Category Archives: Elimination

Leadership and Support for Malaria Pre-Elimination in Nepal

Emmanuel Le Perru, Jhpiego field staff in Nepal, shared his experiences in aiding the malaria pre-elimination efforts in the country during a retreat that preceded the 65th Annual Meeting of the American Society of Tropical Medicine and Hygiene in Atlanta. Here are some highlights of his talk.

risk-mapMalaria Pre-Elimination efforts are targeting 0 deaths as well as investigation of 100% of confirmed cases in Nepal. Systematic entomology investigation/interventions are required. Glucose-6-Phosphate Dehydrogenase deficiency (enzyme genetic defect causing hemolysis with primaquine) testing for Plasmodium vivax in high G6PDd prevalence communities is required. Cases should receive treatment within 72 hours of symptoms for Pf (to quickly prevent transmission and gametocyte reservoir). There is also a need to distinguish between indigenous and imported cases.

Jhpiego is providing technical assistance and capacity building for Nepal’s Ministry of Health pre-elimination efforts as follows:

  • Integrated Vector Management
  • Micro-stratification
  • Entomology curriculum to be conducted in medical college (need new positions)
  • Case-based Surveillance guidelines
  • Private-sector engagement (for increased reporting and product quality control/procurement such as Antigen RDTs)
  • Capacity Assessments in 9 health systems strengthening components at central and district levels (Jhpiego Malaria Implementation Guide)
  • Human resources: clear job descriptions and performance goals
  • Leadership & Management development program

gfatm-bednets-distProgram highlights include the fact that the Global Fund malaria grant rating improved from B2 (inadequate but demonstrating potential) in January 2016, but now A2 (meeting expectations) in November 2016. Concept note for operational research at 2 or 3 border check points has been developed in order to determine whether such intervention (communication & voluntary screening) is cost-effective and relevant to catch/target imported cases, raise awareness on malaria available services, detect/prevent sources of potential outbreaks. This will inform GFATM on the relevance to fund such intervention. A similar approach was done at the China-Myanmar border but was not recognized by not WHO.

Nepal's Global Fund Grant Indicators for Malaria Case Management

Nepal’s Global Fund Grant Indicators for Malaria Case Management

Although the National Malaria Strategic Plan refers to high risk groups (forest workers, national parks security personnel, refugees, prisoners, etc.) evidence is needed to back this up. A study or improved investigation forms are needed to identify such groups and use this information to design appropriate behavior change communications and other interventions.

Special Programming Highlights include proposing a focus on Closed/Isolated Settings/Foci (limited migration, duration and population) to WHO and GFATM. Considering a targeted mass drug administration (MDA) Plasmodium vivax (not yes recommended by WHO) with Primaquine/G6PD testing. Consideration is being given to new drugs in the pipeline such as Ivermectin. Molecular Testing using Polymerase Chain Reaction (PCR) to detect low parasitemia, asymptomatic or re-infection cases (Pv includes inactive/dormant sporozoites known as hypnozoites) is being proposed.

Community based testing as proposed in the Global Fund grant needs strengthening. Therefore RDT use by Female Community Health Volunteer is being considered. Active case detection is another possibility for those areas moving toward pre-elimination. As mentioned, there is also need for studies of asymptomatic infection.

Lessons learned so far for best practices for efforts in identifying specific pre-elimination interventions include the value of getting consensus at national level through the Malaria Technical Working Group. There is also need to challenge WHO recommendations and engage dialogue to get creative. At present there is a risk of a Catch 22 situation wherein the GFATM asks for innovative interventions but at the same time tries to adhere strictly WHO to existing guidance.

The Nepalese malaria program is in constant dialogue with the GFATM Fund Portfolio Manager and team on the local context and technical challenges in order to get them involved in looking for innovative solutions.

Challenges arise in malaria diagnostics. While systematic microscopy is the gold standard, quality can be poor because of low stain/re-agent quality, constant staff turnover and donor reluctance to fund additional training. Also microscopy confirmation and slide quality control are time consuming, and often this process is not clear or well followed. PCR require specific equipment, training and qualifications. Takes time to be operational.

