Tropical Health Matters

On April 5th 2011 the Johns Hopkins Bloomberg School of Public Health observed Global Health Day. A key event was a series of poster presentations by students who had won global health grants to undertake field projects. Several were on malaria.  We are fortunate that the presentation below has been shared with us. Hopefully more will follow.

Use of Mobile Technology to Increase ANC Attendance and IPTp Uptake – Results from a Pilot Study in Uganda
Hsin-yi Lee, MSPH Candidate, Johns Hopkins Bloomberg School of Public Health

In search of innovative ways to increase IPTp uptake, the Stop Malaria Project (SMP) in Uganda wished to investigate whether mobile technology can be part of the solution. With nearly 42% of the population owning a mobile phone, mobile technology has demonstrated its incredible potential creates an impact at scale.

The SMP SMS pilot campaign was designed to address the issue of irregular Antenatal Care (ANC) attendance and low uptake of IPTp by sending out text message reminders to pregnant women and their close contact. The program was piloted at four facilities in Mukono District with 327 pregnant enrolled during their first antenatal visit.

Results from a post-campaign survey shows that after adjusting for control variables, program exposure remained a significant factor to determining ANC and IPTp completion rates. Respondents who received three to four messages had the highest odds for completing their ANC visits and were five times more likely to complete two doses of IPTp compared to those that received less than two messages.

Results also show that women whose husband or other contact had talked to them about the messages had higher ANC completion rates. The husband felt a “shared responsibility” about the women’s antenatal care by receiving the message on his phone. An unexpected outcome of the campaign was the clients increased trust towards the facility and health providers. Respondents from the survey had talked about how the messages showed that “the providers were responsible” and “caring.”

The Pilot SMS Campaign has demonstrated that text messages can play an effective role in promoting antenatal care attendance and uptake of IPTp. However, voice messaging methods should be further explored to overcome the issue of illiteracy. How to integrate a mobile health component into routine antenatal care in a resource limit setting is another pressing issue for program scale-up.

Further reading for similar mhealth programs:

• MoTECH  initiative – Ghana

• “Wired Mothers” – Tanzania

• Better Border Healthcare Program –Thailand

News this week from The Lancet confirming suspicions of malaria parasite resistance to artemisinin-based drugs deals a double blow to malaria control efforts coming just a few months after announcements by Global Fund to cancel Round 11 funding.  Pressure on malaria drugs is nothing new, especially since the same problem has arisen in the same region of the world for two previous and cheaper mainstays of malaria case management.

In all our hopes for rolling back malaria over the past 14 years, did we tell ourselves that such resistance was this time not inevitable?   Unlike in previous waves of resistance, this time we should have been better prepared with effective anti-vector measures. BUT this assumes that we have met our RBM targets and are happily progressing toward 2015 expecting no more malaria deaths.

We get reports that scale-up and case reduction are occurring, such as a recent newspaper article from Jigawa State in Nigeria, but basically we have not achieved our 2010 scale-up targets – so what will come first – 2015 success or the wave of parasite resistance spreading out from Southeast Asia?

The hopes of the current RBM effort were based on the fact that by 2000 we had 3-4 effective anti-malaria interventions, unlike the reliance on mainly one during the first stab at eradication.  Unfortunately the question is still the same as it was in the 1950s-60s – are our health systems strong enough to deliver the goods? More effective interventions that do not reach people will not present a strong bulwark against spreading drug resistance.

Frustration may mount even more when we realize that all the insecticide treated nets distributed over the prolonged period of campaigns from 2009-2012 will need to be replaced, mostly well before 2015.  Our coverage to date has not been adequate, our funding is threatened – what guarantees that we can keep up with adequately containing malaria before the resistant strains of the parasite reach Africa where the bulk of cases and deaths occur?

Some of our ‘easy’ eradication targets like guinea worm and polio are still flaunting their capacity to harm.  These like other previous efforts are at risk from donor fatigue.  Malaria, which is more complex than those two diseases, is at even greater risk. The RBM Partnership needs to develop a serious and workable strategy to get well ahead to the resistance wave NOW.

Recent research has stressed the increase risk of death from malaria that elderly tourists face. Mortality from P. falciparum malaria increased steadily with increasing age with case fatality rate peaking in the group aged over 65 years. The authors explain that, “These data are supported by previous reports of increased case fatality and higher levels of parasitaemia in elderly people,” but the three studies cited focus only on travelers and tourists back in the UK, not adults and elderly people living in endemic regions.

This leads on to wonder about the risks malaria poses to elderly people in endemic countries, especially as populations throughout the world are aging.

