Tropical Health Matters

The Demographic and Health Survey Program has released final and summary reports for both DHS and Malaria Indicator Surveys (MIS) for 2021 from several malaria endemic African countries. Below is a brief summary of some of the findings from Madagascar, Nigeria, Burkina Faso, Mali, Côte d’Ivoire, and Senegal. Click the link on each country to download a copy for yourself.

The proportion of the population who slept under an insecticide treated bednet the night before the survey varied. In Madagascar it was 49%, While in Nigeria it was 59%. Mali achieved the highest coverage at 73%, while Burkina Faso had the lowest previous night coverage at 41%.

Senegal showed a worrying decrease from 63% in 2016 to 46% in 2021. Côte d’Ivoire did not report total household use, but indicated that 72% of homes had at least one net, with 58% of children below 5 years of age and 64% of pregnant women sleeping under them.

At least three doses of sulfadoxine-pyremethamine is recommended for Intermittent preventive treatment of malaria in pregnant women. The national average was 38% for at least 3 doses in Senegal, although ironically 92% had been reached with the first dose. In Mali only 35% received at least a third dose. Burkina Faso started out with 92% for the first dose, but reached 57% with three or more. Côte d’Ivoire started with 80% receiving their first dose and concluded with only 35% receiving a third. Both Madagascar and Nigeria had the lowest 3-dose coverage at 31%.

Malaria testing and treatment using rapid diagnostic tests and artemisinin-based combination therapy (ACT) was reported. Nigeria demonstrates the challenges of following guidelines. Although 63% of children under 5 years of age were reported to have had a fever in the two weeks preceding the survey, only 24% of those received a diagnostic test. The summary results report that 74% of those with fever “who took any anti-malaria medicine” used the recommended ACT. The implication is that many received medicine without confirmatory testing such that some may have gotten ACT who needed another medicine and some who actually had malaria may have missed the correct treatment.

A similar low level of testing was seen in Senegal (22%), Mali (23%), and Madagascar (20%). Côte d’Ivoire reported 38% of febrile children having been tested. Burkina Faso performed better for testing with 65%.

These brief findings indicate that implementation of Malaria interventions are far from ideal. We know that some of the blame can be placed on health service disruptions due to demands of COVID-19 activities by health ministries and partners. Still, with 8 years remaining until 2030, Reinvigorated efforts are needed in all endemic countries if these six examples are indicative of the challenges we face.

Andaratu Wuni has contributed this posting to the Blog site for the JHU site for the course Social and Behavioral Foundations of Primary Health Care.

(Graphic source: https://www.aafp.org/news/health-of-the-public/20210429vacchesitancy.html)

Covid 19 has unarguably wrecked devastating consequences globally since its emergence and has proven to to be a ubiquitous public health health problem. Vaccination against the virus has been shown to be the most effective way of limiting severe disease and mortality. However the spate of vaccine hesitancy in Ghana has continued to rise in the last year. The World Health Organization defines vaccine hesitancy as the delay in acceptance or refusal of vaccination despite availability of vaccination services. This public health problem has far reaching consequences not only in Ghana but globally. Currently the vaccine hesitancy rate in Ghana is about 30% and counting! with people 25 years and under leading the hesitancy core.

(Graph Source: https://figshare.com/articles/thesis/Examining_drivers_of_COVID-19_vaccine_hesitancy_in_Ghana/14494851)

Since Ghana rolled out vaccines to the general public over one year ago, only 25.9% of the population have been fully vaccinated as of August 19,2022.Ghana has a target of vaccinating 22.9million eligible Ghanaians; that is about 60% of the population in order to achieve herd immunity, however only 8.2 million Ghanaians have been fully vaccinated to date.

Many reasons account for the rise in covid 19 vaccine hesitancy in Ghana; from the depletion of rigorous and continuous education and the consequent lack of community engagement, relaxation of covid 19 protocols, to vaccine misinformation and conspiracy theories as well as political influence. It is time for a policy that will mitigate this crucial problem, which the WHO(before the covid pandemic) described as one of the top ten greatest threats to global health.

