Category Archives: Ebola

Malaria News Today 2020-09-08

Today we share news and abstracts concerning detecting malaria in pregnancy, news about the opening remarks from the WHO Director General at a special malaria and COVID-19 webinar, resumption of NTD activities after COVID-19 restrictions reduced, and mapping of Ebola carrying bats whose territory overlaps malaria in Africa. Click on the links to read more.

Prevalence and clinical impact of malaria infections detected with a highly sensitive HRP2 rapid diagnostic test in Beninese pregnant women

While sub-microscopic malarial infections are frequent and potentially deleterious during pregnancy, routine molecular detection is still not feasible. This study aimed to assess the performance of a Histidine Rich Protein 2 (HRP2)-based ultrasensitive rapid diagnostic test (uRDT, Alere Malaria Ag Pf) for the detection of infections of low parasite density in pregnant women.

This study demonstrates the higher performance of uRDT, as compared to cRDTs, to detect low parasite density P. falciparum infections during pregnancy, particularly in the 1st trimester. uRDT allowed the detection of infections associated with maternal anaemia.

The distribution range of Ebola virus carriers in Africa may be larger than previously assumed

Since Ebola overlaps both symptomatically and geographically with malaria in Africa, it is “Worrying that science has hitherto underestimated the range of Ebola-transmitting bat and fruit bat species. In this case, the models would provide a more realistic picture,” explains Dr. Lisa Koch

Based on ecological niche modeling, his team was able to show that the respective bat and fruit bat species are able to thrive in West and East Africa, including large parts of Central Africa. A wide belt of potential habitats extends from Guinea, Sierra Leone, and Liberia in the west across the Central African Republic, the Republic of the Congo and the Democratic Republic of the Congo to Sudan and Uganda in the East. A few of the studied bats and fruit bats may even occur in the eastern part of South Africa.

WHO Director-General’s Opening Remarks At the Webinar – Responding to the Double Challenge of Malaria and Covid-19

The WHO Director General is encouraged by efforts to maintain malaria services despite the COVID-19 outbreak, but says, “I would like to recognize and applaud all these efforts, and to thank all of you who have worked so hard to preserve and maintain those services to the greatest degree possible. However, despite these actions, it breaks my heart to report that we still expect to see an increase in cases and deaths from malaria.

“In a recent WHO survey of 105 countries, 46% of countries reported disruptions in malaria diagnosis and treatment. These disruptions threaten to set us back even further in realizing our shared vision for a malaria-free world.”

NTD Disease treatments restart in Africa as COVID-19 restrictions ease

It is not just malaria services that have been disrupted by COVID-19 responses. Treatment programmes that will reach millions of Africans at risk from debilitating neglected tropical diseases (NTDs) have restarted in a significant step towards COVID-19 recovery. Around one million people in Jigawa state, Nigeria have received antibiotics to treat the blinding eye disease trachoma and stop it from spreading.

Nigeria is the first country that Sightsavers and partners has supported to resume work on NTDs, which can have a devastating impact on some of the poorest communities in the world, with other African countries due to follow soon. In April, the threat of COVID-19 led the World Health Organization to recommend suspending mass treatment campaigns, which treat and prevent these diseases, but it has since provided guidance on restarting activities safely.

Malaria News Today 2020-09-04

Today, we are sharing more updates from newsletters and journal abstracts found online. Issues include citizens in Rwanda trapping mosquitoes, the need for standardizing microscopy, more information on Uganda’s Malaria fund, the challenge of containing three epidemics at once, an increase in cases in Namibia and genetic diversity of the parasite in Comoros. Click on links to read details.

Citizen science shows great potential to reduce malaria burden

A year-long collection of mosquitoes with self-made traps and over a hundred volunteers in rural Rwanda reporting levels of mosquito nuisance revealed when and where malaria risks were the highest. In addition to their reporting, the volunteers appeared to distribute knowledge and skills on controlling malaria within communities. Studies by Wageningen University & Research and the University of Rwanda show that citizen science has great potential to reduce the disease burden across the globe.

Uganda renews fight to eliminate malaria by 2030 – more on Malaria Free Uganda Fund

Uganda says it is fast-tracking efforts to eliminate malaria, which continues to take lives and bleed the country’s economy more than any other disease. The disease is responsible for 30 to 40 percent of outpatient hospital visits, 15 to 20 percent of admissions, and 10 percent of inpatient deaths, mostly pregnant mothers and children, according to the health ministry figures. The country on September 2 launched the board of directors of the Malaria Free Uganda Fund as part of its continued investment to eliminate the disease by 2030, as per the global target.

