Tropical Health Matters

David Kanamugire has published a blog on the need to add the malaria vaccine to Tanzania’s arsenal of malaria elimination strategies. The original posting is found in the class blog for the Social & Cultural Basis for Community and Primary Health Programs class at the Johns Hopkins Bloomberg School of Public Health. Below is his perspectives on the issue.

Malaria is still a major public health problem. In 2021, malaria killed an estimated 619,000 people – 95 percent of them in Africa. Children under the age of 5 accounted for 80 percent of Africa malaria deaths. Tanzania is among 4 countries that account for just over half of all global malaria deaths.

The country has significantly reduced malaria cases, from a prevalence of 18% in 2008 to 8.1% in 2022. This reduction is attributed to intervention such as Insecticide Treated bed Nets, Indoor Residual Spray, effective drugs and Malaria Rapid Diagnostic tests.

But recently the global progress on malaria has stalled and this could be due to emerging drug resistance, insecticide resistance and the spreading of invasive species Anopheles stephensi. For the past 3 years, the global malaria death remains above 600,000. Therefore there is need for new approaches to help in efforts to prevent and control malaria.

Photo: Gavi, the Vaccine Alliance

Vaccines are safe and cost-effective way combat communicable diseases and improve health outcomes. One of malaria vaccine that have been approved by the WHO is R21. It was developed by Oxford and is produced at a large scale by the Serum Institute of India.

The R21 vaccine is cheap and can be easily produced thus making it ideal for Africa countries. The R21 is also effective against malaria as three initial doses followed by a booster give up to 80 percent protection against malaria.

Essential Medicines, Commodities and Supplies Needed for Community Level Primary Health Care Interventions is our 2-credit online course offered from 5-9 June 2023 as part of the Global Health Systems Summer Institute. Please check the syllabus and share with colleagues.

Course Description” Essential commodities are among the 8 basic primary health care services and the 6 health systems building blocks as defined by the World Health Organization

Primary health care programs in low and middle-income countries require essential health commodities be made available at the community level. Logistic systems need to be developed to ensure that commodities are adequately estimated and delivered. In addition, systems for safely maintaining and monitoring stocks are needed at the community level.

The Summer Institute offers a variety of short-term courses in a variety of global health areas between 5-30 June 2023. The Global Health Systems Summer Institute provides early- and mid-career public health professionals with cutting-edge skills in a variety of global health topics. The Institute is also a great opportunity for part-time MPH and other Hopkins students and fellows to learn a valuable set of skills in an in-demand and rapidly growing field of public health. Below are issues covered in the Essential Medicines course.

• Overview of Essential Medicines for Primary Health Care
• Essential Medicines for Primary Health Care
• Basic Primary Health Care Procurement and Logistics
• Financing for Essential Medicines
• Implementation of Essential Medicines Programs in Primary Health Care
• Preventative Chemotherapy for Neglected Tropical Diseases
• Ensuring Essential Pharmaceuticals Go “Beyond the End of the Road”
• Supply Chains
• The Role of Indigenous Medicine
• Supply Chain Management for CDI: The Malaria Example
• Logistics Management Information System in Community Based PHC
• Community Mass Drug Distribution
• The CDI Process: Expanding Beyond Ivermectin
• Supply Chain Management in Ethiopia
• Community Supply Chain Challenges in Nigeria

Solomon Afolabi, a graduating MPH student from the JHU Bloomberg School of Public Health examined the challenge of epidemics and outbreaks in Africa with special reference to Uganda as an example. The abstract of his report is found below.

According to the WHO, preparedness for emergency health conditions like infectious disease outbreaks should be an ongoing action supported by adequate funding, resources, partnerships, and political will that is executed at all levels to keep it sustained. Emergency preparedness is a framework that identifies practical in-country health emergency preparedness principles and elements by acknowledging lessons learned from previous response activities for priority planning, implementation, and reinforcing operational capacities.

Uganda is an ecological hotspot for various infectious diseases making the country liable to outbreaks. In the last two decades, multiple significant outbreaks have occurred, prominent of which are from yellow fever, Ebola virus disease, and COVID-19 global pandemic. Efforts to build a strategic framework for emergency outbreak preparedness and to strengthen the national operational capacity led to the establishment of the Ugandan National Institute of Public Health (UNIPH) in 2013.