There are opportunities moving forward.  Progress could be made if there were more “elimination experts” to position to influencer to WHO to seek and propose new interventions for the pre-elimination stage. Nepal provides an ideal opportunity to test new ideas. It will also be necessary for the national malaria program staff to receive regular technical updates on program issues such as new drugs (Ivermectin?) and on-going pilots of MDA.

Malaria Day in The Americas Forum

In commemoration of Malaria Day in the Americas 2016

The Pan American Health Organization, The UN Foundation, The Milken Institute School of Public Health at The George Washington University, and Center for Communication Programs at The Johns Hopkins Bloomberg School of Public Health

Cordially invite you to attend the

“End Malaria for Good” Forum

Featuring videos, presentations and discussions on

The work of the ‘Malaria Champions of the Americas 2016’

malariaevite-2016-americasWHEN: Thursday, November 3, 2016, TIME: 1:00 p.m. to 3:30 p.m.

WHERE: Room B, PAHO Headquarters, 525 23rd Street NW, Washington, DC—20037

RSVP: Please fill out the form at https://goo.gl/0oaPzX

Light refreshments will be served

Does Malaria Meet the Criteria for Eradication?

World Malaria Report 2015 CoverWhat it is that makes a disease “eradicable,” or more correctly what makes it possible to eliminate malaria in each country leading to the total eradication world-wide. Bruce Aylward and colleagues identified three main sets of factors by drawing on lessons of four previous attempts to eradicate diseases (including the first effort at malaria eradication in the 1950s and ‘60s).[1]

  1. biological and technical feasibility
  2. costs and benefits, and
  3. societal and political considerations

So far smallpox is the only success because as Aylward et al. pointed out biologically, humans were the only reservoir and on the technical side a very effective vaccine was developed. The eradication campaign was promoted in clear terms of economic and related benefits. While the early malaria eradication efforts started with political will and recognition of the potential economic benefits of malaria eradication, the will was not sustained over two decades. On the technical side at that time there was only one main tool again malaria, indoor residual insecticide spraying, and mosquitoes quickly developed resistance to the chemicals. Are we better able to meet the three eradication criteria today?

Today’s technical challenges are embodied in intervention coverage problems. The World Malaria Report of 2015[2] (WMR2015) explains that the problem is most pronounced in the 15 highest burden countries, and consequently these showed the slowest declines in morbidity and mortality over the past 15 years. Use of insecticide treated nets and intermittent preventive treatment for pregnant women hovers around 50%, while appropriate case management of malaria lags well below 20%, a far cry from the goals of universal coverage. A further explanation of the technical challenges as outlined in the WMR2015 lies in “weaknesses in health systems in countries with the greatest malaria burden.”

The economic benefits criteria should be most pronounced in the high burden countries, but these are also generally ones with low personal income. Ironically, the WMR2015 points out that it is the high costs of malaria care and the malaria burden that further weaken health systems. More investment is needed in order to see more economic benefits.

Biological challenges to elimination are also identified in the WMR2015. Examples of existing and arising biological difficulties include –

  • Plasmodium vivax malaria which requires a more complicated regimen to affect a cure.
  • “Since 2010, of 78 countries reporting (insecticide resistance) monitoring data, 60 reported resistance to at least one insecticide in one vector population.
  • “P. falciparum resistance to artemisinins has now been detected in five countries in the Greater Mekong subregion.” Historically chloroquine and sulfadoxine-pyrimethamine resistance spread from this area and now artemisinin resistance marks a ‘Third Wave” of resistance emanating from the region.[3]
  • “Human cases of malaria due to P. knowlesi have been recorded – this species causes malaria among monkeys in certain forested areas of South-East Asia,” and so far human-to- human transmission has not been documented.

On the positive side greater political support to elimination efforts has been expressed by the African Leaders Malaria Alliance (ALMA) who met at the African Union Leaders Summit in Addis Abba early in 2015 and resolved to eliminate malaria by 2030.[4] This call to action was backed up with an expansion of ALMA’s quarterly scorecard rating system of African countries’ performance to include elimination indicators.[5]

In conclusion, political will exists, but needs to be backed with greater financial investment in order to produce economic benefits. Time is of the essence in taking action because biological and technical forces are pressing against elimination. 2030 seems far, but we cannot wait another 15 years to take action against these challenges to malaria elimination.

