Tropical Health Matters

The efforts to eliminate guinea worm from Nigeria are coming to a close 28 years after the challenge was taken up at national conference in 1985. At the time there were over 650,000 cases in the country. In just eight years between 1988 and 1995 Nigeria saw a precipitous decline in cases down to 16,374 as seen in the attached map from the Carter Center.

1995 had been posited as the first target date for global guinea worm eradication (see countdown calendar page below), and while efforts came close to eliminating it in Nigeria, the process dragged on for 14 more years until we reached zero annual reported cases. Now there are only a few countries left. The last verifiable case in Nigeria was November 2008. What is the process of ensuring that guinea worm has been eliminated from Nigeria?

A major step over the past few years has been to maintain surveillance since guinea work thrives from neglect.  As Steve Dada from This Day reported, “WHO officials say finding and containing the last remaining cases of the disease is the most difficult stage of the eradication process, because cases usually occur in remote, hard-to-reach areas.” The communities were involved, as evidenced from a radio announcement heard in Jos, Plateau State last Saturday in which people were encouraged to keep looking for the disease.Surveillance efforts have even made use of events like national immunization days to seek out information on possible cases.

As reported recently in the Vanguard, “The Federal government is offering a cash reward of N25,000 (~$160) for every report of authentic new guineaworm cases in any part of the country. In 2011, a N10,000 reward was offered for a similar report.” So far no authentic case has been found, but indigenous beliefs about the disease has meant many false positives over the years, accounting for the many rumors reported by the Vanguard. These efforts are part of the program to prepare Nigeria for a visiting team from the World health Organization in June 2013 to certify elimination.

In preparation for eventual certification of all countries, WHO established in 1995 “an independent International Commission for the Certification of Dracunculiasis Eradication in 1995. The Commission comprises 12 public health experts from all six WHO regions.”  WHO explains that, “A country reporting zero cases over a period of 12 consecutive months is believed to have interrupted transmission of dracunculiasis and is classified as being in the pre-certification stage … After at least three years of pre-certification and consistent reporting of zero indigenous cases, a country becomes eligible for certification.”

What does all this mean for malaria? First, even though we are talking about a process in Nigeria that spanned nearly three decades, this is relatively short.  The characteristics of guinea worm disease (and even small pox, its predecessor in eradication) make it relatively easy to spot. Few people could confuse a worm emerging from one’s body, as seen in the photo from the Carter Center, with another disease. One does not need a microscope either.

We have been reminded recently that malaria parasites can even ‘hide’ at submicroscopic levels without causing any symptoms. Even with malaria symptoms there is easy confusion by the public with other diseases. We are certainly nowhere near the point of offering $100 rewards for detection of malaria cases.

There are a number of other key differences such as a ‘vector’ that stays in the pond for guinea worm, while malaria carrying mosquitoes can fly a few miles.  The key lesson therefore, is the need to adapt elimination efforts and timelines to the realities of each disease.  So while we will not be giving financial rewards for case detection just yet, we should continue to give recognition to Malaria Champions like President Joyce Banda of Malawi.

Another lesson is the fact that WHO established its guinea worm elimination certification process long before all countries were close to reaching goals.  This can help malaria program planners envision the surveillance processes they will need to out in place to eliminate the disease, especially since it will likely be, like guinea worm, hiding in the more remote and poor areas of a country.

Finally we must congratulate Nigeria in its guinea worm elimination success and hope this provides motivation for malaria elimination, too.

The Affordable Medicines Facility malaria (AMFm) was aimed at ensuring high quality low cost medicines reached the public and saved lives.  Nigeria was one of the biggest challenges for AMFm with having the highest burden of disease of any single country.  Unfortunately the vastness of the problem seemed to work against the effort.

Instead of concentrating the resources on a few pilot states of local government areas, as often happens, the project was spread thinly across the nation. There was no way that enough medicine would be provided to treat the large number of cases seen annually in the country. In the states only selected medicine shops received training and supplies. Out-of-stock syndrome was common.

