Tropical Health Matters

Intermittent preventive treatment for pregnant women (IPTp) with sulfadoxine-pyrimethamine (SP) remains a powerful tool against malaria in countries with moderate to high stable malaria transmission. Yet there has been confusion, lapses and very poor coverage with this intervention with little progress toward the Roll back malaria target of 80% coverage with two doses during pregnancy.  WHO has recently revisited this strategy and has issued revised recommendations reproduced fully below. Importantly, these also address some of the myths about IPTp with SP. Please share these widely with program managers and health workers.

——————

Updated WHO Policy Recommendation (October 2012) on Intermittent Preventive Treatment of malaria in pregnancy using Sulfadoxine- Pyrimethamine (IPTp-SP)

During the last few years, WHO has observed a slowing of efforts to scale-up intermittent preventive treatment of pregnant women (IPTp) for malaria with Sulfadoxine- Pyrimethamine (SP) in a number of countries in Africa. While there are several reasons for this, confusion among health workers about SP administration for IPTp may also be playing a role. For this  reason, WHO is clarifying its  recommendations, and urging national health authorities to disseminate these recommendations widely and ensure their correct application.

In several countries in Africa, some Plasmodium falciparum parasites carry quintuple mutations linked to SP resistance which are associated with in vivo therapeutic failure to SP. IPTp  with  SP  remains  effective in preventing the adverse  consequences  of malaria on maternal and fetal outcomes in areas where a high proportion of Plasmodium falciparum parasites  carry these  quintuple  mutations [1].  Therefore,   IPTp  with  SP  should  still  be administered to women in such areas.

All possible efforts should be made to increase  access to IPTp with SP  in all areas with moderate-to-high transmission in Africa, as part of antenatal care services. Based on new evidence the following updated recommendations are provided.

In areas of moderate-to-high malaria transmission, IPTp with SP is recommended  for all pregnant women at each scheduled antenatal care visit. WHO recommends a schedule of four antenatal care visits.

• The first IPTp-SP dose should be administered as early as possible during the 2nd trimester [2] of gestation
• Each SP dose should be given at least 1 month apart
• The last dose of IPTp with SP can be administered up to the time of delivery, without safety concerns
• IPTp should ideally be administered as directly observed therapy (DOT)
• SP can be given either on an empty stomach or with food
• Folic acid at a daily dose equal or above 5 mg should not be given together with SP as this counteracts its efficacy as an antimalarial [3]
• SP should not be administered to women receiving cotrimoxazole prophylaxis

In some countries where IPTp with SP is currently being implemented, transmission of malaria has been reduced substantially.  In the absence of information on the level of malaria transmission  below which IPTp-SP is no longer cost-effective,  such countries should not stop IPTp. [4]

There is currently insufficient evidence to support a general recommendation for the use of IPTp-SP outside Africa.

Monitoring of IPTp-SP effectiveness and safety of multiple doses is essential and should continue. Research is ongoing to define the best methodology for such monitoring; this will be shared when available.

Footnotes:

[1] The findings  of an observational  study  in Tanzanian women in an area with high levels of quintuple mutation strongly associated with drug resistance and where the parasite  dhps resistance mutation of codon 581 was also present showed increased placental  parasite  density  and inflammatory changes  in women reporting IPTp with SP  use. This needs  further investigation although it is important to note that this specific dhps resistance mutation is currently not common.

[2] IPTp administration should be avoided during the 1st  trimester of gestation but should start as soon as possible in the 2nd trimester.  The fact that a woman has entered the second trimester  can be determined  by the onset of quickening or by measurement of fundal height by ANC health personnel.

[3] WHO recommends daily iron and folic acid supplementation in pregnant women at the dose of 30-60 mg of elemental iron and 0.4 mg of folic acid, to reduce the risk of low birth weight infants, maternal anaemia and iron deficiency at term.

[4] Cost-effectiveness modelling studies are ongoing to address this question. Risk-benefit of SP administration needs also to be taken into account when considering recommendations on IPTp implementation.

Emmanuel Fiagby of the VOICES for a Malaria-Free Future in Ghana shares a recent workshop of the Ghana Revenue Authority at Kpetoe, Volta Region, Ghana. Below are his experiences.

