Tropical Health Matters

Keep up with MIP meeting on Twitter #MIP2012

Bill Brieger ?@bbbrieger – #MIP2012 universal coverage of ITNs not just to protect vulnerable groups against #malaria but also reduces mosquito population

Krisztian Magori ?@BiteOfAMosquito -bbbrieger: #MIP2012 MSF has found where no mass distribution of nets give pregnant woman 2… http://goo.gl/fb/xnHkd  – Bill Brieger ?@bbbrieger – #MIP2012 MSF has found where no mass distribution of nets give pregnant woman 2 nets ensure she gets to use at least one to prevent #malaria

bbbrieger: #MIP2012 non-use of nets related to real reduction in ventilation – both a design… http://goo.gl/fb/kdFMA – Bill Brieger ?@bbbrieger #MIP2012 non-use of nets related to real reduction in ventilation – both a design issue and an educational issue on net benefits #malaria

MHTF ?@MHTF – Challenges: Funding. Advocacy. ITN coverage in ANC. Incentives for net producers to make lasting nets.-Olivi Net @PSIHealthyLives #MiP2012

MHTF ?@MHTF – Net challenges: Funding. Advocacy. Limited ITN coverage in ANC. Need to incentivize bednet producers to make longer lasting nets. #MiP2012

Bill Brieger ?@bbbrieger – #MIP2012 Elena Olivi PSI need get manufacturers make stronger nets and new insecticides to deal with resistance #malaria; #MIP2012 Olivi PSI. even before when sufficient fund, not all ANC provided ITNs to protect pregnant women against #malaria

MHTF ?@MHTF We are in the midst of a funding crisis. Nets expire after 3 years & need to be replaced. -Olivi @PSIHealthyLives #MiP2012 #malaria #MNCH

Bill Brieger ?@bbbrieger #MIP2012 Olivi PSI: gap analysis underway to see countries at greatest risk of loosing ITN coverage gains #malaria

MHTF ?@MHTF Take homes: Nets save lives. African countries know how to deliver them. Technical champions exist. -Olivi @PSIHealthyLives #MiP2012 #MNCH

Sam Lattof ?@slattof Olivi: Writing women prescriptions for bednets relieves #ANC nurses of the duty, minimizes stockouts, and strengthens supply chain. #MiP2012

Bill Brieger ?@bbbrieger #MIP2012 Olivi PSI: challenges exist – we are in funding crisis and nets need replacement after 3 years. threat to MIP – risk loosing gains!

MHTF ?@MHTF Olivi @PSIHealthyLives: No need to get overly clever w/bednet distribution. Just do it. #MiP2012 #malaria #pregnancy #maternalhealth #MNCH

Bill Brieger ?@bbbrieger #MIP2012 Olivi PSI: Burundi experiment with ‘prescribing’ ITNs at ANC so woman collects from pharmacy. streamline ANC, better ITN tracking

Bill Brieger ?@bbbrieger #MIP2012 Elena Olivi PSI – ITN campaigns can reach poorer people, especially women who may not attend ANC or not yet start ANC #malaria

MHTF ?@MHTF Olivi @PSIHealthyLives: ANC best distribution channel of bednets for pregnant women. Other channels important for other groups. #MiP2012

Bill Brieger ?@bbbrieger #MIP2012 Elena Olivi PSI understanding of all kinds of ITN distribution channels and while ANC best for pregnant women, others can help

Intermittent Preventive Treatment of pregnant women (IPTp) for malaria has been a major, if not terribly well implemented malaria control strategy in countries with high and stable malaria transmission. Combined with use of insecticide treated nets (ITNs) and appropriate case management with artemisinin-based combination therapy (ACTs), IPTp offered an important third prong to protect this vulnerable population who in theory are reachable since most pregnant women in endemic countries attend antenatal care (ANC).

The area benefiting from IPTp covers the bulk of sub-Saharan Africa, but not countries on the periphery of malaria transmission, like Namibia and Botswana, where transmission is seasonal or epidemic. Here, as well as in countries that have made substantial progress in reducing the burden of malaria like Rwanda, ITNs themselves often carry the burden of protecting pregnant women since case management is dependent of treatment seeking in a variety of formal and non-formal care settings.

IPTp as we know it is threatened. First is the growing resistance of malaria parasites to sulphadoxine-pyrimethamine (SP), the drug of choice. The problem has been compounded by countries’ neglect in curbing the continued and unrecommended use of SP for treatment. Secondly, on a more positive note, as countries reduce their malaria burden and become more like those with low and unstable transmission, widespread IPTp does not make much sense as a strategy.

