All posts by Bill Brieger

Population Health: Malaria, Monkeys and Mosquitoes

On World Population Day (July 11) one often thinks of family planning. A wider view was proposed by resolution 45/216 of December 1990, of the United Nations General Assembly which encouraged observance of “World Population Day to enhance awareness of population issues, including their relations to the environment and development.”

A relationship still exists between family planning and malaria via preventing pregnancies in malaria endemic areas where the disease leads to anemia, death, low birth weight and stillbirth. Other population issues such as migration/mobility, border movement, and conflict/displacement influence exposure of populations to malaria, NTDs and their risks. Environmental concerns such as land/forest degradation, occupational exposure, population expansion (even into areas where populations of monkeys, bats or other sources of zoonotic disease transmission live), and climate warming in areas without prior malaria transmission expose more populations to mosquitoes and malaria.

Ultimately the goal of eliminating malaria needs a population based focus. The recent WHO malaria elimination strategic guidance encourages examination of factors in defined population units that influence transmission or control.

Today public health advocates are using the term population health more. The University of Wisconsin Department of Population Health Sciences in its blog explained that “Population health is defined as the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” World Population Day is a good time to consider how the transmission or prevention of malaria, or even neglected tropical diseases, is distributed in our countries, and which groups and communities within that population are most vulnerable.

World Population Day has room to consider many issues related to the health of populations whether it be reproductive health, communicable diseases or chronic diseases as well as the services to address these concerns.

Liberia’s Fight against Malaria Continues

Liberia was making steady progress against malaria in the years after the civil war. Despite the devastation of Ebola, the health authorities have continued to push against malaria. The DHS Program has released key findings from the 2016 Malaria Information Survey. We have compared those against the 2011 MIS, and while there is progress, much work needs to be done in this highly endemic area – not just in fighting malaria, but in rebuilding health systems damaged by war and Ebola.

Targets for Intermittent Preventive Treatment in pregnancy of malaria have risen from at least 2 doses in 2011 to three or more when the 2016 data were collected. While the IPTp2+ doses have increased by a little less than 5%, the challenge of IPTp3 and greater has become quite evident. It is interesting that coverage of IPTp is slightly better in rural areas, but there is still a long way to go to protect pregnant Liberian women.

The situation with access to and use of insecticide treated nets has also improved over the 5-year period, but still remains well below the targets of universal coverage. Even though nearly two-thirds of households have at least one ITN, only a quarter have enough nets to reach the goal of one net for every two people. Net use by children below the age of 5 years is better than that of pregnant women, though in both cases less that half of these vulnerable populations are covered. Nets are particularly important for pregnant women who cannot take IPTp in the first trimester.

Care for febrile children also has improved, but questions remain about appropriate care due to the nature of the questioning processes in the MIS.  Seeking advice increased by 20% as did getting blood tests (RDT or microscopy) once care is sought.  Double the number of febrile children received artemisinin-based combination therapy in 2016 compared to 2011, but since the rate of testing is low, we do not know if they were being appropriately treated – given ACT only is tests were positive.

Liberia does receive support from donors such as the Global Fund and the US President’s Malaria Initiative. These and other partners need to strategize with the Liberian Ministry of Health and other local partners (NGOs, Businesses, etc.) in order to mobilize the support to put Liberia more squarely on the road to malaria elimination.

Enhancing Civilian-Military Cooperation to Accelerate Malaria Elimination in Southeast Asia

Our colleague Sara Canavati attended the recent meeting on civilian and military collaboration to eli8minate malaria in Southeast Asia. Herein she shares some of the highlights of the meeting. Sara is affiliated with both the Centre for Biomedical Research, Burnet Institute, Melbourne, Australia and the Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok.

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The Heads of State from ASEAN member nations stated their commitment to an “Asia Pacific free of Malaria by 2030” at the 9th East Asia Summit. This mandate for a malaria-free Asia Pacific creates an unprecedented opportunity to strengthen ties between civilian and military health systems and regional militaries.

On 26-28 June 2017, the Armed Forces Research Institute of Medical Science (AFRIMS) organized a meeting titled: “Enhancing Civilian-Military Cooperation to Accelerate Malaria Elimination in Southeast Asia” in Bangkok, Thailand. The meeting brought together Ministry of Defense and Ministry of Health malaria officials from Myanmar, Thailand, Cambodia, Laos, Indonesia, Vietnam, Australia, and the United States.

