Category Archives: Burden

The Weekly Tropical Health News 2019-06-29

Below we highlight some of the news we have shared on our Facebook Tropical Health Group page during the past week.

Polio Persists

If all it took to eradicate a disease was a well proven drug, vaccine or technology, we would not be still reporting on polio, measles and guinea worm, to name a few. In the past week Afghanistan reported 2 wild poliovirus type 1 (WPV1) cases, and Pakistan had 3 WPV1 cases. Circulating vaccine-derived poliovirus type 2 (cVDPV2) was reported in Nigeria (1), DRC (4) and Ethiopia (3) from healthy community contacts.

Continued Ebola Challenges

In the seven days from Saturday to Friday (June 28) there were 71 newly confirmed Ebola Cases and 56 deaths reported by the Democratic Republic of Congo’s Ministry of Health. As Ebola cases continue to pile up in the Democratic Republic of the Congo (DRC), with 12 more confirmed Thursday and 7 more Friday, a USAID official said four major donors have jump-started a new strategic plan for coordinating response efforts. To underscore the heavy toll the outbreak has caused, among its 2,284 cases, as noted on the World Health Organization Ebola dashboard today, are 125 infected healthcare workers, including 2 new ones, DRC officials said.

Pacific Standard explained the differences in Ebola outbreaks between DRC today and the West Africa outbreak of 2014-16. On the positive side are new drugs used in organized trials for the current outbreak. The most important factor is safe, effective vaccine that has been tested in 2014-16, but is now a standard intervention in the DRC. While both Liberia and Sierra Leone had health systems and political weaknesses as post-conflict countries, DRC’s North Kivu and Ituri provinces are currently a war zone, effectively so for the past generation. Ebola treatment centers and response teams are being attacked. There are even cultural complications, a refusal to believe that Ebola exists. So even with widespread availability of improved technologies, teams may not be able to reach those in need.

To further complicate matters in the DRC, Doctors Without Borders (MSF) “highlighted ‘unprecedented’ multiple crises in the outbreak region in northeastern DRC. Ebola is coursing through a region that is also seeing the forced migration of thousands of people fleeing regional violence and is dealing with another epidemic. Moussa Ousman, MSF head of mission in the DRC, said, ‘This time we are seeing not only mass displacement due to violence but also a rapidly spreading measles outbreak and an Ebola epidemic that shows no signs of slowing down, all at the same time.’”

NIPAH and Bats

Like Ebola, NIPAH is zoonotic, and also involves bats, but the viruses differ. CDC explains that, “Nipah virus (NiV) is a member of the family Paramyxoviridae, genus Henipavirus. NiV was initially isolated and identified in 1999 during an outbreak of encephalitis and respiratory illness among pig farmers and people with close contact with pigs in Malaysia and Singapore. Its name originated from Sungai Nipah, a village in the Malaysian Peninsula where pig farmers became ill with encephalitis.

A recent human outbreak in southern India has been followed up with a study of local bats. In a report shared by ProMED, out of 36 Pteropus species bats tested for Nipah, 12 (33%) were found to be positive for anti-Nipah bat IgG antibodies. Unlike Ebola there are currently no experimental drugs or vaccines.

Climate Change and Dengue

Climate change is expected to heighten the threat of many neglected tropical diseases, especially arboviral infections. For example, the New York Times reports that increases in the geographical spread of dengue fever. Annually “there are 100 million cases of dengue infections severe enough to cause symptoms, which may include fever, debilitating joint pain and internal bleeding,” and an estimated 10,000 deaths. Dengue is transmitted by Aedes mosquitoes that also spread Zika and chikungunya. A study, published Monday in the journal Nature Microbiology, found that in a warming world there is a strong likelihood for significant expansion of dengue in the southeastern United States, coastal areas of China and Japan, as well as to inland regions of Australia. “Globally, the study estimated that more than two billion additional people could be at risk for dengue in 2080 compared with 2015 under a warming scenario.”

Schistosomiasis – MDA Is Not Enough, and Neither Are Supplementary Interventions

Schistosomiasis is one of the five neglected tropical diseases (NTDs) that are being controlled and potentially eliminated through mass drug administration (MDA) of preventive chemotherapy (PCT), in this case praziquantel. In The Lancet Knopp et al. reported that biannual MDA substantially reduced Schistosomiasis haematobium prevalence and infection intensity but was insufficient to interrupt transmission in Zanzibar. In addition, neither supplementary snail control or behaviour change activities did not significantly boost the effect of MDA. Most MDA programs focus on school aged children, and so other groups in the community who have regular water contact would not be reached. Water and sanitation activities also have limitations. This raises the question about whether control is acceptable for public health, or if there needs to be a broader intervention to reach elimination?

