Tropical Health Matters

As part of the work for the Johns Hopkins University course on Social and Behavioral Foundations of Primary Health Care, Bea Manjon posted in the class blog about the threat of hypertension to people and the health system in the Philippines as seen below.

by smanjon

As part of the work for the Johns Hopkins University course on Social and Behavioral Foundations of Primary Health Care, Skylar Chapdelaine posted in the class blog about HIV/AIDS Treatment in South Africa.

South Africa has the highest global burden of HIV with over 7.7 million people living with the virus. While over 5 million people are on antiretroviral therapy (ART), the decline of international funding especially from the U.S. President’s Emergency Plan for AIDS Relief challenges the sustainability of this.

For years the United States has played an important role in financing South Africa’s HIV response; however, as this money is expected to be lost, South Africa must seek alternative funding mechanisms to sustain programming.

Initiatives and Challenges

Despite financial uncertainties, South Africa has announced a goal of putting an additional 1.1 million people on treatment by the end of 2025 as a step towards their ending AIDS as a threat by 2030.

However, challenges persist. The loss of funding has already affected healthcare personnel, drug supply chains, and monitoring systems. Community organizations such as the Treatment Action Campaign (TAC) have previously been instrumental in expanding ART access, but the financial constraints are limiting their availability to help advocate for patients.

Additionally, international pharmaceutical companies dominate the ART market. Intellectual property restrictions limit local production making ART expensive and difficult to scale up. Without affordable alternatives, millions with HIV could face interruptions in treatment.

Strategies for Engaging Stakeholders

To influence policymakers to secure a sustainable future for HIV treatment, stakeholders need to be strategically engaged.

One of the most crucial stakeholders in this, the South African National AIDS Council (SANAC), plays an important role in coordinating the national HIV response through uniting multiple sectors. SANAC can lead by organizing regular policy roundtables and cross sector forums that bring government officials, civil society leaders, and private sector representatives together. By facilitating these conversations, SANAC can guide the development of policy briefs that offer evidence based solutions, such as strategies to boost local ART production and sustainable financing models and engage policymakers.

Without urgent action from policymakers to begin securing sustainable funding, millions of South Africans are at risk of disruptions in their treatment.

As part of the work for the Johns Hopkins University course on Social and Behavioral Foundations of Primary Health Care, Simon Riek posted in the class blog about a community-based health initiative in South Sudan as seen below.

South Sudan continues to experience high maternal and child mortality rates, limited healthcare access, and a shortage of trained professionals. The Boma Health Initiative (BHI) is a community-based healthcare program that trains and deploys Community Health Workers (CHWs) to deliver maternal care, immunizations, and disease management in underserved areas. While promising, BHI faces funding instability, supply shortages, and a lack of standardized training and supervision. To ensure sustainable impact, I strongly advocate for increased financial investment in CHW’s training as a priority policy goal.

For this policy to succeed, we must engage key stakeholders strategically. World Health Organization (WHO) – Department of Health Systems Governance & Financing. WHO supports community-based health models and can provide technical and financial resources. Advocacy Approach: Partner with WHO to champion CHW training through reports, policy dialogues, and media engagement.

South Sudan’s Ministry of Health (MoH) – Directorate of Community Health Services. As the lead health agency, MoH oversees BHI implementation and CHW workforce management. The advocacy approach should push for MoH to allocate domestic funding for CHW training, ensuring sustainability beyond donor reliance.

The World Bank’s Human Development Practice Group funds health initiatives but has not directly committed to BHI. Advocacy approaches include presenting cost-effectiveness evidence to secure investment in CHW training programs.

Some physicians from the South Sudan Doctor’s Association (SSDA) fear CHWs will replace trained professionals, while others support task-sharing. Advocacy approaches include collaborating with SSDA to define CHW roles, ensuring they complement rather than replace professional healthcare providers.

In order to expand BHI and improve CHW training, I urge the South Sudanese government to commit long-term funding. Partners, including WHO and World Bank need to invest in capacity-building initiatives. Finally the SSDA must support CHWs as a critical part of the healthcare system.

The Demographic and Health Survey Program (DHS) has been a mainstay for tracking malaria indicators in endemic countries over the past three decades. When visiting the website now, one is met with the following message, “Due to the on-going review of US foreign assistance programs, The DHS Program is currently on pause. We are unable to respond to any data or other requests at this time. We ask for your patience.” Surveys completed and published before the end of 2024 are still available to view and download, but work that wan is progress has halted.