The Ghana Revenue Authority has made a giant stride in the implementation of its Employee Wellbeing Program (EWP) by initiating a program which will result in the development and implementation of a Malaria Control Strategy and Program of Action for the Authority. A total of 45 officials of the GRA mostly EWP Focal Persons participated in the program.

Launching the program at the Customs Excise and Preventive Services (CEPS) Academy here, the Commissioner General of the  GRA Mr. George Blankson stated that the GRA has since its establishment shown tremendous commitment towards the welfare, health and wellbeing of its staff who are its most valued asset and therefore finds the theme for its Malaria Control strategy development exercise, “Turning Revenue Makers in to Malaria champions; a true demonstration of corporate social responsibility,” an apt reflection of what the GRA stands for.

Mr. Blankson emphasized that, the aim of the GRA in setting up its EWP of which malaria is becoming a key component is to set the pace as a leading healthy workplace in Ghana where staff and management work together to protect and promote the health, safety and wellbeing of its over 7,000 staff and almost 30,000 community members on a sustainable basis. “Today we stand at the threshold of expanding the frontiers of the Employee Wellbeing Program (EWP) to encompass malaria control programs for our staff and the wider community which GRA serves. I am extremely certain that this effort will lead to the total obliteration of the 25% absenteeism of our workforce attributed to malaria and the random deaths this disease wrecks on our institution,” the Commissioner General reiterated. He called on all officers selected to lead the malaria program and noted that by becoming champions for malaria control, they will be “contributing to sustaining a stronger workforce, a stronger community and therefore a more productive and taxpaying community.”

In her key note remarks, Dr. Kezia Malm, Deputy Manager of the National Malaria Control Program (NMCP) stressed that Ghana has made tremendous progress in the fight against malaria and it’s only through the collaborative efforts of parastatal institutions such as the GRA and others that the country would be able to sustain the gains. “Our journey to eliminating malaria can only end successfully if the support of every sector of our development effort – the public sector, private sector, NGOs, and the donor community is sustained,” she concluded.

The two day GRA Malaria Control Strategy development and action plan development program was organized by the Johns Hopkins University Center for Communication Programs Voices Project in collaboration with the Ghana Revenue Authority and the National Malaria Control Program. In setting the stage for the program, the Country Director of the Voices for a Malaria-free Future Project, Mr. Emmanuel Fiagbey pointed out that the GRA, a non-health institution becoming a champion for malaria control should be an effort worth emulating by other powerful parastatal institutions. “That the ‘Revenue Makers’ our tax officials have become malaria advocates and mentors for their colleagues should not only result in preserving the health of the GRA Workforce against malaria, it must also lead to speedy action on malaria commodities and their documentation that come to the tables of the tax officials in the course of their work,” Mr. Fiagbey emphasized.

The Ghana Revenue Authority is a major parastatal institution in Ghana made up of the Customs Excise and Preventive Service, the Internal Revenue Service and the VAT Service. Fifteen senior officers of the Authority including Mr. K. E. Enyimayew the Deputy Commissioner HR, Deputy Directors of the three arms of the Authority, Service Commanders/Commissioners and the Director of the CEPS Academy also participated in the opening activities of the program.

Malaria is often a major cause of absenteeism – either for the sick worker or the worker who has to stay home with a sick child or relative.  The GRA sets a great example how malaria training for members of the workforce can improve occupational, family and community health.

Preliminary results of the Tanzania indicator survey for HIV and Malaria have been released. This makes it possible to track over time some of the basic indicators for success in malaria programming using various Demographic and Health as well as Malaria Indicator Surveys.  The trends recall concerns of more than a decade ago when USAID organized the Malaria Action Coalition to address the relative ‘neglect’ in malaria case management and malaria in pregnancy program components.  At least in Tanzania, ten years on, the problem persists.

We can see clear progress in insecticide treated net use by vulnerable populations over time. The push for universal coverage since 2009 seems to have paid off in Tanzania.  We hope this victory is sustainable, but more and more we are receiving reports that the duration of the long lasting aspect of LLINs is far from the hoped for 5 years.  Eighteen months is more realistic.

So after a major campaign to achieve the targets seen in the attached figure we have to ask whether Tanzania is positioned to do massive replacement, either through routine services like immunization programs and antenatal care, over the next several years.