While the recent controversial study that suggests that malaria deaths in adults have been underestimated world-wide, it does not specifically address the suspected prevalence of malaria morbidity and mortality in older adults. Specifically the authors “estimated more deaths in individuals aged 5 years or older than has been estimated in previous studies: 435 000 (307 000-658 000) deaths in Africa and 89 000 (33 000-177 000) deaths outside of Africa in 2010.”

Concerning the “outside Africa” component mentioned above, a study of adult and child malaria mortality (both falciparum and vivax) in India published in 2010 did report a higher malaria mortality risk in persons over 60 years of age.

More documentation on malaria morbidity and mortality in persons over 60 years in age in endemic countries is needed. Although portions of this segment of the population may no longer be in their productive years, they do consume health care resources, and as grandparents play important roles in child care.

In addition there is need to ascertain reasons for any differing patterns that may be detected. The study on tourists did not think that co-morbidity in elderly patients was responsible but instead implied that older people on holidays may forget to take their prophylaxis.

What differences in health behavior might be found in elderly populations in malaria endemic countries – maybe greater reliance on less efficacious indigenous concoctions? Are there differences in terms of perceptions of severity and seriousness of illness? Are there differences in care access?

The respect and quality of care we give the elderly says a lot about the societies in which we live.

By the end of this week someone will be nominated to replace Robert Zoellick as President of the World Bank.  Traditionally this nomination has been made by the United States, and it appears that this tradition is likely to be maintained.  The question is whether the traditional nominee – a white, older male of US citizenship – will be able to lead the World Bank in the Twenty-first Century.

The Washington Post today features two articles on this critical rite of passage. Howard Schneider raises, “The question now is whether the bank’s new leader, who could be named in the coming days, can enhance the institution’s role at a time when developing countries are emerging as the engines of world economic growth.” The mixed roles of the Bank – lender, donor, provider of technical assistance – and the emergence of other major and upcoming economic strong houses leads Amar Bhattacharya of the G-24 Secretariat to ask whether there is a clear goal for the institution at this point in time. His answer is ‘No.’

In contrast Michael Gerson sees a positive future because Zoellick’s leadership, he believes, leaves the “rarest of legacies: a multilateral institution with its reputation enhanced. Zoellick acted decisively to help stabilize the finances of struggling nations during the worst of the financial crisis, as well as to provide relief to countries hit hard by a worldwide spike food prices. He has increased transparency at the bank while successfully raising funds to recapitalize it.”

Gerson stresses the Bank’s need to listen to countries that receive its loans or grants since he sees no ‘silver bullet’ emanating from external development or aid experts. He traces as an example the evolution in country needs and requests from Rwanda which asked for emergency food aid in 2007, but a few years later sought investments to increase agricultural productivity and “Now is asking for help building storage facilities, so expanding crop yields are not wasted.”

Schneider does stress that the technical knowledge provided by the Bank is of equal importance as the financial resources it can mobilize. Who then is in the best position to marshal needed technical inputs while at the same time maintaining a humble leadership style that emphasizes that we need to learn from the low and middle income countries themselves?

According to the Washington Post, the current suspected nominees have ranged from Hillary Rodham Clinton and Sen. John Kerry to Susan Rice and Lawrence H. Summers, though for various reasons these have said they are not interested or are unlikely choices.

Jeffrey Sachs has let it be known that he is interested in the job, though Schneider notes, “But he says the administration has not approached him.” Sachs is certainly familiar with the needs of low and middle income countries, but would he or the other US candidates take a learning, rather than a prescriptive approach to working with these countries?

Another name breaks the US white male mold – Nigeria’s Finance Minister and Coordinating Minister for the Economy, Dr. Ngozi Okonjo Iweala. CP-Africa recently reported that, “Dr. Okonjo Iweala reportedly recently told the BBC that it is time to open it up to competition and that top jobs at international institutions should be filled on merit.”  They also though that such an appointee would only be successful with support from China.

What is at stake for the malaria community? Currently the World Bank has commitments for malaria control in 21 African countries up to US$ 762.8 million.  This has been used to finance over 73.8 million treated mosquito nets and 25.3 million doses of effective malaria medication over the past five years, a major dent in the overall efforts to scale up malaria control.  Given the current questionable status of Global Fund support, efforts by all other partners including the World Bank are crucial.  Hopefully the new leadership at the Bank will sustain this in line with the commitments of each national malaria control program.