[1] Aylward B, Hennessey KA, Zagaria N, Olivé J, Cochi S. When Is a Disease Eradicable? 100 Years of Lessons Learned. American Journal of Public Health, 2000; 90(10): 1515-20.

[2] World Health Organization. World Malaria Report 2015. WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland, 2015.

[3] IRIN (news service of the UN Office for the Coordination of Humanitarian Affairs). “Third wave” of malaria resistance lurks on Thai-Cambodia border. August 29, 2014. http://www.irinnews.org/report/100549/third-wave-of-malaria-resistance-lurks-on-thai-cambodia-border

[4] United Nations Secretary-General’s Special Envoy on MDGs. African Leaders Call for Elimination of Malaria by 2030. Feb. 3, 2015. http://www.mdghealthenvoy.org/african-leaders-call-for-elimination-of-malaria-by-2030/

[5] African Malaria Leaders Alliance. ALMA 2030 Scorecard Towards Malaria Elimination, December 2014. http://alma2030.org/sites/default/files/sadc-elimination-scorecard/alma_scorecards_poster_english.pdf

Winning the fight against malaria in Huambo Province, Angola

Colleagues[1] from the Ministry of Health, Huambo, Angola and Jhpiego are presenting a poster at the 64th ASTMH Annual Meeting in Philadelphia at noon on Tuesday 27th October 2015. Please stop by Poster LB-5246 and discuss the results as presented in the Abstract below.

Angola malaria mapHuambo is on of Angola’s 18 provinces, with close to 2 million inhabitants. Traditionally malaria has accounted for a large portion of clinic consultations, hospitalizations, and child and maternal mortality. Angola has three epidemiological strata: hyper-endemic area (north), meso-endemic stable area (central area), where Huambo is located, and meso-endemic unstable area (south).

The main malaria vector is Anopheles gambiae (ss, melas and arabiensis) and Anopheles funestus. Parasitological studies show 85% of cases are P falciparum and 15% are P vivax.

The Huambo Provincial Health Directorate has been working with stakeholders including national and international NGOs, traditional leaders, churches, religious leaders, police, army and media to fight malaria. This collaboration is showing results.

Huambo ProgressCases have dropped steadily from 620,300 in 2008 to 68,547 in 2014. Likewise deaths have declined from 1,559 to 17 in the same period. During this period there has been an increase in training and supervision of health professionals to improve their malaria prevention, diagnosis and treatment skills.

Rapid diagnostic tests have been deployed to all health units. Work with community organizations has resulted in health fairs (Uhayele Vimbo) in more remote locations. Over the most recent 5-year period the number of antenatal care clients receiving two doses of IPTp with SP has increased from 10,938 to 68,183 or from 30% to 54%.

Finally 330,000 ITNs were distributed between 2010 and 2014. The Province and its organizational and community partners are committed to sustaining these achievements in order to further reduce malaria morbidity and mortality.

[1] João Carlos F. Juliana, Jhony Juarez, Clementino Sacanombo, William R. Brieger

 

Readiness for Malaria Elimination: Using HMIS data to Map Malaria Test Positivity in Huambo Province, Angola

20150908_103625Colleagues[1] from the Ministry of Health Angola, Jhpiego and the Johns Hopkins Bloomberg School of public Health are presenting a poster at the 64th ASTMH Annual Meeting in Philadelphia at noon on Monday 26th October 2015. Please stop by Poster LB-5094 and discuss the results as presented in the Abstract below.

Huambo Province in the south central highlands of Angola has a population of nearly 2 million, or 15% of the nation’s total. It is classified in the stable meso-endemic belt of the country, but is in the process of revising its malaria strategy to bring it closer to the pre-elimination phase on the pathway to malaria elimination. This means aiming to achieve 5% slide positivity rate for malaria parasites during the height of the transmission season (NovembSlide positivity rateser to January).

