Tropical Health Matters

With the big push to achieve universal coverage of long lasting insecticide-treated nets (LLINs) by the end of 2010, most countries are relying on procurement from a few big companies, most not located in endemic regions. As the Roll Back Malaria Partnership explains:

Rapidly scaling up to universal coverage for populations at risk is critical to achieve the targets of 50% mortality and morbidity reduction by 2010 and a 75% reduction in morbidity and near zero mortality by 2015. The principle of scale-up has been promoted since 2005 by the RBM Partnership. This commitment has been reaffirmed by the UN Secretary-General’s call on World Malaria Day in April 2008 to “put a stop to malaria deaths by ensuring universal coverage by the end of 2010” through the use of vector control and case management tools and strengthening of community-level efforts.

Because most country coverage figures show a major gap in net ownership AND use, the term ‘catch up‘ has been used to describe this massive scale up. For example, the recently released 2008 Nigeria Demographic and Health Survey shows

• 17% of households have any kind of bed net, treated or not
• 12% of children under 5 years of age slept under any net
• 11% of these children slept under an ITN
• 12% of pregnant women also slept under any net

Kenya’s newly launched national malaria strategy documents that in 2007 40% of pregnant women slept under an ITN, as did 50% of children under 5 year old.

These figures are well below the 2010 RBM coverage target of 80%. As the UN concedes, “Nigeria and Kenya (are) two nations which together account for one third of the estimated 1 million deaths worldwide from the deadly disease.” While Nigeria alone is in the process of distributing more than 60 million LLINs by the end of 2010, this feat aby itself will not guarantee achieving the MDGs.  As RBM explains …

Even if parasite prevalence falls to low levels, malaria control will not eliminate the mosquito vector, the parasite, or the favorable environmental conditions for transmission in many locations. To keep malaria at bay, countries need to maintain high levels of coverage even in the absence of a large number of cases. Relaxation of control—whether because of the decline in political will, decrease in funding, or some other reason—could lead to resurgence in transmission and to epidemics.

The maintenance phase of intervention is known also as ‘keep up.’ This means replacing LLINs that are damaged or lose their insecticide strength or to provide nets to new members of a population.

RBM has estimated a 4-5 year life-span for LLINs. As Stephen Smith from CDC reminds us, “Long-lasting nets don’t last forever.”  Smith cites data from Laos and Ghana that show in field conditions nets may be effective for only 1-3 years. This in part stems from the fact that manufacturers do not guarantee the strength of the insecticide beyond 20 washings. Behavior change to prevent frequent washings has not been easy. Nets are also damaged with holes and tears, and while this does not affect the insecticide potency, it may expose the sleeping person to mosquito bites.

So where are the continuous net supplies coming from to keep up? The New Times of Kigali provides one answer. “Rwanda’s manufacturing giant, Utexrwa has entered into a partnership with German chemical and pharmaceutical giant, Bayer to produce over 70, 000 anti-malaria bed nets.”

This brings another partner to the continent to join A to Z Textile Mills in Tanzania who through and agreement with Sumitomo Chemical have been producing long lasting nets since about 2003.  Local production has so far not been able to meet the bulk of the scale up needs for malaria control.

Hopefully local production will be positioned to address the keep up/maintenance needs for nets. This will require coordination between manufacturers, national malaria control programs and the private commercial sector to guarantee a market for nets.  This also assumes that WHO’s pesticide evaluation processes is scaled.

Local production is often made synonymous with capacity building. Without a realistic business plan and collaboration among malaria partners, local production may become a disappointment.

Pneumonia, diarrhoeal diseases and malaria are the biggest killers of children in the tropics. Malaria is the recipient of major funding efforts from the World Bank, the Global Fund, US President’s Malaria Initiative, DfID, Unicef plus many other bilateral, corporate and NGO donors.  Efforts to place a spotlight on diarrhoeal diseases and prevent mortality using oral rehydration in the 1980s and ’90s never really took off.  Pneumonia likewise has been a neglected disease.

