All posts by Bill Brieger

The Weekly Tropical Health News 2019-07-13

In the past week more attention was drawn to the apparently never-ending year-long Ebola outbreak in the northeast of the Democratic Republic of the Congo. Regarding other diseases, there is new information on the RTS,S malaria vaccine, river prawns have been found to play a biological control role in schistosomiasis, and an update from the World Health Organization on essential medicines and diagnostics. New malaria vector control technologies are discussed.

Second Largest Ebola Outbreak One Year On

Ronald A. Klain and Daniel Lucey in the Washington Post observed raised concern that, “the disease has since crossed one border (into Uganda) and continues to spread. In the absence of a trajectory toward extinguishing the outbreak, the opposite path — severe escalation — remains possible. The risk of the disease moving into nearby Goma, Congo — a city of 1 million residents with an international airport.”

They added their voices to a growing number of experts who are watching this second biggest Ebola outbreak in history and note that, “As the case count approaches 2,500 with no end in sight, it is time for the WHO to declare the outbreak a public health emergency of international concern — a ‘PHEIC’ — to raise the level of global alarm and signal to nations, particularly the United States, that they must ramp up their response.” They call for three actions: 1) improved security for health workers in the region, 2) stepped up community engagement and 3) extended health care beyond Ebola treatment. The inability to adequately respond to malaria, diarrheal diseases and maternal health not only threated life directly, but also threated community trust, putting health workers’ lives at risk.

Olivia Acland, a freelance journalist based in DRC, reporting for the New Humanitarian describes the insecurity and the recent “wave of militia attacks in the Democratic Republic of Congo’s northeastern Ituri province has left hundreds dead and roughly 300,000 displaced in recent weeks, triggering a new humanitarian crisis in a region.” Specifically, “Ituri, a fertile region rich in gold deposits, has been an epicentre of conflict in Congo for decades. Between 1999 and 2003, around 60,000 people were killed here, as a power struggle between rebel groups escalated into ethnic violence,” related to traditional tensions between Hema cattle herders and Lendu farmers with roots in Belgian colonization.

Updates from the DRC Ministry of Health report on average 11 new Ebola cases per day in the past week. So far over 160,000 people have been vaccinated, and yet the spread continues. The Ministry also describes new protocol contains three vaccinations strategies that can be used depending on the environment in which confirmed cases are found including:

  • Classic Ring: The classic strategy of vaccinating contacts of confirmed cases and contact contacts.
  • Enlarged ring: It is also possible to vaccinate all inhabitants of houses within 5 meters around the outbreak of a confirmed case.
  • Geographical Ring: In an area where team safety can not be guaranteed, they can vaccinate an entire village or neighborhood.

Malaria Vaccines, Essential Drugs and New Vector Control Technologies

Halidou Tinto and colleagues enrolled two age groups of children in a 3-year extension of the RTS,S/AS01 vaccine efficacy trial: 1739 older children (aged 5–7 years) and 1345 younger children (aged 3–5 years). During extension, they reported 66 severe malaria cases. Overall they found that, “severe malaria incidence was low in all groups, with no evidence of rebound in RTS,S/AS01 recipients, despite an increased incidence of clinical malaria in older children who received RTS,S/AS01 compared with the comparator group in Nanoro. No safety signal was identified,” as seen in The Lancet.

WHO has updated the global guidance on medicines and diagnostic tests to address health challenges, prioritize highly effective therapeutics, and improve affordable access. Section 6.5.3 presents antimalarial medicines including curative treatment (14 medicines) for both vivax and falciparum and including tablets and injectables. Prophylaxis includes 6 medicines including those for IPTp and SMC. The latest guidance can be downloaded at WHO.

Paul Krezanoski reports on a new technology to monitor bednet use and tried it out in Ugandan households. As a result. “Remote bednet use monitors can provide novel insights into how bednets are used in practice, helping identify both households at risk of malaria due to poor adherence and also potentially novel targets for improving malaria prevention.

In another novel technological approach to vector control, Humphrey Mazigo and co-researchers tested malaria mosquito control in rice paddy farms using biolarvicide mixed with fertilizer in Tanzanian semi-field experiments. The intervention sections (with biolarvicide) had lowest mean mosquito larvae abundance compared to control block and did not affect the rice production/harvest.

Prawns to the Rescue in Senegal Fighting Schistosomiasis and Poverty

Anne Gulland reported how Christopher M. Hoover et al. discovered how prawns could be the key to fighting poverty and schistosomiasis, a debilitating tropical disease. They found that farming the African river prawn could fight the disease and improve the lives of local people, because the African river prawn is a ‘voracious’ predator of the freshwater snail, which is a carrier of schistosomiasis.

The researchers in Senegal said that, “market analysis in Senegal had shown there was significant interest among restaurant owners and farmers in introducing prawns to the diet.” The prawn could also for the basis of aquaculture in rice paddies and remove the threat of schistosomiasis from the rice workers.

—- Thank you for reading this week’s summary. These weekly abstractings have replaced our occasional mailings on tropical health issues due to fees introduced by those maintaining the listserve website. Also continue to check the Tropical Health Twitter feed, which you can see running on this page.

The Weekly Tropical Health News 2019-07-06: Eliminating Malaria in Low Transmission Settings

This week started with articles that drew attention to the challenges of malaria in low transmission areas and with low density infections. Malaria Journal has provided several insightful articles toward this end.

