Tropical Health Matters

Recently we have seen some online discussion about mosquitoes biting 24/7, and while this is true, it is not all species of mosquitoes that bite all the time – only that anytime during the day/night one might be bitten, but by different types of mosquitoes, carrying different diseases at different times. Below is a chart that tries to draw some of the distinctions among the different types of mosquitoes.  It is not all inclusive. Some references are listed at the end. Finally there is an abstract about possible changes in malaria mosquito biting behaviors, although we should use caution in that this has not been verified universally.

Reference Links

• How Mosquitoes Work. http://science.howstuffworks.com/zoology/insects-arachnids/mosquito1.htm
• Be vigilant to different mosquito breeding grounds. http://www.fehd.gov.hk/english/safefood/images/Pestnews_9e.pdf
• Biological Notes on Mosquitoes. http://www.mosquitoes.org/LifeCycle.html
• Mosquito. From Wikipedia, the free encyclopedia. http://en.wikipedia.org/wiki/Mosquito
• Anopheles Mosquitoes. http://www.cdc.gov/malaria/about/biology/mosquitoes/
• Differentiate Culex, Anopheles and Aedes Mosquitoes. http://profwaqarhussain.blogspot.com/2012/10/differentiate-culexanopheles-and-aedes.html
• Flight performance of the malaria vectors Anopheles gambiae and Anopheles atroparvus. http://www.ncbi.nlm.nih.gov/pubmed/15266751

Effects of changing mosquito host searching behaviour on the cost effectiveness of a mass distribution of long-lasting, insecticidal nets: a modelling study. Malaria Journal 2013, 12:215 doi:10.1186/1475-2875-12-215. Olivier JT Briët (olivier.briet@unibas.ch). Nakul Chitnis (nakul.chitnis@unibas.ch)

Abstract: Background The effectiveness of long-lasting, insecticidal nets (LLINs) in preventing malaria is threatened by the changing biting behaviour of mosquitoes, from nocturnal and endophagic to crepuscular and exophagic, and by their increasing resistance to insecticides. \

Methods: Using epidemiological stochastic simulation models, we studied the impact of a mass LLIN distribution on Plasmodium falciparum malaria. Specifically, we looked at impact in terms of episodes prevented during the effective life of the batch and in terms of net health benefits (NHB) expressed in disability adjusted life years (DALYs) averted, depending on biting behaviour, resistance (as measured in experimental hut studies), and on pre-intervention transmission levels.

Results: Results were very sensitive to assumptions about the probabilistic nature of host searching behaviour. With a shift towards crepuscular biting, under the assumption that individual mosquitoes repeat their behaviour each gonotrophic cycle, LLIN effectiveness was far less than when individual mosquitoes were assumed to vary their behaviour between gonotrophic cycles. LLIN effectiveness was equally sensitive to variations in host-searching behaviour (if repeated) and to variations in resistance. LLIN effectiveness was most sensitive to preintervention transmission level, with LLINs being least effective at both very low and very
high transmission levels, and most effective at around four infectious bites per adult per year. A single LLIN distribution round remained cost effective, except in transmission settings with a pre-intervention inoculation rate of over 128 bites per year and with resistant mosquitoes that displayed a high proportion (over 40%) of determined crepuscular host searching, where some model variants showed negative NHB.

Conclusions: Shifts towards crepuscular host searching behaviour can be as important in reducing LLIN effectiveness and cost effectiveness as resistance to pyrethroids. As resistance to insecticides is likely to slow down the development of behavioural resistance and vice versa, the two types of resistance are unlikely to occur within the same mosquito population. LLINs are likely cost effective interventions against malaria, even in areas with strong resistance to pyrethroids or where a large proportion of host-mosquito contact occurs during times when LLIN users are not under their nets.

——–

Finally please note that one malaria intervention alone will not solve our problems so we need to apply a mix that includes Nets, Indoor Residual Spraying, Diagnosis with mRDTs, Appropriate treatment with Artemisinin-based Combination Therapy, Intermittent Preventive Treatment, one day a vaccine and others …

In 1978 the US Centers for Disease Control and Prevention reported that, “As of April 14, 1978, no cases of smallpox have been reported to the World Health Organization (WHO) from anywhere in the world since the last case had onset of rash on October 26, 1977, in Merka town, Somalia. However, a total of 2 years of effective surveillance must elapse before this last endemic area can be confirmed to be smallpox-free.” Thirty-five years later Somalia is linked with difficult efforts to eradicate another disease, polio.

