Posts or Comments 25 February 2021

Monthly Archive for "May 2018"

Children &Equity &IPTp &ITNs &Monitoring Bill Brieger | 26 May 2018

Malawi Makes Progress and Plans to Defeat Malaria: Directions from the 2017 Malaria Indicator Survey

Malawi has conducted four Malaria Indicator Surveys (MIS), with the most recent being in 2017. Such surveys are crucial tools for [planning and evaluating efforts by national control programs and their partners. Dr. Dan Namarika, Secretary for Health, Ministry of Health in the preface to the 2017 Report sums up the context and progress best, and so first, we have reproduced his narrative below.

Then we look at the example of the insecticide treated net (ITN) data as a way to guide future planning. The MIS format itself has seen improvements with much better color graphics in addition to the traditional tables. Some of these are also shared herein.

According to Dr Namarika, “Malaria is a major public health problem in Malawi where an estimated 4 million cases occur each year. Children under age 5 and pregnant women are most likely to have severe illness. The Ministry of Health, in collaboration with partners, has developed the Malawi Health Sector Strategic Plan 2017-2022, which articulates the priorities for health sector development in the next 6 years and prioritizes malaria. In line with that emphasis, the National Malaria Control Program has just finished the development of the National Malaria Strategic Plan 2017–2022 with the goal of scaling up malaria interventions to reduce morbidity and mortality by 50% in 2022.

“We strive for progress in achieving prompt, effective malaria treatment. We hope to improve access to early intervention and treatment by expanding village clinic services, using insecticide-treated nets, spraying inside residences, managing the environment, encouraging changes in social behaviour and communication, and preventing malaria in pregnancy. We have set for ourselves high targets for these interventions, and we are confident that we will achieve our strategic goals of halving the incidence of malaria and deaths, as well as reducing the prevalence of malaria and malaria-related anaemia.

“Surveys such as the current Malaria Indicator Survey (MIS) are essential measures of progress towards these goals. Without measurement, we can only guess about progress. The 2017 Malawi Malaria Indicator Survey (MMIS) is the country’s fourth nationally representative assessment of the coverage attained by key malaria interventions. Interventions are reported in combination with measures of malaria-related burden and anaemia prevalence testing among children under age 5.

“Overall, there has been considerable progress in scaling up interventions and controlling malaria. We noted a decline in malaria prevalence from 33% in 2014 to 24% in 2017. Insecticide-treated net (ITN) ownership has increased from 70% in 2014 to 82% in 2017.

“Results of the 2017 MIS also show improvement on use of intermittent preventive treatment during pregnancy (IPTp) by pregnant women age 15-49. Coverage has increased from 64% for two or more doses in 2014 to 77% in 2017. The percentage of women who took three or more doses of SP/Fansidar for prevention of malaria in pregnancy increased from 13% in 2014 to 43% in 2017.

“In addition, numbers of children receiving a parasitological test and artemisinin-based combination therapy continue to increase.

“These results represent the combined work of numerous partners contributing to the overall scale-up of malaria interventions. I would like to request that all partners make use of the information presented in this report as they implement projects to surmount the challenges depicted here.”

According to PMI, “The 2017-2022 National Malaria Strategic Plan (MSP) builds on the successes achieved and lessons learned during implementation of previous strategic plans.” The example of ITN targets is illustrative and is included in the target, “At least 90% pf the population use one or more malaria preventative interventions.”

So in addition to showing progress with ITNs, the MIS 2017 report also points to gaps that require strengthened intervention. While there has been an increase of household net ownership we can see in the graph that the target for universal coverage of 1 net for 2 people still needs work. We can also see in the graphs that equity remains a challenge with a lower proportion of poorer households owning a net. In addition net ownership is lower in the Central Region of the Country.

We learn from the graphs that having access to a net in the household does not guarantee that people will actually use or sleep under them. The tables show us that the traditionally defined ‘vulnerable groups’ like pregnant women (62.5%) and children below the age of 5 years (67.5%) were more likely to sleep under nets than household members in general (55.4%). The push towards universal coverage stresses that all household members contribute to the health, welfare and wealth of the family and should be protected from malaria.

Now we should Return the comments by Dr Namarika on the value of having MIS data. All endemic countries need to ensure their malaria data are up-to-date to ensure they use this information to keep their strategic plans on track to defeat malaria.

Agriculture &Development &Epidemiology &Food Security &Integrated Vector Management &ITNs Bill Brieger | 25 May 2018

Agriculture and Promotion of Food Security Can Affect Malaria Transmission

The link between malaria and food security in a global context has been made. The influence of malaria on food security was examined. Now the connection between agriculture practices/food security and malaria is pursued below.