Being an island has certainly helped Zanzibar make progress toward malaria elimination as witness the fact that malaria prevalence has remained below 1% for the past decade. Not only does Zanzibar still face threats of infection from the mainland, it may also experience an upsurge locally if residual transmission and the role of human behavior and community actions are not well understood. April Monroe et al. conducted in-depth interviews with community members and local leaders across six sites on Unguja, Zanzibar as well as semi-structured community observations of night-time activities and special events to learn more.

While there was high reported ITN use, there were also times when people were exposed t mosquitoes while being outdoors during biting times. This could be around the house, or at special night events like such as weddings, funerals, and religious ceremonies. Men spent more time outdoors than women. Clearly appropriate interventions and needed and should be promoted in culturally appropriate ways in order to further reduce and eventually eliminate transmission.

Angela Early and colleagues presented findings on a diagnostic process of deep sequencing for understanding the dynamics and complexity of Plasmodium infections, but stress that knowing the lower limit of detection is challenging. They present “a new amplicon analysis tool, the Parallel Amplicon Sequencing Error Correction (PASEC) pipeline, is used to evaluate the performance of amplicon sequencing on low-density Plasmodium DNA samples.”

The authors learned that, “four state-of-the-art tools resolved known haplotype mixtures with similar sensitivity and precision.” They also cautioned that, “Samples with very low parasitemia and very low read count have higher false positive rates and call for read count thresholds that are higher than current default recommendations.” Better understanding of the genetic mix of plasmodium infections as countries move toward low transmission and elimination is crucial for selecting appropriate interventions and evaluating their outcomes.

Hannah Edwards and co-researchers examined conditions for malaria transmission along the Thailand-Myanmar border in areas approaching malaria elimination. While prevalence may be less than 1%, residual transmission still occurs. Transmission occurs not only around residences but in the forests where people work. The researchers therefore looked at the behavior of both humans and insects. Overall, they found that, “Community members frequently stayed overnight at subsistence farm huts or in the forest. Entomological collections showed higher biting rates of primary vectors in forested farm hut sites and in a more forested village setting compared to a village with clustered housing and better infrastructure.”

While mosquitoes preferred to bite inside huts, their threat was magnified by those who did not use long lasting insecticide-treated nets (LLINs). While out in the farms and forests, people tended to wake early and increase their likelihood of being bitten. The authors discuss the challenges of dual residences in terms of LLIN ownership and even concerning the potential access to indoor residual spraying. The definition for universal net coverage needs to expand from one net per two people to include adequate nets wherever people are located.

The Amazonian area of Brazil is another area working toward malaria elimination, in particular, Plasmodium vivax. Felipe Leão Gomes Murta et al. also looked at the human side of the equation and identified misperceptions by both community members and health workers that could inhibit elimination efforts. They found, “many myths regarding malaria transmission and treatment that may hinder the sensitization of the population of this region in relation to the use of current control tools and elimination strategies, such as mass drug administration (MDA),” and LLINs.

Problematic perceptions included mention by both groups that the use of insecticide-treated nets, may cause skin irritations and allergies. Both community members and health professionals said malaria is “an impossible disease to eliminate because it is intrinsically associated with forest landscapes.” They concluded that such perceptions can be a barrier to control and elimination.

Efforts to eliminate malaria from low transmission settings are an essential to the overall global goals. These four articles tell us that close attention to and better understanding of humans, parasites and mosquitoes is still needed to achieve these goals.

Nigeria’s 2018 Demographic and Health Survey: Malaria Situation

The Demographic and Health Survey for 2018 in Nigeria has released preliminary findings. These cover insecticide Treated Nets (ITNs), Intermittent Preventive Treatment of malaria in pregnancy (IPTp), and treatment of children with Artemisinin-Based Combination Therapy (ACT).

The key findings have been converted into graphs.  We can see that ITN ownership by a household (HH) is greater in rural areas, but overall reaches only a national average of 60% of households having at least one net. People may recall that the 2010 target by the Roll Back malaria Partnership was 80% for all key indicators with the hope that by attaining and then maintaining 80% coverage or more, malaria incidence would drop and elimination would be on the horizon.

Nigeria is not among WHO’s Elimination by 2020 (E2020) countries, and it is not clear when transmission will move in that direction when key interventions are still not reaching targets. This is due also to the fact that 60% of households covered does not mean that residents are protected. In fact only 30% meet the goal of universal net coverage with at least one net for every two household members.

On the positive side, comparison of household net ownership and wealth status appears to favor the poorer households. 72% of the poorest households have at least one net compared to 48% of the highest income quintile.  Unfortunately the gap between rich and poor narrows when it comes to the target of 1 net for 2 people.

Although these days we stress universal coverage of all household members, DHS still collects data on what are often termed ‘vulnerable’ groups, children below the age of 5 years and pregnant women.  Just over half of each group slept under an ITN the night before the survey. It is obvious that access plays a role, so in those households that actually own at least one net 74% of children and 82% of pregnant women slept under an ITN. These figures might even be higher if the target of 1 net per two people were met.

Nigeria is a huge and diverse country in terms of geography, epidemiology and ethncity. The country has 6 regions that are used for planning and analysis purposes. The map attached shows that there are major regional variations in households owning at least one net and households having at least one net for every 2 people residing there.