This paper presents a blend of literature that takes account of the successes, challenges faced, and gaps identified in the preparedness and response capacities to the infectious disease outbreaks experienced in the last two decades. It also reviewed how the national efforts had fared in operational readiness for an emergency response to epidemics, building a resilient health system, practicing the One-Health human-animal-environment interface, and in government, community, and individual capacities to contribute effectively to strengthen the national emergency preparedness and response to these frequent disease outbreaks. The findings revealed that Uganda’s outbreak preparedness had made much progress over two decades, from the overwhelming Sudan strain Ebola virus outbreak in 2000-2001 to a similar episode from the same species in 2022 to 2023.

The response measures that feature the activation of a national response plan by the MoH were well coordinated locally to swiftly lead to the activation of NTF, NRRT, DTF, DRRT, and VHTs for immediate mobilization and deployment of operational resources to affected districts. The response was strengthened by well-organized local coordination by the MoH and development partners (WHO, CDC, UN agencies, etc.). The immediate setting up of treatment and isolation centers, provision of Ebola kits, training of more health workers, and coverage of 10 high-risk districts ensured a significant impact.

The provision of more than 5000 doses of vaccines with the support of WHO and partners was a global capacity milestone impact, and the country was declared Ebola-free in a record 69 days. Uganda’s current national emergency preparedness and response plan has received commendations locally and from global international partners, having progressively built capacity from lessons learned in just over a decade of responding to frequent infectious disease outbreaks and using the recommendations proffered accordingly.

This sustained momentum of preparedness supported the swift transition to contain COVID-19 and laid a good foundation for their strengthened readiness for an emergency response to outbreaks.

World Malaria Day 2023 is focusing on three key themes, Investment, Innovation, and Implementation, the 3 I’s. The recently approved malaria vaccines and those still under development embody these themes fully.  They all represent decades of investment in innovation, research, and now implementation.

After extensive several decades of clinical research and three years of field implementation in Ghana, Malawi, and Kenya by the World Health Organization and National Malaria and Immunization Programs, the RTS,S/AS01 malaria vaccine is being rolled out with assistance of GAVI, the Global Vaccine Alliance. During the malaria vaccine implementation program (MVIP) and also based on GAVI’s philosophy for vaccine programs generally, a key strategy was to provide RTS,S as routine immunization services alongside other essential services including a comprehensive package of malaria control and elimination interventions. RTS,S is not only being made available to the three MVIP countries, but as supplies come on board, other falciparum malaria endemic countries have started to apply for supplies and funding through GAVI.

It was well known from the beginning that although RTS,s might be first out the gate, other vaccines would be following closely on its heels. The benefits as well as the efficacy limitations of RTS,S were well known.  Therefore, talk was common for new products being available by 2026. Now in 2023, countries have started to move ahead on another vaccine candidate.

BBC reported that “Ghana is the first country to approve a(nother) new malaria vaccine that has been described as a ‘world-changer’ by the scientists who developed it.” R21 appears to be more effective than its predecessor, so Ghana’s drug regulators moved ahead quickly using final trial data on the vaccine’s safety and effectiveness, which is not even public, to approve it. Interestingly, this move is in parallel to the World Health Organization’s consideration of approving the vaccine.  Shortly thereafter, Nigerian medicine regulators also approved R21. Reuters noted that these “approvals are unusual as they have come before the publication of final-stage trial data for the vaccine.” The actual roll out will ultimately depend on official publication of the safety data and sourcing of funds.

As mentioned above, these malaria vaccines represented considerable investment of time and resources, embody the kind of innovation that is needed to tackle malaria as drug and insecticide resistance threaten progress toward elimination, and require detailed planning right down to the grassroots levels to ensure that a malaria vaccine delivery is part of a comprehensive package of malaria and child health services.

We need to return to the theme of investment. While international organizations, universities, ministries of health, and of course pharmaceutical companies have been investing in developing a safe, effective, and feasible product, these innovative products will not save lives until funds are invested for both purchase and service delivery are guaranteed. GAVI and Partners have put together over $200 million in support for RTS,S implementation for three years. The first window was open in September 2022 for the initial three MVIP countries, and a second window for others, depending on available supplies was open in December 2022.