Many malaria partner organizations depend on the media to disseminate malaria information and generate support for their programs. And yet, unless the malaria organization itself issues carefully crafted press releases, interaction with the media can be challenging.

This week has seen two examples of the media getting it wrong on malaria-related stories. The first came from the Yemen Post from where reports of an impending malaria and polio vaccination campaign emerged. This was later clarified to be measles and polio, but not before many people wondered ongoing research on malaria vaccines had become operationalized so quickly.

A newspaper in Nairobi issued the second questionable story.  Supposedly a study had been issued that showed less than half the people in Nyanza were using their insecticide treated nets properly.  The Nairobi Star  said that people were not using nets because of taboos or were using them to protect their gardens. It is not that net misuse does not happen, but the scale that was reported, 51%, was startling.

In short order it was revealed that no such study had been done, but that the press had relied on anecdotal reports from a community group.  In fact health researchers familiar with the area, on reading the story raised another important issue – because there are no proper plans for disposal of old nets, it is possible some people were re-purposing those, not the new nets.

Mosquito misinformation is quite common. The press in Ghana often reports on the activities of sanitation companies and local government councils who are engaging in environmental management of vector breeding and claims this is malaria control. Their efforts to clear garbage and dirty gutters are commendable, but this work is aimed at other mosquitoes, not anopheles who tend to breed in clear, sunlit collections of water.

Malaria endemic countries often have many national and local newspapers, but this does not mean that they have adequate strength in professionally trained science and health journalists, who can spot the problems noted above, or at least be curious enough to check the facts.

Most times these stories go unread by the malaria community, but occasionally they can cause confusion and embarrassment when they misrepresent program activities. Monitoring the press after such stories are published is not the answer. Working with the press to help them understand malaria technical issues and activities is recommended.

An update by Ogu Omede, National Malaria Control Program, Nigeria

Nigeria has targeted 64 million LLINs to be distributed. 45 million have already been distributed (71% of target). 28 states out of 37 completed with 9 left.

States lead the actual campaign implementation in collaboration with NMCP using the principle of the ‘three ones’: one plan, one implementation process, one monitoring mechanism.  The State Support Team (SST) is an implementation arm of NMCP that providea Technical Assistance for the LLIN campaign. This consists of 4 teams of 7 persons each; 3 workstream advisors and 2 overall coordinators. Distribution efforts are funded by DFID, USAID and World Bank.

Several challenges exist. There was inability to access operational funds from World Bank due to audit since September 2011.  There are inadequate stocks of LLINs in Millennium Development Goal States. Degradation of some storage areas has occurred.

Some states want to distribute this slow moving inventory without adherence to National Guidelines because of delays. Support operations face SST attrition, partner fatigue, and increased operational costs. There is even loss of nets that have been in storage for over a year.

The way forward can be achieved by getting support outside the WEorld Bank for now for 1) Operational funds, 2) Gaps in SST facilitation costs and 3) Procurement of LLINs to meet the gaps in MDG States targets

The NMCP and its partners are increasing support for the promotion of the net use culture which means undertaking Behavior Change Communication beyond the campaign period.  We are also encouraging transparent states and local government areas counterpart funding.

Guest Posting by Bright Orji, Jhpiego, Nigeria

Malaria control in pregnancy in endemic nations is an integral component of Ante-natal Clinic and made up of three essential components. These include the 1) use of long lasting insecticide treated nets (LLINs), 2) intermittent preventive treatment of malaria (IPTp) using sulfadoxine-pyrimethamine, and 3) effective case management.

In recent times, National Malaria Control Programs (NMCP), State Governments and the Development partners embarked on campaigns for nets distribution and use through various methods that include routine, stand alone and through integration with other interventions such as measles campaign most times with under-five children and pregnant women as key entry points. However, these efforts have improved net ownership and use. Ownership of at least one ITN among households in Nigeria increased from 2% in 2003 to 8% in 2008 and more recently to 42% in 2010; similarly  net use increased from 1.3% to 5% and 33.7% during the same period (NDHS 2003, 2008; MIS 2010).

Other components of malaria in pregnancy control have not enjoyed similar large scale campaign as nets. In 2003 National survey, IPT with sulfadoxine-pyrimethamine use among pregnant women was found to be 1%, and then increased to 5% in 2008 and further to 13.2%  in 2010 (NDHS 2003, 2008; MIS 2010) compared to the global RBM target of 80% and PMI 85%. IPTp and insecticide treated bed nets (ITNs) is a recommendation of World Health Organization. IPTp was first piloted as a project in 2002/2003 in three Local Government Areas (Akinyele, Ibadan South East and Ibadan North) of Oyo State, Nigeria. The outcome of this project among others informed policy direction for Nigeria.