The truth is, a single policy may not totally solve the problem as the issue of vaccine hesitancy is a complex one. The best approach will be for policymakers to enact policies to make vaccination a condition for other essential services in Ghana.

Intensify mandatory vaccination especially in high risk individuals and high risk locations, eliminate vaccine exemptions based on all but health related reasons, commit to structured community engagements and outreaches using the key stakeholders like the Ghana Medical Association and the Public Health association of Ghana, use stakeholders like UNICEF Ghana and the Ghana Health Service to disseminate accurate and scientifically proven vaccine information and last but not least introduce incentives for citizens who take the vaccine.

Abigail Arthur has contributed this posting to the Blog site for the JHU site for the course Social and Behavioral Foundations of Primary Health Care. Antibiotics are designed after years of research to determine which specific organisms they target, and at which doses they are effective. Hence, they must be used with strict adherence to prescription instructions to ensure maximum effectiveness. Unfortunately, there is a trend here in Lagos showing the gross misuse of antibiotics. Adapted from https://www.downtoearth.org.in/news/health/antibiotic-resistance-nigeria-stares-at-a-major-catastrophe-68915 The factors driving this phenomenon range from the misconceptions and practices of individuals and their contacts to factors associated with the communities and institutions within, same as well as the policies governing both. In Lagos, much of the misuse is fostered by extremely easy access to antibiotic medications aided by poorly implemented drug regulation policies. For instance, in 2005, there were 100 times more basic drug stores (patent and proprietary medicine vendors) than licensed pharmacy shops in Nigeria. ? While the operators of these basic drug stores have very little to no pharmaceutical knowledge, they are the first point of call for medications in the community.

The effect?

The next time you use the red and black tablet(ampicillin) for a skin infection, or an upper respiratory tract infection, it may not work due to the resistance built by microbes to these abused antimicrobials. ? Antimicrobial resistance (AMR) leads make treatments dear as newer generation (and pricier!) medication is then needed. Unfortunately, AMR can also lead to fatalities.

The way forward:

Antimicrobial Stewardship Programs (AMS) instituted by the Ministry of Health was implemented across only 6 health facilities in Lagos state in 2021. ? Our focus of advocacy is to encourage policy makers to consider antimicrobial resistance as an upcoming emergency following the progressive misuse of antimicrobials in the country. We call for proper control on the sale and advertisement of antimicrobials, an improvement in the patient to prescriber ratio and a strengthening of the Antimicrobial Stewardship Program already in place.

Edwin Chng has contributed this posting to the Blog site for the JHU site for the course Social and Behavioral Foundations of Primary Health Care.

Dengue has been endemic in Singapore for many decades, with all four dengue serotypes (DENV-1-4) in active circulation. It presents a significant impact on the economy, with the financial burden of dengue estimated to be US$1.04 billion from 2010 to 2020. (Mosquito Photo credit: http://bitly.ws/twG2)

Despite aggressive conventional vector control measures such as fogging and breeding site elimination, Singapore continues to have persistent outbreaks annually. The number of cases in recent years have also surged. From January to July 2022, 9 deaths and 22,468 cases have been reported thus far – the latter number is more than 4 times the number of cases reported in the whole of 2021. Dengue cases is likely to continue to increase, as the traditional peak dengue season in the country is from June to October each year. (Dengue Cases Graph Photo credit: NEA)

 

Singapore’s dengue crisis can be attributed to climate change and a recent change in the prevailing serotype. In the past, the dominant strains in Singapore were DENV-1 and DENV-2, hence the Singapore population has lower immunity to the other two strains. As a result, a large proportion of the population remains susceptible to DENV-3, which is emerging as the dominant strain in Singapore.