The example of Nigeria is instructive. One finds a table on the Nigeria Country page that summarizes 25 national level health and development indicators from 1990 to 2021 using either the DHS or the Malaria Indicator Survey (MIS). A 2024 DHS survey was undertaken and a preliminary report is available, but the final detailed report was not written before the transition in administrations.

The 1990-2021 summary table included one malaria variable, children under five years of age sleeping under an insecticide-treated net the night prior to the study. Out of interest the information is posted in a chart herein. Of note, no bednet data were available for 1990. fortunately the 2024 preliminary MIS includes this.

Of note is the coverage in the context of earlier targets of 80% in 2010 and subsequent efforts to cover all children as time passed. The chart shows a slow start reaching only 29% of children by 2010 and then dropping to 17% in 2013. over the next four surveys, the coverage rate hovered in the mid 40% range topping 50% only once.

The Nigeria  National Malaria Control Program changed its name some time ago to National Malaria Elimination Program in hopes that this new moniker might lead to improved efforts. Unfortunately this was not to be the case. The value of the DHS/MIS was that countries could easily see progress and challenges and plan accordingly.

The Federal Ministry of Health, Nigeria, in collaboration with the National Population Commission (NPC) have been the local implementers of these surveys over the years. In addition to USAID, other partners such as WHO, UNFPA, The Bill & Melinda Gates Foundation, and the Global Fund have provided assistance in conducting the surveys.

Hopefully Nigeria (and other countries) and various partners will continue to see value in obtaining national and sub-national health and development statistics that document progress and help plan the future efforts to rid endemic populations of malaria and other scourges.

In the lead up to World Malaria Day 2025, the Johns Hopkins Malaria Research Institute held an Expert Briefing for the Media to discuss  the Global State of Malaria: New Research, Evolving Risks, and Silver Linings. The session was moderated by Ellen Wilson.

The two experts included Jane M. Carlton, PhD, director of the Johns Hopkins Malaria Research Institute at the Johns Hopkins Bloomberg School of Public Health and a Bloomberg Distinguished Professor in the Department of Molecular Microbiology and Immunology at the School and George Dimopoulos, PhD, MBA, also a professor in the Department of Molecular Microbiology and Immunology.

The speakers discussed and responded to questions regarding the current state of malaria, the need for global commitment to malaria prevention, control, and research, advancing diagnostics and therapeutics, current mosquito vector control methods and their limitations, and the need for an integrated approach to malaria control. As an overview, attendees were told that malaria is a mosquito-borne disease that in 2023 took nearly 600,000 lives in 83 countries, the majority being children under age 5 years in the WHO African Region.  In the U.S., the risk of contracting malaria remains low; however, continued vigilance is needed to prevent increases in both domestic cases from foreign travel and as occurred in 2023 for the first time in 20 years, locally transmitted cases.

Jane Carlton expressed concern that malaria cases had increased from 2022 to 2023, but was hopeful because of innovations such as vaccines, and genetically modified mosquitoes. One could also draw hope from efforts to establish local manufacturing capabilities in endemic countries, including partnerships for African vaccine development and production. And in fact, she noted, in 2022, “one company in Kenya became the first African-based manufacturer to receive WHO pre-qualification for a malaria drug. There is a second Nigerian manufacturer that is making progress.” There are several research organizations and universities in African countries that are working towards new drug and intervention development. Studies are ongoing perhaps to use some local plants as anti-larval treatments.

Prof. Carlton explained that the burden of malaria in India has reduced dramatically. “There’s been about a 70% reduction in cases from just over 6 million in 2017 to 2 million in 2023,” although two million cases is still quite a large number.

Prof. Carlton was also asked about the effect climate change on malaria transmission and the potentially expanding the geographic range of malaria. How are researchers adapting? She observed that, “Yes, that’s a very interesting question. In fact, it goes against intuition in a way but increasing the temperature doesn’t always increase the number of malaria cases. The malaria parasite and the mosquito that carries operate within quite a tight temperature range.

In reality, it can get too hot, but as some areas get wetter and formerly cool areas become warmer due to climate change, malaria transmission can move to new locations. “So, there is an increasing shift and an increasing understanding that surveillance of this particular issue is important,” especially needing to monitor climate contexts. For example, scientists have looking at the invasive Anopheles stephensi, which is severely disrupting activities of National Malaria control programs.

There’s been an analysis from the Oxford Malaria Atlas Project, or MAP, and they have projected that with a freeze for one year of PMI activities, this would result in up to 18 million additional malaria cases and up to 107,000 additional malaria deaths. This represents an increase in morbidity of 13%. This would occur in PMI’s focus geographies across 27 African countries. This analysis doesn’t account for the additional impact of PMI supported diagnostics.