Malaria Free Uganda Fund is a nonprofit public-private partnership established to mainstream responsibility for malaria across all sectors and help remove financial and operational bottlenecks in fighting the disease. The National Malaria Control Program currently faces a three-year 206 U.S. million dollars budget gap, or 33 percent of the total, according to the ministry of health.  External donors, according to the ministry, fund over 95 percent of the fight against the disease in the country. The country is now looking at domestic resourcing in view of the global uncertainties like the COVID-19 pandemic that is affecting foreign financing. “The talent and experience we have mobilized to this board from the private and civil society will help the government achieve a significant reduction of malaria cases and deaths in Uganda,” said Ruth Aceng, minister of health while launching the board here.

Namibia records 12,507 malaria cases, 40 deaths in 2020

Namibia’s malaria cases this year increased to 12,507 from 2,841 recorded in 2019, according to statistics from the Ministry of Health. The southern African country recorded 31,000 cases of malaria in 2018. The National Vector-borne Diseases Control Program from the Health Ministry which monitors the weekly malaria situation in the country shows that this year alone 12,507 malaria cases where recorded, while 40 deaths occurred.

The ministry said the huge difference between 2019 and this year is attributed to the fact that 2019, was a drought year and the rainfall pattern was not similar to 2020 and 2018, hence the decline in malaria cases happened in 2019. According to the ministry, currently the implementation of the program activities amid COVID-19 is on halt due to some bottlenecks.

Congo sees increase in plague, at least 10 deaths this year

DR Congo is seeing an upsurge in cases of the plague, as the vast Central African nation also battles outbreaks of COVID-19 and Ebola. Since June, Congo has recorded at least 65 cases of the plague, including at least 10 deaths, in the eastern Ituri province according to Ituri provincial chief of health Dr. Louis Tsolu. While the plague is endemic in Ituri province, the number of cases is increasing and has already surpassed the total recorded in 2019 which had 48 cases and eight deaths, according to WHO.

Towards harmonization of microscopy methods for malaria clinical research studies

Microscopy performed on stained films of peripheral blood for detection, identification and quantification of malaria parasites is an essential reference standard for clinical trials of drugs, vaccines and diagnostic tests for malaria. The value of data from such research is greatly enhanced if this reference standard is consistent across time and geography. Adherence to common standards and practices is a prerequisite to achieve this. The rationale for proposed research standards and procedures for the preparation, staining and microscopic examination of blood films for malaria parasites is presented here with the aim of improving the consistency and reliability of malaria microscopy performed in such studies.

These standards constitute the core of a quality management system for clinical research studies employing microscopy as a reference standard. They can be used as the basis for the design of training and proficiency testing programmes as well as for procedures and quality assurance of malaria microscopy in clinical research.

Genetic diversity of Plasmodium falciparum in Grande Comore Island

Despite several control interventions resulting in a considerable decrease in malaria prevalence in the Union of the Comoros, the disease remains a public health problem with high transmission in Grande Comore compared to neighbouring islands. In this country, only a few studies investigating the genetic diversity of Plasmodium falciparum have been performed so far. For this reason, this study aims to examine the genetic diversity of P. falciparum by studying samples collected in Grande Comore in 2012 and 2013, using merozoite surface protein 1 (msp1), merozoite surface protein 2 (msp2) and single nucleotide polymorphism (SNP) genetic markers.

Zero Malaria Starts after Lockdown?

The novel 2019 coronavirus, also known as COVID-19 and SARS-COV2, is casting a heavy shadow over the 2020 World Malaria Day. People are trying to remain upbeat declaring the tagline “zero malaria starts with me,” but nothing can hide the fear that the current pandemic will both disrupt the current delivery of essential malaria preventive and treatment services, but will have longer term impacts on malaria funding and our capacity to learn new ways to reach malaria elimination goals. As we can see in the graphic to the right, accessible, lifesaving, community-based services may be especially hard hit.

Another ironic image is the indoor residual spray (IRS) team member with a face mask needed for protection from the insecticides being sprayed. When will such teams be able to go back into homes? When can household members actually pack out their belongings so that spraying can commence? When will such masks not be needed for intensive care COVID-19 case management instead?