As such, as per the World Health Organization, dengue vaccination remains an integral part of dengue prevention and control strategy. The vaccine has an efficacy of about 80% against the outcomes of infection, hospitalization and severe infection which is potentially lethal. Unfortunately, the Singapore government has decided not to include it in the national immunization program, hence it is not eligible for government subsidy. As a result, the vaccine which costs a hefty USD450 remains inaccessible to the average Singaporean. (Vaccine Photo credit: http://bitly.ws/twGk).

Various stakeholders including the National Center for Infectious Diseases, primary care physicians and pharmaceutical companies can rally and work together in awareness campaigns and clinical studies. Health economics data from such collaborations can confirm the cost-effectiveness of dengue vaccines and positively influence the government to consider a change in its existing policy to provide subsidies. Increasing its accessibility and affordability to more Singaporeans will definitely contribute significantly to the fight against dengue in Singapore.

 

Sarah McHugh  has contributed this posting to the Blog site for the JHU site for the course Social and Behavioral Foundations of Primary Health Care. Although malaria transmission and infection rates in Senegal have declined in the past two decades from over 300 incidences of malaria infection per 1000 people at risk in 2000 to about 50 in 2020, malaria remains a burden and Senegal is still working with partners and stakeholders to research potential control and elimination strategies. Malaria is endemic in Senegal, where all of its inhabitants are at risk of contracting the disease and the country has a tropical zone of the country, where there is year-round transmission of malaria and a Sahelian zone, where transmission is high during and after the rainy season. (Map: Malaria interventions across transmission zones in Senegal) The WHO currently recommends that children under five years of age who reside in areas that have high seasonal malaria transmission (where most of the annual malaria cases occur during four months of the year) receive SMC during the months of high transmission. Although not currently recommended by the WHO, Senegal is the only SMC country that includes children up to ten years of age in SMC distribution. (SMC District MAP: PMI supported SMC districts in Senegal)

Lisa Marie Clark has contributed this posting to the Blog site for the JHU site for the course Social and Behavioral Foundations of Primary Health Care.

Cervical cancer is among the leading causes of death for Kenyan women. Every day, 9 women die from cervical cancer alone in Kenya. HPV vaccination reduces the risk dramatically, particularly for HPV types 16 and 18, which may be responsible for up to 70% of cervical cancers.

Optimal vaccination is in early adolescence starting at age 10, before sexual activity begins. In 2020, uptake of the HPV vaccine in Kenya was low, with only 33% of the target population receiving the first dose and only 16% percent receiving a second dose.  Low uptake may be due to a variety of factors including misinformation, lack of access, and low supply of vaccines.

In 2019, the Kenyan Ministry of Health began including the HPV vaccine in the routine vaccination schedule. The vaccine, with support from GAVI, the vaccine alliance, is offered free of charge. However, the Catholic Church and medical professional groups influenced by religious ideology have been a major opponent to vaccine uptake. The Kenya Catholic Doctors’ Association has been vocal about urging parents to promote abstinence over vaccination, equating HPV vaccination with permission to engage in sexual activities. See vaccination from Republic of Kenya’s Ministry of Health in photo.

In the face of such obstacles to vaccine uptake, more funding is needed to strengthen Kenya’s vaccination campaign, with a focus on building trust and strengthening partnerships with faith leaders to improve vaccine uptake. With more funding from GAVI and improved community engagement vaccination rates would improve, HPV infection rates would decrease, and lives would be saved as a result.

Please see some excerpts from recent news/media reports on COVID-19, Malaria, Marburg Virus, Ebola, Microplastics and more. Follow links for full articles.

Channels TV reports that Nigeria has confirmed 357 new cases of COVID-19 amid the wave of fresh infections resurging in parts of the country. The number of new cases has continued to rise as authorities have yet to restore the relaxed measures initially put in place to curb the spread of the disease. In a tweet on Tuesday, the Nigeria Centre for Disease Control (NCDC) explained that the fresh infections were confirmed between July 9 and 11. These cases, it stated, were reported in five states and the Federal Capital Territory (FCT).