The health information system of the country reports information of positive and negative results of testing for suspected malaria cases from hospitals and clinics. The former use microscopy, while the latter rely on malaria rapid diagnostic tests (mRDTs). This information was analyzed for the past three high transmission periods and variations are reported herein among the 11 municipalities (districts) of the province.

The overall test positivity rates for all three seasons were 11% for microscopy and 25% for mRDTs among the 212,102 persons tested. The 4 municipalities in the northern part of the province ranged from 16-26% slide positivity and 24-44% mRDT positivity. The remaining municipalities in the south and central area ranged from 1-5% slide positivity and 3-16% mRDT positivity. Only one municipality achieved a positivity rate of <5% for both tests.

Moving forward, Huambo first intends to improve on the quality and coverage of malaria testing. The Ministry of Health will also focus on sustained control measures in the north, and begin more detailed mapping of malaria incidence in the central and southern municipalities to provide better targeting of interventions.

——-

[1] João Carlos F. Juliana, William R. Brieger, Jhony Juare3, Connie Lee, Clementino Sacanombo

Jhpiego Malaria Activities Featured in Posters at ASTMH Annual Meeting

AM15bannerToday marks the start of the 64th annual meeting of the American Society of Tropical Medicine and Hygiene from 25-29 October 2015 in Philadelphia. Please stop by the poster sessions Monday, Tuesday and Wednesday to see a sampling of Jhpiego’s malaria programs. We are featuring Angola, Nigeria, Burkina Faso, Tanzania, Kenya and Rwanda. You can also discuss with Jhpiego staff at Booth #100 in the Exhibition Hall.

Poster Session A Monday 26 October 2015JHPIEGO Logo 2007

  • LB-5094 – Readiness for Malaria Elimination: Using HMIS data to Map Malaria Test Positivity in Huambo Province, Angola – João Carlos F. Juliana1, William R. Brieger2, Jhony Juarez3, Connie Lee3, Clementino Sacanombo1 – 1Ministry of Health, Huambo, Angola, 2The Johns Hopkins University, Baltimore, MD, United States, 3Jhpiego, The Johns Hopkins University, Baltimore, MD, United States.
  • 385 – Health Systems Strengthening: Improving quality of services for prevention of malaria in pregnancy through the Standards-Based Management and Reward approach in Kenya – Augustine M. Ngindu1, Gathari Ndirangu2, Sanyu N. Kigondu2, Isaac M. Malonza3 – 1USAID-MCSP, Kisumu, Kenya, 2USAID-MCSP, Nairobi, Kenya, 3Jhpiego Kenya, Nairobi, Kenya

Poster Session B Tuesday 27 October 2015

  • 969 – Improving provision of malaria services through provider training in Burkina Faso – Ousman Badolo1, Stanislas Nebie1, Moumouni Bonkoungou1, Mathurin Dodo1, Thierry Ouedraogo1, Rachel Waxman1, William R. Brieger2 – 1Jhpiego, Baltimore, MD, United States, 2Johns Hopkins University, Baltimore, MD, United States
  • 680 – Institutionalization of Quality of Care in Health Facilities Improves Management of Malaria in Pregnancy in Tanzania – Jasmine W. Chadewa, Rita Mutayoba – Jhpiego, Dar es Salaam, Tanzania, United Republic of Tanzania
  • LB-5224 – Health systems strengthening – Advocacy facilitates availability of sulfadoxine pyrimethamine for prevention of malaria in pregnancy in Kenya – Augustine M. Ngindu1, Gathari G. Ndirangu2, Wekesa Kubasu3, Isaac M. Malonza4 – 1USAID-MCSP, Kisumu, Kenya, 2USAID-MCSP, Nairobi, Kenya, 3MOH, Bungoma, Kenya, 4Jhpiego,, Nairobi, Kenya Poster
  • LB-5246 – Winning the fight against malaria in Huambo Province, Angola – João Carlos F. Juliana1, Jhony Juarez2, Clementino Sacanombo1, William R. Brieger3 – 1Ministry of Health, Huambo, Angola, 2Jhpiego, The Johns Hopkins University, Baltimore, MD, United States, 3The Johns Hopkins University, Baltimore, MD, United States