Prof. Carlton observed that “globally, total investments in malaria control reached an estimated $4 billion in 2023, but this already fell short of the $8 billion funding target” of the World Health Organization Roll Back Malaria Partnership.

George Dimopoulos stressed e importance of community engagement in vector control activities. He explained that malaria is one of the diseases of poverty where the poor are disproportionately at risk and impacted. He then responded to a question about gene-drive technology based on the

CRISPR-Cas9 system that can spread mosquito genes in natural populations. “This has advanced very significantly in mosquitoes over the past roughly 10 years.”

Prof. Dimopoulos explained that gene-drive “can also work in all malaria vector species. In this way it becomes a malaria control strategy that could work in all malaria endemic areas.” Prof. Dimopoulos’ team has also done research on the effects of sugars and micro-organisms on the mosquito gut and malaria transmission. “We have shown through our research that the health of the mosquito gut depends on a protein quality control system. With appropriate control interventions, “The mosquitoes become very sick and a large proportion of them will actually die.”

In conclusion, the “Silver Linings” mentioned in the session’s title include advances in both parasite and vector control. Deployment of two malaria vaccines offers one ray of hope. New vector control technologies such as gene-drive, offer another. The speakers encouraged people to attend the upcoming JHU-MRI Malaria Day conference to learn more.

The RBM Partnership to End Malaria has developed a communication kit to help plan for the upcoming World Malaria Day on April 25th. Below are some of the highlights and links they have shared.
To mark World Malaria Day 2025,  the RBM Partnership to End Malaria in collaboration with World Health Organization (WHO) have developed a Messaging Framework and Social Media Toolkit to support partners and individuals in raising awareness and advocating for a malaria-free world.

Objectives for this year include…

• Re-energize efforts at all levels, from global policy to community action, to accelerate progress towards malaria elimination
• Advocate for increased investment in malaria control and elimination programs, including through stepped-up domestic financing and successful replenishments for the Global Fund and Gavi in 2025.
• Promote innovative strategies and approaches to tackle evolving challenges in malaria
• Prioritize country ownership, actively engage communities, and implement data-driven strategies

The emphasis is on three pillars. First in REINVEST, which recognized that “Malaria control and elimination programs don’t just save lives – they’re also a smart economic investment for malaria-endemic countries and their international partners.”

The second pillar calls on us to REIMAGINE. We must Accelerate innovation by investing in the research and development of new and more effective antimalarial drugs, diagnostics, insecticides, vaccines and vector control methods” and turning that research into action.

The third pillar is a call to REIGNITE based on “a renewed sense of urgency and commitment is needed to accelerate the fight against malaria.” This is called the “Big Push against malaria (and) is a multistakeholder effort to drive progress.”

Follow the links to learn more and plan action.

As part of the work for the Johns Hopkins University course on Social and Behavioral Foundations of Primary Health Care, Jenny Truong posted in the class blog about the challenges of Antibiotic Resistance as shared below. Unregulated sale of antibiotics over-the-counter (OTC): In some areas of Vietnam, nearly 91% of antibiotics are sold without a medical prescription. A prescription is required by a 2005 pharmacy law, updated in 2016 and 2024, but in practice, there is little legal enforcement. The 2024 amendment expands health insurance coverage and prohibits operating without a Pharmacy practice certificate but does not specifically address OTC sales, retaining the same fine for selling antibiotics without prescription. Expanded insurance alone won’t stop unregulated sales: 48.6% of study participants said they would still buy antibiotics without prescription even when told they were breaking the law.

We ask that the Ministry of Health and Ministry of Industry and Trade raise the fine on drug sellers from 25 USD to at least 50 USD to curb unlawful sale. There should be consequences as heavy as shutting down the business after multiple infractions. With strong penalties for operating outside of “Good Distribution Practice (GDP) requirements,” there may be a chance to slow the spread of antibiotic resistance (AR). Only when the unregulated drug supply is gone will consumers be pushed to actually use their expanded insurance to see doctors and buy antibiotics with prescription.

Three key stakeholders support regulation. The World Health Organization (WHO) recognizes the irrational use of antibiotics in Vietnam. We must involve them in planning and advocating for funding to support efforts to educate and enforce fines on unlawful sellers. The Food and Agriculture Organization (FAO) supports Vietnam’s National AMR (antimicrobial resistance) Strategy to address antibiotic resistance. We must also involve them in planning efforts and align all sectors for comprehensive education. Corporations may support antibiotic stewardship efforts, like GlaskoSmithKline (GSK). We can collaborate with them to ensure they don’t distribute antibiotics to unlicensed sellers.