Investment FOR implementation is a challenging subject because GAVI and collaborating agencies are not a bottomless well of money. What level of national investment by a country to protect its own children is feasible? Is there the national political will to contribute and invest in children in endemic countries, and not continue depending heavily on donors?

Malaria vaccines are a perfect example of what the 3 I’s can achieve. But beyond celebrating this addition to the malaria elimination toolkit, will we also be celebrating commitments by endemic countries of local funds to make zero malaria a reality?

By Jordan Kerr and originally posted in the Social and Behavioral Foundations of Primary Health Care Blog.

Malawi is making strides in increasing HPV vaccinations among adolescent girls across the nation. Since the official implementation of the HPV vaccine program in 2019, 20 out of the 29 districts in Malawi have begun administering the vaccine to adolescent girls between the age of 9 and 14. Despite this success, Malawi continues to be one of the leading countries worldwide in cervical cancer-related mortality. New cases of cervical cancer in Malawi are reported at a rate five times higher than the global average.

This highly preventable disease places a more significant burden on low-income countries like Malawi due to poor access to healthcare services and resources. International agencies are improving their outreach efforts to reach girls not enrolled in school and address vaccine hesitancy in districts with higher vaccine refusal rates. Due to this outreach vaccine registration is improving however healthcare facilities are experiencing stockouts. In some districts, healthcare facilities are reporting that the main reason individuals are not receiving vaccinations is that they are running out of vaccine stocks.

The World Health Organization (WHO) set a goal in 2018 to eliminate cervical cancer by increasing HPV vaccination uptake globally. This initiative has shown to be successful in addressing disparities in low- and middle-income countries however, in 2020 an HPV vaccination shortage began and is expected to continue through 2025.

The Center for Strategic and International Studies (CSIS) presents several strategies that can be used to address this shortage to keep on track with the goal to eliminate cervical cancer. Efforts must be taken to support facilities developing the HPV vaccine to ensure stockouts do not continue. We need policymakers to lobby for policies that increase funding for vaccination development and establish priority vaccination allocations to countries like Malawi that are experiencing high mortality rates from cervical cancer

By Lauren Koranteng and originally posted in the Social and Behavioral Foundations of Primary Health Care Blog. “Overcoming poverty is not a task of charity, it is an act of justice. Like Slavery and Apartheid, poverty is not natural. It is man-made and it can be overcome and eradicated by the actions of human beings. Sometimes it falls on a generation to be great. You can be that great generation. Let your greatness blossom.” – Nelson Mandela According to the World Health Organization, Schistosomiasis is a “disease of poverty that leads to chronic ill-health “. It is caused by a parasitic worm that lives in freshwater snails. The larval forms of the parasite is released by the snails. Humans who make contact with the water during various activities like recreation, agriculture and also for livelihood get infected. The prevalence rate in Ghana is 23.3% , however there are some areas that have localized prevalence levels that are >50% ( Kulinkina et al). A vulnerable population that is often infected are school aged children who access the waters mostly for recreational reasons (Antwi et al). These are usually school aged children who live in hard to reach areas in the country with poor sanitation. It is important for the disease to be controlled because chronic ill health also impacts the cognitive abilities of the children. Praziquantel is a drug used for preventative chemotherapy against Schistosomiasis. It offers a solution to eradication of the disease and could be executed through drug administration of praziquantel through the school system. This kind of mass administration has been done before in the country, but unfortunately, the behavior of children swimming in these infected waters did not change. This behavior of continuous exposure of children to these water bodies presented a limited factor in the eradication of this disease and intervention. Using the national health insurance program in the country, praziquantel can be made available again but through school programs in these rural areas.  Additionally, the school curriculum can include health education that will encourage children to avoid fresh water bodies where possible. Sanitation improvement and reduced human and infected water contact will also be a priority health development goal. So, in working with stakeholders such as the Ghana Health Service and the Ministry of Education, a realistic plan can be developed and executed.  This can include a mass drug administration program, health education and sanitation improvement.  This may be reasonable interventions to use to support children who are in contact with fresh water bodies and at a high risk of contracting Schistosomiasis.