Since malaria is a common problem in the military, and since malaria does not know borders, regional collaborations involving all affected populations are important to achieve malaria elimination. The meeting was instrumental for reviewing existing military and civilian national malaria collaborations, identifying and prioritize key areas of mutual military-civilian interest, and discussing ways in which regional militaries can assist national malaria elimination goals.

Three action points on how the civilian and military sectors can more effectively collaborate to achieve elimination in four areas of mutual interest (Case Detection and Management and Disease Prevention; Surveillance, Monitoring and Evaluation; Operational Research/Training and Advocacy) were identified and documented by meeting attendees through a breakout team format.

Advocacy for malaria elimination was the theme that military attendees found most challenging due to the hierarchical structure of the military.  Among several presentations, East Africa Malaria Task Force and Experiences from African Military Medical Departments were shared to serve as an example of military-advocacy. Financing was another key barrier identified. The chair of the regional steering committee (RSC) for the Global Fund, Prof Arjen Dondorp and The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFTAM) Geneva assured their support and commitment to finance military operations for malaria elimination in South East Asia. This was a historical achievement as this will be the first time ever the GFTAM finances the military for malaria elimination.

One significant outcome of the meeting is that the military will now be represented in the RSC for the Global Fund “Regional Artemisinin-resistance Initiative 2 Elimination (RAI2E)” malaria grant.

Links to some of Sara’s recent malaria publications:

Burundi: when will citizens see real protection from malaria?

Preliminary findings from Burundi’s 2015-16 DHS have been made available. The country has a long way to go to meet targets for basic control of malaria.

LLIN availability by household is an overall disappointing 32%. Ironically there is greater coverage of households in in urban areas (50%) than rural (30%). There is also great variation among the provinces with 52% coverage in Bujumbura metropolitan but only 19% in Canzuko. The overall average is less than one treated net per household.

A major concern is equity. The chart above shows a steep gradation from 19% coverage among the lowest fifth of the wealth quintile, up to 48% in the highest. Even in households that have at least one net, only 17% of of people slept under a net the night before the survey.

In terms of use by those traditionally defined as vulnerable, the DHS shows only 40% of children below 5 years of age overall slept under a treated net the night prior to the survey. Even in households that own at least one net, 78% of these children slept under one.

A similar pattern is seen for treated net use by pregnant women. Overall 44% slept under a treated net, and 84% did so in households that owned at least one treated net. The internal household dynamics of net use where one is available does appear to favor these two groups.

Overall coverage of Intermittent Preventive Treatment for pregnant women is very low. Less than 30% of pregnant women received even the first dose of SP. This decreased to 21% for two doses and 13% for three. In contrast to net coverage, more rural women (31%) received the first dose of IPTp than urban ones (19%).

Nearly 40% of children below five years of age were found to have had a fever in the two weeks preceding the survey. Among those care was sought for only two-thirds. Eleven percent of those with fever received an artemisinin-based combination therapy drug. The report did not mention whether these children had received any testing prior to treatment, so appropriateness of treatment cannot be judged. Prevalence testing of the children in the sample found 38% with parasitemia. Therefore one might assume that more children should have received ACTs.

Burundi still faces major political and social challenges. Even so Burundi is the recipient of malaria support from the Global Fund. For example 18 million LLINs were distributed in 2015 and 19 million in 2016.

Much work is needed to bring Burundi even close to universal coverage of malaria interventions. In today’s climate of questionable donor commitment, it is hoped that regional partners may play a role since malaria knows no boundaries.

Refugees and Malaria

June 20th is World Refugee Day.  The United Nations explains that, “Refugees are among the most vulnerable people in the world. The 1951 Refugee Convention and its 1967 Protocol help protect them.” This protection includes the right to public relief and assistance, and in that context the UN High Commission for Refugees aims to provide refugees with “clinics, schools and water wells for shelter inhabitants and gives them access to health care and psychosocial support during their exile.” Major physical health problems and symptoms of internally displaced persons in Sub-Saharan Africa included were fever/malaria among 85% of children and 48% of adults.