A depressing finding is the last of progress in intermittent preventive treatment for pregnant women as seen below.

• 2008 – 30%
• 2010 – 26%
• 2012 – 32%

Reports over the years have singled out procurement and supply problems arising after Tanzania switched from sulphadoxine-pyrimethamin (SP) to ACTs as its first line antimalarial drug. SP fell off the radar in many places.  One wonders also what this says about Tanzania’s overall commitment to maternal health.

Case management is similarly in the doldrums. This is ironic because Tanzania was one of the beneficiaries of the Affordable Medicines Facility malaria (AMFm) pilot effort that was generally credited with enhancing access to quality malaria drugs.  Tanzania has also pioneered an accredited drug outlet program aimed at upgrading the quality of the typical patent medicine shop.

As is often the case, much soul searching is needed to look at the health systems – especially those delivering child health and maternal health services – to find the bottlenecks to this problem.  Neighboring countries like Rwanda that want to move toward pre-elimination will find it difficult if their neighbors fall behind in implementing the basic malaria interventions.

Recently Matt Lynch of the Johns Hopkins Center for Communications Programs and the USAID NetWorks Project was asked about the challenges of disposing old ITNs. His response has been shared on Malaria Update, but we thought readers on Malaria Matters, who are not Update subscribers, could also learn from Matt’s Ideas. Matt urges that each country and community needs to find its own economic and ecological solutions as seen below.

————————————-
I would urge a careful look at all the options (including leaving the nets in the households) before leaping into actions which may end up with worse consequences than no action at all.

Much that I have heard on this topic begins with the assumption that nets must be collected – this is not necessarily true, and no one has been able to adequately describe to me exactly what the problem of leaving the used nets for households to re-purpose might be.  They are, on the other hand, very ready to describe the massive costs associated with collecting the nets, and the problems which will follow from concentrating enough old nets in one spot to actually have insecticide and plastic concentrations which do become quantifiable problems.

As far as I can tell from asking the manufacturers, most pyrethroids decay when exposed to UV light, and are broken down by soil bacteria.  This is why pyrethroids are so popular in agriculture – they don’t persist in the environment.  They are apparently quite toxic to fish, so that’s worth exploring in the island environments.  Dumping them into the sea is probably not a great idea.

In Africa, one frequently sees old, holed nets being used to cover plants, chicken coops, or to screen windows.  Such uses, as far as I can tell, do no harm and probably some good (who knows, the residual insecticide may help control chicken mites?).  In addition, they provide an opportunity for the UV light and soil bacteria to begin breaking down the insecticides.

One might expect polyethylene nets to pose more of a problem in terms of solid waste, but I have not seen any reports of drains being blocked by old bednets (plastic bags, frequently!).  Polyester nets are even more difficult to imagine as a serious solid waste problem – after all, there were millions of pretty toxic-looking polyester leisure suits sold in Africa through the 1980’s and no one seems concerned about their disposal…

So, I don’t mean to trivialize the issue;  I think we need a clear description of precisely what the problem is with letting households dispose of their worn-out nets through their usual practices.  There may well be harmful disposal practices that need to be addressed, but I do think we need a clear description of the problem before we rush into complicated, expensive and potentially hazardous “solutions”.   I personally doubt the optimal solution will be to collect the nets.

The First Rwanda Malaria Forum was organized by the National Malaria Programme from the 26th to 28th September 2012 in Kigali Rwanda. The aim of the Forum was to recommend actions that Rwanda should take to accelerate the attainment of zero malaria deaths. The forum brought together experts from Rwanda, East Africa, Southern Africa, the United States of America and Europe. WHO was prominently represented by the Director Disease Prevention and Control on behalf of the Regional Director WHO AFRO.