WHO is urging “countries to move quickly to save lives from malaria in sub-Saharan Africa” because “New analysis supports the WHO call to minimize disruptions to malaria prevention and treatment services during the COVID-19 pandemic.” This will be difficult in high burden countries like Nigeria that are already on lockdown with over 1,000 coronavirus cases detected already. Modeling by WHO and partners has projected, “Severe disruptions to insecticide-treated net campaigns and in access to antimalarial medicines could lead to a doubling in the number of malaria deaths in sub-Saharan Africa this year compared to 2018.”

The Global Malaria Program offers guidance for tailoring malaria interventions to the present circumstances. Great concern is drawn from previous epidemic situations when observing that, “it is essential that other killer diseases, such as malaria, are not ignored. We know from the recent Ebola outbreak in west Africa that a sudden increased demand on fragile health services can lead to substantial increases in morbidity and mortality from other diseases, including malaria. The COVID-19 pandemic could be devastating on its own – but this devastation will be substantially amplified if the response undermines the provision of life-saving services for other diseases.”

Specifically, GMP recommends that national malaria programs should ensure the following:

  • a focal point for malaria is a member of the National COVID-19 Incident Management Team.
  • continued engagement with all relevant national COVID-19 stakeholders and partners.
  • continued access to and use of recommended insecticide-treated mosquito nets (ITNs)
  • continuation of planned targeted indoor residual spraying (IRS)
  • early care-seeking for fever and suspected malaria by the general population to prevent a spike in severe malaria
  • access to case management services in health facilities and communities with diagnostic confirmation through rapid diagnostic tests [RDTs]
  • treatment of confirmed malaria cases with approved protocols
  • continued delivery of planned preventive services normally provided to specific target populations (SMC, IPTi, IPTp)
  • the safety of all malaria personnel and their clients in the process of carrying out the above interventions

In editorial in the American Journal of Tropical Medicine and Hygiene by Yanow and Good address the damaging longer term impact of the present shutdown. “The impacts of research shutdowns will be felt long after the pandemic. Many scientists study diseases that do not share the same obvious urgency as COVID-19 and yet take a shocking toll on human life. For example, malaria infects more than 200 million people and takes the lives of nearly half a million people, mostly young children, each year.1 During laboratory closures and without clinical studies, there will be no progress toward treating and preventing malaria: no progress toward new drugs, vaccines, or diagnostics.”

The case for continuing malaria services to save hundreds of thousands of lives is not difficult to make. The actual implementation during lockdowns and quarantines is a management challenge. The importance of malaria testing to provide patients with appropriate care for the right disease is crucial. The question is whether in resource strapped endemic countries these decisions and management arrangements can be made in a timely fashion and for the long term whether the next generation of research can proceed with much needed new medicines and technologies.

Lessons Learned from Ebola Management in Sierra Leone

Figure #1: Image of a Village Health Worker in Sierra Leone Preparing Chlorinated Water

Lessons can still be learned from the Ebola experience in West Africa. Daniel Ehrenpreis and Masahiro Katahira as members of the class, Social and Behavioral Foundations of Primary Health Care, have posted a blog on the importance of financing at the local government level to ensure better disease control efforts. Their thoughts are posted below.

In 2015, Sierra Leone experienced the height of the Ebola epidemic, where there were over 13,000 confirmed cases; 29% of which were fatal. The prolific nature of this disease made controlling the spread difficult to manage. The government of Sierra Leone initially coordinated the Ebola mitigation efforts by allocating funding to centralized approaches . This method quickly became ineffective as the virus rapidly proliferated and mortality skyrocketed. Different Ebola response efforts were needed to curb the spread of this infectious disease.

While many international organizations were funneling funding into national response measures, localized infection control interventions were being undermined. This created uncoordinated Ebola control measures that exacerbated the virus’ mortality rate. Furthermore, localized non-governmental organizations (NGOs) were disproportionately underfunded and thus did not have the resources to implement effective Ebola mitigation techniques.

Figure #2: National vs. Localized Ebola Response

The National Ebola Response Center (NERC) consisted of the army of Sierra Leone and England, including international agencies such as, UNMEER, WHO, and CDC. All 14 districts of Sierra Leone had a District Ebola Response Center (DERC). (See Figure #2)

The DERC had localized roles, such as surveillance, alerts, burials, community mobilization & education, and quarantine. Low capacity of district health infrastructure and insufficient funding challenged DERCs and local NGOs. With a lack of medical resources including protective clothes due to their poor logistics system, reduced communication between staff in the NERC due to no electricity, distrust from community members, and an inadequate number of staff, there were many barriers preventing the success of localized Ebola response. Also, since every DERC had to meet the needs of different communities, the DERCs did not always act in alignment with the NERC’s plan. It was clear that more funding and resources were needed in the DERCs.