One can find the AMFm logo on empty boxes of medicine as seen in the attached photos from medicine shops.  The shop keepers do find the boxes useful for storing other things, and then resort to selling chloroquine to their customers. When will we learn how to conduct pilot programs so that thy actually produce meaningful results and guide future policy decisions?

The AMFm Evaluation Phase 1 Report acknowledges the following among the many factors hindering the AMFm implementation in Nigeria:

• Delayed approval of ACT orders to FLBs
• Inadequate supply of ACTs
• Unstable supply of ACTs
• High transport costs to rural areas
• Inadequate ACT supply pipelines
• Inadequate distribution of ACTs to rural areas
• Re-indication of chloroquine
• Interrupted ACT supplies nationally
• Availability of chloroquine in market

These were certainly issues that could have been addressed with focus on a smaller and more clearly defined pilot area.

Our second Guest Posting by Erica Kuhlik examines important questions on the relationship between communicable and non-communicable diseases.

Targeting children of primary school age with health education and behavior change interventions is essential in developing countries.  Due to the success of illness prevention programs targeting children under the age of five in developing countries, more children survive longer than ever before.[1]  This is an incredible achievement for public health, but also means there are more older children at risk of illness and death from diseases like malaria.

For instance, one study in Kenya found that despite living through the most vulnerable first five years, children of primary school age still suffered an average of 25 episodes of illness over the 30-week study period.[2]  Our photo shows an application of this idea where members of the malaria club prepare to present their skit about malaria at Jolly Mercy Primary School in Wakiso District.

The result of chronic illness on children is tragic.  Repeated bouts of malaria can cause anemia, increased susceptibility to other diseases, and long-term neurological problems.[3]  Chronic illness also causes children to miss school and reduces their capacity to succeed.[2] The extent of serious illness among children in developing countries makes them prime targets of health interventions.

Such interventions are met with success because children of primary school age are at a stage in their lives when they are both impressionable and beginning to develop new habits.[4]  Children are open to learning healthy habits and behaviors that will help prevent the diseases to which they are vulnerable, like malaria. Additionally, the aforementioned study showed that in 19% of the illness episodes, children were self-treating using herbal remedies and Western medicines.2

These results show that children have the capacity to take responsibility for their health and also suggest that health education programs can target children with information on disease prevention and treatment.  Children can share what they learn as seen in our photo where a student at Nakatunya Primary School in Soroti District displays her malaria message.

Taken together, children represent a population that can be highly vulnerable to disease, in need of health interventions, and in an impressionable stage of their lives, thus allowing for the opportunity to introduce healthy habits and behaviors to reduce their burden of disease.

—–

All pictures were taken by the author with permission from August to October 2012.

• [1] Bundy, D., Shaeffer, S., Jukes, M., Beegle, K., Gillespie, A., Drake, L., Lee, S. F., Hoffman, A., Jones, J., Mitchell, A., Barcelona, D., Camara, B., Golmar, C., Savioli, L., Sembene, M., Takeuchi, T., & Write, C. (2006). School-Based Health and Nutrition Programs. In D. Jamison, J. Breman, A. Measham, G. Alleyne, M. Claeson, D. Evans, P. Jha, A. Mills, & P. Musgrove (Eds.), Disease Control Priorities in Developing Countries (pp. 1091-1108). New York City: Oxford University Press.
• [2] Geissler, P. W., Nokes, K., Prince, R. J., Achieng’ Odhiambo, R., Aagaard-Hansen, J., & Ouma, J. H. (2000). Children and medicines: self-treatment of common illness among Luo schoolchildren in western Kenya. Social Science & Medicine 50, 1771-1783.
• [3] Malaria Consortium
• [4] Harre, N., & Coveney, A. (2000). School-based scalds prevention: reaching children and their families. Health Education Research, 15(2), 191-202.
• For more information see: Kolucki, B., & Lemish, D. (2011). Communicating with Children: Principles and Practices to Nurture, Inspire, Excite, Educate and Heal. UNICEF.