Symposium #83 Organized by Jhpiego, RBM Malaria in Pregnancy Working Group – Prioritizing Malaria in Pregnancy as Malaria Transmission Declines – Tuesday, October 27, 2015 1:45 – 3:30 PM

Poster Session C Wednesday 28 October 2015

  • 1655 – Intermittent Preventive Treatment in Pregnancy: Increasing the Doses in Burkina Faso – Ousman Badolo1, Stanislas P. Nebie1, Mathurin Dodo1, Thierry Ouedraogo1, Rachel Waxman1, William R. Brieger2 – 1Jhpiego, Baltimore, MD, United States, 2Johns Hopkins University, Baltimore, MD, United States
  • 1330 – Use of community health volunteers to increase coverage for integrated community case management in Bondo, Kenya – Savitha Subramanian1, Mark Kabue2, Dyness Kasungami1,   Makeba Shiroya-Wadambwa3, Dan James Otieno4, Charles Waka3 – 1John Snow, Inc., Rosslyn, VA, United States, 2Jhpiego, Baltimore, MD, United States, 3Jhpiego, Nairobi, Kenya, 4John Snow, Inc., Nairobi, Kenya
  • 1657 – LLIN distribution campaign processes: Lessons learned and challenges from Akwa Ibom State, Nigeria – John Orok1, Bright Orji2, Enobong Ndekhedehe2, William R. Brieger3 – 1Ministry of Health, Akwa Ibom State, Uyo, Nigeria, 2Jhpiego, Baltimore, MD, United States, 3Johns Hopkins University, Baltimore, MD, United States
  • 1656 – Use of Long Lasting Insecticide-Treated Bednets in Akwa Ibom State Nigeria after a Major Distribution Campaign – Enobong U. Ndekhedehe1, John Orok2, Bright C. Orji1, William R. Brieger3 – 1Jhpiego, Baltimore, MD, United States, 2Ministry of Health, Akwa Ibom State, Nigeria, Uyo, Nigeria, 3Johns Hopkins University, Baltimore, MD, United States

Eradication, Elimination: What is Feasible – WHO Global Malaria Program

Over the past few months several key malaria partners have been discussing the potentials for malaria elimination and mentioning target dates. Based on these discussions and publications Dr Pedro Alonso, Director, Global Malaria Programme or the World Health Organization has provided a reminder of WHO’s position and strategy. We share his comments for our readers below.

24 October 2015

Dear colleagues and partners,

Global Malaria Strategy Cover Page blue borderIn recent weeks, you may have seen press articles stating that the United Nations and partners are calling on the world to eradicate malaria by the year 2040.

The World Health Organization (WHO) shares the vision of a malaria-free world and – to that end – we welcome the commitment of all of our partners. However, I would like to clarify the strategy, targets and timeline that our organization has endorsed at this point in time.

WHO’s work on malaria is guided, as you will recall, by the Global Technical Strategy for Malaria Elimination 2016-2030, adopted in May 2015 by the World Health Assembly. The strategy calls for accelerated action toward malaria elimination in countries and regions but does not set a time frame for global eradication.

This WHO strategy is complemented by the Roll Back Malaria advocacy plan, Action and Investment to Defeat Malaria 2016-2030.  Both documents were the result of an extensive consultative process involving the participation of more than 400 malaria experts from 70 countries. They set ambitious but achievable global targets, including:

  • Reducing malaria case incidence by at least 90% by 2030
  • Reducing malaria mortality rates by at least 90% by 2030
  • Eliminating malaria in at least 35 countries by 2030
  • Preventing a resurgence of malaria in all countries that are malaria-free

The timeline of 2016-2030 is aligned with the 2030 Agenda for Sustainable Development, the new global development framework adopted by all UN Member States in September.

