Tropical Health Matters

Today is Labor Day in the United States. This holiday was first celebrated in 1882 with a parade in New York. Many countries observe a similar holiday on May 1st.  Regardless of the date, we should always consider the impact of malaria on the labor force of endemic countries and the subsequent economic impact of the disease.

For example, in Vietnam, Morel and colleagues conclude that, “Whilst government provision of malaria treatment keeps the direct costs relatively low, the overall loss in income due to illness can still be significant given the poverty amongst this population, especially when multiple cases of malaria occur annually within the same household.” The article goes on to document the cost in terms of loss of household productive workdays.

In India, Kumar and colleagues documented that, “The maximum DALYs lost (53.25%) were in the middle productive ages from 15 to 44 years of age, followed by children < 14 years of age (27.68%), and 19% in those > 45 years of age.” They continue by describing efforts to calculate the economic burden of the disease over the past 75 years.

A study of Ethiopian farmers who reported a malaria-like illness “stayed in bed for a mean duration of 7.8 days. Suspected, in this rural population, is a cycle of malnutrition, disease, and activity restriction that begins in childhood. Needed are interventions that reduce the prevalence of childhood stunting and health services that provide adequate prevention and treatment of diseases such as malaria.”

There is hope for workers. O’Meara et al. report, “substantial, lasting declines linked to scale-up of specific interventions,” in southern African countries. Countries in the Horn of Africa have also, “experienced substantial decreases in the burden of malaria linked to the introduction of malaria control measures.” In other countries the switch to ACTs after chloroquine began to fail, “led to immediate improvements; in others malaria reduction seemed to be associated with the scale-up of insecticide-treated bednets and indoor residual spraying.”

Will elimination of malaria lift endemic countries out of poverty? To find out, we need to achieve universal coverage and maintain a high level of intervention.

(see updated Ghana Advocacy News)

The Malaria in Pregnancy Consortium (MIPc) highlighted its ongoing research activities at the recently held 5th Pan-African Malaria Conference in Nairobi.  While results on issues like new malaria treatment and preventive regimens are still in the works, the MIPc did report on preliminary efforts to measure the burden of malaria in pregnancy.

Although international agencies like WHO have given estimates of malaria in pregnancy (MIP) risk, one has not always been sure of how these figures were derived. The MIPc has begun to gather and reanalyze current data to get a better picture of the situation in 2007 since we expect that there will definitely be changes as progress is made toward malaria elimination.

The standard figures have been an annual 50 million pregnant women at risk globally, with 25-30 million in Africa. This may have been nased on live births reported. Other unknowns, according to the MIPc is whether Plasmodium vivax was considered and whether distinctions were made between stable and unstable transmission areas.

Advances made with the Malaria Atlas Project have helped as have UNDP population data for women aged 15-49 years.  There was also the challenge of going beyond live births to counting all pregnancies, whether these terminated early or went to term. MIPc was able to determine that around 13% of pregnancies may end in miscarriage. This is important since malaria itself may lead to miscarriage – live births only would not pick this up.

The attached chart shows calculations presented by MIPc. They noted that the African P. falciparum numbers were not much different than have been estimated to date.  more work on these data is underway, but the information presented in Nairobi provides us with the beginnings of a baseline prior to achievement of universal malaria intervention coverage and entry into the malaria elimination phase of intervention.

Another interesting MIP presentation was given by Patrick Duffey during the final plenary session of the MIM conference.  He summarized research that has identified a genetically different form of P. falciparum that infects pregnant women, especially those pregnant for the first time. Some immunity is developed in later pregnancy. This research should contribute to vaccine development.

Dr Duffey also shared information that similar biomarkers for pre-eclampsia are found in women who are pregnant for the first time and have malaria.

The MIM conference has been an important venue for stressing the continued importance of addressing and preventing malaria in pregnancy as a central strategy in our efforts to eliminate malaria overall.

——- see for example …
Muehlenbachs A, Fried M, Lachowitzer J, Mutabingwa TK, Duffy PE. Natural selection of FLT1 alleles and their association with malaria resistance in utero. Proc Natl Acad Sci U S A. 2008 Sep 23;105(38):14488-91. Epub 2008 Sep 8.