The fate of pneumonia may change this year. One reports that during this year’s “World Health Day, a group of organizations and activists launched an effort to encourage the United Nations to declare November 2nd as World Pneumonia Day. Pneumonia which is the leading killer of children around the world taking upwards of 2 million lives of children under 5 every year is rarely discussed in the media as a childhood killer and is often thought of only as a disease of the elderly.”

GAVI observes that, “Pneumonia has been overshadowed as a priority on the global health agenda, and rarely receives coverage in news media. World Pneumonia Day will help bring this health crisis to the public’s attention and will encourage policy makers and grass roots organizers alike to combat the disease.”

Likewise Save the Children says, “We’re thrilled that so many people and organizations want to join forces for World Pneumonia Day to reduce the impact of the largest killer of children. Through our efforts, we expect to change the lives of millions of young children and parents by making childhood pneumonia deaths a part of history.”

Attention to Pneumonia does not detract from efforts to control malaria.  In fact the attached maps from the Malaria Atlas Project (MAP) and pneumoADIP show that the two diseases share common ground in the tropics. What is needed is an integrated at the community and household level that empowers local people to prevent and control childhood diseases through such actions as prompt and appropriate home management, hand washing, bednet use and vaccination.

Coordination at the local level is the key to success. District health systems must be strengthened for us to realize the full potential that communities have to deliver the goods for child survival.

Before we start counting malaria out for World Malaria Day 2009, it is still valuable to look back at the disease that knows no borders (WMD 2008).  The Angolan-Namibian border in particular recently came into the news: “The Health Ministries of Angola and of Namibia wish to collaborate, soon, in the combat to malaria and HIV/AIDS along the common border, in order to find solutions that guarantee better living conditions of the local population.” The WHO Regional Director was also involved in the coordination “mainly aimed at assessing the activities of health centres lying along the common border.”

Both Angola and Namibia have Global Fund malaria grants. Even though much of this border area has seasonal, unstable malaria, it still has malaria, and coordinated efforts will protect both countries. Angola, with US PMI assistance, is also targeting some of the border provinces for indoor residual spraying (IRS), which is an ideal intervention in such an environment. Namibia is also implementing IRS.

Borders are not always friendly places, and cross-border problems may threaten gains against malaria. Reports from Rwanda show major progress against malaria. Sievers and colleagues suggest that, “both admissions for malaria and laboratory markers of clinical disease among children may be rapidly reduced following community-based malaria control efforts.” Otten et al. likewise note that a “combination of mass distribution of LLIN to all children <5 years or all households and nationwide distribution of ACT in the public sector was associated with substantial declines of in-patient malaria cases and deaths in Rwanda …”  In terms of IRS, “Health centers in Rwanda’s Kigali province have reported a 30% decrease in malaria cases since the country initiated an indoor-insecticide spraying program in 2007.”

One wonders how gains in Rwanda can be maintained when there is frequent flare up of fighting on the western border in DRC, a challenge which has roots in Rwanda itself.  Mass displacement of people due to violence creates hunger and disease.  The BBC reported in August 2008 that only a tiny fraction of deaths have been due to violence. “Most died for mundane reasons associated with malnutrition, simple diseases or childbirth.” These people also die because, “Functioning public hospitals and clinics are rare – and those that do exist are in an appalling condition.”

Then to the north is Uganda where the Daily Monitor reported in November 2008 that, “The National Medical Stores has reduced the amount of malaria drugs it supplies to government hospitals by half due to dwindling stocks.” Malaria, either in mosquitoes or people, is not going to sit at the borders waiting for a visa to cross.

The Africa Union, which appears to be a central organization when it comes to addressing border issues on the continent has made some statements about malaria control. A 2007 AU Communique announced the launch of the “African Malaria Elimination Campaign.” The communique recommends …

… strong surveillance and health information systems as appropriate and strong inter-country and cross border collaboration are critical in order to achieve reduction in the burden. Once this stage is completed, the duration of which depends on the efforts and achievements of individual countries, this group of countries would subsequently aim to move on to the stage of malaria elimination.