A common complaint with programs that distribute insecticide-treated bednets to prevent malaria is that the nets may be used for other purposes that the intended effort to prevent infected mosquitoes from biting people. All informants interviewed for a study in Western Zambia reported that ITNs are regularly used for fishing and the misuse is widespread. Unsustainable fishing practices, drought and population pressure were mentioned as reasons for fishery decline. The implication was that the use of free ITNs for fishing at least saved the population money in a time of declining fortunes.

A broader review of the ITNs for fishing issue was done through contacting expert witnesses across Africa. Mosquito net fishing (MNF) was found to be a broadly pan-tropical activity, particularly prevalent in sub-Saharan Africa. The authors found that, “Perceived drivers of MNF were closely related to poverty, revealing potentially complex and arguably detrimental livelihood and food security implications.”

The mosquito breeding potential of dams cuts across Africa with the number of dams located in malarious areas projected to increase according to Kibret and colleagues. This is because “The population at risk of malaria around existing dams and associated reservoirs, is estimated to increase from 15 million in 2010 to 21-23 million in the 2020s, 25-26 million in the 2050s and 28-29 million in the 2080s.” In addition, areas with dams but without malaria transmission at present, will likely transition to regions of unstable transmission due to climate change.

Likewise, a study in Ethiopia starts with the assertion that, “Dams are important to ensure food security and promote economic development in sub-Saharan Africa,” and then stresses the importance of understanding the consequences of these projects. The researchers found that “the mean monthly malaria incidence and anopheline larval density was generally higher in the dam villages than in the non-dam villages” in all the three dam settings studied. So while dams can increase agricultural production, the authors concluded that, “the presence of dams intensifies malaria transmission in lowland and midland ecological settings.”

Hydro-agricultural projects include dams and irrigation. Human bait mosquito captures volunteers in hydro-agricultural and river bank sites in Cameroon Akono et al. found that mosquito biting rates were higher in hydro-agricultural sites of less urbanized and urban settings than in natural river banks sites. An additional implication is that urban farming, an important component of food security, may influence mosquito and malaria prevalence.

Stoler and colleagues pursued this question of urban agriculture. The odds of self-reported malaria are significantly higher for women in Accra, Ghana who are living within 1 km of urban agriculture compared with all women living near an irrigation source, the association disappearing beyond this critical distance. Likewise in Kumasi, Afrane et al. learned that “adult and larval mosquito abundance and larval survival were high in the irrigated fields in the irrigated (urban) vegetable farm. This therefore, contributed significantly to adult mosquito populations and hence malaria transmission in the city.”

Even agricultural practices in smaller subsistence farms can foster malaria mosquito breeding. Practices found in southwest Nigeria include collection of pools of water in the farms for soaking cassava tubers, digging of trenches, irrigation of farms, and the presence of fish ponds.

Communities can perceive how agricultural practices may contribute to malaria. In Tanzania a fair number of rural respondents associated growing of rice with malaria. They also noted that the need to sleep on their farms at times meant they could not benefit from the mosquito nets hanging back in their house, some hours walk away. The idea of rice cultivation and malaria was tested in central Kenya. Mwangangi and co-researchers found that, “Rice fields and associated canals were the most productive habitat types,” for malaria mosquito breeding. Overall, Mboera et al. found, “evidence that malaria transmission risk varies even between neighbouring villages and is influenced by agro-ecosystems.”

Although we can establish the two-way link or intersection between malaria and food security, we can see that recommended joint or integrated programming may not always be optimal at various levels from the nation to the community. Greater collaboration between health and agricultural ministries and agencies is needed, supported by national policies that see malaria and food production as part of overall national development goals.

Agriculture &Costs &Economics &Food Security &Nutrition Bill Brieger | 24 May 2018

Malaria Affects Agriculture and Food Security

The connections between malaria and food security are recognized in various international health and development frameworks. Below is a look at one side of the equation, how malaria in the household affects food security and agricultural production.

Lewnard and colleagues reported that severe food insecurity was associated with increased risk for positive malaria tests among the Batwa pygmies in Uganda. Also malaria control interventions were associated with decreases in child mortality, accounting for the effect of rainfall and food security in central Tanzania. The authors concluded that achieving targets like the MDGs, “requires the contribution of many health interventions, as well as more general improvements in socio-environmental and nutritional conditions,” i.e. an integrated development approach.

A study in Niger hypothesized that Unconditional Cash Transfers (UCT) would have a positive impact on food security. Two different UTC regimens were tested along with a supplemental food package, but ironically the study found no difference in endline food security between arms. The group felt that the results were possibly driven by increased fever/malaria in children, and thus nonfood related drivers of malnutrition, such as disease, may limit the effectiveness of UCTs.

Tusting and co-researchers recognize that agricultural development interventions reduce poverty. They also documented that relative agricultural success was associated with higher socio-economic position, which in turn, was associated with lower human biting rate of malaria-infected mosquitoes. They conclude that “Further interdisplinary research is needed to understand fully the complex pathways between poverty and malaria and to develop strategies for sustainable malaria control.” One possible pathway would be malaria prevention interventions. A study in Ghana reported that, “Children who slept under a bednet were also more likely than those who did not to live in a food secure household.”