BioNTech to take malaria vaccine into clinical trials later this year as reported on 12-Jul-2022 By Rachel Arthur. BioNTech is readying to take its mRNA malaria vaccine candidates into clinical trials later this year.

Mzuzah Webinar on “The Effects of Microplastics on Human Health” on Tuesday, July 26, 2022 from 10:00 AM to 12:00 PM CDT. Mzuzah Africa is a multidimensional platform, which connects stakeholders from key sectors in the sustainability discourse. These dialogues are essential to ensure the development of Sustainable Leadership with highly skilled, right-thinking individuals leading the transformational movement in Africa.

Faced with COVID and monkeypox, new USAID leader draws strength from African proverb. From NPR July 11, 2022. Dr. Atul Gawande began a challenging new job this year. The surgeon, former New Yorker staff writer and bestselling author of books like Being Mortal: Medicine and What Matters in the End, is now the head of global health for the U.S. Agency for International Development, which provides foreign and humanitarian aid around the world. So far it’s been quite a daunting year. The pandemic has of course continued and cases are now surging in many countries. Then there’s the worldwide monkeypox outbreak, the potential global repercussions of the U.S. Supreme Court’s decision to overturn Roe v. Wade, and other health crises that have arisen in the wake of the pandemic. Gawande spoke to NPR about the agency’s top health priorities in low-income countries.

On July 11, 2022 Jessica Nye wrote that Ebola Reduces Visual Quality of Life in Pediatric Patients. Survivors of EVD and their close contacts were found to have poor health- and vision-related quality of life, especially among children with one or more ocular complications. Shantha JG, Canady D, Hartley C, et al. Ophthalmic sequelae and psychosocial impact in pediatric ebola survivors. EClinicalMedicine. 2022;49:101483. doi:10.1016/j.eclinm.2022.101483

The Express (UK) reported that Marburg Virus, an Ebola-like virus with 88% death rate has hit Ghana as fever sparks ‘serious concern’ AN OUTBREAK of a deadly virus similar to Ebola, called Marburg, has been identified in Ghana, as two people were diagnosed with the highly contagious disease after they had died. Vassia Barba wrote on Jul 8, 2022. The World Health Organization (WHO) said on Thursday “preparations for a possible outbreak response are being set up swiftly as further investigations are underway”. In a statement, the WHO said preliminary assessment of samples from the two patients indicate the cases were positive for Marburg. However, it clarified those results must be confirmed by a laboratory in Senegal.

FutureLearn is offering an online course, The Resistant Mosquito: Staying Ahead of the Game in the Fight against Malaria. Discover how we can keep the upper hand in our fight against the malaria mosquito by managing insecticide resistance development. This course will be available on FutureLearn from 25 July 2022. The link to the course will follow on July 25th.

A May 28^th press release from the World Health Organization states that, “Togo eliminates trachoma as a public health problem.” The article explains that …

“Validation of trachoma elimination as a public health problem in Togo was based on evidence. Several population-based trachoma surveys were conducted starting from 2006 to 2017. The 2017 survey using WHO recommended methodology found that the prevalence of key indicators was below the WHO trachoma elimination threshold. There was also evidence that Togo’s health system is able to identify and treat new cases of late complications of trachoma.”

This raises the question, is Trachoma gone from Togo or does trachoma continue to exist at some low level whereby, as WHO notes, Togo has joined, “12 other countries that have been validated by WHO for having eliminated trachoma as a public health problem.”

This description of disease elimination contrasts sharply with the global concerns when “health authorities in Malawi have declared an outbreak of wild poliovirus type 1 after a case was detected in a young child in the capital Lilongwe. This is the first case of wild poliovirus in Africa in more than five years.” Wild polio virus had been declared eliminated in Africa, and just one case in one country grabs international attention.