New WHO estimates

Recent news articles have reported a wide range of estimates on case incidence, mortality and global investment for malaria, which may have caused confusion. Please find below two documents with the latest WHO-approved estimates:

  1. A fact sheet with key global and regional estimates from the WHO-UNICEF report “Achieving the malaria MDG target,” published on 17 Sept. 2015. http://www.who.int/mediacentre/factsheets/fs094/en/ (see some excerpts below)
  1. An updated WHO general fact sheet on malaria.
    http://www.who.int/malaria/media/malaria-mdg-target/en/

Best regards,

Dr Pedro Alonso
Director, Global Malaria Programme
World Health Organization

Elimination

Malaria elimination is defined as interrupting local mosquito-borne malaria transmission in a defined geographical area, typically countries; i.e. zero incidence of locally contracted cases. Malaria eradication is defined as the permanent reduction to zero of the worldwide incidence of malaria infection caused by a specific agent; i.e. applies to a particular malaria parasite species.

On the basis of reported cases for 2013, 55 countries are on track to reduce their malaria case incidence rates by 75%, in line with World Health Assembly targets for 2015. Large-scale use of WHO-recommended strategies, currently available tools, strong national commitments, and coordinated efforts with partners, will enable more countries – particularly those where malaria transmission is low and unstable – to reduce their disease burden and progress towards elimination.

In recent years, 4 countries have been certified by the WHO Director-General as having eliminated malaria: United Arab Emirates (2007), Morocco (2010), Turkmenistan (2010), and Armenia (2011). In 2014, 13 countries reported 0 cases of malaria within their own borders. Another 6 countries reported fewer than 10 cases of malaria.

The WHO Global Technical Strategy for Malaria 2016-2030 sets ambitious but achievable global targets, including:

  • Reducing malaria case incidence by at least 90% by 2030.
  • Reducing malaria mortality rates by at least 90% by 2030.
  • Eliminating malaria in at least 35 countries by 2030.
  • Preventing a resurgence of malaria in all countries that are malaria-free.

“Nobel” drug discoveries rewarded, but delivery of malaria and filarial medicines to the community also matters

Herbs, soil and hard scientific work have yielded Nobel Prizes in Medicine/Physiology for three scientists whose results now save millions of lives from death and disability due to malaria, onchocerciasis (river blindness) and filariasis (elephantiasis), according to the New York Times. Two of the winners, “Dr. Campbell and Dr. Omura, developed Avermectin, the parent of Ivermectin, a medicine that has nearly eradicated river blindness and radically reduced the incidence of filariasis.” Dr Tu Youyou, “inspired by Chinese traditional medicine in discovering Artemisinin, a drug that is now part of standard anti-malarial regimens and that has reduced death rates from the disease.”

Community Case Management of Malaria in Rwanda using Rapid Diagnostic Tests and ACTs

Community Case Management of Malaria in Rwanda using Rapid Diagnostic Tests and ACTs

The development of these chemicals into human medicines was a long time coming, and in the case of artemisinin, over 2000 years. The Guardian quotes the Deputy Director of the Liverpool School of Tropical Medicine as saying that, “Artemisinin was discovered when fatalities from malaria were rocketing and the world was terrified we’d be looking at a post-chloroquine era. It has been a real game-changer.”

In fact artemisinin in combination with other medicines or artemisinin-based combination therapy (ACT) rescued many lives in the face of parasite resistance to earlier first line drugs like chloroquine and sulfadoxine-pyrimentamine (though artemisinin resistance is now growing). ACTs are also made freely available to populations in malaria endemic countries through such programs as the Global Fund to fight against AIDS, TB and Malaria (GFATM), the US President’s Malaria Initiative, the World Bank and others.

Avermectin began its medical role as a veterinary drug that killed parasites in livestock. Eventually research by Merck based on the similarities between animal and human filarial worms led to the testing and development of ivermectin to control onchocerciasis through annual doses that killed microfilariae.

Not only are both ACTs and ivermectin on WHO’s essential medicines list, but they form the basis of global efforts to eliminate disease. Once Merck determined that ivermectin was safe and effective in humans, it began donations of the drug to what has become the African Program for Onchocerciasis Control (APOC) and its counterpart that is working to eliminate the disease in the Americas. APOC and its national counterparts now reache people in over 200,000 endemic villages in 18 African countries with annual doses.