Now unfortunately, “Somalia hadn’t had a case of polio for nearly six years. But in the past few months, the virus has come back,” according to National Public Radio (NPR)  In fact the 73 cases reported from Somalia so far this year, surpasses the 59 cases reported in the rest of the world. NPR further notes that, “Somalia has the rate of polio vaccination in the world after Equatorial Guinea, according to the World Health Organization.”

Thirty-five years ago, challenges hampering disease eradication were the natural environment. “During October and November surveillance in Somalia has been severely hampered by heavy rains that have made it difficult or impossible to travel by vehicle. Since work has had to be continued on foot, there have been some delays in reporting and incomplete search coverage in certain areas,” CDC reported.

Today it is human conflict, not the weather, that inhibits control. NPR’s report notes that, “The Somali government directs the campaigns, but it doesn’t control or have access to vast swaths of the country. Some of the most recent polio cases have occurred in areas that are considered off limits to vaccination teams.” Conflict in Pakistan in December-January also tried to create off limits areas by killing polio workers.

Because polio is a fecal-oral disease it spreads with people. Not surprisingly, cases are appearing in Somali refugee camps in Kenya.  All countries in the region are on alert as extra vaccination efforts will be needed. And as NPR observes, this may draw resources from countries like Nigeria that are very close to eliminating the disease.  Ironically the polio virus strain found in Somalia was traced to Nigeria.

Polio cannot be easily compared with malaria which has a vector, and also an larger arsenal of effective tools – insecticide treated nets, indoor residual spraying, chemo-prevention drugs, rapid diagnostic tests and effective medicines.  But the diseases face similar challenges that are more often human than deriving from the natural environment.  Human conflict deters malaria control in eastern Democratic Republic of the Congo, in the Central African Republic and in South Sudan.

Unlike for polio, we are not even close to numbering malaria cases in the dozens, but the as the recent Abuja Summit has shown, we must have the political will to rise above conflict and inefficient health systems and face down these devastating diseases.

(PS – fortunately as we can see in the attached map, malaria is not a pressing problem in Somalia.)

A Breakfast Briefing was given to African Ministers of Health and Foreign Affairs on 13th July 2013 in Abuja, Nigeria to review progress in Africa’s fight against malaria and to announce a new initiative to support 10 high-burden countries as part of the Special African Union Summit on HIV/AIDS, Tuberculosis and Malaria.

Dr Fatoumata Nafo-Traoré, Executive Director, Roll Back Malaria (RBM) Partnership in her welcome address) acknowledged the high level of commitment of partners and the high level of leadership from endemic countries over the past decade in the fight against malaria resulting on 44 countries seeing a > 50% reduction in malaria cases, but we cannot rest in the face of financial and technical challenges.

Dr Mustapha Sidiki Kaloko, the African Union Commission’s Commissioner for Social Affairs in his opening remarks reminded us that external funding has never been guaranteed, and as it is ebbing we need to scale up domestic financial support. The AU will work with all stakeholders to help close the $4b gap and not let gains reverse. In order not to lose momentum innovative domestic funding models are needed.

Joy Phumaphi, Executive Secretary of the African Leaders Malaria Alliance (ALMA) delivered the ALMA Scorecard update. She noted that the scorecard provides a roadmap and pushes countries to demonstrate results. Very positive results in terms of adopting policies that oppose artemisinin monotherapies and promote community case management are the norm now.

The challenge is the low scores on public sector management and effective use of existing resources. Efficiency gains could deliver up to 40% more services with available money. Continued scorecard success also depends on global attention remaining focused on Africa as post MDG goals are being set.

Dr Robert Newman, Director of the WHO Global Malaria Programme (WHO-GMP) introduced the new Larval Source Management (LSM) Manual. He told the gathering that the new LSM Manual was a result of advocacy by Nigeria’s Minister for Health.  IRS and ITNs have been success stories, but we need to use all available tools in appropriate manners. LSM has a unique niche where one finds discrete, fixed and definable water bodies as opposed to water in multiple diffuse sources like cattle foot prints on a rutted road that come and go over days.

Larvicides are expensive and labor intensive and need regular monitoring. People need to remember that environmental management is another larva control tool.  With all vector measures “commodities don’t deliver themselves”, but require commitment and action of people at all levels form the national to the community.