By Blessing George & Chino Nduaka and originally posted in the Social and Behavioral Foundations of Primary Health Care Blog. More than 50% of deaths from malaria are from four African countries, and Nigeria heads the list, contributing a significant part at more than 30%. Nigeria faces a major public health burden, with an estimated 65 million cases and over 100,000 deaths in 2021, representing over 50% of malaria cases in West Africa. With most outpatient visits in Nigeria being caused by malaria, this disease has taken a toll on the economy. Malaria is among the top five causes of under-five mortality in Nigeria. Over the years, various organizations have joined hands in the fight against this deadly disease. However, Nigeria remains at the top of the list contributing significantly to the mortality rate. Insecticide-treated nets (ITNs), indoor residual spraying, and free sharing of anti-malaria drugs for prophylaxis and treatment constitute ways the country has tackled the disease burden. With the funding allocation repeatedly given by international organizations such as the WHO, the World Bank, and the Global Fund channeled to these interventions that have proved somewhat ineffective, we are at crossroads that begs the question, what next? In 2016, the world’s pioneer malaria vaccine, RTS, S, sold with the brand name, Mosquirix, was introduced for pilot implementation in three malaria-endemic countries. It has been administered to over a million children with positive results on its effectiveness. In 2022, the Nigerian government officially applied to receive the vaccine through GAVI but was hit back with the response that currently, there is an insufficient supply of vaccines. Nigeria tops the list of the global malaria mortality rate and should be prioritized. The Nigerian Ministry of Health, in collaboration with the Nigerian Primary Healthcare agency, needs to fight for the health of its citizens, respond to GAVI, and state the concrete reasons why the country should be prioritized. The goal is to ensure that these vaccines are made available for the under-5 population in Nigeria by 2025 such that in the malaria world report of 2030, Nigeria should not be named a major contributing country to malaria mortality.

By Peace Ige, and originally posted in the Social and Behavioral Foundations of Primary Health Care Blog.

In Nigeria, typhoid fever continues to be a significant disease, and its prevalence is on the rise. The disease is transmitted through the oral consumption of contaminated food or water and can also be spread through personal contact due to unsanitary practices (Enabulele et al., 2016). The increasing incidence of antibiotic-resistant strains of the bacteria makes treating typhoid fever challenging. The lack of proper surveillance, limited laboratory capacity, and inadequate data availability in Nigeria make it difficult to assess the actual prevalence of typhoid fever.

There needs to be more reliable and consistent data on the incidence of typhoid fever in Lagos and Nigeria, making it challenging to assess the disease’s prevalence accurately. This under-reporting is due to several reasons, including using antibiotics before confirmatory laboratory tests and patients’ failure to seek medical attention, as laboratory services are often not affordable (Enabulele et al., 2016).

According to a study published in The American Journal of Tropical Medicine and Hygiene (primary article), the lack of epidemiological data tracking regarding typhoid fever in sub-Saharan Africa prompted the World Health Organization (WHO) to call for a continent-wide approach to generate more accurate disease incidence and antimicrobial susceptibility data in 2008. The study emphasizes the importance of antibiotic resistance as a significant health security issue, as S. Typhi has developed resistance to multiple drugs, making it difficult to treat.

Typhoid fever remains endemic in Lagos, Nigeria, and the larger sub-Saharan Africa region, posing a significant public health challenge. To address this issue, coordinated efforts are needed from all stakeholders. Strengthening surveillance systems to collect accurate data on typhoid fever incidence, prevalence, and antimicrobial susceptibility is critical (Enabulele et al., 2016). This requires government funding to improve laboratory infrastructure and trained personnel. Accessible data can guide policy decisions and interventions. Improving sanitation and hygiene practices is also vital to combating typhoid fever.

The government should invest in improving access to potable water, wastewater management systems, and community education on personal hygiene practices. Public and private sector partnerships can be established to improve water and sanitation infrastructure in vulnerable communities. Increased vaccination campaigns are a cost-effective intervention in reducing the incidence of typhoid fever. The Nigerian government should increase the coverage of the typhoid fever vaccine in Lagos state, especially for vulnerable populations such as children and those in low-income communities.

A robust public health campaign should promote vaccine uptake and raise awareness of typhoid fever and its causes. A multi-sectoral approach is needed to address the root causes of typhoid fever in Lagos. Collaboration between the government, healthcare providers, the private sector, and other stakeholders is necessary to ensure the implementation of effective interventions. Advocacy efforts are necessary to ensure political commitment and support for policies addressing typhoid fever in Lagos. By implementing these strategies, Lagos can reduce the incidence and impact of typhoid fever on its population.

