Tropical Health Matters

Today there are two sessions that provide information on Malaria in Pregnancy at the Global Maternal Health Conference holding in Arusha this week. Session topics and speakers are outlined below. These can be followed through the Maternal Health Task Force (MHTF) on Twitter, at the MHTF Website or the Conference Website.

The recently released 2012 World Malaria Report (WMR) brought in to focus both malaria progress as well as the charges in malaria funding for the 104 malaria-endemic countries. Increased rates of coverage with vector control and malaria case management measures has mean that 274 million cases and 1.1 million deaths have been averted between 2001 and 2010. Unfortunately, The WMR observes that, “The enormous progress achieved appears to have slowed recently. International funding for malaria control has leveled off, and is projected to remain substantially below” projected needs.

We are not talking about small amounts of money or minor contributions to date. The WRM reports that, “The past decade has witnessed tremendous expansion in the financing and implementation of malaria control programmes. International disbursements for malaria control rose steeply from less than US$ 100 million in 2000 to US$ 1.71 billion in 2010 and were estimated to be US$ 1.66 billion in 2011 and US$ 1.84 billion in 2012.” This must be put in context with amounts estimated to be needed to achieve universal coverage (including use) of the major prevention and treatment interventions.

The WMR explains that “The enormous progress achieved appears to have slowed recently.” As noted above international funding for malaria control has leveled off, and “is projected to remain substantially below the US$ 5.1 billion” annually required to achieve and maintain universal coverage of malaria interventions. The Roll Back Malaria Partnership has estimated a higher projected annual need. “Resource requirements for global malaria prevention, control and elimination were estimated in the GMAP (Global Malaria Action Plan) to amount to some US$6.1 billion annually between 2012 and 2015.” This figure includes both program management costs as well as research needed to develop new tools.

The link between funding and coverage is clear in the WMR. The number of ITNs procured in 2012 (66 million) is far lower than in 2011 (92 million) and 2010 (145 million). “With the average useful life of ITNs estimated to be 2 to3 years, ITN coverage is expected to decrease if ITNs are not replaced in 2013.” Recent reports from a regional malaria elimination meeting in Kigali show that replacement time may be even shorter, possibly every 18-24 months based on local use and environmental conditions.

When identifying what is happening in malaria financing, it is important to recognize that there are relatively few direct donors. Major international malaria funders accounting for over 90% of donor financing are Global Fund, US President’s Malaria Initiative (PMI), Department for International Development (DfID), World Bank, and AusAid. Others include bilateral assistance, corporate donors and foundations.

The Global Fund as an entity and as the sum of its country contributors shocked the malaria and global health communities in 2011 when it announced the cancellation of its Round 11 of annual funding. The situation was complex and reflected weak financial pledging and inputs as well as internal management issues. The new funding approach was discussed in the WMR.  There are some uncertainties causing concern for the malaria community.

According to the 2012 WMR, “countries will be grouped by the Global Fund into Country Bands based upon a composite score which is a combination of a country’s GNI and its disease burden. Then there will be a “global disease split (i.e. 52% for HIV, 32% for malaria and16% for TB), until a new formula is determined, the Board,” that will be combined with a split according to Bands.  Finally actual allocation decisions will be made by the country coordination mechanisms (CCMs).  Malaria appears to be in greater direct competition with the other two diseases than what obtained in the past.  How other donors will compensate for any country shortfalls is unknown at present.

One possible implication of bands is that there may be less focus on lower burden countries that are heading toward malaria elimination.  Just because disease burden is low, or becomes low due to effective intervention does not mean that funding is not needed. Continued surveillance and case containment activities are not cheap, and require constant vigilance and sustained efforts since not all of one’s neighboring countries are at the same stage of malaria elimination.

Lymphatic filariasis, like malaria, is a mosquito-born disease. Below, Michelle C. Stanton, Moses J. Bockarie and Louise A. Kelly-Hope of the Centre for Neglected Tropical Diseases, Liverpool School of Tropical Medicine, share an abstract of their study on vector control for lymphatic filariasis. Michelle was one of the candidates for the Young Investigators’ Award at the 2012 American Society for Tropical Medicine and Hygiene meeting in Atlanta.

Abstract

Vector control, including the use of bed nets, is recommended as a possible strategy for eliminating lymphatic filariasis (LF) in post-conflict countries such as the Democratic Republic of Congo (DRC).

This study examined the geographical factors that influence community bed net coverage in DRC in order to identify the hard-to-reach areas that need to be better targeted. In particular, urban/rural differences and the influence of population density, proximity to cities and health facilities, plus access to major transport networks were investigated.

Demographic and Health Survey geo-referenced cluster data were used to map the proportion of households with at least one bed net (unspecified), with at least one insecticide-treated net (ITN) and ITNs per person for 300 communities. Spatial statistical methods and bivariate and multiple logistic regression analyses were used to determine significant relationships.