Our Guest Posting by Erica Kuhlik describes a project in which she was involved for the MSPH degree requirements at the Johns Hopkins Bloomberg School of Public Health. STOP Malaria is a USAID funded project managed by JHU’s Center for Communications Programs.

Schools have been found to to be an ideal place for young people to learn about malaria. The Stop Malaria Project (SMP) in Uganda has been using an exciting approach to combat the high prevalence of malaria in rural communities: a school health program that teaches children about malaria and empowers them to act as agents of change in their communities. Previous study in Kenya has shown that school children can learn about malaria and other common diseases and have an influence on their peers and families.

The program uses active and participatory learning techniques to teach children about malaria transmission, infection, diagnosis, treatment, and prevention. Participatory learning methods show children how certain behaviors can reduce malaria and also allow children to practice the behaviors, thereby improving their self-efficacy to perform them.  A “Talking Compound” as seen in the photo is one way to help students learn. In these ways, participatory learning empowers children to adopt the promoted behaviors.

The students are also encouraged to share the malaria messages with their peers and families, effectively acting as change agents in their communities.  By empowering children to act as agents of change, school health programs can reach secondary audiences in the community at little or no cost.   Taken together, the use of active learning methods to teach and encourage children to be agents of change is known as the child-to-child approach.

Despite its recent launch, the Stop Malaria Project’s malaria education program already has significant reach.  In its fourth year alone, SMP reached over 350,000 students across Uganda through thousands of health education sessions using the child-to-child approach (The Uganda Stop Malaria Project Annual Performance Report: 2012 Year 4. Kampala, Uganda).

Discussions with these children have shown them to be highly knowledgeable of SMP’s malaria messages about prevention, diagnosis, and treatment and can demonstrate correct insecticide-treated net use as seen here.  Their teachers have used participatory learning techniques by integrating the malaria information into songs, poetry, drama plays, drawings, and posters.  Some children have even reported behavior change in their households as a result of sharing the malaria messages with their parents.

The experience of the Stop Malaria Project demonstrates that school health programs using the child-to-child approach can be implemented in developing countries.  As we can see, the children have developed their own malaria messages. These programs offer the opportunity to reach vulnerable children and their families with valuable health information to improve the local health conditions.

[All pictures were taken by the author with permission from August to October 2012.]

Smita Das and Douglas E Norris of the Johns Hopkins Bloomberg School of Public Health Department of Molecular Microbiology and Immunology and Johns Hopkins Malaria Research Institute have written our guest blog posting based on a poster they presented at the recent JHU Global Health Day.

As part of the International Centers of Excellence in Malaria Research (ICEMR) in Southern Africa project, mosquito collections are being conducted in Nchelenge District in Luapula Province, Zambia. Nchelenge experiences hyperendemic malaria despite continued implementation of indoor residual spraying (IRS) and long-lasting insecticide nets (LLINs) as control measures.

Center for Disease Control light trap (CDC LT) and pyrethroid spray catch (PSC) collections performed during the wet season in April 2012 revealed the presence of both Anopheles gambiae s.s. and An. funestus s.s. Both species were highly anthropophilic and the Plasmodium falciparum sporozoite infection rate in An. funestus was higher compared to An. gambiae.

In the dry season collections, An. funestus continued to be the dominant species with even fewer An. gambiae caught compared to the wet season.  Due to the abundance of An. funestus and high human malaria infection rates in Nchelenge, it is predicted that the human blood index and entomological inoculation rate for An. funestus is higher than that of An. gambiae in both seasons.

The multiple blood feeding behavior and insecticide resistance status of both malaria vectors will also be explored as this can give us an idea of estimating the transmission potential of these mosquitoes. The vector data in Nchelenge present unique opportunities to further our understanding of malaria transmission and the implications for malaria control in high-risk areas.