To respond effectively to future Ebola epidemics, national governments should consider allocating funding from both internal finance and international donors to decentralized health management approaches. The 2015 Ebola epidemic in Sierra Leone exemplified the need to strengthen local health sectors, and it is the responsibility of national policymakers to bolster the capacity of our localized health systems for effective control and response.

Deforestation and Disease

Much attention is focused on the broader environmental and climatic consequences of deforestation, especially as this has seemed to pick up pace in places like the Amazon Basin. More attention is also needed concerning the disease transmission implications of deforestation. Recent studies have shed light on the problem. Basically deforestation as a result of urbanization or expanding commercial agriculture and related human activity brings people closer to areas where diseases can spread.

The connection between bats and the spread of Ebola in humans has been posited for some time. Forest News notes that “Fruit bats (Pteropodidae) are suspected reservoir hosts for the Ebola virus,” and thus, “Deforestation may accelerate the spread of the deadly Ebola disease in the rainforests of West and Central Africa by increasing human-bat interactions.” They are sharing information by Olivero and colleagues recently published in Mammal Review.

These researchers “show that the range of some fruit bat species is linked to human activities within the favourable areas for the Ebola virus. More specifically, the areas where human activities favour the presence of five fruit bat species overlap with the areas where EVD outbreaks in humans were themselves favoured by deforestation.” They have modeled and mapped an area in West and Central Africa based on climate, including annual temperature ranges, the presence of rainforest and mammal distribution to create an area known as “The Ebola Virus Area.”

Concerning malaria, research by Chua and colleagues in Malaysia found that, “contributes to a growing body of evidence implicating environmental changes due to deforestation, expansion of agricultural and farming areas, and development of human settlements near to forest fringes in the emergence of P. knowlesi in Sabah.” Their research is part of more than a dozen studies over the past nine years that links deforestation and greater interaction between humans and macaque monkeys, the normal victim of P. knowlesi. One of the earlier studies reports that, ” ongoing ecological changes resulting from deforestation, with an associated increase in the human population, could enable this pathogenic species of Plasmodium to switch to humans as the preferred host.”

Eliminating the mammal hosts of these diseases is not an option because as Olivero explained about bats, “The entire function and ecology of forests would be put at risk if these vital pollinators and seed dispersers are eliminated.”

Considering another tropical disease, Visser warns that, “Climate change, deforestation, urbanization, and increased population mobility have made the risk of large outbreaks of yellow fever more likely than ever.” The lesson from these experiences is not mainly that we need to increase coverage of proven preventive measures, but that we need broader change in our approaches and policies toward land use.

Ebola Crisis Takes a Turn: Increased US Intervention Necessary

As part of the course on Social and Behavioral Foundations in Primary Health Care, Allan Ciciriello posted in the class blog. We have shared his thoughts below.

Confirmed and probable Ebola virus disease cases by week of illness onset by Kivu region health zone. Data as of 13 August 2019

Historically, the 2018 – 2019 Ebola outbreak is the biggest the Democratic Republic of the Congo has ever seen. As a whole, it is also the second largest documented epidemic of the disease on record. The epicenter of the eruption is located in the Kivu region, which has also been in the midst of a conflict between the Congolese military and rebel groups, which has prevented necessary assistance from making its way into the country. Due to the decline of the situation over the past year, culminating with a confirmed case of Ebola in the capital city of Goma, the World Health Organization officially announced it as a Public Health Emergency of International Concern in July 2019.

The spread of the virus to bordering countries is a matter of great importance in the global health community. This includes the nations of Burundi, Rwanda, South Sudan, and Uganda. Given that Goma is a major transportation hub connecting these territories together, it is imperative that the transmission of Ebola be stopped quickly in the Kivu region.

Ebola virus disease in the Democratic Republic of the Congo – Operational readiness and preparedness in neighbouring countries
Recently, the World Health Organization has claimed the current funding is not enough to sustain response activities on a multi-national scale. The United States, who played a large role in the 2014 – 2015 outbreak of Ebola, has had limited participation this time around. This is largely due to the ability of the global health community to respond more adequately to the disease through large improvements in technical capabilities. Security factors with the military conflict have also prevented the United States from getting on the ground in the Democratic Republic of the Congo. However, due to recent changes in the situation, the Congolese government and the World Health Organization cannot efficiently resolve the epidemic without additional help from UN partners, most notably the United States.
‘We won’t get to zero cases of Ebola without a big scale-up in funding,’ UN relief chief warns