Malaria interventions can also affect agricultural productivity. In a Zambian experiment, access to subsidized bed nets was randomly assigned at the community level, and 516 farmers were followed over a one-year farming period. The researchers found “large positive effects of preventative health investment on productivity: among farmers provided with access to free nets, harvest value increased by US$ 76, corresponding to about 14.7% of the average output value.”

Malaria and other endemic diseases affect agricultural productivity, income, and thus quality of housing

Studying the effects of malaria on employees of an oil palm plantation in Papua New Guinea, Pluess and team found that, “on average, an employee sick with malaria was absent for 1.8 days, resulting in a total of 9,313 workdays lost.” This is an indirect influence on a family’s food security.

farming communities often have access only to small medicine shops in the markets

Seeking malaria care can have untoward effects when fees are attached to health services. Johnson and co-researchers report that, “The qualitative data reveal multi-faceted health and socioeconomic effects of user fees, and illustrate that user fees for health care may impact quality of care, health outcomes, food insecurity, and gender inequality, in addition to impacting health care utilization and household finances.”

Malaria can deprive the household of funds needed for food. It can also reduce the ability of the family to work and produce or buy food. Such economic, social and nutritional impacts need to be taken into account in developing intersectoral malaria policies.

Agriculture &Coordination &Food Security Bill Brieger | 23 May 2018

Global Frameworks Link Malaria and Food Security

Forty years ago the Alma Ata Declaration on Primary Health Care became one of the first global frameworks to consider health in the context of development.[i] Specifically the Declaration stated that, “Economic and social development, based on a New International Economic Order, is of basic importance to the fullest attainment of health for all and to the reduction of the gap between the health status of the developing and developed countries.” Within that, 8 essential services were articulated. One was “Promotion of food supply and proper nutrition,” and another emphasized, “Prevention and control of locally endemic diseases.” This set the stage for future efforts that could place malaria control and food security on an integrated platform.

Twenty years later world leaders came together to establish the Millennium Development Goals (MDGs),[ii] an 8-goal framework for tackling the most pressing development challenges. As part of Goal 1, Eradicate extreme poverty and hunger, Target 1.C aimed to halve, between 1990 and 2015, the proportion of people who suffer from hunger, which was thought to be best understood by analysing the different dimensions of food security. One dimension was “Nutritional failures are the consequence not only of insufficient food access but also of poor health conditions and the high incidence of diseases such as diarrhoea, malaria, HIV/AIDS and tuberculosis.” Thus Goal 6, Combat HIV/AIDS, malaria and other diseases,” set Target 6.C to have halted by 2015 and begun to reverse the incidence of malaria and other major diseases.

While recognizing some major successes in the MDGs, the global community again came together to conceptualize a new framework to take off after the MDG process ended in 2015. The new Sustainable Development Goals (SDGs) had 17 components and many sub-goals with the purpose of painting as full a picture of a desired social, economic, environmental, health and political landscape as possible.[iii] Goal 2 focused on ending hunger, achieving food security and improving nutrition, and promoting sustainable agriculture. Unlike Alma Ata and the MDGs, the health goal appears a bit diffuse: Goal 3 was to ensure healthy lives and promote well-being for all at all ages. Among 13 sub-goals was 3.3 that stated by 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases.

A thorough reading of the three mentioned documents/frameworks importantly shows that malaria and food security do not exist in isolation. Their potential interaction and intersection happen in a context of poverty, the environment and climate change.

[i] World Health Organization and UNICEF. Declaration of Alma-Ata, International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978.

[ii] United Nations. The Millennium Development Goals Report 2014. New York, 2014.

[iii] United Nations. Transforming Our World: The 2030 Agenda for Sustainable Development. A/RES/70/1.

Capacity Building &Costs &Research &Seasonal Malaria Chemoprevention &Surveillance &Treatment Bill Brieger | 04 May 2018

Multilateral Initiative for Malaria: Posters Range from Prevention to Cost to E-Learning and Beyond

A major feature of all conferences are the poster sessions. These are often overlooked due to timing and placement. Fortunately at the recent 7th Multilateral Initiative for Malaria Conference in Dakar, tea breaks and lunch were made available in the poster tent ensuring more people came to view. Even so some people may have missed the valuable knowledge shared through this medium. We tweeted many of the posters during the event, but below are six posters in more detail.

These range from evaluating a malaria surveillance system to financing systems to sustain malaria drug supplies, including through community pharmacies. The potential of E-Learning for malaria capacity building was explored, and the process pf establishing a national malaria operations research agenda was presented. Several posters examined the seasonal malaria chemoprevention (SMC) program in the Sahel of West Africa including one from Mali as seen below.

Please contact the authors for additional information and updates. Readers who presented a poster at MIM are welcome to share their findings with us.