While today it technically the sixth World Malaria Day, one should actually trace the origins back 13 years to the first Africa Malaria Day (AMD) in 2001, held to encourage progress based on the Africa malaria Summit in Abuja just one year before.  And since the Abuja summit and its resulting declaration were backed by the Roll Back Malaria Partnership, which formed in 1998, one could say the world has 15 years to considering in judging progress in and plans for partner investments in ridding the world of malaria.

In 2001 organizers of Malaria Day events were encouraged to feature a ‘new’ medicine that WHO said could save 100,000 child healths annually in Africa. artimisinin-based combination therapy (ACT) drugs are now the front line treatment in most all endemic countries, and deaths have declined somewhat on the order of 400,000. At that time there was only one major manufacturer of ACTs. Investments by pharmaceutical companies in generic ACTs now means that there are at least nine companies that produce prequalified ACTs. What is needed is more indigenous African pharmaceutical companies approved to invest in ACT production.

The first AMD stressed the risk of malaria to pregnant women and recommended widespread use of Intermittent Preventive Treatment in pregnancy (IPTp).  This recommendation has been adopted in countries with stable falciparum malaria transmission, but has lagged in terms of implementation, and coverage still lags below the 80% target set at the 2000 Abuja Summit.  There are missed opportunities to provide IPTp at antenatal clinics due to stock-outs, provider attitudes, and client beliefs. Weak health information systems mean that even when services are provided, reporting may not accurately reflect true coverage of IPTp.

In the meantime resistance is growing to sulphadoxine-pyrimethamine (SP), the drug used for IPTp in part due to the inability or unwillingness of country drug authorities to curb its inappropriate use for case management.  WHO now recommends more that the original two IPTp doses and suggests that pregnant women get SP at each ANC visit after quickening.  In the meantime research is underway to find substitutes for SP.

The first AMD addressed the role of insecticide treated nets (ITNs) in helping halve the world’s malaria burden by 2010.  Major progress came in 2008 when the whole United Nations community and of course companies invested in net production got behind universal coverage. In addition the advent of the long lasting insecticide-treated net with insecticide infused in the fabric from point of production pointed the way to success.

These three core interventions – ACTs, IPTp and ITNs – have been strengthened with better diagnostics and a variety of other vector control measures, Hopes for a vaccine still remain a dream, though an achievable one.  While we have high expectations for eradication, we can see that some of the health systems challenges that thwarted the first malaria eradication effort are still with us including weak procurement and supply management, inadequate human resources and gaps in health information systems.

The foregoing implies that we need at least two forms of future investment in malaria. First is investment by governments in strengthening the health system that deliver malaria services. The second investment is in continued biomedical research in order to fend off resistance by mosquitoes and parasites and of course social research to address issues of behavior, adoption of innovations and program management practices. Let’s hope that when World Malaria Day 2014 rolls around, we can measure these increases investments.

The 2015 Millennium Development Goals milestone of reducing malaria morbidity and mortality is sometimes hard to see from here because of the many carts that got ahead of the horses and clogged the road.  We discussed earlier this week about the big push for universal coverage with long lasting insecticide-treated nets that got ahead of thoughts and plans for disposing the net packaging as well as old nets in an environmentally sound way.

Only a few efforts are underway to find a solution to old net disposal. In fact the need to replace LLINs much sooner than expected because of less than desired durability in real life field settings was another cart that surprised some horses and may lead to stock-outs in the next few years as financial sources for nets are not as certain as before.

A classic example ‘carthorsology’ is the roll out of artemisinin-based combination therapy medicines long before appropriate, easy to use diagnostic procedures were in place. Certainly we needed to save lives, but while most endemic African countries replaced first line drugs to which parasites had developed resistance with ACTs between 2005 and 2008, there was no alternative to clinical diagnosis in place.

Hopes that net use and other preventive measures would bring down the demand for ACTs were thwarted when health workers had to rely on their clinical judgment and continued to prescribe the more expensive ACTs presumptively just as they had done for the cheaper chloroquine and sulphadoxine-pyrimethamine. When RDTs finally became more common, there was an uphill battle to convince health workers that their clinical diagnosis was no longer acceptable.