The communique goes further to suggest the following strategy: “Building of inter-country and cross border initiatives and efforts including encouraging cross border cooperation and management to sustain areas freed of malaria.”  To become a reality such recommendations need to be backed with active efforts to reduce cross-border tensions and conflict. The Angola-Namibia example should be followed if malaria will truly be eliminated from Africa.

With about 2 months and 3 days to go until World Malaria Day 2009 partners are encouraged by RBM to start preparing to tell their own stories “to show the international community how far it has come – and how far it needs to go to reach its global malaria response.” Our target now for 2010 is 100% – universal coverage – with hopes of bringing malaria deaths near zero by 2015.

Its good to set targets and timetables – just as long as these are realistic – and do not ultimately discourage people. Guinea worm was supposed to have been eradicated in 1995, but remains in Sudan, Nigeria, Ghana, Burkina Faso, Niger, Togo and Ivory Coast according to a BBC report in December.  Donor fatigue sets in.  And in these days of economic downturn, even if donors are not tired, their purses are not as deep.  Counting funds and resources also needs to be part of the RBM countdown.

Nigeria is a high burden country and a good place to keep watch on progress toward targets. The National Malaria Control Program and colleagues has been good at publishing progress.

• An article last summer pointed out that by October 2005 only 13% of children under 5 years of age slept under any kind of net the night prior to the survey.
• Another article this month based on August 2007 survey data shows progress with 51% having slept under a net.

In both cases there were regional disparities – children in the south were more likely to sleep under a net than those in the north. This was not for lack of trying, since the recent article also documents net distribution in the study areas over a 12-month period.  It will be interesting how and if RBM partners will rally to help Nigeria double its net coverage rates in the next two years.

The Nigeria studies reported on number of children who slept under nets the night before the study, which is one of the key indicators of Roll Back Malaria success.  Counting alone will not be helpful in documenting progress towards universal coverage and eventual elimination unless all partners use standard measures. RBM’s Monitoring and Evaluation Reference Group has provided guidelines and toolkits, which all partners should read and use when reporting on their own progress.

When “Counting Malaria Out” on 25 April 2009, RBM encourages partners to, “Make 2009 the start of the countdown. Make the lives of every man, woman and child count as the international community intensifies its battle against malaria.” This will definitely require a well funded and coordinated effort.

Malaria control rests heavily on support from or activities of other development sectors besides health.  Power supply and agriculture provide two current examples.

Yewhalaw and colleagues explore the ramifications of dam construction for electricity supply in Ethiopia and see how human activity can increase mosquito breeding and the spread of malaria. Their work concludes –

This study indicates that children living in close proximity to a man-made reservoir in Ethiopia are at higher risk of malaria compared to those living farther away. It is recommended that sound prevention and control programme be designed and implemented around the reservoir to reduce the prevalence of malaria. In this respect, in localities near large dams, health impact assessment through periodic survey of potential vectors and periodic medical screening is warranted. Moreover, strategies to mitigate predicted negative health outcomes should be integral parts in the preparation, construction and operational phases of future water resource development and management projects.

At the same time Médecins Sans Frontières (MSF) has issued a warning about how agricultural market dynamics may have negative bearing on artemisinin supplies in the very near future. MSF explain that –

Current best estimates, based on available stocks and current planting efforts, demonstrate that there will be a shortfall of about 40 tons of artesiminin starting material in 2010 to produce the expected 240 million treatments needed. Taking into account that it takes about 14 months from the planting of Artemisia annua to the availability of the finished product, the availability in 2010 depends on what is being planted by farmers in the next weeks and months. We believe that market forces will not resolve the short-term artemisinin supply problem. Because it is extracted from plants, the supply of artemisinin is impacted by the highly volatile market of food crops which affect farmers’ decisions of whether or not to plant Artemisia annua.