Lagos, Nigeria, must take responsibility for addressing the issue of typhoid fever and external support. The World Health Organization (WHO) has already called for a continental approach to generate accurate disease incidence and antimicrobial susceptibility data, and Nigeria must take advantage of this support. One of the critical areas where external support is essential is strengthening the healthcare system’s capacity for surveillance and diagnosis of typhoid fever. This includes improving laboratory facilities and providing training for healthcare workers.

Support from organizations such as WHO and the Centers for Disease Control and Prevention (CDC) can help develop effective policies and programs to control the spread of typhoid fever. Another area where external support is critical is promoting research into new and effective treatments for typhoid fever. This includes developing new antibiotics and vaccines and studying the disease’s epidemiology and ecology to understand better how it spreads and can be prevented.

External support is essential in helping to raise awareness of the issue of typhoid fever and its impact on public health in Nigeria. By working with local communities and stakeholders, external organizations can help to educate people about the disease, how it is spread, and how it can be prevented. This can create a sense of urgency around the issue and mobilize local communities and governments to take action.

The bluish line in the graph shows the rate of S. Typhi that can resist ampicillin. The orange line shows Chlora6mphenicol-resistant S. Typhi. Co-trimoxazole-resistant Staphylococcus typhi prevalence is shown by the gray line. S. the yellow line shows Typhi tetracycline resistance. The dark blue line shows the proportion of S. Typhi resistant to ciprofloxacin. The green line shows cefuroxime-resistant S. Typhi.

In 2003, cefuroxime entered clinical use. The red line shows the proportion of S. Typhi strains resistant to cefotaxime. In 2008, cefotaxime was made available to the public. In conclusion, typhoid fever remains a significant public health issue in Lagos, Nigeria. The persistence of the disease can be attributed to poor surveillance, inadequate data availability, restricted laboratory capacity, and resource and financial limitations that contribute to poor quality water, sanitation, and hygiene infrastructure.

The adoption of proper measures can significantly reduce the incidence of typhoid fever in Lagos. The Lagos State Government and stakeholders in Nigeria must show more commitment and will to provide the necessary means to combat the endemic disease. The involvement of external forces such as WHO, CDC, and other international organizations in promoting the eradication of the disease is essential. Their support in generating more accurate disease incidence and antimicrobial susceptibility data, improving laboratory capacity, and providing resources for disease surveillance and control is a significant step toward eradicating the disease.”

All stakeholders must work together to ensure the necessary measures are taken to end the endemic disease. With proper measures in place, we can significantly reduce the incidence of typhoid fever in Lagos, Nigeria, and ultimately eradicate the disease.

Ref.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4924394/

Adegbola and colleagues note that “the efficacy of SP-IPTp is threatened by the emergence of sulfadoxine-pyrimethamine resistant malaria parasites, “which has been observed in East Africa. They therefore, studied the situation in Nigeria, the country with the highest malaria burden in the continent. Their study showed that “the prevalence of VAGKGS haplotype seems to be increasing in prevalence.”

In conclusion, they worried that, “If this is similar in effect to the emergence of 581G in East Africa, the efficacy of SP-IPTp in the presence of these novel Pfdhps mutants should be re-assessed” in Nigeria. This situation threatens the use of sulfadoxine-pyrimethamine (SP) in two major prevention programs including intermittent preventive treatment during pregnancy (IPTp) and seasonal malaria chemoprevention (SMC) for children.

The benefits of IPTp using SP is the ability to administer chemoprevention in a single directly observed dose. Alternative medications are being explored, but from the behavioral intervention perspective, the low cost and simplicity afforded by SP is ideal.

The IPTp strategy had been modified a decade ago from requiring 2 doses, to monthly doses from the second trimester onwards because of parasite resistance or what is also termed drug tolerance by the parasite. Tolerance implies that the drug may still work, but at higher or more frequent doses. Such changes have cost and behavior change implications. Many country reports from the Malaria Indicator Surveys show an expected drop-off in uptake of SP between the first and third doses. For example in the 2021 Nigeria MIS IPTp1 uptake was 58%, while IPTp3 had reduced to 31%.