In actuality, RDT supplies are still not matching need – i.e. enough to test all fevers and suspected cases of malaria. So in hindsight we are rushing to invest more heavily in RDTs and health worker diagnostic training and trying to find ways to safely dispose old nets.

Processes like RoapMap planning sponsored by RBM and WHO are certainly moving us in the right direction that views holistically the totality of the malaria intervention package intervention. One wonders though if any other carts lie unforeseen ahead to block our horses.

One example of needed foresight is the development of appropriate strategies for end game pre-elimination and elimination.  In particular are appropriate surveillance systems in place?

Donors, especially the Global Fund seem reluctant to support the challenges of pre-elimination in countries like Swaziland, Namibia, Solomon Islands and others who are on the frontline of the elimination effort.  Fortunately the Clinton Health Initiative is one of those with foresight.  Hopefully we can keep investing in the forward march without additional unforeseen diversions in the RoadMaps.

Karen E. Kirk, a MSPH-Internal Health Candidate at the Johns Hopkins Bloomberg School of Public Health has written this guest posting based on a poster she presented at the School’s Global Health Day earlier this month.

The inability to eliminate malaria in low endemic settings due to importation by infected individuals is considered a potential barrier in the fight to eradicate malaria worldwide.  Individuals living in the rural Choma District, Southern Province, Zambia have seen a dramatic decline in malaria since 2007 with the implementation of malaria control programs that include active case detection; mass distribution of insecticidal treated nets (ITNs); and widespread use of indoor residual spraying (IRS).  However, malaria elimination has still not been achieved in this region of the country.

The first photo shows field staff collecting blood samples from household members to test for malaria parasitemia in Choma District

A household survey was conducted in the Choma District to assess human population movement (HPM) and its association with confirmed or suspected malaria cases of individuals living in the district. The survey looked at travel history of 196 individuals from 42 randomly selected households between December 2012 and March 2013.  It collected data on travel patterns of individuals from the previous 4 weeks who stayed overnight for at least one night outside of their village. In addition, it collected blood sample for the testing of malaria parasitemia.  This survey was included in both the longitudinal and cross-sectional household surveys being conducted by the International Centers of Excellence in Malaria Research (ICEMR).

The second photo shows Field staff conducting malaria community health and HPM survey with mother in Choma District

Of the 196 individuals surveyed there were 97 (49.5%) adults (ages >17), and 99 (51.5%) children (<17).  There were a total of 34 trips taken by 31 (15.8%) individuals, 18 adults and 13 children. The majority of these individuals (59.3%) traveled for 7 days or less and 27 (87.1%) individuals traveled within the Choma District.  No malaria cases were detected in this study and therefore the results of this preliminary data were not able to show an association between HPM and malaria incidence rates.  However, with an increase in data collected over time, trends could be ascertained to determine seasonal patterns with HPM and its impact on malaria incidence rates in this hypoendemic setting.  The hope is that with adequate funding in malaria research with HPM, these types of studies can contribute important information on malaria transmission and help achieve the goal of regional elimination and ultimately eradication of this harmful disease.

[Bill Moss of JHSPH served as Principal Investor of this project]

Clearly no one wants to argue against efforts to curb a deadly disease. The question is whether the approaches to doing so have any negative consequences that can be easily ameliorated.

Vector control gets the most attention. One concern is the plastic bagging in which long-lasting insecticide treated nets are packaged. Rwanda, which has outlawed commercial use of plastic bags for shopping, is taking the LLIN packaging seriously.  The photo shows net packaging that has been removed at a health center and stored for later incineration. Clients take their nets home in paper bags and are encouraged to hang them immediately.

Another net concern is disposal of old, used, damaged nets. LLINs do not have under ‘normal’ conditions the 5-year lifespan originally hoped. Plans for proper disposal are not fully developed in most settings, but the massive distribution of nets to achieve universal coverage from about 2009-12 are about to need replacement. It is possible that some of the net misuse reported in the media is actually repurposing of old nets. More information from communities and local health authorities is needed.