Many of today’s refugees are located in malaria endemic areas of the world, and movement from familiar areas to uncertainly increases refugees’ exposure to malaria. As the Roll Back Malaria Partnership noted, “exposure to malaria is significantly increased when moving from low- to high- transmission areas, because they have no acquired immunity and frequently little knowledge of malaria prevention or treatment.”

Efforts to prevent malaria among refugees who came from South Sudan in in Northern Uganda is crucial as they experience malaria as one of their major health problems. This led to the provision of intermittent preventive treatment for malaria (IPTc) in two refugee camps among children aged 6 months to 14 years through help from Médecins Sans Frontières.

In Australia guidelines for assessing needs for services for refugees include an emphasis on person-centred care and risk-based rather than universal screening for hepatitis C virus, malaria, schistosomiasis and sexually transmissible infections.” Based on country of origin “refugees and asylum seekers to Australia and includes country-specific recommendations for screening for malaria, schistosomiasis and hepatitis C.” This includes use of malaria Rapid Diagnostic tests.

Efforts to reach refugee populations with insecticide treated bednets can be a challenge.  Studies in a displaced persons camp in the Democratic Republic of the Congo found that there was lower access to nets by camp dwelling children than those in nearby settled villages. Considering the high burden of malaria in the area the authors recommended increased attention to net distribution for these internal refugees.

World Refugee Day is a time for people in malaria national control/elimination programs to take note of the refugee and displaced populations within their boundaries and step up efforts to protect everyone.

 

Donate Blood, Not Malaria

June 14th is World Blood Donor Day. This year’s theme stresses the importance of donating now before a disaster strikes. This requires good storage facilities (and strong systems) in countries where disasters may occur,  which may not always be the case.  We know that blood donation facilities are concerned about testing for infectious diseases like HIV and Hepatitis C. What of malaria?

Studies have found that when people return to a non-endemic setting from malaria endemic countries, “Semi-immune individuals are more likely to transmit malaria as they may be asymptomatic” and serological data, not just circumstantial epidemiological information are also needed that if transmission through blood donations are to be prevented. There is also concern about the longevity of malaria infection depending on the species of Plasmodium in different parts of the world.

In endemic countries malaria antibodies can be present in basically all of asymptomatic adult blood donors. Unfortunately currently available screening assays appear unsuitable to minimize transfusion malaria.

Researchers in Brazil reported that, “The real-time PCR with TaqMan probes enabled the identification of P. vivax in a high proportion of clinically healthy donors, highlighting the potential risk for transfusion-transmitted malaria. Additionally, this molecular diagnostic tool can be adopted as a new laboratory screening method in haemotherapy centres, especially in malaria-endemic areas.”

Knowing the seasonal prevalence of malaria among blood donors in Bamako, Kouriba et al. suggest “A prevention strategy of transfusion malaria based on the combination of selection of blood donors through the medical interview, promoting a voluntary low-risk blood donation and screening all blood bags intended to be transfused” to vulnerable groups.

So while we recognize the life saving importance of adequate blood donations and supplies for transfusion, we also stress the importance of blood safety and expand our horizons to the possibility that malaria may be one of the potential problems shared with blood.

World No Tobacco Day – except to make malaria drugs

May 31st marks World No Tobacco Day. The Theme for 2017 is “Tobacco – a threat to development.” According to WHO, “Tobacco control has been enshrined in the Sustainable Development Agenda. It is seen as one of the most effective means to help achieve SDG target 3.4 of a one-third reduction globally, by 2030, of premature deaths from  noncommunicable diseases (NCDs).” Control is also associated with positive environmental and anti-poverty outcomes.

It is ironic then that the tobacco plant itself may be modified to produce life saving anti-malarial medicines. Nature reported that because Artemisia annua produces a precursor of the compound, artemisinic acid, only in low quantities, it is expensive to grow.  Consequently, “a team led by Ralph Bock at the Max Planck Institute of Molecular Plant Physiology in Potsdam-Golm, Germany, inserted genes for artemisinic acid synthesis into tobacco plants’ chloroplasts — abundant organelles that have their own DNA. By adding ‘accessory genes’ that make artemisinic acid production more efficient, they created a line that pumps out 120 milligrams of artemisinic acid per kilogram of biomass.”