The United States must change its current policies on intervening in the Democratic Republic of the Congo Ebola outbreak. Most important is contributing additional funding to sustain the World Health Organization’s role in halting the spread of the virus within the current borders, while also supporting the surrounding nations’ prevention efforts. USAID is a critical source of backing in this ongoing battle, and without them it is likely to falter. I would also reconsider the hesitancy of placing United States government personnel on the frontlines, because as the problem gets more dire the harder it will be to act from within the country. The CDC is another key player in this game, and I would advise the US take advantage of the United Nations Organization Stabilization Mission in the Democratic Republic of the Condo’s (also known as MONUSCO) peacekeeping forces to get public health workers back on the frontline with guaranteed protection from rebel militias.

Tropical Health Update 2019-08-04: Ebola, Malaria Vectors, Snakebite and Trachoma

In the past week urban transmission in Goma, a city of at least 2 million inhabitants in eastern Democratic republic of Congo, was documented as a gold miner came home and infected his wife and child. To get a grip on the spread of the disease, DRC is considering another vaccine, not without some controversy. WHO provides detailed guidance on all aspects of response. On the malaria front we have learned more about malaria vectors, natural immunity and reactive case detection.

Ebola Challenges: Vaccines, Urban Transmission

The current Ebola vaccine being deployed to over 150,000 people in North Kivu and Ituri Provinces was itself an experimental intervention during 2016 when it was first used in the largest ever outbreak located in West Africa. BBC reports that, “World Health Organization (WHO) data show the Merck vaccine has a 97.5% efficacy rate for those who are immunised, compared to those who are not.”

The proposed addition of a Johnson and Johnson vaccine would be in that same experimental phase if introduced in DRC now. It has been proven safe as well as effective in other primates. The challenge is that even though the Merck vaccine supplies are near 500,000, this is not enough to cover the potential needs in an area with over 10 million people, although Merck is still producing more. At present, BBC says, “Those pushing for the use of the new Johnson & Johnson vaccine, had proposed using it to create a protective wall, vaccinating people outside the outbreak zone.” In addition, the new national response team is concerned that “Only about 50% of cases of Ebola in the Democratic Republic of Congo are being identified.”

Finally, there is the issue of community mistrust of government workers and challenging logistics. “There are also concerns that the new vaccine – which requires two injections 56 days apart – may be difficult to administer in a region where the population is highly mobile, and insecurity is rife.”

If efforts at vaccination are needed soon in Goma, up to 2 million doses might be needed. Reuters reports that, “Congolese authorities were racing to contain an Ebola epidemic on Thursday, after a gold miner with a large family contaminated several people in the east’s main city of Goma before dying of the hemorrhagic fever.” Readers may recall that the West Africa outbreak of 2014-16 in Guinea, Sierra Leone and Liberia accelerated greatly after infected people went to major cities in search of help.

The miner is the second ‘imported case into Goma, which borders Rwanda, but because his family lives there, he has already infected his wife and one of his 10 children. Contacts are being traced and monitored, but this urban and border threat is one of the factors that led WHO to finally declare the current outbreak a public health emergency.

Malaria

As we move toward malaria elimination Reactive Case Detection (RCD) has been proposed as an integral part of these efforts with the hopes that is can be conceived of as a way of gradually decreasing transmission, according to an article in Malaria Journal. In fact, the value of RCD may be limited as follows:

  • RCD alone can eliminate malaria in only a very limited range of settings, where transmission potential is very low
  • In other settings, it is likely to reduce disease burden and help maintain the disease-free state in the face of imported infections

Another article looks at “natural exposure to gametocytes that can result in the development of immunity against the gametocyte by the host as well as genetic diversity in the gametocyte.” The researchers learned that there can be variations in immune response depending on season and geography. This information is helpful in planning malaria elimination interventions.

On the vector front a baseline susceptibility testing was conducted in 16 countries in sub-Saharan Africa for neonicotinoids. “The target site of neonicotinoids represents a novel mode of action for vector control, meaning that cross-resistance through existing mechanisms is less likely.” The findings will help in the preparation for rollout of clothianidin formulations as part of national IRS rotation strategies by PMI and other partners.

Researchers also called on us to learn more about malaria vectors in other parts of the world. In order to eliminate Plasmodium falciparum from the Caribbean and Central America program planners should consider local vector characteristics such as An. albimanus. They found that, “House-screening and repellent IRS are potentially highly effective against An. albimanus if people are indoors during the evening.”