This reduction in burden does not mean that pregnant women are no longer at risk in malaria endemic countries that are making progress.  It means that aside from continued use of ITNs and other vector management interventions, we must step up the accuracy of timely case detection and case management.

A new study of malaria rapid diagnostic tests during pregnancy in Tanzania sums up the current situation nicely: “Microscopy underestimated the real burden of malaria during pregnancy and RDTs performed better than microscopy in diagnosing PAM. In areas where intermittent preventive treatment during pregnancy may be abandoned due to low and decreasing malaria risk and instead replaced with active case management, screening with RDT is likely to identify most infections in pregnant women and out-performs microscopy as a diagnostic tool.”

Others have suggested an active detection and case management process using ANC as a platform – intermittent screening and treatment (IST). One of the earliest allusions to IST was in a 2008 study in Ghana, where the researchers concluded that RDTs fit easily into ANC procedures and outlined the benefits of “antenatal RDT screening and treatment.” One of the researchers actually used the term IST during a presentation on malaria intervention options for Asia at the 11th meeting of the Roll Back malaria Partnership’s Malaria in Pregnancy Working Group in 2008.

In 2010 the same research team again reported from Ghana on comparing IPTp during ANC with IST using two different drug regimens. All three arms showed a reduction of parasitemia near the end of their pregnancies, but with the benefit of reduced drug use in the two IST arms.

Research continues on IST. Rwanda has recently completed a malaria in pregnancy prevalence study using RDTs and treatment of those with parasitemia during first ANC visit and is in the process of determining guidelines for formalizing this as part of ANC.  School based studies of IST in Kenya have yielded encouraging results. Unicef in collaboration with USAID is piloting IST in selected regions of Indonesia.

Practical issues of integrating the RDT testing and ACT provision need to be addressed including funding and procurement processes to ensure adequate supplies at ANC. Training of ANC workers on the procedures as well as planning on how to ensure IST fits seamlessly into ANC procedures are a few of the operational challenges.

In conclusion, IST offers a promising intervention in low transmission countries as well as high burden countries as they move closer to elimination. As with most malaria interventions, the science will be easier to solve than the logistics and staff attitudes.

A new study from Zambia reports that despite mass distribution efforts towards achieving universal coverage only half the children in houses with nets slept under them the night before the survey. When the researchers checked for nets they discovered that, “… ITNs in poor condition are more likely to be observed hanging than ITNs in new or good condition.”

The proposed solution for this dilemma was, “In the context of free mass distribution of ITNs, behaviour change communication and activities are necessary to improve use. Results suggest campaigns and messages that persuade recipients to hang up their ITNs would contribute towards closing the gap between ownership and use.”

Coincidentally, another study set in several malaria-endemic countries examined the complaints that people often give when explaining why they do not use nets – ‘thermal discomfort’.

The researchers found that, “Bed nets reduce airflow, but have no influence on temperature and humidity. The discomfort associated with bed nets is likely to be most intolerable during the hottest and most humid period of the year, which frequently coincides with the peak of malaria vector densities and the force of pathogen transmission.”

Airflow is crucial because even a little breeze can make one feel cooler even if the temperature is not objectively different inside or outside the net. Not surprisingly denser mesh size reduced airflow even more.

These researchers took a different approach to solving the net use problem – instead of blaming the user, they suggested considering architectural issues like housing ventilation and net design issues that would increase airflow without jeopardizing protection against mosquitoes.

Sometimes it is the scientists, manufacturers and the program managers who need to change, not the community members.

As we have recently noted actual use of insecticide treated bednets (ITNs) by pregnant women in malaria endemic countries is not meeting targets.  In addition to tracking general coverage, we have reviewed Demographic and Health  or Malaria Indicator Survey (DHS/MIS) data showing that even in households that own nets, pregnant women may not be using them.

Now we need to take a step back and examine our indicators in light of the need to protect women fully. Two issues arise. First in the context of universal coverage, all women in a household should have access to sleeping spaces that have nets.  Women need strength before they become pregnant, especially younger ones who may be experiencing their first pregnancy.  Nets are one means of ensuring that women do not enter pregnancy already in an anemic state.

The second issue is pragmatic. Since a woman may not know for sure that she is pregnant in the early days and weeks of her pregnancy, she benefits from already being protected from malaria by nets that should have been provided through universal coverage. Intermittent preventive treatment can not be used with current drugs in the first trimester, so nets are the most important preventive measure during that time.