Science magazine followed up to report that although “several years ago researchers transplanted the drugmaking genes into yeast, allowing them to collect the compound from a microbial brew, the fermentation process is still relatively expensive.” Tobacco, on the other hand, is an “inexpensive, high-volume crop.” Inserting the right genes into tobacco, they noted, would enable “harvesting artemisinic acid from a plot of land 200 square kilometers—less area than a city the size of Boston—would provide enough artemisinin to meet the entire worldwide demand.”

Malhotra et al. discovered another novel approach that found that, “Partially purified extracts from the leaves of transgenic tobacco plants inhibited in vitro growth progression of Plasmodium falciparum-infected red blood cells. Oral feeding of whole intact plant cells bioencapsulating the artemisinin reduced the parasitemia levels in challenged mice in comparison with commercial drug. Such novel synergistic approaches should facilitate low-cost production and delivery of artemisinin and other drugs through metabolic engineering of edible plants.”

Another approach looks at malaria vaccines. Beiss et al. note that malaria “transmission blocking vaccine (TBVs) need to be produced in large quantities at low cost.” They found a high level  transient expression in fresh leaves of Nicotiana benthamiana of an effective TBV candidate. Likewise Jones et al. demonstrated the potential of the new malaria vaccine candidate and also support feasibility of expressing Plasmodium antigens in Nicotiana benthamiana.

The American Cancer Society observed that most African Countries are in the early stages of the tobacco epidemic. This may be a good time to switch the production of tobacco on the continent from purveyor of cancer and NCDs to a ‘factory’ for producing malaria medicines. The sooner this can be done, the better since artemisinin  resistance is a growing threat.

Ghana – spotlight on malaria indicators

The Demographic and Health Surveys has released a brief on key indicators from the Ghana Malaria Indicator Survey of 2016. While much of the malaria community is discussing the elimination framework and processes, the reality is that many high burden countries are still trying to scale up basic interventions to achieve universal coverage.

The overall prevalence across the country in children aged 6-59 months at the time of the survey was 27% using Rapid Diagnostic test and 20% using microscopy.  Among children reporting fever in the previous two weeks care/advice was sought for only 72%. Although only only 30% received some sort of blood based diagnostic test, 61% of the febrile children were given the antimalarial artemisinin-based combination therapy drugs.

Children are still being treated without the benefit of parasitological testing, a key procedure highlighted in WHO case management guidelines. Presumptive treatment for malaria without testing means that a child could inappropriately receive antimalarial drugs and die of another underlying febrile illness. Appropriate testing and adherence to test results is one of the main areas of focus of Ghana’s grants from the US President’s Malaria Initiative. Improved testing is also an important element in Ghana’s current Global Fund support. Clearly more value for money is needed from these inputs.

Preventive measures as documented in the MIS fare somewhat better., but at present only 73% of households own an insecticide treated bednet. When considering the recommended 1 net for every 2 household members, the indicator drops to 50%. Concerning the typical ‘vulnerable’ populations, we see that only 52% of children below the age of 5 years slept under an ITN the night before the survey; only 50% of pregnant women did likewise.

Malaria prevention in pregnancy results reflect the fact that Ghana has promoted at least three IPTp doses for around ten years. Most pregnant women (78% ) had received the previously recommended minimum of two doses, and now 60% have received at least three doses.

One of the important issues stressed in WHO’s new malaria elimination framework is stratifying the country by prevalence to the lowest level possible in order to plan appropriate interventions. Fortunately the Ghana 217 MIS key indicator brief does stratify prevalence and intervention coverage by region.  Prevalence through RDT testing ranges from nearly 5% in the urbanized greater Accra area to 44% in the Central Region. Interestingly ITN use is nearly 20% higher in Central than greater Accra.

Hopefully future planning in Ghana will build on this stratification. Better mobilization of donor, national and private sector resources will address likely issues of stock-outs and increase the likelihood of universal coverage of basic interventions that is needed to move the country along the road to malaria elimination.

Nepal on the Path to Malaria Elimination

Jhpiego’s Emmanuel Le Perru has been placed with Nepal’s malaria control program by the Maternal and Child Survival Program (USAID) to strengthen the agency’s overall response to malaria as well as ensure top performance of Nepal’s Global Fund Malaria grant. Emmanuel shares his experiences with us here.