Vectors are also of concern on the edges of malaria transmission, particularly in South Africa, one of the ‘elimination eight’ countries of the Southern Africa Development Community. Researchers examined the, “potential role of Anopheles parensis and other Anopheles species in residual malaria transmission, using sentinel surveillance sites in the uMkhanyakude District of northern KwaZulu-Natal Province.” They found Anopheles parensis is a potential but minimal vector of malaria in South Africa “owing to its strong zoophilic tendency.” On the other hand, An. arabiensis was found to be the major vector responsible for residual malaria transmission in South Africa. Since these mosquitoes were found in outdoor-placed resting traps, interventions are needed to control outdoor-resting of vector populations.

NTDs of Concern

During the week, the member states of the African Union renewed their commitment to fight and permanently eliminate Neglected Tropical Diseases. Africa.com reported that, “Achievements to date include 1 billion people treated against at least one NTD and 37 countries have completed the removal of at least one NTD.”

Although some reports have discounted the idea of trachoma in Namibia, there may be reason to re-examine the situation. On Twitter Anthony Solomon notes that Namibia needs #trachoma prevalence surveys. A just-completed joint Ministry of Health & Social Services/@WHO mission found active trachoma & trichiasis in Zambezi & Kunene Regions.

The Times of India draws attention to snakebite. It says that “Under-reported and inadequately treated, fatalities in India are estimated at close to 50,000 a year, the world’s highest.”

Overall we can see that the concept of ‘neglect’ has several uses. There is neglect if half of Ebola cases are undetected. There is neglect if we do not understand malaria vectors in low transmission areas. Finally, there is neglect if we do not conduct up-to-date disease surveys to determine whether a disease is present or not. Elimination of tropical diseases is challenging when key processes are neglected.

Tropical Health Update 2019-07-28: Ebola and Malaria Crises

This posting focuses on Malaria and Ebola, both of which have been the recent focus of some disturbing news. The malaria community has been disturbed by the clear documentation of resistance to drugs in Southeast Asia. Those working to contain Ebola in the northeast of the Democratic Republic of Congo saw a change in political leadership even in light of continued violence and potential cross-border spread.

Malaria Drug Resistance

Several sources reported on studies in the Lancet Infectious Diseases concerning the spread of Multidrug-Resistant Malaria in Southeast Asia. Reuters explained that by sing genomic surveillance, researchers concurred that “strains of malaria resistant to two key anti-malarial medicines are becoming more dominant” and “spread aggressively, replacing local malaria parasites,” becoming the dominant strains in Vietnam, Laos and northeastern Thailand.”

The focus was on “the first-line treatment for malaria in many parts of Asia in the last decade has been a combination of dihydroartemisinin and piperaquine, also known as DHA-PPQ,” and resistance had begun to spread in Cambodia between 2007 and 2013. Authors of the study noted that while, “”Other drugs may be effective at the moment, but the situation is extremely fragile, and this study highlights that urgent action is needed.” They further warned of an 9impending Global Health Emergency.

NPR notes that “Malaria drugs are failing at an “alarming” rate in Southeast Asia” and provided some historical context about malaria drug resistance arising in this region since the middle of the 20th century. “Somehow antimalarial drug resistance always starts in that part of the world,” says Arjen Dondorp, who leads malaria research at the Mahidol Oxford Tropical Medicine Research Unit in Bangkok and who was a lead author of the report about the randomized trial. Ironically, “one reason could have something to do with the relatively low levels of malaria there. When resistant parasites emerge, they are not competing against a dominant nonresistant strain of malaria and are possibly able to spread easier.

When we are talking about monitoring resistance in low resource and logistically and politically challenging areas, we need to think of appropriate diagnostic tools at the molecular level. Researchers in Guinea-Bissau conducted a proof of concept study and used malaria rapid diagnostic tests applied for parallel sequencing for surveillance of molecular markers. While they noted that, “Factors such as RDT storage prior to DNA extraction and parasitaemia of the infection are likely to have an effect on whether or not parasite DNA can be successfully analysed … obtaining the necessary data from used RDTs, despite suboptimal output, becomes a feasible, affordable and hence a justifiable method.”

A Look at Insecticide Treated Nets

On a positive note, Voice of America provides more details on the insecticide treated net (ITN) monitoring tool developed called “SmartNet” by Dr Krezanoski in collaboration with the Consortium for Affordable Medical Technologies in Uganda. The net uses strips of conductive fabric to detect when it’s in use. Dr. Krezanoski was happy to find that people given the net used it no differently that if they were not being observed. The test nets made it clear who what using and not using this valuable health investment and when it was in use. Such fine tuning will be deployed to design interventions to educate net users based on their real-life use patterns.