There is better coverage of at least one net per household in the northern zones than the southern, with the Northwest achieving 86% and then 42% for covering two people with one net.  When it comes to that latter measure, the remaining 5 regions are all in the 20% level, meaning that for most of the country, there is a long way to go to achieve universal net coverage.

Intermittent preventive treatment of pregnant women  with sulphadoxine-pyrimethamine (SP) has been a long standing intervention to protect women and their unborn children from the devastating effects of malaria. For at least six years now, WHO has recommended that pregnant women take three or more monthly doses of IPTp from the 13th week of pregnancy, onward.

A challenge to getting IPTp is contact with antenatal care services, and only 67% of women who delivered a child in the 5 year preceding the survey attended ANC even once.  Not surprisingly, only 40% of those pregnant women received two doses of IPTp and only 17% got three doses.

Finally, only 28% of children with fever in the two weeks prior to the survey took ACT, although we are not certain about the proportion who had been tested. It is difficult to interpret this finding since we do not know what proportion of those with fever might have been tested and found to harbor malaria parasites. ACTs should only be given to those with positive parasitological tests.

DHS and its sister survey, the Malaria Indicator Survey are performed at approximately three-year intervals. These data sources are valuable for evaluating past interventions and planning new. Clearly some serious planning is needed to address the shortfalls in malaria intervention coverage and save more lives.

The Weekly Tropical Health News 2019-06-29

Below we highlight some of the news we have shared on our Facebook Tropical Health Group page during the past week.

Polio Persists

If all it took to eradicate a disease was a well proven drug, vaccine or technology, we would not be still reporting on polio, measles and guinea worm, to name a few. In the past week Afghanistan reported 2 wild poliovirus type 1 (WPV1) cases, and Pakistan had 3 WPV1 cases. Circulating vaccine-derived poliovirus type 2 (cVDPV2) was reported in Nigeria (1), DRC (4) and Ethiopia (3) from healthy community contacts.

Continued Ebola Challenges

In the seven days from Saturday to Friday (June 28) there were 71 newly confirmed Ebola Cases and 56 deaths reported by the Democratic Republic of Congo’s Ministry of Health. As Ebola cases continue to pile up in the Democratic Republic of the Congo (DRC), with 12 more confirmed Thursday and 7 more Friday, a USAID official said four major donors have jump-started a new strategic plan for coordinating response efforts. To underscore the heavy toll the outbreak has caused, among its 2,284 cases, as noted on the World Health Organization Ebola dashboard today, are 125 infected healthcare workers, including 2 new ones, DRC officials said.

Pacific Standard explained the differences in Ebola outbreaks between DRC today and the West Africa outbreak of 2014-16. On the positive side are new drugs used in organized trials for the current outbreak. The most important factor is safe, effective vaccine that has been tested in 2014-16, but is now a standard intervention in the DRC. While both Liberia and Sierra Leone had health systems and political weaknesses as post-conflict countries, DRC’s North Kivu and Ituri provinces are currently a war zone, effectively so for the past generation. Ebola treatment centers and response teams are being attacked. There are even cultural complications, a refusal to believe that Ebola exists. So even with widespread availability of improved technologies, teams may not be able to reach those in need.

To further complicate matters in the DRC, Doctors Without Borders (MSF) “highlighted ‘unprecedented’ multiple crises in the outbreak region in northeastern DRC. Ebola is coursing through a region that is also seeing the forced migration of thousands of people fleeing regional violence and is dealing with another epidemic. Moussa Ousman, MSF head of mission in the DRC, said, ‘This time we are seeing not only mass displacement due to violence but also a rapidly spreading measles outbreak and an Ebola epidemic that shows no signs of slowing down, all at the same time.’”

NIPAH and Bats

Like Ebola, NIPAH is zoonotic, and also involves bats, but the viruses differ. CDC explains that, “Nipah virus (NiV) is a member of the family Paramyxoviridae, genus Henipavirus. NiV was initially isolated and identified in 1999 during an outbreak of encephalitis and respiratory illness among pig farmers and people with close contact with pigs in Malaysia and Singapore. Its name originated from Sungai Nipah, a village in the Malaysian Peninsula where pig farmers became ill with encephalitis.

A recent human outbreak in southern India has been followed up with a study of local bats. In a report shared by ProMED, out of 36 Pteropus species bats tested for Nipah, 12 (33%) were found to be positive for anti-Nipah bat IgG antibodies. Unlike Ebola there are currently no experimental drugs or vaccines.

Climate Change and Dengue

Climate change is expected to heighten the threat of many neglected tropical diseases, especially arboviral infections. For example, the New York Times reports that increases in the geographical spread of dengue fever. Annually “there are 100 million cases of dengue infections severe enough to cause symptoms, which may include fever, debilitating joint pain and internal bleeding,” and an estimated 10,000 deaths. Dengue is transmitted by Aedes mosquitoes that also spread Zika and chikungunya. A study, published Monday in the journal Nature Microbiology, found that in a warming world there is a strong likelihood for significant expansion of dengue in the southeastern United States, coastal areas of China and Japan, as well as to inland regions of Australia. “Globally, the study estimated that more than two billion additional people could be at risk for dengue in 2080 compared with 2015 under a warming scenario.”