From 3,000 cases in 2010, Nepal reported around 1,000 cases in 2016, including 85% Plasmodium vivax cases. However private sector reporting is almost null so number of total cases may be the double. Nepal’s National Malaria Strategic Plan (NMSP) targets Elimination by 2022 (0 indigenous cases) with WHO certification by 2026.

Ward Level Micro-stratification is an important step for targeting appropriate interventions. Key interventions in the NMSP include case notification system by SMS (from health post workers or district vector control inspectors) to a Malaria Disease Information System, later to be merged with DHIS2. Case investigation teams conduct case and foci profiling as well as “passive cases” active detection and treatment (including staff from district such as surveillance coordinator, vector control inspector, and entomologist).

Malaria Mobile Clinics actively search/treat new cases in high risk areas (slums, brick factories, river villages or flooded areas, migrant workers villages, etc.). PCR diagnosis with Dry Blood Spot or Whole Blood is used to identify low density parasite cases, relapses or re-introduction. Coming up in April-June 2018 will be a Pilot of MDA (primaquine) for Plasmodium vivax in isolated settings (80% of cases in the country are P vivax).

Recent successes in the national malaria effort include the number of cases notified by SMS went from 0% to 45%. Also the number of cases fully investigated went from 22% to 52%, though this needs to go up to 95% for elimination. 73% of districts are now submitting timely malaria data reports per national guidelines, an increase from 52% in November 2015.

The border runs right through this town making importation of malaria cases easy

The Global Fund (GFATM) malaria grant rating went from B2 to A2. Nepal Epidemiology Disease Control Division (EDCD), WHO and GFATM are keen to pilot MDA for P vivax in isolated setting which MCSP/Jhpiego Advisor taking the lead.

Moving forward the malaria elimination effort needs to address Indo-Nepal Cross boarder collaboration since 45% cases are imported. Hopefully WHO will help EDCD Nepal to propose a plan of action to India. The program still needs to convince partners of relevance of malaria mobile clinics vs community testing and of the relevance of MDA for P vivax. More entomological and PCR/laboratory expertise is needed. With these measures malaria elimination should be in sight.

Supporting Midwives to Prevent Malaria on International Day of the Midwife

Midwives play at least two crucial roles when it comes to saving the lives of pregnant women in malaria endemic areas. First as the health staff responsible for providing intermittent preventive treatment for malaria in pregnancy (IPTp), midwives can ensure that women do not suffer the consequences and complications of malaria in the first place. Secondly, knowing that we may not be able to reach all pregnant women with the full package of malaria interventions in a timely manner, midwives are there to save lives from the complications to the mother and fetus arising from malaria-associated anemia and low birth weight. Today we focus on prevention.

Today on the International Day of the Midwife is a good time to examine how to strengthen midwives’ roles in preventing malaria and protecting women from its consequences. This year’s theme, “Midwives, Mothers and Families: Partners for Life!” is in line with our overall concern about ending malaria through partnership at all levels.

In providing antenatal/prenatal care (ANC) in stable malaria endemic areas, midwives are tasked with ensuring that pregnant women get an adequate number of doses of IPTp at the right time in their pregnancy. Previously only two doses were required, but now a pregnant woman can receive IPTp monthly from the beginning of the second trimester. The ability of the midwife to attract women to ANC and ensure that once there gets the required doses can be daunting.

A study in Uganda found that many pregnant women did not get the full regimen of IPTp and learned that several factors were responsible. Midwives’ education level and professional experience had a positive effect. Management issues such as the availability of safe drinking water and the drugs for intermittent preventive treatment were crucial. “Midwives who provided frequent health education to pregnant women, cooperated with village health team members and received in-service training were likely to provide effective anti-malaria services to pregnant women.” In short there are training and management interventions that can enable midwives to protect pregnant women better.

Examination of malaria prevention in ANC clinics in Malawi showed that providers generally did have correct information about IPTp, but at times did know understand the exact timing of doses. They knew that those on HIV infection prevention prophylaxis should not take IPTp and that IPTp should be given as directly observed treatment, but in many clinics there were lack of official written guidelines to help them recall procedures post-training.

Again, we can see that a variety of learning and management interventions can help midwives prevent malaria. Additional work in Uganda has shown the valuable role midwives can play as community health educators in encouraging ANC attendance and thus IPTp uptake. They need full support from the health system to do this important outreach.