Trachoma on the Way to Elimination

Speaking of elimination, WHO has announced major “sustained progress” on trachoma efforts. “The number of people at risk of trachoma – the world’s leading infectious cause of blindness – has fallen from 1.5 billion in 2002 to just over 142 million in 2019, a reduction of 91%.” Trachoma is another NTD that uses the MDA strategy.

The news about NTDs from Dengue to Schistosomiasis to Trachoma is complicated and demonstrates that putting diseases together in a category does not result in an easy choice of strategies. Do we control or eliminate or simply manage illness? Can our health systems handle the needs for disease elimination? Is the public ready to get on board?

Malaria Updates

And concerning being complicated, malaria this week again shows many facets of challenges ranging from how to recognize and deal with asymptomatic infection to preventing reintroduction of the disease once elimination has been achieved. Several reports this week showed the particular needs for malaria intervention ranging from high burden areas to low transmission verging on elimination to preventing re-introduction in areas declared free from the disease.

In South West, Nigeria Dokunmu et al. studied 535 individuals aged from 6 months were screened during the epidemiological survey evaluating asymptomatic transmission. Parasite prevalence was determined by histidine-rich protein II rapid detection kit (RDT) in healthy individuals. They found that, “malaria parasites were detected by RDT in 204 (38.1%) individuals. Asymptomatic infection was detected in 117 (57.3%) and symptomatic malaria confirmed in 87 individuals (42.6%).

Overall, detectable malaria by RDT was significantly higher in individuals with symptoms (87 of 197/44.2%), than asymptomatic persons (117 of 338/34.6%)., p = 0.02. In a sub-set of 75 isolates, 18(24%) and 14 (18.6%) individuals had Pfmdr1 86Y and 1246Y mutations. Presence of mutations on Pfmdr1 did not differ by group. It would be useful for future study to look at the effect of interventions such as bednet coverage. While Southwest Nigeria is a high burden area, the problem of asymptomatic malaria will become an even bigger challenge as prevalence reduces and elimination is in sight.

Sri Lanka provides a completely different challenge from high burden areas. There has been no local transmission of malaria in Sri Lanka for 6 years following elimination of the disease in 2012. Karunasena et al. report the first case of introduced vivax malaria in the country by diagnosing malaria based on microscopy and rapid diagnostic tests. “The imported vivax malaria case was detected in a foreign migrant followed by a Plasmodium vivax infection in a Sri Lankan national who visited the residence of the former. The link between the two cases was established by tracing the occurrence of events and by demonstrating genetic identity between the parasite isolates. Effective surveillance was conducted, and a prompt response was mounted by the Anti Malaria Campaign. No further transmission occurred as a result.”

Bangladesh has few but focused areas of malaria transmission and hopes to achieve elimination of local transmission by 2030. A particular group for targeting interventions is the population of slash and burn cultivators in the Rangamati District. Respondents in this area had general knowledge about malaria transmission and modes of prevention and treatment was good according to Saha and the other authors. “However, there were some gaps regarding knowledge about specific aspects of malaria transmission and in particular about the increased risk associated with their occupation. Despite a much-reduced incidence of malaria in the study area, the respondents perceived the disease as life-threatening and knew that it needs rapid attention from a health worker. Moreover, the specific services offered by the local community health workers for malaria diagnosis and treatment were highly appreciated. Finally, the use of insecticide-treated mosquito nets (ITN) was considered as important and this intervention was uniformly stated as the main malaria prevention method.”

Kenya offers some lessons about low transmission areas but also areas where transmission may increase due to climate change. A matched case–control study undertaken in the Western Kenya highlands. Essendi et al. recruited clinical malaria cases from health facilities and matched to asymptomatic individuals from the community who served as controls in order to identify epidemiological risk factors for clinical malaria infection in the highlands of Western Kenya.

“A greater percentage of people in the control group without malaria (64.6%) used insecticide-treated bed nets (ITNs) compared to the families of malaria cases (48.3%). Low income was the most important factor associated with higher malaria infections (adj. OR 4.70). Houses with open eaves was an important malaria risk factor (adj OR 1.72).” Other socio-demographic factors were examined. The authors stress the need to use local malaria epidemiology to more effectively targeted use of malaria control measures.