These are two examples of how human actions exacerbate the scourge of malaria.  Such human influences are common throughout the history of malaria control. Intersectoral planning and surveillance is needed since malaria is not just a health affair.

Malaria control and immunization programs do work together in the form of national or local immunization campaigns where insecticide treated nets are also distributed.  There is an assumption that there will be a synergistic effect on coverage of combining these efforts, but an important question is whether the existing base platforms of immunization programs in countries can really deliver better vaccine coverage, let alone better ITN ownership and use.

Colleagues at the World Bank have conducted a qualitative inquiry into immunization program management to identify factors that might lead to success and thus, form the basis for more structured research.  The Expanded Program for Immunization has at least a 30-year history to draw on, and thereby, offers a good foundation for study.  The researchers chose the period 1997-2002 and looked at four sets of African countries: those with higher than average coverage that has increased over the 6-year period, those with high but decreasing coverage, those with low but increasing coverage and ones with both low and decreasing coverage.

In-depth study was conducted in six countries that covered the four categories of countries.  The study focused on five core management functions: 1) demand, 2) financing, 3) governance/institutional framework and the supply function which was divided into 4) management and 5) service delivery strategy.  A summary score of indicators achieved under each function yielded a 4-point score which is seen in the attached chart.

The authors noted that, “What distinguished the two high performers from all other countries in our exercise was a robust implementation of their immunization programmes. Only (those two countries) combined reasonably good governance and a solid institutional framework with reasonably good management, service delivery, financing and demand.”

The researchers suggested that, “One way that multilateral and bilateral partners in immunization may help is by offering countries  performance-based incentives without earmarking their assistance for specific functions.”

They also found that, “Reasonably good performance on at least some functions (the high but decreased coverage examples) appeared to be more beneficial to coverage than deficient performance across all (the two low coverage countries); doing a few things well, however, did not appear to be sufficient to ensure a high level of sustained success.”

Since wide scale implementation of malaria control is still coming on board in most countries, there are few examples of widespread intervention where a similar study could be conducted right now. Even so a preliminary assessment of factors that affect such management functions in crucial so that both scale-up and sustainability can be promoted until such time that eradication is truly feasible.

Lymphatic filariasis (also known as elephantiasis) is another mosquito borne disease that plagues much of the population in malaria endemic areas. In fact is is the same anophelene species of mosquitoes which carry malaria that also transmit lymphatic filariasis in much of Africa. With talk of integration of disease control programs, one wonders what are the potential synergies of combining efforts against malaria and lymphatic filariasis?

Both share the preventive measure of bed nets, which is a major strategy for malaria control, but the main approach to eliminating filariasis is Mass Drug Administration (MDA). Two drugs in combination, ivermectin (or diethylcarbamizine citrate) and albendazole, are given annually. These annual doses kill the microfilaria and have some effect on the adult worms. Success as measured by prevalence below 1% can b achieved after 6 rounds of MDA depending on 1) initial level of LF endemicity; 2) effectiveness of vector mosquitoes; 3) MDA drug regimen; 4) population compliance.

If the two diseases share geography and in some cases a vector, have there been any actual attempts at a joint effort? At least two countries have attempted such within the context of their global fund grants for malaria, Togo and Papua New Guinea (PNG). Togo’s Round 4 GFATM grant aimed at “demonstrating the synergy effect of MDA on the impact of malaria control activities” in co-endemic areas. This was based in part of research that showed a negative impact of helminths on malaria infection.

An innovation in the PNG GFATM proposal is “Training of field staff to disseminate information about malaria and HIV/AIDS (who) will also be used for annual mass drug administration for lymphatic filariasis elimination.”