Schistosomiasis – MDA Is Not Enough, and Neither Are Supplementary Interventions

Schistosomiasis is one of the five neglected tropical diseases (NTDs) that are being controlled and potentially eliminated through mass drug administration (MDA) of preventive chemotherapy (PCT), in this case praziquantel. In The Lancet Knopp et al. reported that biannual MDA substantially reduced Schistosomiasis haematobium prevalence and infection intensity but was insufficient to interrupt transmission in Zanzibar. In addition, neither supplementary snail control or behaviour change activities did not significantly boost the effect of MDA. Most MDA programs focus on school aged children, and so other groups in the community who have regular water contact would not be reached. Water and sanitation activities also have limitations. This raises the question about whether control is acceptable for public health, or if there needs to be a broader intervention to reach elimination?

Trachoma on the Way to Elimination

Speaking of elimination, WHO has announced major “sustained progress” on trachoma efforts. “The number of people at risk of trachoma – the world’s leading infectious cause of blindness – has fallen from 1.5 billion in 2002 to just over 142 million in 2019, a reduction of 91%.” Trachoma is another NTD that uses the MDA strategy.

The news about NTDs from Dengue to Schistosomiasis to Trachoma is complicated and demonstrates that putting diseases together in a category does not result in an easy choice of strategies. Do we control or eliminate or simply manage illness? Can our health systems handle the needs for disease elimination? Is the public ready to get on board?

Malaria Updates

And concerning being complicated, malaria this week again shows many facets of challenges ranging from how to recognize and deal with asymptomatic infection to preventing reintroduction of the disease once elimination has been achieved. Several reports this week showed the particular needs for malaria intervention ranging from high burden areas to low transmission verging on elimination to preventing re-introduction in areas declared free from the disease.

In South West, Nigeria Dokunmu et al. studied 535 individuals aged from 6 months were screened during the epidemiological survey evaluating asymptomatic transmission. Parasite prevalence was determined by histidine-rich protein II rapid detection kit (RDT) in healthy individuals. They found that, “malaria parasites were detected by RDT in 204 (38.1%) individuals. Asymptomatic infection was detected in 117 (57.3%) and symptomatic malaria confirmed in 87 individuals (42.6%).

Overall, detectable malaria by RDT was significantly higher in individuals with symptoms (87 of 197/44.2%), than asymptomatic persons (117 of 338/34.6%)., p = 0.02. In a sub-set of 75 isolates, 18(24%) and 14 (18.6%) individuals had Pfmdr1 86Y and 1246Y mutations. Presence of mutations on Pfmdr1 did not differ by group. It would be useful for future study to look at the effect of interventions such as bednet coverage. While Southwest Nigeria is a high burden area, the problem of asymptomatic malaria will become an even bigger challenge as prevalence reduces and elimination is in sight.

Sri Lanka provides a completely different challenge from high burden areas. There has been no local transmission of malaria in Sri Lanka for 6 years following elimination of the disease in 2012. Karunasena et al. report the first case of introduced vivax malaria in the country by diagnosing malaria based on microscopy and rapid diagnostic tests. “The imported vivax malaria case was detected in a foreign migrant followed by a Plasmodium vivax infection in a Sri Lankan national who visited the residence of the former. The link between the two cases was established by tracing the occurrence of events and by demonstrating genetic identity between the parasite isolates. Effective surveillance was conducted, and a prompt response was mounted by the Anti Malaria Campaign. No further transmission occurred as a result.”

Bangladesh has few but focused areas of malaria transmission and hopes to achieve elimination of local transmission by 2030. A particular group for targeting interventions is the population of slash and burn cultivators in the Rangamati District. Respondents in this area had general knowledge about malaria transmission and modes of prevention and treatment was good according to Saha and the other authors. “However, there were some gaps regarding knowledge about specific aspects of malaria transmission and in particular about the increased risk associated with their occupation. Despite a much-reduced incidence of malaria in the study area, the respondents perceived the disease as life-threatening and knew that it needs rapid attention from a health worker. Moreover, the specific services offered by the local community health workers for malaria diagnosis and treatment were highly appreciated. Finally, the use of insecticide-treated mosquito nets (ITN) was considered as important and this intervention was uniformly stated as the main malaria prevention method.”

Kenya offers some lessons about low transmission areas but also areas where transmission may increase due to climate change. A matched case–control study undertaken in the Western Kenya highlands. Essendi et al. recruited clinical malaria cases from health facilities and matched to asymptomatic individuals from the community who served as controls in order to identify epidemiological risk factors for clinical malaria infection in the highlands of Western Kenya.

“A greater percentage of people in the control group without malaria (64.6%) used insecticide-treated bed nets (ITNs) compared to the families of malaria cases (48.3%). Low income was the most important factor associated with higher malaria infections (adj. OR 4.70). Houses with open eaves was an important malaria risk factor (adj OR 1.72).” Other socio-demographic factors were examined. The authors stress the need to use local malaria epidemiology to more effectively targeted use of malaria control measures.

The key lesson arising from the forgoing studies and news is that disease control needs strong global partnerships but also local community investment and adaptation of strategies to community characteristics and culture.