Overall, bed net (30%) and ITN (9%) coverage were very low with significant differences found between urban and rural communities. In rural communities coverage was significantly positively correlated with population density (p<0.01), and negatively with the distance to the two largest cities, Kinshasa or Lubumbashi (p<0.0001). Further, coverage was significant negatively correlated with the distance to primary national roads and railways (all bed net measures), distance to the main river (unspecified only) and the distance to the nearest health facility (ITNs only).

Logistic and Poisson regression models fitted to the rural community data indicated that, after controlling for the effects of the measured covariates, coverage levels in the Bas-Congo province close to Kinshasa were much larger than expected. This was most noticeable when considering ITNs and ITN density which were 5.1 times higher in the Bas-Congo province compared to all other provinces.

These maps and spatial analyses provide key insights into the barriers of bed net coverage, which will help inform both LF and malaria bed net distribution campaigns as part an integrated vector management (IVM) strategy.

The 13th meeting of the RBM HWG is taking place in Dakar, Senegal this week. Some thoughts about the. Current status of malaria programs emerged from member experiences and are shared here.

Since the cancellation of the Global Fund Round 11 may have been denied around one billion dollars annually. If funding does not fully resume until 2014, we could be looking at nearly $3B loss.

In the meantime there is need to help countries spent what remains most efficiently. Effort to secure approval for phase two renewal of existing grants is a priority.

Some countries may have many donor partners but still face problems due to lack of coordination. Problems come when countries do not budget for major activities likely implementation of LLIN (net) campaigns. Procurement and supply management problems persist. Stock-outs are the resulting “disease” but we need to find the root causes.

Not all partners bring funds and commodities, but their input is still important. For example Peace Corps has been making important contributions in advocacy and community education.

When there are funding gaps we need to document the impact. Lives may be lost. Advocacy is needed using country case studies.

As malaria prevalence reduces there is still a possibility of outbreaks, especially in context if cross border situations. Better epidemic response planning is needed with full collaboration of neighboring countries. The challenge is that funding is still country based.

Vigilance is needed to determine how the new Global Fund financing processes will affect malaria prospects.

Issue 204 of the Global Fund Observer explains efforts to clarify funding challenges with the Ugandan malaria grant from the Global Fund. Their posting is shared below to increase access to this information. The financial problems have extended over several years, and GFO provides links to its previous articles on the problem, of which putting money into personal bank accounts was just one example.

… NEWS: Uganda and the Global Fund to strengthen control and financial oversight of anti-malaria programmes: Global Fund insists on refund of ineligible expenses: PR told to stop transfers of malaria programme funds to personal bank accounts

The Global Fund and Uganda’s Ministry of Health are implementing a plan to safeguard Fund disbursements in the country following concerns over possible mismanagement of a $51 million grant to support antimalarial bednet distribution. The principal recipient (PR) for the grant was the Ministry of Finance, but the implementing entity was the Ministry of Health (MOH).

The Fund said in a statement that options to strengthen financial oversight and management to mitigate the risk of fraud are also being discussed.

The statement follows a review by the local fund agent, PriceWaterhouseCoopers Limited Uganda, which was commissioned by the Global Fund. The purpose of the review was to assess part of anti-malaria support programmes which involved the procurement and distribution of over seven million insecticide-treated nets to pregnant women and mothers with young children. As a result of the findings from this review, the Global Fund asked the LFA to expand its review even further.

Meanwhile, Uganda’s MOH carried out an internal audit to verify expenditures and address the internal control weaknesses.

The Fund said in the statement that it instructed the PR to discontinue transfers to individual personal bank accounts of funds intended for programme implementation. The Fund has also warned Uganda that it will seek a refund of all improper payments related to the $51 million grant for supply of anti-malarial bednets, and will insist on appropriate disciplinary action against anyone found to be involved.

Global Fund programmes in Uganda currently provide ARV treatment for 291,000 people and have distributed 7.7 million insecticide treated nets. According to the country’s Malaria Control Strategic Plan, malaria kills between 70,000 and 100,000 people in Uganda annually.

A detailed account of the genesis of the problems facing Global Fund grants in Uganda can be found in GFO issues 90, 103, 113 and 125. [This article was first posted on GFO Live on 21 November 2012.] To comment on this article at the GFO website, click here.

Articles in The Lancet have reminded us of the seriousness of the global problem of preterm births which lead to 1.1 million infant deaths annually and is the second biggest cause of child deaths (those below 5 years old) after pneumonia. With over 11% of the world’s babies being “born too soon“, this is a problem of global magnitude.