An NGO example of integration has been piloted by the Carter Center. “In 2004, the Carter Center-assisted Lymphatic Filariasis Elimination Program received 57,000 bed nets from the Nigerian Ministry of Health in a combined effort to prevent the spread of lymphatic filariasis, being addressed by the Center, and malaria, a project of the health ministry. The nets are treated with the insecticide deltamethrin, which is safe for humans yet kills the mosquitoes that are the carriers of both diseases in rural Africa. The bed nets have been distributed in four local government areas of Plateau and Nasarawa states in Nigeria, which are endemic for both diseases.”

The Carter Center has been using the same community distribution system found effective for onchocerciasis control. “Community volunteers distributed 38,600 insecticide-treated bed nets, while simultaneously treating 150,800 persons with ivermectin/albendazole.” A 30-cluster survey found a 9-fold increase in bednet ownership compared to baseline. “This first linkage of insecticide-treated bed net distribution with mass drug administration resulted in substantial improvement in insecticide-treated bed net ownership and usage, without adversely affecting mass drug administration coverage. Such integration allowed two programs to share resources while realizing mutual benefit, and is one model for rapidly improving insecticide-treated bed net coverage objectives.”

Since the Global Fund programs have yet to focus on neglected tropical diseases, these examples of integration between malaria and lymphatic filariasis, may be the best way to ensure parasite-free populations in endemic areas.

A colleague in Bamako – home of the famous Bamako Initiative – shared an experience with one of the staff members in her organization who sought malaria treatment for a sick 3 and 1/2 year old child at a front line community health clinic.  On the first visit the child was prescribed quinine injection for that cost about US 28 cents.  After three days the child was still sick and returned to receive ACTs at a cost of $10.07.

This raised a few questions. Why were RDTs not used? Why were ACTs not the first line of treatment? Why did the family have to pay for the medicines?

One can answer the first question with the concern that children under 5 years can benefit from prompt and presumptive treatment as a life saving measure.  When the presumptive treatment is NOT the first line drug, one senses that the value of prompt treatment may be negated. Even though the Ministry of Health has printed and circulated malaria treatment guidelines, when one looks at the cost differences, one can get an idea of what the health worker might have been thinking – and it was unlikely to be the guidelines.

The Bamako Initiative is a community based and community managed cost recovery mechanism. The program has been working in Mali for over 15 years. This makes sense for inexpensive essential drugs. So why was the family charged what appears to be the cost of an adult dose for a small child? The ultimate answer may be that the community health service has had to buy ACTs for resale because Mali is what one might call “in between grants”.

The Round 1 Global Fund Grant for Malaria wrapped up almost two years ago. The Round 6 Grant is just taking off. PMI support is available, but also in a start-up phase.

Fortunately the child ultimately got the correct ‘presumptive’ treatment, and also fortunately the parents could afford it.  This scenario may repeat itself in other countries. Therefore all partners must coordinate their efforts in a country and work together to close the “ACT gap.”

The countries of southern Africa are more often known for their HIV problems than for malaria, but as Korenromp and colleagues point out, “… in Botswana, Zimbabwe, Swaziland, South Africa, and Namibia, the incidence of clinical malaria increased by < 28% (95% confidence interval [CI] 14%–47%) and death increased by < 114% (95% CI 37%–188%) … due to high HIV-1 prevalence in rural areas and the locally unstable nature of malaria transmission that results in a high proportion of adult cases.” Three of these countries, South Africa, Botswana and Zimbabwe, along with Mozambique, lie along the course of the Limpopo River, where malaria is seasonal but endemic.

Interest in another larger river, the Zambezi, this year has drawn attention to the cross-border challenges to malaria control.  The Limpopo provides another key example of the disease that knows no borders.

The Global Fund malaria overviews of these four Limpopo countries varies widely from 13,400 and 22,400 annual cases in South Africa and Botswana to 1.3m and 5m cases in Zimbabwe and Mozambique.  The latter two countries of course share the malaria endemic Zambezi watershed, while the former two do not even have a malaria grant from the Global Fund. And yet, malaria is endemic along two-thirds of its 1,750 kilometer long arc of a course that starts in South Africa, heads north, then northeast, east and finally south to empty into the Indian Ocean in Mozambique (as seen in the map from Encarta).