The Weekly Tropical Health News Update 2019-06-22

For almost 20 years we have been maintaining an email list where current news and articles have been shared with those interested in tropical health and malaria. The listserve host we have been using is changing to a paid model. While there are still some free listserve options, these are cumbersome to produce. Since we are already maintaining this blog, we thought it best to provide a weekly summary of key news events through this medium.

Mapping Plasmodium Vivax

The Malaria Atlas Project has published in The Lancet a global burden of Plasmodium Vivax mapping study. The authors describe the contribution of this study as: “Our study highlights important spatial and temporal patterns in the clinical burden and prevalence of P vivax. Amid substantial progress worldwide, plateauing gains and areas of increased burden signal the potential for challenges that are greater than expected on the road to malaria elimination. These results support global monitoring systems and can inform the optimisation of diagnosis and treatment where P vivax has most impact.”

Ebola Spread from DRC to Uganda

Since the major ongoing outbreak of Ebola Virus Disease in North Kivu and Ituri Provinces of the Democratic Republic of Congo (DRC) started nearly a year ago, there has been concern that the disease might spread to neighboring countries like Uganda, Rwanda, South Sudan and the Central African Republic. This fear same true recently when a family affected by Ebola crossed from DRC into Uganda to connect with relatives in Kasese District Uganda. Uganda has had many years’ experience dealing with Ebola and was able to contain the situation.

A press release this week noted that, “As of today (21 June 2019), Uganda has not registered any new confirmed Ebola Virus Disease (EVD) case in Kasese District or any other part of Uganda since the last registered case one week ago. There are no new suspect cases under admission. Currently, 110 contacts to the confirmed Ebola cases in Kagando and Bwera are being followed up daily. A total of 456 individuals have been vaccinated against EVD using the Ebola-rVSV vaccine in Kasese District, Western Uganda.”

Although many people expected that the meeting of the “International Health Regulations (2005) Emergency Committee} for Ebola virus disease in the Democratic Republic of the Congo would finally declare the current outbreak a Public Health Emergency of International Concern (PHEIC) because it crossed a border, the result was noting that the challenge was still an emergency only for DRC. WHO did note that there were serious funding gaps and support from other countries for the DRC’s predicament. Ironically, such gaps make it more likely that Ebola can spread more widely.

As of 21 June 2019, the DRC reported a total of 2,211 cases since the start of the epidemic last year, of which 2,117 have been confirmed and 94 are probable. There have been 1,489 deaths. To date 139,027 persons have been vaccine with the Merck rVSV-ZEBOV vaccine.

Progress toward Eliminating Malaria – the E-2020 Countries

The process of eliminating malaria from the world needs to start in a step-by-step fashion. WHO explained that, “Creating a malaria-free world is a bold and important public health and sustainable development goal. It is also the vision of the Global technical strategy for malaria 2016-2030, which calls for the elimination of malaria in at least 10 countries by the year 2020.”

Actually, WHO identified 21 countries, spanning 5 regions, that could defeat malaria by 2020. The progress report charts the effort. During the recent World Health Assembly two countries received recognition for being certified malaria-free, Argentina and Algeria. This week WHO also announced that 5 more countries have not had malaria cases in the past year. There was also release of a downloadable report on progress toward the 2020 target for selected countries.

Reconsidering Yaws Eradication

In the 1950s and 1960s the world focused on the possibility of eradicating Yaws through screening and treatment interventions. Like the early malaria eradication programs from the same period, the Yaws effort slowed, stopped and experienced a resurgence. The Telegraph reported that, “Between 1952 and 1964, Unicef and the WHO screened some 300 million people for the illness, in a coordinated programme which treated more than 50 million cases. Yaws was on the brink of being wiped out and reports of the disease dropped by 95 per cent.” WHO continues to work on treatment strategies with azithromycin and for resistant cases, benzathine benzylpenicillin injection.

WHO noted that there were 80,472 cases reported in 2018, although this figure is likely to be much higher in actuality. The challenge of case detection exists but may be overcome, according to the Telegraph with a new molecular rapid diagnostic test which detects yaws within 30 minutes, and thus could allow on-the-spot diagnosis in remote regions.

Measles Cases Continue to Increase

The problem of measles in the DRC may not be receiving much attention because of the Ebola epidemic. Ironically, Outbreak News Today reports that, “In a follow-up on the measles outbreak in the Democratic Republic of the Congo (DRC), UN health officials report an additional 7500 suspect cases in the past 2 weeks, bringing the total cases since the beginning of the year to 106,870. The death toll due to the measles outbreak has reached 1815 deaths (case fatality ratio 1.7%).”

Vaccine coverage challenges in the DRC result from health systems weaknesses. Unfortunately, a global study has shown that increasing cases in the Global North are not due to weak systems, but ‘vaccine hesitancy.’ The Guardian reports that a global survey has revealed the scale of the crisis of confidence in vaccines in Europe, “showing that only 59% of people in western Europe and 50% in the east think vaccines are safe, compared with 79% worldwide.” The Guardian observes that, “In spite of good healthcare and education systems, in parts of Europe there is low trust in vaccines. France has the highest levels of distrust, at 33%.”

For more news and daily updates check our other services, a closed/private Facebook Group and a Twitter feed. For those who do not use social media, please check here each weekend to find a summary of some of the stories we have shared during the week.