Even if a woman suspects she is pregnant, it is considered in many places culturally inappropriate for her to publicly announce or take public actions (like attending antenatal care) that let people know she is pregnant. If she waits in a culturally appropriate manner until ‘it shows’, she and the unborn child would have already been exposed to life threatening malaria infections. Universal coverage of nets prior to pregnancy maintains both the woman’s confidentiality and health.

To date few of the recent DHS/MIS have reported on net use by women of reproductive age (15-45 years) in general. The graph here shows a similar pattern for this group as observed for pregnant women. Problems of both access and use persist.

Because of the protection offered by ITNs in the earliest stages of pregnancy, it is extremely important not only for malaria endemic countries to undertake and maintain universal coverage that will reach women, but also track this as an important indicator of program success.

Professor Oladele Akogun (akoguno@yahoo.com) of the University of Common Heritage Foundation and the Federal University of Technology, Yola, Nigeria pays tribute to his colleague Professor CO Onwuliri

The death has been announced of one of Nigeria’s leading parasitologists, Professor Celestine Onwuliri in the DANA Air crash in Lagos earlier this month.  Professor Onwuliri taught helminthology at the University of Jos, where he made significant contribution to the epidemiological mapping and control of onchocerciasis in Nigeria.

He also trained many parasitologists who now hold positions in academics and policy both in Nigeria and overseas. Professor Onwuliri has also carried out research on malaria in recent times.

Professor Onwuliri was the President of the Nigeria Society for Parasitology in the mid-90s. He has also served as Commissioner in the government of Imo State, Nigeria. He was a university administrator holding position of Deputy Vice Chancellor and Acting Vice Chancellor at the University of Jos before his penultimate appointment as Vice Chancellor of the Federal University of Technology, Owerri.

His most recent position was at the National University Commission (NUC). He was a fellow of the Parasitology and Public Health Society of Nigeria and a member of the Nigeria Academy of Science.  With his departure the Parasitology community will miss one of its most beloved academics and leaders.

The recent fatal crash of Dana Air in Lagos, Nigeria claimed the life of a renown parasitologist and educator, Professor C.O. Onwuliri, most recently the Vice Chancellor of the Federal University of Technology Owerri. In his remembrance we are sharing the abstracts of two recent malaria publications of which he was a co-author. His various publications also focus on onchocerciasis, lymphatic filariasis and other parasitic diseases.

Perceptions on the use of insecticide treated nets in parts of the Imo River Basin, Nigeria: implications for preventing malaria in pregnancy. Chukwuocha UM, Dozie IN, Onwuliri CO, Ukaga CN, Nwoke BE, Nwankwo BO, Nwoke EA, Nwaokoro JC, Nwoga KS, Udujih OG, Iwuala CC, Ohaji ET, Morakinyo OM, Adindu BC. Afr J Reprod Health. 2010; 14(1): 117-28.

ABSTRACT: This study aimed at assessing perceptions on use of ITNs in parts of the Imo River Basin, Nigeria and its implications in preventing malaria in pregnancy. Data was collected using focus group discussions, key informant interviews and structured questionnaires. Results showed high awareness on the benefits of ITNs. Factors affecting use of ITNs included its high cost, perceptions of chemicals used to treat them as having dangerous effects on pregnancy, low utilization of antenatal care, husband’s lack of interest in malaria prevention and perceptions  that adolescent girls are at low risk of getting malaria. The implications of these findings include demystifying the negative perceptions on the chemicals used for net treatment and subsidizing the cost of ITNs to increase access. These findings provide important lessons for malaria programmes that aim at increasing  access to ITNs by pregnant women in developing countries.

Malaria infection in HIV/AIDS patients and its correlation with packed cell volume (PCV). Goselle ON, Onwuliri CO, Onwuliri VA. J Vector Borne Dis. 2009; 46(3): 205-11.

OBJECTIVES: The study was designed: (i) to determine the prevalence of malaria parasites; (ii) to determine the relationship between parasitaemia and age/sex; (iii) to correlate the PCV levels with parasitaemia; and (iv) to determine the influence of protection against natural transmission on the prevalence of malaria.

METHODS: Participants were recruited at the Plateau State Human Virology Research Laboratory (PLASVIREC), Robert Gallo House at the Plateau State Specialist Hospital, Jos and grouped into: (i) Malaria and HIV co-infection group (n = 64);  and (ii) HIV infected group without concurrent malaria infection (n = 136). Standard laboratory procedures were used for the HIV and Plasmodium parasites screening, malaria parasite density, and packed cell volume.