A related problem in Nigeria is the ubiquitous availability of SP in medicine shops across the country in contrast to official policy limiting it to use in IPTp and SMC. The challenge is finding affordable and feasible alternative medicines for IPTp. In the meantime, we have not even reached coverage targets using SP nor fully achieved rollout of companion interventions such as the use of Insecticide Treated Nets. Much work is still needed to protect pregnant women and fetuses from the malaria induced problems of anemia, low-birth-weight, stillbirth, and more.

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A related study from Cameroon: The occurrence of sub-microscopic P. falciparum parasites resistant to SP and intense malaria transmission poses persistent risk of malaria infection during pregnancy in the area. ITN usage and 
monitoring spread of resistance are critical.

https://malariajournal.biomedcentral.com/articles/10.1186/s12936-023-04485-7

Dr Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization, reminds us in this year’s edition of the World Malaria Report (WMR 2022) that, “Although hard hit, most countries held the line and were able to maintain services to prevent, detect and treat malaria – a remarkable feat in the midst of a pandemic. Nonetheless, more than 600 000 people still die of malaria every year – most of them children. Even with the heroic efforts to maintain services during the pandemic, malaria control efforts face many hurdles in addition to the already significant COVID-related disruptions and other health system challenges.”

Even though there was an increase in cases between 2020 and 2021, there are now more strategies in the malaria control and elimination toolkit than ever before. One in particular is an updated take on an old concept of chemoprophylaxis, which fell out of use due to mounting drug resistance. Years of research with pregnant women and young children led to the development over time of using regularly scheduled treatment doses of malaria medicines as chemoprevention. Intermittent Preventive Treatment for pregnant women (IPTp) and Seasonal Malaria Chemoprevention for young children, both targeted to appropriate epidemiological settings, are now common. Countries are also exploring IPT for children in other settings.

We were, therefore, curious what the current WMR shares on chemoprevention initiatives. Specifically, the WMR summarized WHO recommendations as follows: “Updated guidelines provide recommendations on intermittent preventive treatment of malaria in pregnancy (IPTp), perennial malaria chemoprevention (PMC) and seasonal malaria chemoprevention (SMC), intermittent preventive treatment of malaria in school-aged children (IPTsc), post-discharge malaria chemoprevention (PDMC), mass drug administration (MDA) and elimination.”

In summary, WMR 2022 notes that, “The average number of children treated per cycle of SMC increased from about 0.2 million in 2012 to almost 45 million in 2021,” and “Using data from 33 countries in the WHO African Region, the percentage of IPTp use by dose was computed. In 2021, 72% of pregnant women used ANC services at least once during their pregnancy. About 55% of pregnant women received one dose of IPTp, 45% received two doses and 35% received three doses.” This is not just progress over time, but also represents an expansion targets and work required for success. For pregnant women the increase represented a change in target from only two doses during pregnancy to a minimum of three. Starting with pilot efforts, SMC now covers children in 15 countries.

The targeted three doses for IPTp shows that two thirds of women who register for antenatal (prenatal) care (ANC), fail to achieve full coverage. Stronger collaboration is needed between malaria control and maternal health programs to ensure that pregnant women actually attend ANC and do so early and often enough to receive 3 monthly doses minimum in their second and third trimesters. More emphasis is needed on community IPTp distribution, since we know that community health workers have been crucial in achieving SMC as well as integrated community case management efforts.

Similar challenges exist for SMC as research looks into whether additional doses are needed based on mosquito breeding and malaria transmission season factors in endemic countries. Adding extra months to the program will tax resources, but also save lives.

Both maternal and child efforts at chemoprevention will need to address research that first shows increasing resistance to the common medicines used, and the potential for introducing new drug combinations in light of that resistance. Challenges here reflect another aspect of SMC, the need for CHWs to guarantee that on any given distribution round, three doses on medicine are required. Recent reports show that within any given round, community adherence to SMC has been good. We need to apply those lessons to IPTp when the regimen changes.

Ultimately, chemoprevention has proven to be an important life saving tool. The challenges of multiple contacts and doses that lead to success rely not only on having effective medicines, but also on culturally appropriate behavior change strategies and well-funded efforts to strengthen the health systems that deliver preventive treatments.