Refugees and Malaria

The 2019 Theme of World Refugee Day is #StepWithRefugees – Take A Step on World Refugee Day. Taking steps in solidarity with refugees ensures that one recognizes that refugees experience several health problems, with malaria being especially devastating. Refugees may come from a malaria endemic area and move to one where there is no malaria and health workers may not recognize and treat it correctly. In contrast they may move from a non-endemic area into one with malaria transmission. Even if refugees move from one malarious area to another, the conditions of the camps where they shelter may lead to increased malaria morbidity and mortality.

In fact, Jamie Anderson and colleagues observe that, “Almost two-thirds of refugees, internally displaced persons, returnees and other persons affected by humanitarian emergencies live in malaria endemic regions. Malaria remains a significant threat to the health of these populations.” They found that, “an average of 1.18 million refugees resided in 60 refugee sites within nine countries with at least 50 cases of malaria per 1000 refugees during the study period 2008-2009,” a major disease burden. According to the authors, groups like UNHCR and the UN Foundation’s Nothing But Nets aim to increase LLIN coverage of vulnerable groups in emergency situations.

The US Centers for Disease Control and Prevention offers guidance to health staff in the United States who may encounter refugees coming from a malaria endemic country. These guidelines look at appropriate treatment regimens for either pre-travel or on arrival presumptive treatment. They address the challenges of sub-clinical disease, as well as testing and treatment for people with symptoms. Likewise, the Refugee Technical Assistance Center stresses the need for, “All refugees from malaria endemic areas, including those who have been presumptively treated for P. falciparum, should be tested for malaria if they develop clinical signs or symptoms of the disease.” Stefan Collinet-Adler et al. found that “Overseas presumptive therapy has greater cost-benefits than U.S. based screening and treatment strategies.”

The challenge of refugees moving from one endemic country, such as Burundi, to another was highlighted by MSF staff in Tanzania. Saschveen Singh reported that she, “was well versed in the emergency management of these cases from my previous training and from reading all the MSF clinical guidelines. But it was quite overwhelming to see how many admissions we had on the wards, and to see the outpatient area absolutely overflowing with patients with malarious fevers, and the number of our Burundian staff succumbing to the disease. With malaria, the worst of the worst cases are sadly always children.”

A few years ago, the US President’s Malaria Initiative in Kenya contributed to indoor residual spraying at a refugee camp. “Malaria has also been a recurrent problem in Kakuma Refugee Camp, particularly following large-scale population influxes from South Sudan, where malaria is endemic. Both ITNs and IRS have been used historically for malaria prevention in the camp along with prompt, effective case management for persons diagnosed with malaria. With the pyrethroid donation from PMI-Kenya, NRC implemented a successful IRS program,” covering an estimated 143,000 people.

It is encouraging to note that many agencies, international and domestic, and not just those specializing in refugee needs, lend a hand guaranteeing that refugees have a right to basic malaria prevention and treatment.

Malaria – an old disease attacking the young population of Kenya

Wambui Waruingi recently described her experiences working on malaria in Kenya on the site, “Social, Cultural & Behavioral Issues in PHC & Global Health.” Her thoughts and lessons are found below.

Malaria is an old disease, and not unfamiliar to the people of Lwala, Migori county, Nyanza province, situated in Kenya, East Africa. The most vulnerable are pregnant women and young children.The Lwala Community Alliance have reduced the rate of under 5 mortality to 20% of what it was 10 years ago, and about 30% of what it is in Migori county (reported 29 deaths/ 1000 in 2018) https://lwala.org/wp-content/uploads/2019/02/Lwala-2018-Annual-Report.pdf

Of the scourges that remain, malaria is one of them.

Malaria is caused by a protozoal species called Plasmodium spp; the most severe is Plasmodium falciparum, the predominant type in the region.It’s life cycle exemplifies evolution at it’s most sophisticated, albeit vulnerable, needing two hosts of different species to complete it’s life cycle, the mosquito, and mammalian species in stages of asexual then asexual reproduction respectively. https://www.mayoclinic.org/diseases-conditions/malaria/symptoms-causes/syc-20351184https://www.cdc.gov/malaria/about/biology/index.html

The mosquito types responsible for malaria in the area are A. gambiae spp and A. arabiensis spp. To complete it’s life cycle, the mosquito requires water, or an aquatic environment to develop it’s larvae. This insect therefore seeks to lay it’s eggs in pools of fresh water, abundant in the area due to Lake Victoria, and important source of the local staple fish, and areas of underdeveloped grassland surrounding the lake and village. https://malariajournal.biomedcentral.com/articles/10.1186/1475-2875-9-62

WHO reported 219 million cases of malaria world wide, with 435,000 deaths in the same year. In this day and age, malaria remains burdensome in 11 countries, 10 of them being in Africa. WHO recommends a focused response. https:// who.int/malaria/en/. I advocate a focus on prevention by eradicating mosquitoes and episodes of mosquito bites in the region. WHO vector control guidelines run along the idea of chemical and biological larvicides, topical repellents,and personal protective measures, such as bed nets, wearing long sleeves and pants (hard to do in the heat of Migori), bug spray and insecticide treated nets. These are effective.

In the area, mosquitoes capitalize on both daytime and nighttime feeding. Lwala benefits from a mosquito net distribution program so there is at least 1 net/ per household and a coverage of about 95%, https://lwala.org/wp-content/uploads/2019/02/Lwala-2018-Annual-Report.pdf, but there is an average of 5.5 individuals per household,
file:///C:/Users/Owner/Downloads/Migori%20County.pdf , so it conceivable that not all children under 5 currently sleep under a net.