Dr Richard Kamwi, Hon. Minister of Health, Namibia, shared that in the 1990s there were 7,000 malaria deaths in his country annually, but only 4 in 2012. Namibia has a mixed strategy especially in the northern border area, and is close to pre-elimination.

Dr Robert Newman, Director of WHO-GMP gave a presentation on the Malaria Situation Room concept and explained that even though progress has been made and millions of lives saved, there are over 219 million cases of malaria annually and 660,000 deaths/ A disproportionate burden of malaria deaths even now is in African children under five years of age. We have responsibility for these children.  This burden is focused on 10 countries which account for 70% of malaria cases in Africa and 56% globally.

The Malaria Situation Room will be a way to collate data on funding, intervention, commodities and results.  International partners will continue to support all endemic countries, but malaria elimination will remain elusive unless more coordinated action is aimed at high burden areas.

With only 900 days left before the MDGs reach their target date (end of 2015), we want to anticipate and prevent problems like stock-outs, but wait to hear that there have been no antimalarials in clinics for over a month. We want to be proactive in the face of potential dis-investment to protect 10 years of progress which could be undone in only one malaria transmission season.

Dr Alexandre Manguale, Hon. Minister of Health, Mozambique noted that his country is one of the ten in the “situation room.” Mozambique has made great progress in case reduction in the south with support from the cross border Lubombo Spatial Development Initiative. The rest of the country poses special challenges with logistics and weather (flooding). Under these circumstances partners need to coordinate and be flexible in response to gaps and bottlenecks. Information gathered and shared through the situation room will make this possible.

At this point Dr Newman, Dr Nafo-Traoré and Dr Kaloko officially launched the Malaria Situation Room with a ribbon-cutting. Now the work begins to make this ‘room’ a pro-active place to eliminate malaria.

The International Certification Team (ICT) for Guinea Worm Disease Eradication held a debriefing meeting with the Honorable Minister of Health of Nigeria on Friday 12th July 2013.  The team of over a dozen international and national experts had been working in-country to review the certification report prepared by the Nigerian Guinea Worm Eradication Program (NIGEP) within the Federal Ministry of Health (FMOH) for three weeks to learn if claims that the last case of the disease occurred in 2008 and that measures were in place to detect any imported or locally transmitted case in the interim. (Photo shows Nigeria’s Honorable Minister for Health, Prof. C.O. Onyebuchi Chukwu at right, receiving report from ICT lead by Prof. Molyneux on left, with Nigeria’s WHO representative center.)

This ICT visit in 2013 marks 25 years since the launch of NIGEP at a time when there were over 650,000 cases found in over 6,000 villages/communities, the highest burden of the disease in Africa and likely the world at that time.  The leader of the ICT, Prof. David Molyneux, thanked all the partners over the past two and a half decades who made today’s good news briefing possible. Prof. Molyneux is also Chairman of the International Commission for the Certification of Dracunculiasis (guinea-worm disease) Eradication (ICCDE) based in WHO.

The Commission has certified that two of Nigeria’s neighbors, Benin and Cameroon, are already free of guinea worm. Niger to the north is also in the pre-certification phase, while active transmission is still occurring on a small scale in Chad. Prof. Molyneux explained that the concern about these neighbors to the north and northeast is the potential of imported cases through population migration, hence the need for continued strong surveillance as part of an overall national health surveillance system.

In the process of verifying information in the national report on guinea worm elimination and validating its contents the ICT visited 17 States and the Federal Capital Territory, 60 Local Governments, 136 villages and interviewed 1,630 people using standardized questionnaires. Prof. Molyneux said the team took each State into consideration as a separate entity since some are larger than whole countries that have previously been certified.

Surveillance that helped Nigeria document no new cases since 2008 included 1) regular reporting on multipurpose surveillance forms at all frontline clinics, 2) incorporation of case searches into community and house-to-house health activities such as national immunization days/child health days and ivermectin distribution for onchocerciasis control, and 3) radio advertisements/jingles that describe guinea worm and offer a reward of N25,000 (approximately $160) and subsequent follow-up of rumored reports that this stimulates. These activities need to continue as long as countries in the region may still harbor the disease.

The team also reviewed contributing factors to maintaining a guinea worm free Nigeria, in particular village water supplies. While they noted that access to safe water had increased in many rural villages, there was still a problem of maintaining various kinds of wells and water systems.  At the start of global guinea worm eradication efforts during the United Nations Water Decade (the 1980s) the importance of guinea worm being the main infectious disease transmitted only through poor water supplies was stressed.

