social services.

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IRIN has been a strong source of news and information for our postings. Please look at the new posting on IRIN’s website concerning its future. “You may have seen some public discussion recently about IRIN’s future, arising most recently from this online petition, an independent initiative launched by a US-based reader last week. In the interest of clarity we are taking this opportunity to let you know ourselves what is happening. Full report.”