Community Directed Distribution of Ivermectin in Cameroon

Community Directed Distribution of Ivermectin in Cameroon

While we celebrate the recognition that the drugs and their discoverers are receiving, we should not lose sight of the fact that without good delivery mechanisms these life saving medicines would not reach the poor, neglected, often remote populations who need them.

Beginning in 1995, APOC and the Tropical Disease Research Program of WHO and partners pioneered what has now become known as Community Directed Interventions (CDI) where the thousands of communities “beyond the end of the road” and their selected volunteers organize the annual ivermectin distributions. This community directed approach works for community case management of malaria, too.

Hopefully in the future, groups like APOC will receive Nobel Prize recognition for ensuring that those in need actually receive the medicines they require. In the meantime we encourage more countries to adopt the CDI approach to reduce malaria deaths and work toward the elimination of malaria, onchocerciasis and filariasis.

Initial Evidence Of A Reduction In Malaria Incidence Following Indoor Residual Spraying With Actellic 300 Cs In A Setting With Pyrethroid Resistance: Mutasa District, Zimbabwe

Mufaro Kanyangarara and her PhD thesis adviser, Luke Mullany of the Johns Hopkins Bloomberg School of Public Health Department of International Health, have been looking into the challenges of controlling and eventually eliminating malaria in a multi-country context in southern Africa. We are sharing abstracts from her pioneering work including the following which explores indoor residual spraying in Zimbabwe in a District near the Mozambique border.

sprayed and unsprayed wardsIn order to reduce the vector population and interrupt disease transmission, IRS with appropriate insecticides is essential. In response to local vector resistance, the Zimbabwe NMCP with support from PMI began a large-scale IRS campaign with organophosphates in four high transmission districts in Manicaland province – Chimanimani, Mutare, Mutasa and Nyanga. Using HMIS data, the present study reports on the effect of switching from pyretheroids to OP on malaria morbidity in one of the four high transmission districts selected. In the subsequent high transmission season following the switch from pyretheroids to organophosphates, there was evidence of a 43% decline in malaria incidence reported by health facilities from wards in Mutasa District treated with organophosphates, after accounting for possible confounding by environmental variables. Previous research shows that switching to organophospates effectively reduced biting rates and vector densities in areas with pyretheroid resistant strains in Ghana, Benin and Tanzania. Although previous research focused on using entomological data to show the reduction in the vector population following application of Actellic, organophosphates, this study adds to the literature by showing a decline in malaria transmission using health facility surveillance data.

In the present study, there were variations in rainfall and temperature over the study period, and these changes were associated with changes in malaria incidence. The study results also indicated malaria transmission in Mutasa District was driven by rainfall, proximity to second order streams, elevation and temperature. These results concur with previous research, which found that elevation, temperature, and rainfall are positively associated with malaria incidence. After adjustment for climatic variables and seasonality, malaria incidence rates a downward trend following the 2014 IRS campaign and thus supporting the plausible conclusion that switching to organophosphates in this setting contributed to the observed public health benefits. No major political, socio-economic, or health-care changes with the potential to reduce malaria morbidity by almost half occurred in Mutasa District during the study period.

Observed and predicted weekly malaria counts in MutasaTypically data from health facilities only includes data on the number of suspected cases. The HMIS in Zimbabwe is more sophisticated in that it allows reports of confirmed malaria cases. In calculating of incidence rates, the denominator used was the catchment area population size. The reliability of this value has been questioned as this assumes that people will visit the closest health facility/health facility in their catchment area. It is noteworthy to mention that in the present study the main results did not chance after including an offset for catchment area population size. This indicates that in the Zimbabwean context, the reported catchment area population size may be a reliable estimate. The study also underscores the utility of HMIS data in the evaluation of population level interventions. The HMIS has the advantage of providing quality data quickly and easily, with minimal additional investment. Additionally, HMIS reflects the burden of disease on the health system. Results from this study further suggest that passive surveillance data from the HMIS in Zimbabwe was sufficiently sensitive to detect IRS related reduction in malaria morbidity among residents of Mutasa District.