A recent study examining malaria in South Africa’s Limpopo Province found that the three eastern districts had the highest incidence over a ten-year period, and although the incidence appeared to be reducing, the authors cautioned that more understanding is needed about the nature of malaria in seasonal and epidemic-prone areas (Gerritson et al., 2007). They quote Cox et al., in calling for better estimates for malaria disease burden in countries where malaria epidemics occur to aid in better policy formulation, strategic planning and early warning measures.

The Limpopo experience stresses the importance of understanding both the epidemic nature of the disease and its interactions with HIV. Each river in malaria endemic regions may have its own lessons to teach, and we should be ready to learn.

The collapse of health and other social infrastructure is a common outcome of conflicts such as civil wars. In such settings one does not talk about ‘health sector reform’ glibly, but must consider the whole issue of health sector rebuilding. Two post-conflict countries are currently included in the US President’s Malaria Initiative (PMI), Angola and Liberia. Both are also recipients of GFATM malaria grants. What do lessons about malaria control can we learn from administering these two programs?

The situation in Angola is summed up succinctly by the PMI country assessment. “Angola recently emerged from almost three decades of civil war that severely impacted its development, particularly the health sector. It is estimated that 80% of the health facilities were looted or destroyed during the war and that the existing health system covers only about 30% of the Angolan population, with even lower utilization rates.” The national surveillance system “has limited human and financial capacity and lacks nationwide coverage, standardized procedures for the collection and analysis of data, and an effective communication system to ensure timely reporting.”

In addition to limited laboratory facilities, the PMI assessment found procurement problems. “Given that many key agencies and systems are not yet in place or fully functional, the GFATM proposal proposes that procurement functions be carried out by WHO while providing for support not only for the program of activities under the NMCP but also for strengthening the system in general.” To address these challenges, PMI and GFATM recipients have been working on coordination efforts over the past two years, according to GFATM. In addition GFATM recommends moving away from an external Principal Recipient and that the “PR shall present a revised plan that reflects the gradual transfer of responsibilities to the NMCP staff. A plan with measurable targets for the capacity-building activities should be agreed upon.”

Recently the US President expressed concern to the Liberian President about the continued death of Liberian children from malaria and indicated that PMI would be setting up shop soon. The GFATM Grant Performance Report of August 2007 for Liberia observed that, “The internal audit section has however not been able to conduct these audits in Liberia due to staff shortage as well as the situation of insecurity prevailing in the country.” Human resources for health are scarce generally in much of sub-Saharan Africa, and are exacerbated in post-conflict settings. In Liberia, GFATM noted that, “There is no M&E expert dedicated to this project.” It was further observed that, “There are some tensions existent in regards to having a non-local entity (UNDP) as PR.”

The selection of a non-indigenous Principal Recipient is not uncommon, but in post-conflict settings, lack of strong civil society organizations and weak government bureaucracies may be a factor. The Report further states, “There are very few active donors in Liberia and most organizations are struggling for funds. There is as a result little organized effort for harmonization of programs and requirements.

As of the August 2007 Report, Liberia was behind target in terms of staff training and number of service points supported for malaria case management, though they appear to be on target for reaching pregnant women and distributing ITNs. ITN distribution may be done outside the formal health system, but case management requires a fairly well organized public and private sector, even when volunteer community-based workers are involved.

Some of the health systems and implementation problems mentioned above may not appear terribly different from those faced by other Sub-Saharan countries, and maybe it is a matter of scale. Key lessons appear to be a need for collaboration and coordination among the often few donors on the ground and efforts to build and re-build local capacity. Citizens of these countries have suffered enough and do not need ‘wars’ among donors and recipients and certainly must win the war against malaria.