The next steps after this informal briefing of the FMOH is transmission of the ICT report to the ICCDE. The decision of the ICCDE will then be sent to the Director General of WHO, who will then communicate the findings and recommendations to the Nigeria FMOH officially.  Hopefully before the end of 2013, Nigeria will be declared free of guinea worm, and as Prof. Molyneux said, strong vigilance and surveillance will need to stay in place, including cross-border collaboration to prevent reintroduction of the disease. (Photo shows two Nigeria Guinea Worm pioneers, Prof. Eka Braide on right and Prof Luke Edungbola on left who were among the original zonal coordinators for NIGEP)

Eradication of guinea worm will only be achieved once each endemic country is certified free of the disease.  The certification process is lengthy, thorough but absolutely necessary. Similar processes need to be strengthened for other infectious diseases.

Presented at Jhpiego’s Mini-University, 24 June 2013 in Baltimore by Bill Brieger, Rachel Waxman, Elaine Roman and Ousmane Badolo

Between October 2009 and March 2013, with support from the USAID Malaria Program, the Maternal and Child Health Integrated Program (MCHIP), led by Jhpiego  has worked in close collaboration with the National Malaria Control Program (NMCP) and the Family Health Directorate (MCH) to accelerate malaria prevention and control in Burkina Faso with a focus on nationwide scale up.

Scale up is defined as program coverage nationwide.  During the project years, Jhpiego provided technical and programmatic support to address comprehensive malaria prevention and control with a focus on diagnostics, treatment, and malaria in pregnancy (MIP) in Burkina Faso.  This resulted in: 2,648 health facility providers trained using the integrated malaria training package; these providers in turn, oriented 4,867 of their colleagues.

Other key components of technical support included strengthening- a) supportive supervision; b) pre-service education; c) human capacity (team building); and d) communications and behavior change guidance at national level as well as targeting communication messages to both health facility providers and clients.  Training is US Peace Corps Volunteers helped reinforce that this guidance reached front line health facilities and volunteer community health agents.

Some of the lessons learned in going to scale are balancing reaching providers en mass with quality support; ensuring a link between revised policies and guidelines and both pre-service education and in-service training; and recognizing the need for national level leadership and capacity to ensure effective implementation.

As countries accelerate and scale up their malaria programs, the lessons learned from Burkina Faso a systematic development of an integrated package of malaria policies and guidelines are important to consider moving forward.

Presented at Jhpiego’s Mini-University on 24 June 2013 in Baltimore by Marya Plotkin, Elaine Roman, and Maryjane Lacoste

Malaria in pregnancy (MIP) is a threat to the pregnant women, the unborn child and the newborn and infant. Intermittent Preventive Treatment during pregnancy (IPTp) is one of the few interventions available that specifically targets and protects pregnant women.  As malaria prevalence drops when countries aim at malaria elimination, we need to examine the continued role of IPTp and search for alternatives.

From August 2011 to September 2012, Jhpiego partnered with the Zanzibar Ministry of Health to conduct a study looking at the prevalence of placental malaria infection among women delivering in selected health facilities in Zanzibar who had not had IPTp during the course of their pregnancy. The community-level malaria positivity rate in Zanzibar declined from as high as 20% in 2005 to 1.6% in 2011. In Zanzibar as in the rest of Tanzania, IPTp coverage has been quite low, but pregnant women have access to long-lasting insecticide-treated nets (LLINs) and indoor residual spraying (IRS) is practised in the islands.

Midwives in six clinics in in Unguja and Pemba tested the women using PCR at delivery. Of the 1,356 women with no IPTp exposure enrolled in the study, only nine (0.6%) were found to have placental malaria (95% CI 0.2–1%). Thus, even without benefit of IPTp, other interventions appear to be protecting pregnant women to some degree.

Estimations of the costs of IPTp program put the annual expenditure at $114,678, while the annual cost of intermittent screening and treatment with RDTs (ISTp) would be $155,294.  Given the extraordinarily low prevalence of malaria in pregnancy, as well as pilot experience of testing in the ANC setting, there is a strong argument for adopting ISTp and dropping IPTp in Zanzibar.