Would one case of trachoma tomorrow receive the same concern in Togo? Apparently not according to the WHO definition, “Elimination of trachoma as a public health problem is defined as: (i) a prevalence of trachomatous trichiasis (TT) “unknown to the health system” of < 1 case per 1000 total population; and (ii) a prevalence of trachomatous inflammation-follicular (TF) in children aged 1–9 years of < 5%, in each formerly endemic district.”

So, while no cases of smallpox, guinea worm or polio would be tolerated after elimination has been declared, parents of a child who develops trachoma in Togo tomorrow would be told that your child’s case is only 1 in a 1000 and not of concern to public health. The caveat is though that “the health system (must be) able to identify and manage incident TT cases.” Presumably, if such management capacity does not exist, the disease in question could spread and elimination would be eliminated.

Another Neglected Tropical Disease, Lymphatic Filariasis, faces the same challenge in terms of elimination status. WHO explained in its guidance that, “In 1997, the 50th World Health Assembly resolved to eliminate LF as a public-health problem (resolution WHA50.29). In response, WHO proposed a comprehensive strategy for achieving the elimination goal that included interrupting transmission in endemic communities and implementing interventions to prevent and manage LF-associated disabilities The LF guidance stresses “Effective monitoring, epidemiological assessment and evaluation are necessary to achieve the aim of interrupting LF transmission,” or in a word Surveillance. There is clear concern for “absence of transmission” and worries about “recrudescence.”

While polio has a vaccine and guinea worm relies on providing safe community water, LF and Trachoma elimination depends on mass drug administration (MDA) at planned intervals until such time as transmission is reduced. All require a strong health system to implement, but the challenges of maintaining MDAs until such time as elimination has been validated is somewhat more challenging. In this context the communication is extremely important. Just because WHO validates the elimination of a disease as a public health problem, does not give policy makers license to ignore that disease. Advocacy is continually needed such that even after apparent elimination, neglected diseases will not be forgotten and health systems themselves not neglected.

The World Health Organization’s African Regional Office held a press briefing to mark World Immunization Week/African Immunization Week. Three experts shared their observations of developments and trends and responded to questions over the course of an hour on Thursday 28^th April. The panelists included Dr Benido Impouma, Director, Communicable and Noncommunicable Diseases, WHO Regional Office for Africa, Professor Helen Rees, Executive Director, Wits Reproductive Health and HIV Institute, University of Witwatersrand, South Africa, and Hon. Dr Kailash Jagutpal, Minister of Health and Wellness, Government of Mauritius. In addition, Dr. Mory Keita answered questions about the latest Ebola Virus Disease (EVD) in the Democratic Republic of the Congo (DRC).

Concerns about COVID-19 featured in this immunization briefing for several reasons. First was the low coverage of COVID vaccines on the continent. Second was the way that COVID put demands on health workers’ time as well as on precautions to be undertaken, which limited the reach and coverage of immunization services for other vaccine preventable diseases (VPDs). Also, the resulting reduction in immunization coverage was responsible for other deadly outbreaks, notably measles. Between January and March 2022, for example, there was a 400% increase in measles cases compared to the same period last year.

Dr. Impouma that COVID ‘taught the lesson’ that catch-up campaigns for VPDs were not only necessary but could be handled successfully. Finally, health services learned the importance of integration, whether joining COVID and Yellow Fever vaccination efforts in Ghana or integrating COVID with maternal and child services and immunizations. Ultimately, health workers learned that by strengthening ‘routine’ immunization, health systems overall could be strengthened thus, making progress on achieving Health For all through Universal Health Coverage.

Dr. Jagutpal shared key considerations for successful life-course immunization programs. Mauritius offers free, universal vaccination from birth. Thirty VPDs are addressed ranging from Human Papilloma Virus to flu and not of course, COVID-19. Success is based on involvement of all stakeholders through regular meetings where real time decisions can be made. Mauritius in one of the first to formalize the COVID Vaccine Pass Card and has achieved 60% full vaccine coverage including booster shots.