Another important net issue is local beliefs that may influence use. We can find out when people use nets, but we also need to determine why. In Tanzania, researchers found that people think mosquitoes that bite in the early evening when people are outside relaxing are harmless. As one community member said, “I only fear those that bite after midnight. We’ve always been told that malaria is spread by mosquitoes that bite after midnight.”

Even if people do use their ITNs correctly, we still need to worry about insecticide resistance. A study in Afghanistan reported that, “Resistance to different groups of insecticides in the field populations of An. stephensi from Kunar, Laghman and Nangarhar Provinces of Afghanistan is caused by a range of metabolic and site insensitivity mechanisms.” The authors conclude that vector control programs need to be better prepared to implement insecticide resistance management strategies.

Ebola Crisis Becomes (More) Political

Headlines such as “Congo health minister resigns over response to Ebola crisis” confronted the global health community this week. this happened after the DRC’s relatively new president took control of the response. The President set up a new government office to oversee the response to an outbreak outside of the Ministry of Health which was managing the current outbreak and the previous ones. The new board was set up without the knowledge of the Minister who was traveling to the effected provinces at the time.

The former Minister, Dr Oly Ilunga stated on Twitter that, “Suite à la décision de la @Presidence_RDC.  de gérer à son niveau l’épidémie d’#Ebola, j’ai remis ma démission en tant que Ministre de la Santé ce lundi. Ce fut un honneur de pouvoir mettre mon expertise au service de notre Nation pendant ces 2 années importantes de notre Histoire. (Following the decision of the @Presidence_RDC to manage the # Ebola outbreak, I resigned as Minister of Health on Monday. It was an honor to be able to put my expertise at the service of our Nation during these two important years of our History.)

The former Minister also warned that the “Multisectoral Ebola Response Committee would interfere with the ongoing activities of national and international health workers on the ground in North Kivu and Ituri provinces.” Part of the issue may likely have been “pressure to approve a new vaccine in addition to one that has already been used to protect more than 171,000 people.” People had warned about the potential confusion to the public as well as ethical issues if a second vaccine was used, especially one that did not have the strong accumulated evidence from both the current outbreak as well as the previous one in West Africa.

One might have thought that this would be a time when stability was needed since “The WHO earlier this month declared the outbreak a Public Health Emergency of International Concern, a rare step meant to highlight the urgency of the moment that has been used only four times before.” In addition, “the World Bank said it would release $300 million from a special fund set aside for crises like viral outbreaks to help cover the cost of the response.”

Unfortunately one of the msain impediments to successful Ebola control, violence in the region, continues. CIDRAP stated that. “the Allied Democratic Forces (ADF), a rebel group, attacked two villages near Beni, killing 12 people who live in the heart of the Democratic Republic of the Congo’s (DRC’s) ongoing Ebola outbreak. The terrorists killed nine in Eringeti and three in Oicha, according to Reuters. ADF has not publicly pledged allegiance to the Islamic state (ISIL), but that hasn’t stopped ISIL from claiming responsibility for the attacks.” It will take more than a change of structure in Kinshasa to deal with the realities on the ground.

CIDRAP also observed that since the resignation of the Health Minister, “DRC officials have provided no update on the outbreak, including statistics on the number of deaths, health workers infected, or suspected cases.” The last was seen on 21 July 2019.

ReliefWeb reports that, “Adding to the peril, the Ebola-affected provinces share borders with Rwanda and Uganda, with frequent cross-border movement for personal travel and trade, increasing the chance that the virus could spread beyond the DRC. There have already been isolated cases of Ebola reported outside of the outbreak zone.”

These are troubling times when parasites and mosquitoes are becoming more resistant to our interventions and when governments and communities are resistant to a clear and stable path to disease containment and control.

The Weekly Tropical Health News 2019-07-13

In the past week more attention was drawn to the apparently never-ending year-long Ebola outbreak in the northeast of the Democratic Republic of the Congo. Regarding other diseases, there is new information on the RTS,S malaria vaccine, river prawns have been found to play a biological control role in schistosomiasis, and an update from the World Health Organization on essential medicines and diagnostics. New malaria vector control technologies are discussed.

Second Largest Ebola Outbreak One Year On

Ronald A. Klain and Daniel Lucey in the Washington Post observed raised concern that, “the disease has since crossed one border (into Uganda) and continues to spread. In the absence of a trajectory toward extinguishing the outbreak, the opposite path — severe escalation — remains possible. The risk of the disease moving into nearby Goma, Congo — a city of 1 million residents with an international airport.”