It is important to note that IPTp implementation in Nigeria and elsewhere is faced with multiple challenges. These include lack of trained personnel, SP stock-outs – even though the medicine is available in-country and cheap but due to logistical distribution problem they are not where and when needed;  while  poor ANC attendance however has been identified as one of the major key factor for the low uptake of IPTp.

In the last two decade, there has been effort to improve the health system through the active involvement of communities in the distribution of health commodities. The notable concept in this regard was the Community Directed Distribution (CDI) that was first introduced in 1985 by African Program on Onchocerciasis Control (APOC).  Recently there has been growing effort that keyed into the lessons learned from APOC projects to apply the concept of CDI to malaria control using nets and IPTp as key entry points.

These efforts were piloted in Uganda and Nigeria respectively. The Ugandan project  findings showed that more women accessed IPTp and adhered to 2 doses of SP in the intervention arm compared to the control. Furthermore, ANC attendance increased as well as access and benefits from essential care at health facilities. Similarly, another study  concluded that the involvement of community distributors offered an alternative option in the administration of IPTp given that the strategy does not reinvent the while rather it keys into the existing health system and community structures.

Whilst it may be said that the Ugandan project was under control measures, the Nigerian project  was more of field implementation program. In the Nigerian program in Akwa Ibom State, over 45,000 pregnant women received IPTp in five years with the effect of CDI more on pregnant women access to IPTp, adherence to at least two doses of SP, and ITNs use, relatively very cheap and without distraction to ANC attendance. In both projects, there was no record of adverse event since SP has a very high safety profile if administered properly and appropriately too.

As many African countries struggle with meeting the Millennium Development Goals as well as the global targets for IPTp, the call to explore community IPTp as another option to strengthen the health system to improve the uptake of IPTp is increasing given the growing research evidence. Change does not just come; it comes with conscientious planning, discipline and deliberate effort. Countries might not meet the MDG targets if they choose to continue to do things the same way it is being done over the years.

Selling malaria medicines in Tanzania and elsewhere in Africa is a big business. The market is not one that is easily dominated by a few brands, although the Affordable Medicines Facility malaria (AMFm) would hope otherwise. It appears that volume of relatively low or lower cost malaria drugs is the path to profit, not sales of a pricey mega-drug.

New from Tanzania is that this vast market is attractive to all sorts of manufacturers, even those making fake drugs. According to The Citizen, “The Tanzania Food and Drugs Authority (TFDA) yesterday issued a public warning against the sham product marketed under the name Eloquine (Quinine Sulphate 300mg USP) and packed in a bottle containing 1,000 tablets each.”

IPP Media reported that, “the authority has seized 155 tins of the fake drugs in Dar es Salaam which were yet to be distributed” and a suspect has been detained. The company headquarters in Nairobi helped point out differences in packaging between their products and the fake ones. A major concern of course is that role the fake drug was supposed to play. Normally quinine would be used in a limited way such as for pregnant women, so it is unclear how the fake drug would have been marketed to make a profit.

All of this comes amid efforts of AMFm to ensure that prequalified anti-malarial drugs reach the market (public and private) at prices people can afford. Cheap fake drugs threaten this effort.  A Tanzania study sponsored by the Clinton Foundation/CHAI, “showed promising results: subsidizing the ACTs at the top of the supply chain successfully increased the stocking of ACTs in drug shops and brought down the price of ACTs significantly.”

Prior to AMFm, but after Tanzania changed its malaria drug policy from SP to ACT, “the saleability of ACT was negligible. SP was best-selling.” Pre-AMFm price differentials between ACTs and cheaper but less effective medicines, put ACTs at a disadvantage.
Part of Tanzania’s approach to improving quality of malaria case management in medicine shops is upgrading the quality of these.  Accredited drug dispensing outlets (ADDOs) are places where the sales people and the products are both upgraded. When Tanzania changed its malaria drug policy from SP to ACT, access to ACTs in the private sector was low, while focus was on the public supply of ACTs.  It appears that with the event of AMFm ACT supplies in ADDO shops and other private outlets, but this does not preclude the presence of inappropriate or substandard drugs in non-accredited shops known as duka la dawa baridi.

Despite improved access to ACTs and improved quality of front line medicine store outlets, Tanzania cannot let up on its pharmacovigilence. As we move closer to malaria elimination – for example in Zanzibar in Tanzania – the importance of appropriate parasitological diagnosis and prompt treatment will increase. We cannot afford to have fake and inappropriate drugs compete with ACTs.