Even higher income countries are affected, though in some instances it is a problem of their own making – preterm elective caesarian operations, multiple ovaries in assisted reproduction. Specifically for low/middle income and tropical countries the following was observed: “There are other preventive interventions, ranging from birth spacing to treating maternal infection, notably malaria, HIV, and syphilis, or improving nutrition, which are highly relevant for low-income and middle income countries.”

In her review of malaria in pregnancy Ruth Lagerberg observed that, “Adverse consequences of malarial infection during pregnancy include an increased risk of spontaneous abortion, preterm delivery, LBW, a two-fold increase in the risk for stillbirth regardless of parity, and congenital infection.”

WHO notes important malaria preventive measures that are supposed to be part of routine antenatal care in malaria endemic countries including at least two doses of intermittent presumptive treatment during pregnancy for malaria (IPTp) and the use of bednets and calls for continued research on the effectiveness of these interventions in reducing preterm birth. Fortunately data have been amassed over the years on this very topic.

A recent study in Mali demonstrated that 3 doses of IPTp during pregnancy cut the rates of low birth weight and prematurity in half. In Nigeria IPTp was found to be effective in preventing preterm delivery and low birth weight among pregnant women. In Gabon there was a marked benefit on the prevalence of low birth weight and premature birth for women adhering to national recommendations for IPTp.

Continued research has led WHO to recently recommended increase in the number of doses of IPTp in moderate to high endemic countries to receiving a dose at each ANC visit after quickening.

Malaria treatment should also be in the mix of antenatal interventions. Access to early diagnosis and treatment of malaria among refugees along the Thai-Burmese border was found to be a factor in decreasing low birth weight and prematurity.

The argument has always been made that since most pregnant women in malaria endemic areas of Africa attend antenatal care, it should be possible to reach them with malaria prevention and treatment interventions. Unfortunately coverage of malaria control measures for pregnant women remains low showing that health systems are not working for pregnant women. Greater priority is therefore needed on this neglected portion of the population at risk from malaria.

We are nowhere near eradicating malaria with hundreds of thousands of cases annually throughout the world.  It reappears in Greece, and in subclinical form stymies surveillance efforts in the Solomon Islands. But eventually we will close in on this parasite. What can we learn from eradication efforts of another scourge, polio?

Recently the Express Tribune published an article that provided some shock not only in Pakistan, where the issue was detected, but throughout the polio eradication community. “The Prime Minister’s polio cell, the World Health Organisation (WHO), and the United Nations Children’s Fund (UNICEF) confirmed … a newly-found strain of the polio virus.”

The technical reason for the new stain was explained by the international health agencies: cVDPV cases that cause type 2 poliovirus mutate and attain a form that can cause paralysis after passing through multiple children in environments with substandard sanitation. Fortunately polio associated with vaccines is extremely rare, but a more damning administrative explanation of why this may have happened in Pakistan is “poor routine immunization coverage” that enabled these mutations to occur.

Administrative problems include poor scheduling of the current immunization round during a sacred religious period resulted in four districts not participating, but on top of this was a more pressing problem,  “the global shortage of the oral polio vaccines especially as anti-polio campaigns are increasing .” This calls into question the upcoming second round of immunization in December. The problem is persistent since it was reported earlier this year that,  “Polio coverage (in Pakistan) remained sub-optimal during the past year in Islamabad, as revealed by an independent evaluation report on the post-polio campaign conducted by the World Health Organization.”

Four endemic countries remain as seen in the graph, and Pakistan’s performance to date is actually better than some of the others, but the situation is volatile, as is the civil/political situation in the remaining affected countries. Interestingly, another eradication-targeted disease, Guinea Worm, was down to 1058 cases in 2011 and remains in only 4 countries, but this is 17 years after the initial date set for its eradication.

Polio and Guinea Worm offer malaria some lessons for the present in countries approaching pre-elimination now and those who will hopefully join them over the next decade (if global funding levels are maintained). One lessons is that surveillance is an active part of current polio eradication efforts, otherwise these reports on progress and its challenges would not be published. But the key lesson is that regardless of the effectiveness of the technical intervention (e.g. a vaccine), deployment of the technical intervention is subject to human, administrative, managerial and social complications.

Polio focuses on a vaccine; malaria has treatment medicines, preventive medicines, insecticide sprays, treated bednets, diagnostic tests, and maybe also one day an effective vaccine.  It is not too early to plan on how to coordinate all this into achieving effective disease elimination, nationally, regionally and globally.

Oladele Olagundoye MD, MPH, an Atlas Corps Fellow at the Corporate Alliance for Malaria in Africa (CAMA), GBCHealth, New York, provides a perspective on the recently concluded Neglected Tropical Diseases meeting in Washington….

The Neglected Tropical Diseases (NTDs) community convened at the World Bank for a 2-day conference tagged “Uniting to Combat NTDs: Translating the London Declaration into Action” on November 17 – 18, 2012 in Washington DC. The objective was to provide a forum where all stakeholders in the fight against NTDs can identify the priorities, discuss the challenges and suggest strategies towards achieving the World Health Organization’s (WHO) targets to control and eliminate at least 10 NTDs by 2020.