Avril M, Kulasekara BR, Gose SO, Rowe C, Dahlbäck M, Duffy PE, Fried M, Salanti A, Misher L, Narum DL, Smith JD. Evidence for globally shared, cross-reacting polymorphic epitopes in the pregnancy-associated malaria vaccine candidate VAR2CSA. Infect Immun. 2008 Apr;76(4):1791-800. Epub 2008 Feb 4.

Kabyemela ER, Muehlenbachs A, Fried M, Kurtis JD, Mutabingwa TK, Duffy PE. Maternal peripheral blood level of IL-10 as a marker for inflammatory placental malaria. Malar J. 2008 Jan 29;7:26.

The Malaria Atlas Project (MAP) has been working hard over the past several years to assemble what is known – published and unpublished – about the distribution of malaria around the world.  A press release notes that now, “The most detailed map ever created of malaria risk worldwide is published today by an international team of researchers funded by the Wellcome Trust. The Malaria Atlas Project (MAP) will be a powerful tool for helping target malaria control programmes and suggests that elimination of malaria in three-quarters of the world’s at-risk areas might be less difficult than previously thought.”

The Executive Director of the Global Fund has stressed the importance of MAP in helping donors like GFATM measure and count progress of their investments: “We need to increase the information available to us and to our donors to demonstrate that investing in malaria control does indeed reduce the numbers of people at risk worldwide. With this kind of information, we can reassure donors by graphically showing progress and highlight where further investments are most needed.”

While the publication of the 2007 MAP in this month’s PLoS Medicine marks a culmination in efforts to locate Plasmodium falciparum in the world, it is also a baseline for future updating.  The team now wants to map vivax malaria, too. In addition, the team has been publishing findings in over 30 scientific articles since 2004.

A particularly instructive publication concerned comparison of ITN coverage compared with levels of malaria endemicity and poverty. They documented that areas with some of the highest levels of malaria as well as largest burden of disease have some of the lowest levels of net coverage.  Nigeria was a case in point where its large population accounts for 25% of the children at risk in stable transmission areas of Africa and yet its net coverage was projected at 4% for 2007.

Another important finding from the net study was the clear indication that net distribution mechanism affected coverage.  The best coverage was achieved where nets were free, followed by areas with subsidies. The lowest coverage figures were found in areas where nets were made available through the commercial sector.  Such information about distribution strategies and coverage can help national program planners.

The continued success of MAP depends on researchers and program managers in endemic countries.  Data need to be shared on a regular basis so that the malaria maps can be updated and national and international partners can better target their interventions.  Researchers and program managers with up-to-date malaria information are encouraged to share their results with the MAP team at map@zoo.ox.ac.uk.

Nigeria has been classified as one of the main high burden malaria endemic countries.  The World Bank Booster program notes that the per capita investment in malaria is disproportionately low in largest high burden countries, and this threatens progress across the continent.

The results of this low level of per capita investment were highlighted by Oresanya and colleagues recently when they reported that, “Household ownership of any net was 23.9% and 10.1% for ITNs.” Furthermore, “Utilization of any net by children under-five was 11.5% and 1.7% for ITN.” The Abuja targets look a long way off from Abuja and environs.

One of the key “predictors of use of any net among under-five children … [was] the presence of a health facility in the community.” The implication is that the high burden malaria problem is not only characterized by low relatively investment in malaria control, but a similarly low level of investment in the health system through which malaria interventions can be delivered.

This assumption is reinforced in a report by Michael Reid in the WHO Bulletin stating that, “Despite several attempts at reform over the past 30 years, Nigeria still lacks a clear and coordinated approach to primary health care.” In only two years during the 30 years since the Alma Ata Primary Health Care (PHC) Declaration has the Nigerian budget for health exceeded 5% of the total, despite the formulation and reformulation of PHC policies and the training and re-training of front-line health care workers.