The key lesson arising from the forgoing studies and news is that disease control needs strong global partnerships but also local community investment and adaptation of strategies to community characteristics and culture.

Malaria funding may never be enough, but better program management should be possible

The World Malaria Report shows that malaria cases are up, and even though there are fewer reported cases in 2017 than 2010, the number is greater than 2016. So once again high burden countries are being targeted. Today this focus is on “High Burden to High Impact”, but in 2012-13 it was the “Malaria Situation Room” that also focused on 10 high burden countries.

Progress was being made up to around 2015-16, it then started to reverse. The challenge was not just funding. As the WHO Director General noted in the foreword to the 2018 World Malaria Report (WMR), “Importantly, ‘High burden to high impact’ calls for increased funding, with an emphasis on domestic funding for malaria, and better targeting of resources. The latter is especially pertinent because many people who could have benefited from malaria interventions missed out because of health system inefficiencies.”

Over the years there have never been enough pledged funds to fully achieve targets, but as funding has never reached desired levels, attention is now being drawn more and more to the source of that funding (more emphasis on domestic/endemic countries) and especially how the health system functions to use the funds that are made available. In 1998 during one of the early meetings establishing the Roll Back Malaria Partnership, a speaker stressed that malaria control could not succeed without concomitant health systems strengthening and reform. That 20-year-old thought was prescient for today’s dilemma.

First, what is the funding situation? As outlined in the World Malaria Report …

  • In 2017, an estimated US$ 3.1 billion was invested in malaria control and elimination efforts globally by governments of malaria endemic countries and international partners – an amount slighter higher than the figure reported for 2016.
  • Governments of endemic countries contributed 28% of total funding (US$ 900 million) in 2017, a figure unchanged from 2016.
  • Funding for malaria has remained relatively stable since 2010
  • To reach the Global Technical Strategy 2030 targets, it is estimated that annual malaria funding will need to increase to at least US$ 6.6 billion per year by 2020

The question remains – does investment lead to results. The WMR shows, for example, that “Between 2015 and 2017, a total of 624 million insecticide-treated mosquito nets (ITNs/LLINs), were reported by manufacturers as having been delivered globally. This represents a substantial increase over the previous period 2012–2014, when 465 million ITNs were delivered globally”.

At the same time the report states that, “Households with at least one ITN for every two people doubled to 40% between 2010 and 2017. However, this figure represents only a modest increase over the past 3 years, and remains far from the target of universal coverage.” Is it simply a matter of funding to reach the other 60% of households, or are there serious management problems on the ground?

Then there is the issue of using nets. The WMR traces new ownership and use from 2010 to 2017, and we can see that overall the proportion of the population at risk who slept under a net increased from around 30% to 50%, but only 56% of those with access to a net were sleeping under them. This can be attributed in part but not completely to the adequacy of nets in a household.

We should ask are enough nets getting to the right places, and also are efforts in place to promote their use. Behavior change efforts should be a major component of malaria program management. Even the so called biological challenges to malaria control have a human element. Monkey malaria transmission to people results from deforestation. Malaria parasite resistance to medicines comes from poor drug management on individual and systems levels.

The target year 2030 will be here before we know it. Will malaria still be here, or will countries and donors get serious about malaria financing AND program management?

The Challenge of Reducing Malaria in Angola – High Transmission Provinces

Below is an abstract of a poster presentation today at the American Society of tropical Medicine 65th Annual meeting in Atlanta. The presentation was prepared by Jhpiego’s Angola team including Jhony Juarez, Margarita Gurdian-Sandoval, Julio Bonillo, and William R. Brieger. Please join us at the Late-breaker’s session at noon.

CONTEXTmap

  • Angola has three major belts of malaria transmission
  • The north is high transmission and borders on the heavy burden country of the Democratic Republic of the Congo
  • The mid-section of the country is meso-endemic
  • The south is considered low endemic
  • This low endemic area brings Angola into the Southern African Elimination 8 countries.

METHODS: Field visits were made to six northern high burden provinces. Health information system (HIS) data were collected from each provincial health department. Supplementary HIS information was collected from the national malaria control program

northFINDINGS: Data from the six high burden provinces reveal an overall upward trend in confirmed malaria. Cases from 2011, but with a jump of over 130,000 confirmed cases from 2014 to 2015. This occurred despite support from government and major malaria partners over the past decade. Overall cases in the country have risen from 2.73m in 2011 to 3.25m in 2015

NATIONAL MALARIA EFFORTS

  • Between 2012 and 2015 2 million Long Lasting insecticide treated nets were distributed to a population of approximately 5 million in the 6 provinces
  • This exceeded the desired 2 people per net ratio
  • netsIntermittent preventive treatment in pregnancy reached only 59% of women registering for antenatal care in 2015
  • Only 44% and 18% of women received the second and third IPTp doses respectively.