The Forum recognized the remarkable progress Rwanda has made in reducing malaria morbidity and mortality and recommended that by 2017 Rwanda should aim to achieve zero deaths due to malaria and achieve pre-elimination status. The following were the key recommendations:

A) Maintain the remarkable achievements and further reduce malaria morbidity to pre-elimination levels countrywide

• Increase funding to the fight against malaria (domestic and external)
• Achieve 90% coverage of the population at risk of malaria with locally appropriate vector control interventions based on evidence
• Improve malaria case diagnostics to 100% and treatment at all levels including the private sector.
• Develop a comprehensive advocacy, communication and social mobilization aimed at shifting the understanding of malaria pre-elimination by the leadership and other policy makers, the community and all levels of the health system.
• Develop capacity for malaria pre-elimination including in entomology and epidemiology
• Conduct operational research to support programme implementation and robust documentation of the process

B) Achieve zero malaria deaths by 2017

• Strengthen prompt access to treatment of severe malaria
• Conduct malaria death audits for all cases

C) Investigate and classify all cases and foci in low endemic districts

• Gradually, strengthen epidemiological, entomological and therapeutic surveillance
• Strengthen malaria stratification for local and eventually imported malaria cases
• Further strengthen the health system in readiness for pre-elimination using the WHO 6 pillars
• Strengthen an integrated quality assurance and control system for diagnosis and treatment of malaria cases.

D) Develop and strengthen local and international collaborative and partnership initiatives to accelerate malaria control and pre-elimination in Rwanda and the region.

• Strengthen linkages with other players in the health non-health sectors within the country
• Create a multi-sectoral malaria pre-elimination group
• Develop, with other East African Countries, a cross border strategy to accelerate malaria control and pre-elimination in the region

A key focus of the recently completed First Rwanda Malaria Forum was on cross-border initiatives to help eliminate malaria.  The two most malaria-endemic districts in Rwanda are situated at borders with other malaria endemic countries. Nyagatare borders Uganda and Tanzania, while Gisagara borders Tanzania and Burundi.  The Democratic Republic of Congo, which has some of the highest malaria burden in the world, shares a long border with Rwanda, too.

The Working Group on Cross Border Planning and Initiatives consisted of Nancy Mock (Tulane), Charles Paluku, Okui Albert Peter (Uganda), James Banda (WHO/GMP), Carol Asiimwe, Harriet Pasquale  (South Sudan), Simon Kunene  (Swaziland), Dorothy Memusi (Kenya), Corine Karema (Rwanda), Felicien Ndayizeye (Burundi), Patrick Moonasar ( Rapporteur), Georges A. Ki-Zerbo (WHO/AFRO).  Their overall strategic considerations are found in the table below.

Key action points focused on defining the problem and drafting a concept paper. Defining the problem would require Two meetings with all 5 countries supported by RBM’s East Africa Regional Network (EARN)Earn Support. The first meeting would focus on a conducting situational analysis and drafting of framework for data collection (before 15 December 2012). The second meeting would bring evidence based on Framework for collaboration in moving towards malaria elimination and a draft concept paper (March 2013).

The draft a concept paper would cover the following key issues:

• Disease burden in all neighboring districts
• Coverage target in all neighboring countries  and other factors e.g. demographic and social factors.
• Rational for initiative
• Objectives
• Activities
• Budget
• Coordination mechanism
• Recommendations
• Action plan

Facilitators for this effort should be WHO and EARN. Because of Swaziland’s experience with such cross-border efforts the working group identified its National Malaria Control Program Director, Simon Kunene, as an expert who could provide technical assistance.

In summary key recommendations arising from the Working Group deliberations include:

• A cross border initiative meeting including target district leaders
• WHO/EARN to provide oversight TA, invite target NMCP managers and District Health Management Teams
• Each country shall initiate internal discussions on cross border initiatives
• Each member country to ensure inclusion of Cross-Border initiatives into national strategic plans and share data collection tool at country meetings

A second working group at the recently completed First Rwanda Malaria Forum examined issues around “Malaria Prevention and Vector Control.” A key message from the Forum was the need to protect existing vector control technologies (IRS and LLINs) and well as develop and test new ones in the local setting. These can be deployed in a focused manner as better entomological and epidemiological data are available on district, sub-district and cross-border areas.