Leveraging on the London Declaration of January 30, 2012 by leading pharmaceutical companies, donor agencies and non-governmental organizations (NGOs), to supply the drugs required for preventive chemotherapy (PCT) and the treatment of NTDs, the participants identified three priority areas necessary for the actualization of the WHO’s 2020 targets:

1. Bridging the estimated $US 4.7 billion funding gap by sustaining international commitments and increased domestic funding for NTDs by endemic country governments.
2. Building the human resource capacity and health infrastructure at the country-level to effectively absorb the increased supply of drugs, and for the scale-up of delivery services.
3. Effective integration of intervention programs and incorporation of water and sanitation interventions (WASH), to complement the mass drug administration, and intensified disease management of NTDs.

It was encouraged that Malaria & NTDs (Lymphatic Filariasis & Dengue fever) programs should integrate their services, because the scale-up of vector control interventions (LLINs) will benefit the populations served by both programs. However, a critical barrier limiting this collaboration is the suspicion by malaria programs that NTDs managers intend to leverage on the availability of more funding for malaria programs, to achieve specific NTDs targets.

I recommend that program managers for malaria and NTDs (LF & Dengue fever) should adopt the partnerships and four One’s approach, which has contributed greatly to the success of WHO’s African Program for Onchocerciasis Control (APOC) –

• 1 collaboration mechanism
• 1 budget
• 1 package of interventions and
• 1 monitoring and evaluation framework

The Corporate Alliance on Malaria in Africa announces a Member Meeting that will take place on December 3, 2012 from 10 am – 4 pm in Houston, Texas. They have shared their invitation with us to let interested colleagues know how to take part.

The Corporate Alliance on Malaria in Africa (CAMA) is a unique coalition of companies that share a vision to reduce the incidence of malaria by promoting private sector cooperation in sub-Saharan Africa. Founded by Marathon Oil in 2007, CAMA serves as a platform for private sector collaboration with country governments and other major stakeholders in the global response against malaria.

CAMA’s three principal objectives include –

1. building country-level capacity for effective malaria control and its eventual elimination;
2. providing a forum to exchange knowledge and current best practices in malaria control; and
3. facilitating the establishment of effective multi-sector partnerships to increase the scale and impact of malaria control interventions.

GBCHealth is the implementing partner and secretariat of CAMA.A special Member Meeting will be held Monday, December 3, 2012, in Houston, Texas, to discuss the accomplishments of the past year and to develop the CAMA engagement strategy for 2013. As CAMA transitions into a fully integrated GBCHealth flagship initiative, this CAMA member meeting will be open to all current and prospective GBCHealth members interested in contributing to global malaria efforts.

The meeting will cover the importance of social and behavioral change programs for controlling malaria at the country level and provide a great networking opportunity for companies to meet key malaria stakeholders from academia, business and non-profits.

RSVP by clicking this link.

A Poster Presentation at the 61st Annual Meeting of the American Society of Tropical Medicine and Hygiene, 11-15 November 2012, Atlanta.
Bright C. Orji1, William R. Brieger2, Emmanuel Otolorin1, Nancy Ali1, Jones Nwadike3 – 1Jhpiego/JHU, Baltimore, MD, United States, 2The Johns Hopkins University, Baltimore, MD, United States, 3Dunamis Diagnostic Services, Lagos, Nigeria

Current efforts to reduce burden of uncomplicated malaria among children under-five years old in low income countries is undermined by presumptive treatment of the disease. Proper and early diagnosis of malaria using Rapid Diagnostic Tests (RDTs) in integrated case management may restrict inappropriate use of anti-malarial medicines to children.

This observational study documented diagnostic and treatment patterns for febrile illness management in local government clinics in Akwa Ibom State, Nigeria before and after introduction of RDTs. Audit of outpatient client records before and after RDT introduction was conducted in six primary health care facilities in two Local Government Areas, Onna and Ibeno by three trained nurses.

A total of 1003 children presented with fever prior to RDT introduction, and 90.3% were presumptively treated with anti-malarial medicines; 66.1% also received antibiotics. After the introduction RDTs, records of 800 children who presented with fever were reviewed and 90.9% were tested using RDTs with 41.5% of 720 being confirmed cases of malaria. Of children with positive RDTs results 95.6 received anti-malarial medicines. Among those with RDTs negative results 22.9% received anti-malarial medicines while 88.7% got antibiotics.

The study supports the use of RDTs for febrile illness testing to aid adherence of health workers to integrated child treatment protocols. Though there is still a gap in prescribing behavior, this can be corrected through supervision and ongoing performance quality tools.