CHALLENGES

  • A dual challenge makes performance of malaria indicators difficult
  • The Global Fund grant had expired for more than a year
  • The oil-based economy also suffered from the major global drop in prices

THE WAY FORWARD

  • Angola requires concerted efforts by government and partners to scale up malaria control interventions
  • Universal coverage targets must be sustained if these high burden northern provinces are to begin seeing a decline in the disease

Attaining and Sustaining – malaria targets

Recent reports on the Global Burden of Disease with a focus on Millennium Development Goal #6 has stressed the improvement in malaria morbidity and mortality indicators since the Abuja Declaration of 2000. In particular, “Global malaria incidence peaked in 2003, with 232 million new cases, subsequently falling by about 29% to 165 million new cases in 2013.”

The improvements are attributed in part to the large increase in funding. The remaining challenge derives in part from the fact that four countries, India, Nigeria, Democratic Republic of the Congo and Mozambique account for nearly two-thirds of the global case load. Global progress in reducing disease has been achieved despite the fact that in these and many other countries, achievement of 2010 targets for malaria intervention coverage (80%) have lagged. In some cases national surveys have shown some declines in coverage (e.g. Nigeria).

DSCN7147Ghana provides a good example of the challenges. National surveys in 2006, 2008 and 2011 have shown mixed results in the use of insecticide treated nets by children below the age of 5 years.  While the proportion rose from 20% to 39% between the first two surveys, it stayed steady in 2011. A new survey in underway, but as of 2012 there were still areas of the country that needed nets, and we know that nets wear out in between distributions  and need to be replaced through routine services as seen in the photo.

Ghana 2006,8,11 Child sleep under netThe three surveys so far in Ghana paint a mixed picture as seen in the attached graph.  In six of the ten regions, net coverage for young children declined and in four it increased over the period.  This on balance led to the lack of overall improvement.

Thinking back to the reduced burden of disease overall, one can surmise that even some level of malaria intervention can impact on incidence of the disease, but the goal was no mortality for 2015, just one year from now.  If the trend seen in Ghana (which is reflective of other countries) continues, we will pass 2015 without attaining the 2010 coverage targets and still experience an unacceptable malaria disease burden.  Malaria elimination looks farther away each day.

Malaria, Hypertension and Pregnancy: where communicable and non-communicable diseases may cross paths

WorldHypertensionDay_SmallTomorrow, May 17th, is World Hypertension Day.  Much attention of recent has been focused on the importance of non-communicable diseases (NCDs) like hypertension in terms of global burden, and concerns have been expressed that communicable or infectious diseases (CDs) may become neglected, although they still cause huge levels of morbidity and mortality. What people may not realize is that there are connections between the NCDs and the CDs.

World Hypertension DayBetter research is needed to document the relationships and influences of one on the other, but some preliminary work has been done with pregnant women who are susceptible to both hypertension and malaria.  What does that combination do?

What the existing literature implies so far is that malaria in pregnancy may in fact be associated with hypertension in some cases and that both conditions can lead to intra-uterine growth retardation and low birth weight.  Also boys who were born to mothers with malaria in pregnancy had excess hypertension in their first year of life and girls had higher SBP.

Hypertension malaria LBWThe role of malaria in pregnancy in low birth weight is well established. Furthermore Lackland and colleagues shared that, “there have been numerous ecologic and observational studies that identified significant inverse associations of birth weight with blood pressure levels at various ages in later life.” A graphic posted to the right shows potential malaria and hypertension interactions. These are areas that deserve more observation, documentation and research.

Overall we can see that there is not a real dichotomy between CDs and NCDs, and both interact in the health of individuals, families and communities.

Rural Health and Malaria, a South Africa Example

South Africa’s Rural Health Advocacy Project (RHAP) has released a report or fact sheet on rural health in South African provinces. Of interest is the overlap of rural problems and malaria endemicity.  Three Provinces that border Mozambique are also endemic for malaria – from north to south: Limpopo, Mpumalanga and Kwa Zulu Natal (KZN).

South Africa Provinces and MalariaSeven of the 10 poorest districts in the country fall in two of these endemic provinces, Limpopo and KZN. The two districts with the highest HIV prevalence are in Mpumalanga and KZN, and those two provinces themselves have the highest HIV prevalence among all the provinces.