They added their voices to a growing number of experts who are watching this second biggest Ebola outbreak in history and note that, “As the case count approaches 2,500 with no end in sight, it is time for the WHO to declare the outbreak a public health emergency of international concern — a ‘PHEIC’ — to raise the level of global alarm and signal to nations, particularly the United States, that they must ramp up their response.” They call for three actions: 1) improved security for health workers in the region, 2) stepped up community engagement and 3) extended health care beyond Ebola treatment. The inability to adequately respond to malaria, diarrheal diseases and maternal health not only threated life directly, but also threated community trust, putting health workers’ lives at risk.

Olivia Acland, a freelance journalist based in DRC, reporting for the New Humanitarian describes the insecurity and the recent “wave of militia attacks in the Democratic Republic of Congo’s northeastern Ituri province has left hundreds dead and roughly 300,000 displaced in recent weeks, triggering a new humanitarian crisis in a region.” Specifically, “Ituri, a fertile region rich in gold deposits, has been an epicentre of conflict in Congo for decades. Between 1999 and 2003, around 60,000 people were killed here, as a power struggle between rebel groups escalated into ethnic violence,” related to traditional tensions between Hema cattle herders and Lendu farmers with roots in Belgian colonization.

Updates from the DRC Ministry of Health report on average 11 new Ebola cases per day in the past week. So far over 160,000 people have been vaccinated, and yet the spread continues. The Ministry also describes new protocol contains three vaccinations strategies that can be used depending on the environment in which confirmed cases are found including:

  • Classic Ring: The classic strategy of vaccinating contacts of confirmed cases and contact contacts.
  • Enlarged ring: It is also possible to vaccinate all inhabitants of houses within 5 meters around the outbreak of a confirmed case.
  • Geographical Ring: In an area where team safety can not be guaranteed, they can vaccinate an entire village or neighborhood.

Malaria Vaccines, Essential Drugs and New Vector Control Technologies

Halidou Tinto and colleagues enrolled two age groups of children in a 3-year extension of the RTS,S/AS01 vaccine efficacy trial: 1739 older children (aged 5–7 years) and 1345 younger children (aged 3–5 years). During extension, they reported 66 severe malaria cases. Overall they found that, “severe malaria incidence was low in all groups, with no evidence of rebound in RTS,S/AS01 recipients, despite an increased incidence of clinical malaria in older children who received RTS,S/AS01 compared with the comparator group in Nanoro. No safety signal was identified,” as seen in The Lancet.

WHO has updated the global guidance on medicines and diagnostic tests to address health challenges, prioritize highly effective therapeutics, and improve affordable access. Section 6.5.3 presents antimalarial medicines including curative treatment (14 medicines) for both vivax and falciparum and including tablets and injectables. Prophylaxis includes 6 medicines including those for IPTp and SMC. The latest guidance can be downloaded at WHO.

Paul Krezanoski reports on a new technology to monitor bednet use and tried it out in Ugandan households. As a result. “Remote bednet use monitors can provide novel insights into how bednets are used in practice, helping identify both households at risk of malaria due to poor adherence and also potentially novel targets for improving malaria prevention.

In another novel technological approach to vector control, Humphrey Mazigo and co-researchers tested malaria mosquito control in rice paddy farms using biolarvicide mixed with fertilizer in Tanzanian semi-field experiments. The intervention sections (with biolarvicide) had lowest mean mosquito larvae abundance compared to control block and did not affect the rice production/harvest.

Prawns to the Rescue in Senegal Fighting Schistosomiasis and Poverty

Anne Gulland reported how Christopher M. Hoover et al. discovered how prawns could be the key to fighting poverty and schistosomiasis, a debilitating tropical disease. They found that farming the African river prawn could fight the disease and improve the lives of local people, because the African river prawn is a ‘voracious’ predator of the freshwater snail, which is a carrier of schistosomiasis.

The researchers in Senegal said that, “market analysis in Senegal had shown there was significant interest among restaurant owners and farmers in introducing prawns to the diet.” The prawn could also for the basis of aquaculture in rice paddies and remove the threat of schistosomiasis from the rice workers.

—- Thank you for reading this week’s summary. These weekly abstractings have replaced our occasional mailings on tropical health issues due to fees introduced by those maintaining the listserve website. Also continue to check the Tropical Health Twitter feed, which you can see running on this page.

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.