RESULTS: The results showed a significant difference (p >0.05) among the sexes and age groups. About 64 (32%) of the individuals had Plasmodium infection (30% Plasmodium falciparum, 0.5% P. malariae, and 1.5% mixed infections of P. falciparum and P. malariae). Malaria parasites were more common among the rural dwellers and in the age group of 21-30 yr. Regression analysis showed a negative  association of malaria parasitaemia and PCV among the malaria-HIV positive and malaria-HIV negative (r2 = 0.529; p < 0.001). CONCLUSION: In the present study, PCV might be of useful indicator and if not monitored could lead to AIDS establishment especially where  high malaria parasitaemia is noted. The findings further suggest that the defined stage of HIV infection in the study, malaria coinfection may moderate the impact  of HIV infection on PCV.

The push toward universal coverage of long lasting insecticide-treated bed nets (ITNs/LLINs) does not negate the fact that pregnant women are still a more vulnerable group that needs protection from anemia and death themselves and miscarriage, low birth weight and greater infant and child mortality for their offspring. So far the data on net coverage for pregnant women is not encouraging. Nets are extremely important because they are the one safe malaria control intervention that women can use right from the start of pregnancy.

Recent Demographic and Health and Malaria Indicator Surveys (DHS and MIS) show a common problem.  The graph here shows general access to LLINs is low (orange bars) in many countries relative to the Roll Back Malaria target of 80% coverage by 2010. What is of equal concern is that even when households possess nets, pregnant women do not always use them (blue bars).  Rwanda with its strong national network of community health workers is the exception. What is discouraging women?

The Liberia MIS asks why people do not own nets, and since these surveys prioritize interviewing women of reproductive age, we may assume that these reasons express the views of women.  A few do not perceive mosquitoes to be a problem (especially in the dry season), some simply do not like to sleep under nets while others complain of the cost.  The latter is curious because nets are primarily provided for free these days.

Clearly we need more information on the dynamics of net use at the household level.  Field visits after a universal coverage campaign in Akwa Ibom State discovered that women themselves see alternative uses of for nets.  One picture shows LLINs covering vegetable gardens that are tended by women in this community. Maybe they believe the nets will keep insects off their vegetables, although the sun will soon render the insecticide ineffective.

Another picture shows that a woman has protected the wares in her small kiosk buy covering it with a LLIN. Customers can still see the wares but insects can’t nibble at the food items on sale (nor children easily pilfer some).

Both of these examples highlight the economic roles of women in the community. Are women making net decisions on their perceptions of what is in their best economic interest? In most communities in Nigeria, income from a woman is crucial to the welfare of her child.

The issue of nets for pregnant women will be one of the issues discussed during the upcoming summit, Malaria in Pregnancy: a Solvable Problem—Bringing the Maternal Health and Malaria Communities Together, a meeting in Istanbul, Turkey, June 26-28, 2012, organized by the Maternal Health Task Force at Harvard School of Public Health.  We will be covering the deliberations as they unfold.

Kelly M. Searle, ScM and her advisor at the Johns Hopkins Bloomberg School of Public Health, William J. Moss, MD MPH share the findings from her masters thesis: “Evaluation of Reactive Case Finding to Target Focal Malaria Transmission in Two Different Settings in Macha, Zambia.” They offer ideas on how we can move toward the challenging target of malaria elimination…

With malaria elimination in the minds of many, new methods of identifying and treating asymptomatic parasite carriers are being investigated. The current study evaluated reactive case detection as a malaria transmission intervention. Reactive case detection is the result of a malaria case being identified in a clinic by passive case detection, testing and treating that individual and their household contacts, and surrounding neighbors.

Survey sample data from different areas of Macha, Zambia in 2007 and 2008 were used to determine proportions of malaria infected individuals caught passively and reactively. Simulations were done to extrapolate this data to non-sampled households. Radii surrounding identified positive households (index households) were examined to determine the proportion of positive households in each radius.

In the 2007 transmission setting, screening 500 meters surrounding index households would have identified 89% of all households with an RDT positive resident and 90% of all RDT positive individuals. Screening 1 kilometer surrounding index households would have identified 95% of all households with an RDT positive resident and 94% of all RDT positive individuals (Figure 1). In the 2008 transmission setting, screening 500-meters surrounding index households would have identified 77% of all households with an RDT positive resident and 76% of all RDT positive individuals. Screening 1 kilometer surrounding index households would have identified 89% of all households with an RDT positive resident and 89% of all RDT positive individuals (Figure 2).