The fact sheet also reports that, “Poor rural households in a Limpopo District spend up to 80% of monthly income on health expenditure, travel costs being a significant contributor.”

Limpopo and Mpumalanga are among the four provinces with the lowest distribution (or highest shortages) of human resources for health. Concerning maternal mortality, the fact sheet notes that, “Each year an estimated 4300 mothers die. KZN most affected.”

While one cannot say the exact role malaria plays in rural poverty and rural health disparities, it is important to note that interventions to control and eliminate the disease must have a strong rural focus. Hopefully there will be economic benefits to such interventions.

900 Days Left to Make a Big Difference in Malaria as African Ministers of Health Learn in Abuja

A Breakfast Briefing was given to African Ministers of Health and Foreign Affairs on 13th July 2013 in Abuja, Nigeria to review progress in Africa’s fight against malaria and to announce a new initiative to support 10 high-burden countries as part of the Special African Union Summit on HIV/AIDS, Tuberculosis and Malaria.

final-eng-invite-abuja-mohs-malaria-session-09-07-2013-sm.jpgDr Fatoumata Nafo-Traoré, Executive Director, Roll Back Malaria (RBM) Partnership in her welcome address) acknowledged the high level of commitment of partners and the high level of leadership from endemic countries over the past decade in the fight against malaria resulting on 44 countries seeing a > 50% reduction in malaria cases, but we cannot rest in the face of financial and technical challenges.

Dr Mustapha Sidiki Kaloko, the African Union Commission’s Commissioner for Social Affairs in his opening remarks reminded us that external funding has never been guaranteed, and as it is ebbing we need to scale up domestic financial support. The AU will work with all stakeholders to help close the $4b gap and not let gains reverse. In order not to lose momentum innovative domestic funding models are needed.

Joy Phumaphi, Executive Secretary of the African Leaders Malaria Alliance (ALMA) delivered the ALMA Scorecard update. She noted that the scorecard provides a roadmap and pushes countries to demonstrate results. Very positive results in terms of adopting policies that oppose artemisinin monotherapies and promote community case management are the norm now.

art-mono-banned.jpgThe challenge is the low scores on public sector management and effective use of existing resources. Efficiency gains could deliver up to 40% more services with available money. Continued scorecard success also depends on global attention remaining focused on Africa as post MDG goals are being set.

Dr Robert Newman, Director of the WHO Global Malaria Programme (WHO-GMP) introduced the new Larval Source Management (LSM) Manual. He told the gathering that the new LSM Manual was a result of advocacy by Nigeria’s Minister for Health.  IRS and ITNs have been success stories, but we need to use all available tools in appropriate manners. LSM has a unique niche where one finds discrete, fixed and definable water bodies as opposed to water in multiple diffuse sources like cattle foot prints on a rutted road that come and go over days.

Larvicides are expensive and labor intensive and need regular monitoring. People need to remember that environmental management is another larva control tool.  With all vector measures “commodities don’t deliver themselves”, but require commitment and action of people at all levels form the national to the community.

Dr Richard Kamwi, Hon. Minister of Health, Namibia, shared that in the 1990s there were 7,000 malaria deaths in his country annually, but only 4 in 2012. Namibia has a mixed strategy especially in the northern border area, and is close to pre-elimination.

Dr Robert Newman, Director of WHO-GMP gave a presentation on the Malaria Situation Room concept and explained that even though progress has been made and millions of lives saved, there are over 219 million cases of malaria annually and 660,000 deaths/ A disproportionate burden of malaria deaths even now is in African children under five years of age. We have responsibility for these children.  This burden is focused on 10 countries which account for 70% of malaria cases in Africa and 56% globally.

The Malaria Situation Room will be a way to collate data on funding, intervention, commodities and results.  International partners will continue to support all endemic countries, but malaria elimination will remain elusive unless more coordinated action is aimed at high burden areas.

With only 900 days left before the MDGs reach their target date (end of 2015), we want to anticipate and prevent problems like stock-outs, but wait to hear that there have been no antimalarials in clinics for over a month. We want to be proactive in the face of potential dis-investment to protect 10 years of progress which could be undone in only one malaria transmission season.

dscn3310-sm.jpgDr Alexandre Manguale, Hon. Minister of Health, Mozambique noted that his country is one of the ten in the “situation room.” Mozambique has made great progress in case reduction in the south with support from the cross border Lubombo Spatial Development Initiative. The rest of the country poses special challenges with logistics and weather (flooding). Under these circumstances partners need to coordinate and be flexible in response to gaps and bottlenecks. Information gathered and shared through the situation room will make this possible.