Let’s start by making sure they do by scaling up this program, so that the number of nets corresponds with the number of individuals per household.

Lwala is an active community, and while use of nets will eliminate night feeders such as A. gambiae , little children will be susceptible to mosquito bites given that they are outdoors nearly daily helping with activities such as fishing, goat herding, fetching water and so forth. That is why active programs for mosquito eradication make so much sense in the region. While promoting personal prevention measures such as the use of “bugspray” containing effective substances such as DEET, efforts by the Bill and Melissa gates foundation, through the Malaria R&D (research and development) active since 2004, have devoted over $323 million dollars, about 20% ($50.4 million) of which has gone to the Innovative Vector Control Consortium, (IVCC) led by the Liverpool School of Tropical Medicine. The aim is to fast track improved insecticides, both biological and chemical, and other measures of vector control. I suggest that partnership with the IVCC be scaled up in the area, allowing Lwala to be first line in any benefits thereof. https://www.gatesfoundation.org/Media-Center/Press-Releases/2010/11/IVCC-Develops-New-Public-Health-Insecticides, https://www.gatesfoundation.org/Media-Center/Press-Releases/2005/10/Gates-Foundation-Commits-2583-Million-for-Malaria-Research

Finally, it’s official. Research endorses use of nets and indoor residual spraying as an effective way to reduce malaria density. https://malariajournal.biomedcentral.com/articles/10.1186/s12936-016-1214-9. This should be coupled with house improvement, since much of traditional and poverty-maintained materials, allow environments in which the mosquito can hide, to come out later to feed, and even breed. In Migori county, 72% of the homes have earth floors, 76% have corrugated roofs, and 21% have grass-thatched roofs. file:///C:/Users/Owner/Downloads/Migori%20County.pdf

All these promote a healthy habitat for the mosquito during the rainy season, and easy entry and hiding places all year round. Funding to improve house types so that locally-sourced but sturdy, water-proof homes can be built, will eliminate opportunities for the mosquito to access and bite young children.

Let’s get stakeholders vested in this effective, yet economical way to address malaria deaths in the youngest children. Starting now, funding should be diverted from costly treatments with ever mounting resistance patterns, to causing extinction of the Anopheles mosquito in Migori county. “An ounce of prevention is worth a pound of cure”http://drjarodhalldpt.blogspot.com/2018/02/an-ounce-of-prevention-is-worth-pound.html

Will the Malaria vaccine be a game changer? Too early to call in Malawi

Erin Fleming has recently posted a perspective on the new malaria vaccine intervention testing at “Social, Cultural & Behavioral Issues in PHC & Global Health.” See her observations below. Malaria is one of the world’s deadliest diseases. In Malawi, it is endemic across 95 percent of the country and is one of the leading causes of morbidity and mortality across all ages, and has a disproportionate impact on children under 5. In collaboration with many international partners such as the Centers for Disease Control and Prevention (CDC), the Global Fund to Fight AIDS, Tuberculosis and Malaria, the United States Agency for International Development (USAID), and Gavi, the Vaccine Alliance, the Malawian Ministry of Health’s Malaria Control Program has been combating malaria for years by scaling up distribution of artemisinin-based combination therapies (ACTs), intermittent preventive treatment for pregnant women (IPTp) using sulfoxide-pyrimethamine (SP), and insecticide-treated net (ITNs) based on the World Health Organization’s (WHO) malaria guidelines and national level policies. But now, they may potentially have another tool to add to their existing package of services, a malaria vaccine!
Moms waiting for the malaria vaccine for their children in Malawi.
On April 23, 2019, Malawi, 1 of 3 countries selected for the Malaria Vaccine Implementation Programme (MVIP) pilot rolled out RTS,S/AS01 (RTS,S) – also known as Mosquirix , as part of their routine immunization for children under 5. It has been met with great excitement, as early speculation is that the vaccine could be a gamechanger in the fight against malaria. But there is still a way to go, four years to be exact after the completion of the pilot and research, before we know for sure. IF the pilot findings present positive results, i.e. higher levels of efficacy and effectiveness, does not have any severe adverse health effects, and can be incorporated into national immunization programs, then yes, we may have on our hands a new control to help reduce severe malaria morbidity and mortality in children under 5 in a significant way. Now, despite my excitement regarding the potential impact RTS,S could have on malaria on childhood morbidity and mortality, it is too soon to tell. I am supportive of the vaccine pilot and the potential inclusion into policies and see the life changing benefits for patients, but with reservations. And, perhaps I am taking a more conservative stance based on my experience working and living in sub-Saharan Africa, seeing firsthand some of the systemic issues (i.e. lack of human resources, funding, poor infrastructure – in particular supply chain management, and government commitment) that continue to plague the efforts being made to improve health service delivery – all of which directly impacts routine immunization programs. That said, I’m eager to see what the pilot results yield, in particular as it relates to the economic and operational feasibility of implementation in low-income countries who are the hardest hit by malaria. But while we wait, we must not lose track of continuing to implement existing prevention approaches and enforcing adherence to treatment guidelines, especially as we know malaria is on the rise again in Malawi, and around the world. There still needs to be significant increases of support and investment from cooperating governments and international stakeholders in improved surveillance systems and research on some of the challenges we’re encountering with existing methodologies, i.e. increased insecticide and anti-malarial drug resistance, and the biggest “unknown” of them all, how climate change will impact the mosquito burden and potentially increase the reach of this deadly disease globally.