Azusa Sato raises an important question in a research article on health service choices by Ghanaians – why do individuals turn to traditional medicine only as a second recourse?

In general, Sato’s review of literature on health care choices cite the maxim that indigenous medicine is easily accessible, affordable, available and acceptable. The irony in this study is that indigenous medicine is a more popular second choice than first.  Sato shows that “The most common acute complaint was ‘fever, headache and hot body’ (334/460, or 72.6%),” which people may interpret as possible malaria in a local context.  Interestingly, only 45 respondents used indigenous medicines first whether they sought acute care from outside or found/made it at home.

When a second or additional recourse was added, the number using indigenous medicine rose to 103 people for acute illnesses. Respondents who chose indigenous medicine at some point overwhelmingly had a favorable opinion (77%) of this form of medicine.

Ghana has a dynamic health system that is attempting to bring more people into the orthodox care orbit.  The national health insurance scheme to which over 60-70% of people subscribe, make care seeking at orthodox health facility (either public or private) more attractive and affordable.  Ghana is also working on expanding primary health care through establishing community health compounds – a local building donated by the community and staffed by government trained community health officers. Although these measures are a ways from attaining universality, they may in part explain a tendency to choosing orthodox care first.

Another interesting irony of Ghana’s pharmacy system is the the health authorities have actually approved some indigenous malaria medicines (see picture). These are sold alongside Coartem and artesunate-amodiquine in licensed shops and pharmacies.

Pharmacy stocks and consumer care seeking choices support Sato’s recommendations for seeking more evidence to develop an integrated system of care in Ghana.  With global health funding in seeming decline, any effort to find additional efficacious local resources to expand malaria treatment are most welcome.

Burkina Faso has had an active volunteer community health worker (CHW) scheme for many years. CHWs were the mainstay of guinea worm elimination, for example. At a point they even provided community case management (CCM) of malaria when chloroquine was the first line drug.

In 2008 the Ministry of Health realized that the system of multiple volunteers for multiple health issues was not providing integrated services at the grassroots. At this point the Ministry produced two valuable documents. The first documented that various tasks that CHWs can play in the community, while the second developed an integrated communication strategy for CHWs.

It was also during this period that Burkina Faso was successful in winning two Global Fund Rounds to support malaria, Rounds 7 and 8, which have now been merged for easier management. One component of the combined Round 7/8 is delivery of malaria CCM by the workers known locally as Agents Sante Communautaire (ASC). PLAN Burkina is leading that effort and has revised ASC training guides and produced behavior change materials – a flipchart – for ASCs to use in educating the public about cause, prevention and treatment of malaria (see photo).

Normally there are two ASC per village is the population is 3000 or less and at least 4 in larger villages. The Global Fund supported work asks the community to designate one ASC to be trained for malaria CCM and educational activities.

But back to the Ministry – recognizing the need for a well coordinated delivery of an integrated minimum package of community services, the Ministry created just one year ago a new Directorate for Community Health. This Directorate works closely with all program areas in the MOH to ensure and coordinate community delivery of those basic services.

The Directorate draws on existing health staff. Of the seven or eight members of the District health Management Team, one person is specifically in charge of community activities. Also at the primary care health center level there is what is termed an ‘itinerant’ health worker whose job is outreach to and mobilization of communities and especially the supervision and support of ASCs.

In the meantime the Global Fund project implementers have hired animators to work with the malaria ASCs in the catchment of a health center and district supervisors to coordinate the animators. Although this appears to be a parallel system, the ASCs still must link with their nearest health center to get supplies of malaria medicines, and th animators help summarize malaria ACS records for onward transmission to the health center.

At present the system of itinerant health workers cum ASC supervisors needs strengthening because public the sector experiences staffing and funding shortages that often keep these theoretically mobile workers in the clinic.

The new Directorate of Community Health has begun negotiations and discussions with all parties to harmonize the overall ASC scheme with the specific needs of the malaria ASC effort. Ideally all ASC in a village should be able to provide the integrated package including malaria services so that the current single malaria ASC is not overburdened and frustrated.

While still a work in progress, the new Burkina Faso Community Health Directorate points to the future where the aims of the Alma Ata Primary Health Care Declaration can still become a reality for neglected rural populations around the world.

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PS – the VOICES Project website is undergoing some major improvements. In the process the original link to this blog has become a link to the new Voices blog. Therefore you can keep up with Voices activities and those of partners at http://www.malariafreefuture.org/blog. Happy reading of both blogs!