Members of the group included – Hakizimana Emmanuel, MOPDD-Rwanda; Abraham Mnzava, WHO/HQ; Beata Nukorugwiro, JHPIEGO; Cait Unites, PSI; Beatus Cyubahiro, RBC-MOPDD; Dunia Mwuyakango, RBC-MOPDD; David Wainaina, Bayer; Arielle Mancuso, PMI/RFHP; Moses Turyazooka, CREST Technologies; Richmond Ato Selby, Networks; Christine Ochieng, Vestergaard Frandsen; Tessa  Knox, Vestergaard Frandsen; Levin Nsabiyumva, USAID/Burundi; Kagabo Jean Bosco, World Vision Rwanda; Athanase Munyaneza, RBC/KFHIK; Duschuze Clemence, RBC/MOPDD; Sangala Freddy, Nyagatare Hospital; John Githure, MOPDD/RBC; Francisco Saute, USAID/PMI

The group suggested the following Strategic Objectives to be achieved by or before 2017 …

1. Generate local evidence to guide optimization and diversification of available vector control interventions
2. Build sustainable capacity for entomological  monitoring and vector control at national, district and community levels
3. Formulate policies and procedures for effective and sustainable mobilization of vector control activities
4. 90% of the population at risk of malaria will have access to locally appropriate vector control  interventions based on evidence
5. Establish harmonized mechanism for cross border collaboration on vector control interventions

Key Actions For Strategy 1:

• Establish a national entomological profile (vector ecology and behavior, species composition and distribution, susceptibility to insecticides)
• Re-enforce and expand entomological  surveillance sentinel sites
• Determine the appropriateness of vector control interventions – including new tools
• Conduct operational research on the effectiveness of vector control interventions

Key Actions for Strategy 2:

• Recruit and train entomologists for deployment at district level for vector control interventions and entomological surveillance
• Strengthen and expand field lab/insectary facilities for entomological monitoring at sentinel sites
• Collaborate with the existing Dept. of Environmental Health at the KHI to include medical entomology programme
• Empower the communities through training on vector control

Key Actions for Strategy 3:

• Develop insecticide resistance management plan
• Establish regulatory processes to support timely deployment of existing and new tools as they become available
• Develop a transition plan for decentralization of vector control activities
• Re-orient IEC/BCC strategy to better support pre-elimination efforts
• Evaluate human and other factors influencing the effective lifespan and acceptability of vector control tools

Key Actions for Strategy 4:

• Maintain universal coverage with LLINs in the population at  risk
• Rational deployment of IRS in prioritized risk areas
• Evidence-based deployment of other supplementary vector control interventions (e.g. repellents, screening, LSM) where appropriate

Recommendations

• Establish a national inter-sectoral steering coordination mechanism for planning and implementation of  integrated vector management (IVM)
• Enhance entomological capacity in moving towards pre-elimination phase
• Integrate vector control within district development plans and operational targets
• Long term financial commitment of Government of Rwanda and development partners is essential to achieve and sustain the gains in malaria prevention

Rwanda’s First Malaria Forum has just concluded in Kigali, producing recommendations to help the country, which is already experiencing very low levels of malaria transmission, develop strategies for the path to malaria elimination. After a series of informative talks other countries in the region and international support organizations, working groups distilled the learning from the forum into suggestions for strategic planning. Below we present the deliberations of the Working Group on Surveillance, Monitoring and Evaluation. Group members included Irenee Umulisa, J. Bosco Ahoranayezu, John MacArthur, Arielle Mancuso, Aafje Rietveld, Eric Tongren, Anna Winters.

Preamble: A paradigm change is necessary within the national malaria surveillance system in order to take Rwanda from the stage of malaria control to pre-elimination. Stratification (epidemiological, entomological and environmental) will be used as the basis for applying different programme approaches in the different parts in the country, including surveillance approaches. In high burden strata, the quality of malaria control surveillance will be optimized. In low endemic strata, WHO recommended elimination surveillance approaches will be piloted and gradually introduced to field-try forms & procedures and build systems capacity.

Goals and Vision: By 2017, every febrile patient on the Rwandan territory will visit a health facility within 48 hours for diagnosis and treatment. Under 5s will be treated at community level within 24 hours. A microscopy and RDT quality assurance system (including external quality control) will be in place, ensuring reliable diagnosis at all diagnostic facilities. Every malaria case diagnosed with RDT and treated at community level will be reported to the health center level within 24 hours, accompanied by a microscopy slide for confirmation of diagnosis.