A Mothers’ Day Wish: Lifesaving Maternal, Newborn and Child Health Supplies

Eyelachew Desta shares thoughts as a guest blogger in time for Mothers’ Day. Concern is expressed  about ensuring increased access for low cost essential lifesaving Maternal newborn and child health supplies in Ethiopia. This posting appeared originally at Social & Cultural Basis for Community and Primary Health Programs. Can you imagine? At this time of Mother’s Day celebration, there are thousands of  women living in low income country , unlucky to be a mother to enjoy the celebration of mother’s day because of preventable  birth complications due to lack of  accesses to  essential   low cost medicines and  commodities necessary for maternal, Child and New born Health. One of these low-income countries is Ethiopia where maternal and child mortality is still high. According to an analysis published by Reproductive Health Supplies Coalition (RHSC), a quarter of all deaths between 2009 and 2013  occurred in Ethiopia are maternal mortality. This study indicated  “postpartum hemorrhage (PPH)— uncontrolled bleeding after childbirth—and preeclampsia/eclampsia (PP/E)- a condition which causes high blood pressure and seizures during pregnancy”, among others, are the two leading causes of maternal deaths in Ethiopia ,could be treated by low cost and effective  medicines, Oxytocin and Misoprostol.
See Photo Credit for UNICEF
The availability of accessible, reliable and low cost essential maternal health commodities is indispensable to address maternal and child mortality in Ethiopia. However according to an assessment  study conducted in Ethiopia, there are gaps in the supply chain management of commodities for maternal, neonatal, and child health. According to this study one of these gaps is  “The supply chain system for MNCH commodities is inconsistent and has not been integrated into the Integrated Pharmaceutical Logistics System (IPLS)” of Ethiopia. Further the study indicated that family planning, HIV, tuberculosis, and malaria have been included in this IPLS, but not MNCH commodities. This study also identified that  there is a lack of common understanding at lower level of the health system about the national policy and protocols  as well as its implementation to provide MNCH services and commodities free of charge at primary health care units. To address these gaps, there is a need of immediate actions as well as strong commitment among all stakeholders involved and engaged in the funding, monitoring, regulating and administering the logistic supply of MNCH commodities in Ethiopia. The Federal Ministry of Health (FMOH) should develop a strategy to provide continues education and training at all levels of the health system about its policy of provision of MNCH services and commodities free of charge at primary health care units , ensure policy protocols are implemented properly. In addition to these the FMOH should strengthen its monitoring system to identify gaps in the implementation of the MNCH services and commodities policy and take measures to narrow those gaps. The Ethiopia Pharmaceuticals Fund and Supply Agency should revise its Integrated Pharmaceutical Logistics System (IPLS) to insure MNCH commodities are integrated in the system by 2020. Ultimately international donors like USAID needs to continue and strengthen their financial and technical support to the overall MNCH program of Ethiopia .

HPV Vaccine in South Africa – Don’t Forget the Private Schools

Ramatsobane Johanna Ledwaba provides us with a guest blog to address the need to reach more school aged girls with vaccines for human papilloma (HPV) virus in South Africa and in the process prevent cervical cancer. Her blog originally appeared in Social, Cultural & Behavioral Issues in PHC & Global Health. Cervical cancer is the first most common cancer in women and the first leading cancer related-deaths among South African women, aged 15-44 years. More that 12,000 women are diagnosed with cervical cancer annually, of which 5,500 die from cancer— age-specific incidence rate (15-44 years) of 41.8 per 100,000 women per year and age-specific mortality rate (15-44 years) of 11,7 per 100,000 women per year. Reasons for such a high mortality rate include, low screening coverage of 19.3%, and late presentation with an advanced stage compounded by the high HIV epidemic. The World Health Organization recommends a 2-dose HPV vaccination among girls of 9-13 years. In 2014, the South African National Department of Health introduced a school-based HPV vaccination policy— using 2-dose Cervarix vaccine, as prevention for cervical cancer among girls aged 9 and above in grade 4 attending public schools. The policy aimed to vaccinate 500, 000 young girls from 18,000 public schools before their sexual debut.
HPV vaccine campaign poster distributed by the Department of Health. Source: Government Communication and Information System
Preliminary data showed that 91% of schools were reached and 87% age eligible grade 4 girls were vaccinated, however there is a high dropout rate in the second dose. Although the programme seems a success thus far, there is a need for expanded coverage of the vaccine to include higher grades that could potentially house girls of ages 11-13 years. In addition, the vaccine must be widely available at public health facilities for girls who were missed at school because they changed schools or dropped out. Girls attending private schools are presumed to access HPV vaccine through the private health sector, however the HPV vaccine coverage in the private health sector remains low due to high costs and lack of awareness— which suggest that there is low coverage in private schools. Therefore, the vaccine must be expanded to include private schools. This gap may lead to poor coverage of HPV vaccination and may also increase perceptions or hesitancy against the vaccine because it is not widely available for all girls of targeted age. No girl must be left behind.