Recently we reinforced the point that malaria control must have a strong health system to reach all in need with life saving interventions. One wonders whether the challenge of high burden malaria countries can be addressed without major health care reform. Reid provides other disheartening documentary and interview evidence:

• Nigeria has never learnt or developed any system of authentic and full-scale community health care before Alma-Ata or after it
• The world health report 2000 ranked Nigeria 187 out of 191 countries for health service performance
• Infant mortality rates have been deteriorating from 85 per 1000 live births in 1982, 87 in 1990, 93 in 1991 to 100 in 2003

Reid notes a tendency to blame the problem in part on a colonial legacy of two health systems – one for the elite and the other for the poor.  Other countries with fewer resources than Nigeria have overcome this legacy. Is it a matter of political will?

“Peripheral health facilities have huge potential to make a difference to health and survival at household level in rural Tanzania, even with current human resources,” according to Schellenberg et al. (2008). These peripheral facilities in Nigeria and primary health care for that matter, are the constitutional responsibility of local government in Nigeria. A visit to many of these in Akwa Ibom State last month found shortages of staff and medicines, lack of basic furniture, damaged roofs, abandoned rooms, lack of water supply and light, and staff quarters overgrown by weeds. It would appear that in high burden countries the neglect of PHC is the same as the neglect of malaria control.

The Journal of Tropical Pediatrics reported on a study in Burkina Faso, which showed that afebrile children infected with Plasmodium falciparum, still suffer the consequences of malaria. A graph summarizing the findings by Ouedraogo and colleagues shows moderate to severe anemia also occurs in infected children that do not show obvious signs of the disease.

Even though the children in this Burkina Faso study were only 6-23 months old, the findings reinforce our recent discussion about malaria in school children, who suffer problems of anemia, lethargy and poor attention in school when infected even if they do not show other signs of malaria.

It was not mentioned whether the children in Burkina Faso had access to ITNs. Burkina Faso itself has received little attention from the international malaria partners. Its 2-year Global Fund grant has finished, although the country was awarded a Round 7 grant. By the end of the first grant only 29% of households had an ITN/LLIN.

Much valuable malaria research has been conducted in Burkina Faso. The present study emphasizes that the international community should not forget the needs of Burkinabe for quality malaria programming.

This Day Newspaper reported in May 2007 that, “Unfortunately, Nigeria, according to the World Bank, carries Africa’s greatest malaria burden with 110 million cases per year out of her 140 million people. Malaria accounts for 30 per cent of infant mortality in Nigeria. According to Professor Eyitayo Lambo, Nigeria’s Health Minister and chairman of RBM, malaria costs the country an estimated US$1 billion a year.”

Likewise WHO observed that, “Malaria is the most significant public health problem in Nigeria. It accounts for 25% of under-5 mortality and 30% childhood mortality and 11% maternal mortality. At least 50% of the population will have at least one episode of malaria annually while children that are aged below 5 years (about 24 million) will have 2 to 4 attacks of malaria annually. The economic cost of malaria, arising from cost of treatment, loss of productivity and earning due to days lost from illness, may be as high as 1.3% of economic growth per annum. The disease is a major cause of poor child development.”

Nigeria has been in the forefront of the RBM partnership and hosted the 2000 Abuja Summit that launched the partnership in Africa. Nigeria is also important because as noted above, with the largest population of any single African country, Nigeria bears the greatest burden of malaria. Without progress in Nigeria, there will be little overall progress in the fight against malaria in Africa. Therefore, how far have we progressed in reducing the malaria burden in Nigeria? Unfortunately the Malaria Consortium reports that. “Previous efforts to control malaria in Nigeria have not led to a sustained reduction in the burden of mortality and morbidity.”

Nigeria has kept up with national strategies and planning, but 10 years after RBM was launched and 8 years after the Abuja Summit, the coverage indicators for malaria interventions remain extremely low as seen in the attached chart (UNICEF). Obviously there will be regional and state variations, but even with input from among others, GFATM, USAID, DfID, UNICEF, the World Bank and of course the oil rich national government, the overall picture is bleak. Public statements announcing the imminent demise of malaria in Nigeria had to be withdrawn, yet Nigeria still hopes to reach the 2010 RBM targets.