Insecticides for indoor residual spraying usually are the first thought that comes to mind concerning environmental impact of malaria control. While arguments primarily focus on DDT, it is important to note that WHO has approved over a dozen different insecticides for IRS.  The problem is not so much the use of chemicals for actual IRS, but the misuse outside approved spraying programs for farms and fish kills. At present IRS is a highly geographically focused activity in most countries, and control of the activities seems to be working for the large part, but even the process of preparing for and cleaning up after a spraying exercise can results in spills and contamination. Guidelines exist, but are they followed?

Then we get to the issue of medical waste from rapid diagnostic tests.  Some health centers sharps and waste boxes for short term disposal and as pictured here in Burkina Faso, have incinerators tor final disposal.  Community health worker use of RDTs is usually accompanied by sharps and disposal boxes that can be returned to health centers.  All of this needs careful monitoring.

One must even think about packaging of artemisinin-based combination therapy medicines which are prepackaged by age group. These packets are small and are sent home with patients and care-givers. The paper may be burned or composted, but there are also plastic blisters in the packet. This may not account for much on an individual family basis, but on the community level it may be substantial.

Readers may think of other environmental concerns from their own experiences and share success stories for environmental management accompanying malaria control in their countries.  So, as noted, we will not stop malaria control efforts on Earth Day, but at least we can be more conscious of the materials used, whether they can naturally decompose in the environment and thus make some contribution to a healthier planet.

As global financial support for malaria and other disease control efforts has faltered, there is a greater need for national malaria programs to pick up the slack. A look at Nigeria’s national health accounts does show that ‘foreign’ aid does play a relatively small role in health financing and expenditure in this oil-rich country, but ironically it is the common citizen who picks up the bulk of health financing through out-of-pocket expenditures.

The question of local initiative in the move toward elimination of malaria received a severe blow when the Nigerian Senate Committee on Health questioned the need for continued purchases of long lasting insecticide-treated nets (LLINS). The Guardian newspaper reported that the, “Chairman of the committee, Dr. Ifeanyi Okowa, wondered why Nigeria would still continue to cling to the strategy, which he said was not working, when country like Senegal that has manufacturing plants for LLINs was using other effective means to tackle malaria.”

The Senator’s views contrast with those of national experts and the WHO: “While the Minister of State for Health, Dr.Muhammad Ali Pate, said in January that the ministry proposed N1.8 billion for the procurement of LLINs for additional three states, a World Health Organisation (WHO)’s report shows that Nigeria would need one billion dollars (N158 billion) to stave off backsliding and resurgences of malaria in 2013 and 2014.”

It would seem that the Senator was reacting to perceived pressure from the international community to maintain a malaria control strategy that he thought was less effective than indoor residual spraying (IRS).  Of course one of the biggest challenges in disease control advocacy efforts is to educate policy makers. The Director-General of the Nigerian Institute for Medical Research, Prof. Innocent Ujah, tried to do this. He pointed out cultural factors that inhibit net use – and in fact lack of serious community follow-up efforts after massive net distribution over the past 2-3 years, can be traced as one reason why LLINs may have been wasted.

The Senator did not realize that malaria control leading toward elimination needs a multifaceted strategy. IRS can be part, but has its own limitations of which one is expense.  In highly endemic, stable and year-round transmission environments like Nigeria, spraying would be needed twice a year.  We forget that Nigeria has already once tried IRS a few decades ago and abandoned the effort in part due to the huge logistical challenges required.

Nigeria has tried selling LLINs/ITNs through the private sector, but coverage was low since not all Nigerians could or would buy them despite paying disproportionately out-of-pocket for treatment. If the government refuses to fund massive LLIN distribution, then we can expect the burden to fall on the common people who may die from malaria before they purchase a more costly net on the commercial market.