All malaria cases will be reported into one centralized HMIS, irrespective of the health providers who diagnosed and treated them (public, private, community, army, etc.) and irrespective of the way they were detected (ACD, PCD, surveys).

Health centers in low and moderate malaria burden strata will carry out “enhanced malaria surveillance” allowing foci investigation and classification. Health centers in endemic areas will forward line-listings of patients (ideally also with information about recent travel) to the district level with copy to the central level on weekly basis. Central level will compile from these data weekly updated mapping by village level and track cases against epidemic thresholds.

Strategic objectives and action points:

By 2012, update the stratification map of Rwanda’s malaria burden by including data from HMIS, SIS-COM and any other sources of malaria patient data that may be available. The objective is to be all-inclusive: in malaria elimination every case counts. A more in-depth stratification using entomological and environmental variables and intervention coverage will follow.

• Merge SIS-COM (community) data collection with existing HMI
• Use the map to identify 3-4 zones for stratification of surveillance and intervention methods based upon malaria burden.

By 2013, develop/update the surveillance plan to direct the MOH malaria surveillance strategies over the coming 5 years within the changing epidemiological settings, with a view to (a) attain malaria pre-elimination programme status in low and moderate burden strata by 2017; and (b) maintain and improve upon the current control achievements in higher burden strata.

• Improve and coordinate data management and timeliness.
• Include a plan for human resources necessary to undertake enhanced surveillance.
• Include a timeline to achieve strategic objectives and action points.

By 2014, set up the systems to enable and ensure that all suspected malaria cases (100%) are diagnostically confirmed using available tools and in a timely fashion within both public and private clinics.

• Develop (guided by OR) for each strata a clear case definition of a suspected malaria case who should be tested, ranging from a broad definition (fever) in highly endemic areas to a more restricted definition (perhaps including a travel history or additional symptoms) in low endemic areas. Communicate these definitions to all health care providers and the public in the various strata. The purpose is to ensure that every potential malaria case is promptly tested, without unduly overburdening the health workers in low endemic areas.
• Monitor the use of antimalarials by various health facilities against the numbers of cases diagnosed and reported.

By 2015, pilot “enhanced malaria surveillance” in 1-3 low endemic districts

• In low and moderate burden areas, begin line listing all confirmed malaria cases including travel history and household location with the goal to map cases (2015-2017). Focus initial line listing and case mapping within Kigali or another accessible low burden district (2013).
• By 2014, engage the private sector physicians in Kigali for cooperation in malaria surveillance activities (working with the Rwanda medical association). Enforce full cooperation of the private sector by 2017. Restrict availability of antimalarial medicines to registered facilities with access to diagnostic capacity.
• In low and moderate burden areas, begin collecting weekly malaria data at the health facility level.
• Gradually include immediate notification and due programme follow up (investigation, classification) of cases detected, starting with one district where this seems doable.
• Explore business/private coalitions to support a longer term vision of a malaria-free Kigali / tourism areas.

By 2015, pilot line listing in one endemic district, increasing to all endemic districts by 2017

• Integrate training and data management into existing community health worker programs.
• Develop and deploy a system for active case detection (ACD) as part of case investigation at the community level.
• Map all confirmed cases which are passively and actively detected.
• Develop epidemic thresholds for comparison against weekly case loads.

By 2013, review and start to address the factors that contribute to malaria mortality in Rwanda.

• Conduct death audits for all reported malaria cases that occurred in 2012. The purpose is to identify risk factors for delays in treatment / inadequate treatment that can be addressed by NMCP programme interventions. Use this study to strengthen collaboration of the NMCP with the national school of public health (or equivalent) by engaging a team of university students / scientists in the study.
• Explore possibilities for increasing the use of pre-referral treatment with rectal artesunate, based on an understanding of the barriers and behaviours for accessing pre-referral treatment.
• By 2015, carry out death audits for all reported malaria deaths as they occur, to adjust and target programme interventions.

Continue drug and insecticide resistance monitoring to guide drug and insecticide policies.