At this point Dr Newman, Dr Nafo-Traoré and Dr Kaloko officially launched the Malaria Situation Room with a ribbon-cutting. Now the work begins to make this ‘room’ a pro-active place to eliminate malaria.

Malaria Funding from the Perspective of International Donors

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.

international-funding-sm.jpgThe 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.

Neonatal Mortality – how does malaria contribute?

Over 40% of child deaths are now due to neonatal mortality, according to National Public Radio (NPR). NPR was commenting on a new article published in PLoS Medicine that examines neonatal death trends between 1990 and 2009. Although reducing child deaths is a key component of the Millennium Development Goals, neonatal mortality rates have actually increased in eight African countries, many of which are endemic for malaria.

Malaria contributes to neonatal mortality in two ways.  First, malaria in pregnancy leads to stillbirth and low birth weight babies who are more prone to death that those of normal weight. In a recent review, Ishaque and colleagues reported that, “The clearest evidence of impact in stillbirth reduction was found for adequate prevention and treatment of syphilis infection and possibly malaria.” Low birth weight can be prevented by using intermittent preventive treatment during pregnancy (IPTp).

The second contribution of malaria to neonatal mortality is congenital and neonatal malaria. A recent study in Nigeria has re-emphasized the connection between placental malaria and congenital malaria. Again, IPTp has be found effective in reducing neonatal cases of malaria.

dscn8011-iptp.jpgPublished research from Mozambique confirm that, “IPTp-SP was highly cost-effective for both prevention of maternal malaria and reduction of neonatal mortality in Mozambique.” Ironically, IPTp coverage is one of the key malaria indicators that is lagging as we have passed the RBM 2010 target of 80% coverage with two doses minimum for each pregnant woman in stable transmission areas.

Sufphadoxine-pyrimethamine, the drug used for IPTp, is cheap.  Many women attend antenatal care clinics where IPTp is (or should be given), yet Demographic and Health Survey results show few countries nearing even the 60% coverage mark for two IPTp doses.  There are no excuses in 2011 for pregnant women suffer and their newborns die because of malaria in pregnancy.

Population Growth and Malaria Elimination

A major challenge in successful malaria control programming is correctly estimating the numbers of commodities needed and ensuring their timely delivery.  It is not clear the extent to which this forecasting process accounts for population growth.

Therefore, when the International Herald Tribune (IHT) reports on population growth in the region with the heaviest burden of malaria, we take notice … “What is most striking, though, is the unabated demographic swelling of Africa. Africa’s population has almost doubled between 1975 and 2000, growing from 416 to 811 million; it will add another 75 percent to reach 1.4 billion people in 2025, and presumably another 55 percent to reach the staggering figure of 2.2 billion by mid-century.”

pop3africabig.gifOne wonders whether successful efforts to reach 2015 targets of reduced malaria morbidity and mortality might offset the need for more and more LLINs, ACTs and other commodities? In some countries moving close to elimination, this might be true, but the high burden countries – high because of their large populations and challenging logistics – remain a concern. As the IHT observed, “countries such as Nigeria (230 million in 2025, 390 million in 2050); Ethiopia (110 million and 145 million) and Congo (95 million and 148 million) have since long been identified as the demographic giants of sub-Saharan Africa.”
We already know that universal coverage was not achieved by 31 December 2010 as many endemic countries are still sourcing and distributing nets and other commodities in the hopes of reaching the target in 2011. All the while, population does not remain static.

We also know that there has been strong competition for nets and drugs among endemic countries because of the low number of manufacturers of approved products.  A lesson from the field is that rapid diagnostic test supplies are not close to catching up with supplies of artemisinin-based combination therapy (ACT) medicines, and long lasting insecticide treated nets (LLINs) are not as long lasting as once thought.  Will we be able to get enough nets in 2013-14 to replace those distributed in 2010-11?

So in the short run as population increases, need for malaria control commodities will also increase.  And, one wonders can donor support be counted on?

Ironically even as fertility decreases (though is still high), population grows because of the success in disease control programs and reduced mortality. Also as UNFPA explains, the fact that the majority of people in developing countries are young means that the bulk of the population still has many years of reproductive life ahead, hence population in the foreseeable future will increase even if fertility of lower.
Of course, even when people survive malaria episodes they experience personal costs that holds back the national economy.  The question is whether we can get enough malaria commodities on the scene and in people’s hands before population doubles?