What can be done? Nigeria was on the verge of losing its Global Fund malaria grants in 2006. Quick work to address management and health systems bottlenecks around procurement and supply, monitoring and evaluation and coordination among the three levels of government (federal, state and local) helped save the grants, but these problems obviously have not been banished completely.

When RBM started in 1998 the founders said that malaria could never be rolled back unless these efforts were carried out in the context of health system reform and strengthening. Nigeria may be the most obvious case study for the importance of health systems. Donors who focus only on outcome statistics are missing the point – outcome cannot be achieved, let alone sustained, where systems are weak.

Workers Day is a time to remember that malaria affects the whole population in endemic countries. The American Association for the Advancement of Science reminds us that, “Malaria is likely … to have a long-term impact on household and community productivity.” The long term effects come in part because malaria interferes with the schooling of children.

Bleakley points out that the connection between malaria and poverty may be a two-way street – malaria depresses productivity. But poverty itself depresses the family’s and the community’s ability to fight malaria. The effects may arise from continued exposure to childhood malaria. While an individual episode as an adult may not have large effects, cumulative exposure may. Bleakley explained that after eradication programs in the Americas, “In both absolute terms and relative to the comparison group of non-malarious areas, cohorts born after eradication had higher income and literacy as adults than the preceding generation.”

In many endemic countries a large portion of the labor force works in the informal sector where issues like absenteeism and lost productivity are least likely to be measured. In these settings, “The burden of malaria is often greatest among the very poor as they are least able to protect themselves and seek treatment. Hence, malaria can exacerbate existing inequalities.”

As Onwujekwe et al. (2004) note, “Malaria is the leading cause of mortality and morbidity in Nigeria, resulting in the decreased productive capacities of households and increased poverty.” This creates inequalities in a household’s ability to acuire and benefit from malaria control interventions.

Likewise, Chuma and colleagues (2006) note that wealthier households are better able to cope with malaria. “The impacts of malaria on household economic status unfold slowly over time. Coping strategies adopted can have negative implications, influencing household ability to withstand malaria and other contingencies in future. To protect the poor and vulnerable, malaria control policies need to be integrated into development and poverty reduction programmes.”

These facts are why advocates for malaria control state that all people in endemic communities, regardless of age or occupation, should have the benefits of free malaria treatment and ITNs/LLINs.

A new study published in Tropical Medicine and International Health (TMIH) shows that the burden of malaria falls disproportionately on poorer households. Somi et al. report that, “Poorer households bear a greater economic burden from malaria relative to their consumption than better-off households. Households are particularly vulnerable to malaria in the rainy season, when malaria prevalence is highest but liquidity is lower. Alternative strategies to assist households to cope with seasonal liquidity issues, including insurance, should be investigated. The seasonal variation in the economic burden of malaria has implications for the design and interpretation of studies.” The attached graph shows these findings for the rainy season.

In the same issue of TMIH, Deressa et al. look at the experience of rural families in an area of epidemic malaria and conclude that, “Malaria poses a significant economic burden on rural households and individuals both through out-of-pocket payment and person-days lost.” They suggest that, “The promotion and implementation of insecticide-treated nets would alleviate the economic consequences of the disease.”

Malaria Journal reported last year that, “The impacts of malaria on household economic status unfold slowly over time. Coping strategies adopted can have negative implications, influencing household ability to withstand malaria and other contingencies in future,” in a review article by Chuma et al. These negative coping strategies include borrowing money and selling assets, often because poor people have delayed seeking treatment they know they cannot afford.

As mentioned above, providing ITNs to the poor is a step in the right direction. Other pro-poor interventions that cut mortality and improve equitable access to services include “Strict monitoring of patients, removal of prescription charges for families, and small financial incentives for the staff cut hospital mortality for malaria” and “Implementation of home based practices using prepackaged antimalarial drugs.”

Ultimately, as Chuma et al., suggest, “To protect the poor and vulnerable, malaria control policies need to be integrated into development and poverty reduction programmes.” In short – the Millennium Development Goals see malaria control as part of development, not a vertical disease program. Donors and health planners need to take note.