Two groups are not supportive. Corporations like Hau Giang Pharmaceutical may benefit from unlawful sale and may try to prevent lost revenue. We must defend our position and prevent efforts to blockade our enforcement.Local pharmacies like Pharmacity continue to break the law and sell antibiotics to those who have no prescription. We must defend our position and notify them that there will be increased penalties for breaking the law. Local unions like Giao Tien Women’s Union and Farmers’ Union have varying stances yet can sway local opinions. We can convince them not to misuse antibiotics and to buy only with prescriptions. Then we can collaborate with them to educate their communities.  

As part of the work for the Johns Hopkins University course on Social and Behavioral Foundations of Primary Health Care, Daniel Gomez Ramos posted in the class blog about the challenges of Bird Flu as shared below.

The Avian Influenza (H5N1) is increasingly becoming a significant concern in the kingdom of Cambodia with developing news revealing that a recent novel variant has the potential to increase the risk of a new pandemic in which human transmission could occur if no measures are taken to identify individual via screening/testing.

Given the limited quantity and quality of testing instrumentation, viable standard protocols, low personnel for both operating equipment and investigating areas of high incidence in humans and wildlife, and training programs, it is imperative that a standardized approach is created and implemented. A mandate for integrating real time-Polymerase Chain Reaction (RT-PCR) for individuals (i.e. workers who are in contact with livestock such as cattle and poultry) aged 12-65 years of age would be appropriate while focusing on the southern and central regions of Cambodia.

Bright C. Orji, Charity I. Anoke, William Robert Brieger presented a poster at ASTMH 2024 in New Orleans that analyzed the ability of national surveys to detect health program outcomes.

Intermittent preventive treatment of malaria in pregnant women (IPTp) promotes health of the mother and unborn child. One noteworthy benefit is reduction of low birth weight (LBW, less than 2.5kg). Large survey data sets aid learning about such benefits on a national scale.

We analyzed data from the 2018 Nigeria Demographic and Health Survey (DHS) to document the impact of IPTp on birth weight. Key variables included IPTp which based on national guidelines is given monthly at antenatal clinics from the 13th week, aiming to provide a minimum of 3 doses. DHS obtained this information from women giving birth in the previous two years.

Birth weight included women giving birth in the previous five years. A quarter had a record of newborn weight reported from a health facility.

Since many did not, women were also asked to estimate the size of the baby at birth: very small, smaller than average, average, larger than average, and very large. We combined the latter three categories into “average or larger”.

Of those giving birth in the past 2 years, 23% took only one dose, 24% took 2 doses, while 17% had 3 or more doses. In the broader sample of those giving birth in the previous 5 years 2.8% estimated that their baby was very small.

Among those women with a record of birth weight, 7% were LBW. Preliminary analysis comparing perceived size and IPTp doses found 3% receiving only one dose thought their baby was “very small” at birth, as did 3% of those taking 2 doses and 4% receiving 3 or more.

Among the subset with a recorded birth weight, 9% who took only one dose of IPTp had LBW baby, as did 7% who received 2 doses, and 6% who got 3 or more doses. It appears possible to compare outcomes (LBW) with interventions (IPTp), but data type and availability may limit conclusions.

Even though a smaller subset of women had access to a recorded birth weight (most women delivered outside a health facility), birth weight appears to provide a better indication of IPTp effectiveness than subjective perceptions of child’s size at birth.

The findings even with limitations show the value of national surveys to justify policies protecting pregnant women from malaria.

The World Health Organization has prepared an important document entitled “Health is the Argument for Climate Action: COP29Health is the Argument for Climate Action: COP29 Special Report on Climate Change and Health”. Malaria and other vector borne diseases are highlighted.

The report addresses diseases carried by mosquitoes by stating that, “Climate change increases the transmission of deadly infectious diseases such as dengue, malaria, West Nile virus” and others which are temperature and rainfall dependent. In particular, malaria transmission is intricately connected with temperature and rainfall patterns, and extreme weather events have been shown to cause rapid spikes in cases.”

Climate change not only effects environmentsClimate change not only effects environments where these diseases thrive, but impacts the livelihoods of populations, reducing their ability to pay for prevention and treatment. Migration and displacement also may result increasing vulnerability to disease.

Two of the report’s recommendations have special bearing on malaria. One is the need to “develop and implement innovative financing mechanisms, such as a global health insurance scheme for climate-vulnerable nations” and communities. A second is the importance of “Strengthen(ing) health surveillance systems, particularly in low-income countries, to better track and respond to climate-related health impacts.”

Recognizing the climate dependence of malaria will be a crucial step in eliminating the disease.