Reactive case detection has the potential to be an effective malaria intervention for populations of both moderate transmission settings and transmission settings transitioning (or that have recently transitioned) from moderate to low. With reactive case detection, a large proportion of malaria-infected individuals are accounted for using screening radius of 500 meters. A greater proportion of total households would have to be screened in the lower transmission setting, likely due to the overall lower numbers of cases existing. For reactive case finding to be most effective, it should be targeted at malaria foci and hotspots where transmission is greater than the overall area.

The recent scare concerning the magnitude of fake and poor quality malaria drugs in circulation has raised a number of questions about malaria drug supply management in endemic countries.  The big question is who makes the decisions about what comes in and how it is used? Debates around public and private sector medicine use further complicates the debate.

In all cases there do seem to be national malaria treatment policies that specify the types of medicines appropriate for a ‘normal’ case of malaria, a case of severe malaria and cases of malaria in pregnancy.  Within these policies are strong preferences for artenmisinin-based combination therapy (ACT) drugs. WHO has gone to the extent of examining malaria drug production and has published and regularly updated lists of ‘pre-qualified’ medicines from reliable pharmaceutical companies.  This list usually guides the recommendations and purchases of major donors like the Global Fund and the US President’s Malaria Initiative.

Even with these various safeguards, the situation on the ground – and in the medicine shops and pharmacies – is quite variable. Lets look at two extremes.

Nigeria’s national case management guidelines do specify ACTs for first line malaria treatment.  The main recommendation for treatment in uncomplicated cases is artemether-lumafantrine (AL) and as an alternative artesunate-amodiaquine (AA).  Brand names are not specified, but for government and donor programs the choices do come from the WHO pre-qualified list.

Estimates vary, but roughly half of Nigerians get their malaria treatment in the private sector.  There one still finds chloroquine and sulfadoxine-pyrimethamine products on sale.  Over 100 different ACTs are registered with the National Agency for Food and Drug Administration and Control. It is not clear whether it has been possible to test the efficacy of all these different products. Let the consumer beware.

In Rwanda, not only does the Ministry of Health set malaria drug policy, it actually enforces it.  Even in private pharmacies one can only buy the approved form of AL, Coartem.

Aside from the size of the two countries, what makes the difference? Political will to adhere to scientific evidence!

Closer to Rwanda, Edward Ojulu looks north and observes that, “Just across in neighboring Uganda, authorities say they suspect nearly 30% of the drugs imported into the country to be fake counterfeits. The tragedy is that the National Drug Authority, a Uganda Government agency that regulates manufacture, import and distribution of human drugs in the country, says it has neither the equipment nor the manpower to stop fake drugs from being sold to the people.”

Edward gets to the heart of the matter when he notes that, “Malaria is big business for pharmaceutical companies world-wide and counterfeiters also know this.” It takes a lot of political will to stand in the way of the profit motive. But that may be what is necessary to save the malaria drug supply and save lives.

Of twenty-two malaria endemic countries in Africa that receive support from both USAID/PMI and the Global Fund, eleven reported gaps in malaria medicine funding in the 2011 Road Maps countries prepare for Roll Back Malaria.  Likewise, 16 of these countries reported gaps in RDT financing and supplies.

These stock and procurement problems arise from many causes including ability to forecast need,  poor donor coordination and leadership, and lack of adherence to new guidelines that require diagnostic verification of malaria before treatment among others.  We are well past the 2010 RBM target date to achieve 80% treatment coverage, but the most recent DHS and MIS results from the 22 countries for appropriate treatment of children below five years of age show that the country with the highest achievement of ACT coverage in this age group was Malawi with only 36.2%.  The median among these 22 countries was 16.5%.

Therefore, it was not surprising that The Citizen newspaper reported from Dar es Salaam that, “Thousands of Tanzanians have continued to die from malaria annually due to lack of medicines despite massive investment by the government and donors towards improved supply of relevant drugs in health facilities.” Apparently programs like SMS for Life and AMFm have not had their desired effects.

The Citizen lamented that, “Phone calls to the CEO of Medical Stores Department (MSD), which is charged with responsibility of distributing drugs in the country, went unanswered.”  Other malaria implementation partners gave their own views that the problem was due to lack of professionalism among health officials and a lack of commitment to implementing the malaria program.

If we cannot even achieve malaria treatment targets by 2010, what hope do we have of reducing mortality by 2015 – let alone head toward elimination? Technical assistance may be needed, but cannot succeed if there is a lack of will on the part of program implementation partners from the endemic countries.