There are several important limitations of this study that should be highlighted. Causal inferences between spraying and improvements in malaria incidence should be made with caution as spraying was not implemented as an intervention in a randomized control trial. However, data from 14 health facilities located in unsprayed wards were included in the analysis to serve as a comparison and help understand any possible changes in malaria morbidity unassociated with the 2014 IRS campaign. Although the univariate model indicated that health facilities in unsprayed wards carried a lower burden of malaria, the multivariable model showed no significant differences between health facilities in sprayed and unsprayed wards prior to the IRS pilot, suggesting that climatic variables included in the model adequately adjusted for differences. However, it should be noted that although the study adjusted for environmental factors, it did not account for other factors like population movement, changes in treatment seeking behaviors, changes in the coverage of ITNs during the study period. The model developed in this analysis assumed that these factors remained constant over the study period. This seems reasonable given that the rural population of Mutasa is relatively stable, with access to health facilities providing malaria diagnosis and treatment. Additionally, although the number of suspected malaria cases was not explicitly model, a descriptive analysis does not indicate changes in diagnostic practice over the study period (data not shown). The HMIS in Zimbabwe has been in place for decades and has previously been used to evaluate the impact of changes in malaria morbidity, construct empirical seasonality maps and describe the spatial and temporal distribution of malaria.

Despite these potential limitations, health surveillance systems provide a feasible and efficient means of collecting longitudinal data on measures of malaria morbidity. The pronounced decline in malaria morbidity observed in this study is evidence supporting the benefit of switching to an insecticide class with a different mode of action in response to pyretheroid resistance. Although the IRS strategy implemented by ZNMCP and PMI was successful, continued entomological monitoring will be necessary. Additionally, with emerging resistance to multiple insecticides, this approach may not be sustainable over time. There is need for the development of novel strategies to manage insecticide resistance.

Are we ready to actively support malaria elimination?

As Michael Gerson of the Washington Post said today, “It is now possible to set goals in a number of areas — malaria elimination, an AIDS-free generation, the end of extreme poverty — and not be dismissed as a crank.” He was lamenting the fact that with the 17 new Sustainable Development Goals there are 169 targets – too much to get a handle on. Thus focus on something specific like malaria elimination is important for endemic countries to consider.

The New York Times reports that, “Now, the United Nations and the Bill and Melinda Gates Foundation are calling on the world to eradicate the disease by 2040, potentially saving 11 million lives in the next 25 years. They say this goal can be achieved for between $90 billion and $120 billion and would produce economic benefits of $2 trillion.” Even though some experts may question the feasibility of 2040, they are no longer calling Gates a crank.

2000-2015The challenge has been though that our global malaria programming is largely stuck in the era of scale up of control efforts with a focus on getting more long lasting insecticide-treated nets and increased household spraying out in high burden areas. As recent reports from WHO and partners indicate, the malaria morbidity and mortality map is shrinking, but there do remain high burden areas. It is only that now we need to focus equally on the science and management of the tools needed to eliminate the disease.

The challenges lie in issues like weak health systems and increasing resistance of parasites and vectors to existing tools. These problems can be overcome through research if the international community is willing to provide the funding.

Here is where groups like the Malaria Eradication Scientific Alliance (MESA) come in. They are addressing the following:

  • Basic science and enabling technologies
  • Insecticide and drug resistance
  • Characterizing the reservoir and measuring transmission
  • Specific Tools for elimination
  • Combining interventions and modelling
  • Health systems and policy research

Major donors like the US President’s Malaria Initiative, The Global Fund to fight AIDS, TB and Malaria and the World Bank need to join with groups like MESA and the Gates Foundation and get behind this agenda. Countries, when updating their malaria strategic plans for new funding from the Global Fund, need to be encouraged to include malaria elimination efforts. Opportunities are should not be missed on the frontline in southern Africa including Zimbabwe, Zambia, Angola, Mozambique, Botswana, South Africa, Swaziland and Namibia to study and implement new approaches and document the lessons, which could also be picked up in the countries of the Sahel, the Pacific Islands and South America. Malaria will not eliminate itself!