To do so, the authors argue, thresholds of prevalence or incidence of malaria infection must be set in advance in order to trigger a reconsideration of the IPTp decision, and surveillance of malaria infection in pregnancy must be strengthened.

WHO has recently issued new guidance recommending continuation of IPTp where it is currently being practiced, making Zanzibar’s decision to maintain or discontinue IPTp of particular interest to the malaria in pregnancy community. Better guidance is needed on MIP services as countries move closer to malaria elimination.

The World Health Organization is guiding countries across the Sahel of Africa to begin piloting ‘seasonal malaria chemoprevention” or SMC. We recently featured this in the May 2013 issue of Africa Health. WHO explains that “Seasonal malaria chemoprevention is defined as the intermittent administration of full treatment courses of an antimalarial medicine to children during the malaria season in areas of highly seasonal transmission.” This is an outgrowth of several years of research into intermittent preventive treatment for infants (IPTi) and children.

Malaria program managers wanted a more focused application of IPTi where it would be likely to make a major impact on disease control. Researchers found that areas meeting malaria seasonality definition of 60% of annual incidence within 4 consecutive months were observed more frequently in the Sahel and sub-Sahel than in other parts of Africa, and thus could provide an ideal focus for intervention.

What makes transmission more intense in those four months is the rainy season.  Ironically we have recently seen a more intense rainy season in the Sahel with serious flooding. IRIN reports that, “The African Centre of Meteorological Applications for Development (ACMAD) in a seasonal weather outlook says near-average or above-average rainfall is likely over the western Sahel, which stretches across Mauritania, Senegal and western and central Niger. These regions are ‘expected to be the area with the highest risk of above average number of extreme precipitating events that may lead to flash floods’.”

What does this flooding mean for SMC?  While breeding mosquitoes obviously need the pools that rainwater creates, too much rain may have an opposite effect with flash floods washing out breeding sites (let alone homes and possessions). When flooding results in larger and longer collections of standing water, mosquito breeding may be enhanced, but this will make logistical support for training, supervision, and drug supplies extremely difficult in the region.

The Sahel is one of the areas in Africa where we might hope for some early progress toward malaria elimination. With global climate changes affecting the region we can only wonder whether the weather will cooperate and allow timely implementation of new interventions.  As IRIN implies – contingency planning is extremely important.

Millennium Development Goal Number Two focuses on Universal Primary Education for all girls and boys by 2015.  BBC informs us that “The global figure for the number of children without access to schools has fallen to 57 million, according to the United Nations Educational, Scientific and Cultural Organization,” a fall from an estimate of 61 million missing school in 2010. Unfortunately the improvement is unlikely to be enough to meet the MDG pledge.

The BBC further notes that, “More than half of the children missing out on school are now in sub-Saharan Africa. The last annual report showed that in some countries, including Nigeria, the problem is getting worse rather than better.”

What does education have to do with the elimination of malaria?  We can look at the Malaria Indicator Survey (MIS 2012) from Nigeria to get some ideas.  The attached chart shows that several important maternal health variables are linked with improved educational levels.  It is not that education per se makes women more aware and take action, but education opens their lives and minds to the possibilities of better health and development.

The chart shows that women with higher education report greater exposure to malaria messages in the media.  It is not a simple matter of understanding, since many media programs are in local languages. We are talking about being more attuned to health messages in the available media because of improved education.

Life saving behaviors like attending antenatal care (ANC) and getting services offered there, like intermittent preventive treatment (IPT) for malaria, are enhanced by education.  Interestingly the MIS shows an opposite trend for sleeping under insecticide treated bednets among all women of reproductive age:

• 42% with no education
• 22% with primary education
• 17% with secondary education
• 17% with post-secondary education

This may appear odd until one realizes that campaigns to distribute ITNs intentionally or not address equity issues, reaching less educated (and poorer) households.  More educated and possibly more wealthy households are more likely to have window screening and other aspects of house construction (ceilings) that help keep out mosquitoes.

One wonders then if community campaigns are successful in reversing the education gap in ITN access and use whether such approaches should be used with IPTp.  In fact we have successfully shown that community health volunteers, under the guidance of ANC staff are able to reach poor rural communities and increase IPTp coverage.

Increased access to education will enhance uptake of health interventions. In the meantime we can make every effort to bring these interventions closer to the communities through their own efforts.