Recommendations:

• By 2014, initiate “enhanced malaria surveillance” following WHO recommended strategies for the elimination phase in 1 low endemic district, increasing to 3 districts by 2015 and all low-endemic districts by 2017. This includes investigation, classification and mapping of cases and transmission foci.
• By 2015, institute line listing in one endemic district, increasing to all endemic districts by 2017.
• Encourage and facilitate information sharing among all partners in malaria control.
• Use available resources in a manner that allows continued high quality surveillance in endemic areas combined with gradual introduction of elimination approaches in low endemic districts. Adopt the philosophy of first building up enhanced surveillance systems and then expanding the system as resources and malaria burdens allow.
• Consider including Kigali within the first pilot districts for enhanced surveillance, given the low prevalence and focalized transmission patterns, and to encourage political will.
• Conduct death audits in order to measure progress towards the goal of zero malaria deaths.

The Leadership newspaper in Nigeria reported on Sunday the launching of a new artemisinin-based combination therapy (ACT) drug knwon by the trade name ‘Artiquick.’  In order to ensure that it is not just another route to ‘profit-quick’, we looked into the WHO prequalification list to see if the Chinese company ArtePharm that makes the drug was listed.

Prequalification is based on a comprehensive evaluation of “the quality, safety and efficacy of medicinal products, based on information submitted by the manufacturers, and inspection of the corresponding manufacturing and clinical sites.” The resulting lists of malaria, TB, and HIV drugs and diagnostics is meant to guide various national and international health agencies in their procurement of medicines.

Though not stated and often not practiced, it would be ideal if these lists also guided various drug regulatory agencies in malaria endemic countries. Although it is a somewhat arduous process to get prequalification, it is possible and necessary – two new medicines containing artesunate-mefloquine were just added in 12 September.

The prequalified list as of today contains 25 anti-malaria products from only 10 companies. ArtePharm is not among them.  Yet the manufacturer made it known that, “the   new  drug   which  has  proven  very  effective  since  early  this  year  when  it  underwent additional clinical trials, Nigeria can, thus, be very hopeful, on attaining the Millennium Development Goals (MDGs) target on malaria come 2015.”  In addition the manufacturer mentioned to the press that ACTs generally were recommended by WHO, implying that any ACT, including their own, was approved by WHO.

Finally the ArtePharm representative made it know that their product was tested and approved by Nigeria’s food and drug agency NAFDAC. NAFDAC does ensure that products contain the labeled ingredients in the labeled amounts and that the drug is safe to use. It is important in the fight against counterfeit drugs. But NAFDAC has approved hundreds of ACTs for sale and use in the country. Unlike WHO, NAFDAC and other national agencies do not have the reach to inspect the production processes at the root.

Hopefully ArtePharm will begin the journey of the prequalification process soonest, and that countries where it sells its product will also encourage that company and many others to take the responsible steps needed to ensure we have quality antimalarials that will actually eliminate disease and not just eliminate money from patients’ pockets.

News from Ghana by Emmanuel Fiagbey, Ghana Malaria Voices Project:
The Ghana Football Association (GFA) has held a special media event in Accra to highlight Ghana’s progress in the fight against malaria with support from the National Malaria Control Program and the Voices for a Malaria Free Future project of Johns Hopkins University’s Center for Communication Programs.  Just as in the previous Africa Cup of Nations (AFCON), the 2013 event will promote United Against Malaria (UAM) – an international effort for using football to draw attention to and mobilize support for malaria control efforts.

GFA’s 7th September media event was a prelude to the Ghana–Malawi qualifying match and attracted representatives from 21 print and broadcast outlets and malaria-related agencies and NGOs.

The event was opened by GFA’s president Mr. Kwesi Nyantakyi who reminded those present that …

“Because of GFA’s national reach, Mr. Nyantakyi promised to work towards bringing on board the UAM Partnership local football clubs which belong to the Ghana League Clubs Association to support dissemination of important malaria prevention and treatment messages in communities all over the country.”

Members of the Ghana Media Malaria Advocacy Network (GMMAN) and other journalists who participated in the event were very enthusiastic in continuing to disseminate malaria information through their publications. They however called on the Voices Project to keep them regularly posted on developments at the malaria front.

Maybe the GFA’s enthusiastic support for United Against Malaria helped propel them to success as Ghana Beat Malawi in AFCON 2013 Qualifier a few days later!  Of course no national FA in Africa can afford to ignore the threat of malaria to their teams or their communities.