Prof Rees noted that the term ‘routine services’ makes vaccines seem boring and less important, when in fact, they should be seen as “Core Services”. This central role of vaccines goes beyond preventing specific diseases. By saving children’s lives and reducing the time demands on parents who care for children suffering VPDs, immunization promotes human development, reduces poverty, enhances the economy, and strengthens employment. There remain children who have had no vaccines. Identifying these ‘zero dose’ children and the communities in which they cluster can help us focus on ameliorating the vulnerabilities of their families and bring multi-sectoral resources to bear on strengthening poor communities.

Dr Keita reviewed the two recent cases, now deaths from Ebola in Équateur Province in DRC, its third EVD outbreak. Ebola vaccine teams have started working, reaching 78 contacts. He lamented that much of the DRC has a natural ecological predisposition for the animal reservoirs of Ebola, so more effort on making regular vaccines and treatment available is required. As Prof Rees pointed out, this setting is a perfect example of the need for a One Health approach to many of our health challenges which are zoonotic in nature. Even with coronaviruses, animal reservoirs are a central element of transmission.

Additional research is recommended in several areas. The slowly increasing laboratory capacity in Africa was mentioned. It contributed to finding Omicron and its variants. Potential new ones may have been identified recently. Seropositivity analysis has found that 80-90% of people tested may already have COVID antibodies. Research can clarify the role of vaccines in these circumstances. Research as well as regular program monitoring is still needed to determine the factors that may cause children to miss vaccines. It is often not the case that parents are ‘hesitant’, but that system and community factors combine to prevent them from seeking care. Research can also assist in finding vaccines and tools for tackling other deadly pathogens such as Lassa Fever.

Vaccines save lives from endemic diseases, but in the long-term vaccinated families and communities can fight poverty which itself is a leading factor in illness and death. This will accomplish the theme of this year’s observance, “Long Life for All.”

One might think initially that the convergence of World Malaria Day and World Immunization Week would simply be a coincidence. This year there is a major connection since WHO has approved the first ever RTS,S/AS01 malaria vaccine which has undergone decades to clinical testing and most recently, a successful 3-year pilot intervention in Malawi, Kenya, and Ghana.

During her keynote address at the Johns Hopkins Malaria Institute’s World Malaria Day Webinar today, The WHO Regional Director for the African Region, Dr. Matshidiso Moeti, stressed the importance of integrated disease control efforts drawing on the region’s efforts to tackle neglected tropical diseases, COVID-19 and of course, malaria. She highlighted the importance of surveillance, and in That context pointed out a serious fact. The population of sub-Saharan Africa had doubled since the start of the Roll Back Malaria initiative, meaning that to achieve the same level of coverage of key interventions, one needs to reach many more people, whether for malaria control or child immunization.

Thus, increasing targets and goals affect both immunization and malaria programs, as well as efforts to roll out the malaria vaccine. At present there is only one producer of the vaccine, GlaxoSmithKline, and while that company is working with another company in India to produce RTS,S in the global south, GSK is maintaining control of the AS01 adjuvant. Production targets have so far been geared to meeting the needs in the pilot districts of the three intervention countries, and for the foreseeable future this will address less than 10% of need in P. falciparum endemic areas, especially in Africa.

WHO and partners including UNICEF and GAVI are in the process of figuring out equitable ways to distribute what is available now and encouraging the ramp up of vaccine production. The need to vaccine technology transfer to Africa is also being considered. Additionally, eyes are focused on new malaria vaccine candidates which might come on board in about five years.

The current malaria vaccine, while reducing severe disease, does not have the highest efficacy, and experts caution that is is therefore, not a silver bullet. They do explain that the vaccine is an important addition to the malaria toolkit, and should be a central part of integrated malaria control planning. At present though, we are not only running in place to meet the needs of an ever increasing number of children at risk, and we also must cope in an ethical and efficient way with limited supplies of the vaccine for the near future. This is the double challenge to start Malaria Day and Vaccine Week.