The latest edition of Global Fund Observer (#218) from AIDSPAN raised a lingering question about the Funds founding principles – what is country ownership and how is it practiced? The thoughts range from the more altruistic – let the country decide what it needs to do and we’ll give the money – to the more crude, though not stated as such – give the country enough rope (money) to hang itself.

Another founding principle involved the Global Fund seeing itself as only a financial mechanism, not a technical one like the World Health Organization or UNICEF.  AIDSPAN demonstrates how over time, while still not providing direct technical assistance, decisions from the Technical Review Panel and the Global Fund Board, among others, can be seen clearly as offering a technical guidance that must be heeded if funds are to flow.

In short AIDSPAN has shown how the Global Fund itself has taken a more directive role, though often based on programmatic evidence and advocacy from those who have a stake or experience. We also need to look at th other side of the coin – within the country, who owns the Global Fund process?

A major overhaul of Country Coordinating Mechanisms (CCMs) some years ago was stimulated by the realization that government agencies are not the sole representatives of their countries and peoples.  While civil society and non-governmental organizations were expected to play a role in CCMs, they were often ignored and rarely had major roles in deciding on and implementing Global Fund sponsored programs in their countries.  Sometimes the advocacy mentioned by AIDSPAN was prompted by CSOs and NGOs not being heard within their own countries.

AIDSPAN mentions changes that the Global Fund has strongly suggested such as having dual track principle recipients (PRs) representing government and the non-governmental sectors.  While this may have represented a somewhat heavy hand from Geneva, the results sometimes reflected the status quo ante and NGO PRs were often relegated to less well funded aspects of programming such as behavior and social change.

Global Fund recipient countries represent a wide diversity of political systems in various stages of evolution.  It would be naive to expect that country ownership really embodies democratic participation of all stakeholders, public, private and NGO, in decision making and implementing on an equal footing – and no one really believes that is fully possible in at present.  Still it is a long term goal and a principle that should guide funding decisions as much as the quality of the technical content of proposed activities.

In the meantime we can look for additional ways and means to hold countries accountable for their health and social programming decisions. A good example is peer influence from the African Leaders Malaria Alliance (ALMA) which regularly publishes a scorecard of progress toward key health indicators. This freely available score card shows for example, in the first quarter on 2013 only six countries meeting the criteria of good financial management set by the World Bank. In the countdown to 2015, only eight countries are on track in terms of breastfeeding coverage.

As AIDSPAN observes, “But one has to acknowledge that, in the process, the concept of ‘country ownership’ is certainly evolving. Perhaps it will evolve further under the new funding model.” We hope the concept evolves along lines of full and equal partnership among all stakeholders within a country – that all sectors and peoples within a country will truly ‘own’ and thus influence the decision and actions around programs supported through the Global Fund.

UNICEF’s 2013 State of the World’s Children focuses on “Children with Disabilities.”  Some attention is paid to the role of communicable or infectious disease in the cause of disabilities and the need for children with disabilities to benefit from disease control services, just like any other child.

Of particular focus in the realm of infectious disease is recognition that, “… immunization is an important means of pre-empting diseases that lead to disabilities.” The Report goes on to explain for example, that, “More children than ever before are being reached. One consequence has been that the incidence of polio – which can lead to permanent muscle paralysis – fell from more than 350,000 cases in 1988 to 221 cases in 2012.”

Malaria as an infectious disease continues to exert a disabling effect on children in endemic countries. The Report does present a case study of children who spent several years in a residential home for children with mental disabilities in the Republic of Moldova, but it is also important to recognize that malaria and other infectious diseases can lead to such problems.

In reporting on neurological disease in Sub-Saharan Africa, Donald Silberberg and Elly Katabira explained that, “In addition to the hundreds of thousands of children who die each year from cerebral malaria, many more survive (often repeated attacks) and develop sequelae that have yet to be quantified. These include cognitive disorders and epilepsy.”

Likewise Ngoungou and colleagues after studying children with cerebral malaria in Mali found persistent neurological sequelae including, “ headaches, mental retardation, speech delay, bucco-facial dyspraxia, diplegia and frontal syndrome (one case each), dystonia (two cases), epilepsy (five cases) and behavior and attention disorders (15 cases).”

Immunization is of course a major tool in preventing disability, but we also need to examine the role other disease control efforts can play on preventing disability. Also as mentioned in the case of immunization above, we also need to ensure that all children with any kind of disability in a malaria endemic area promptly receive all necessary treatment and preventive interventions.