Tropical Health Matters

Mary E. Schmidt, M.D. has studied the malaria situation in Haiti for her MPH capstone project at the Johns Hopkins Bloomberg School of Public Health. She has shared the abstract of the project with us here.

Background:  Hispaniola is the only Caribbean island still endemic for malaria.  While the Dominican Republic continues to see improvement in the use of prevention measures and malaria rates, Haiti has been unable to organize, operate and fund a sustainable program.  The city of Jacmel in the South East District has the capacity to create a successful program.

Materials and Methods:  A literature review was performed of population based surveillance studies to understand the epidemiology of malaria in Haiti and the South East District. Individuals were interviewed to understand the Minister of Public Health and Population (MSPP) malaria policy and the current epidemiologic practices.  Haitian physicians and CBO workers were observed and interviewed to understand how malaria is diagnosed and treated, how patients are educated and the current community malaria prevention programs.

A literature review was performed of  materials from malaria experts, the World Health Organization (WHO), Pan American Health Organization (PAHO) and The Global Fund to better understand the components of a successful malaria elimination program.

Results:  This review focused on the current barriers of a malaria implementation program in Jacmel and the national system that would prevent a successful program.   The review led to the creation of a malaria elimination framework for Jacmel and the South East District.

The framework emphasizes a strong management and operations component.  The MSPP office communicates with finance, surveillance, the district health officer, and the operations team.  For a functional system, operations and management communicates with the MSPP oversight team and receives input from finance and surveillance in order to manage training, deployment, communications and local surveillance.

Monitoring and Evaluation is done on a district level and reported to district operations to help with managing the program and to the surveillance team.  Recommendations for policy development include focus on diagnostics, specific treatment, vector control, education and monitoring.  Barriers include funding and implementing an adequate operation and deployment team.

Conclusion:  The implementation of an effective malaria elimination program in Haiti will require MSPP leadership oversight and a strong operations and management team in each district.  The city of Jacmel in the South East District has the  interest and support from local CBOs and business leaders that make it the ideal location to implement the framework and create a sustainable program.

The International Certification Team (ICT) for Guinea Worm Disease Eradication held a debriefing meeting with the Honorable Minister of Health of Nigeria on Friday 12th July 2013.  The team of over a dozen international and national experts had been working in-country to review the certification report prepared by the Nigerian Guinea Worm Eradication Program (NIGEP) within the Federal Ministry of Health (FMOH) for three weeks to learn if claims that the last case of the disease occurred in 2008 and that measures were in place to detect any imported or locally transmitted case in the interim. (Photo shows Nigeria’s Honorable Minister for Health, Prof. C.O. Onyebuchi Chukwu at right, receiving report from ICT lead by Prof. Molyneux on left, with Nigeria’s WHO representative center.)

This ICT visit in 2013 marks 25 years since the launch of NIGEP at a time when there were over 650,000 cases found in over 6,000 villages/communities, the highest burden of the disease in Africa and likely the world at that time.  The leader of the ICT, Prof. David Molyneux, thanked all the partners over the past two and a half decades who made today’s good news briefing possible. Prof. Molyneux is also Chairman of the International Commission for the Certification of Dracunculiasis (guinea-worm disease) Eradication (ICCDE) based in WHO.

The Commission has certified that two of Nigeria’s neighbors, Benin and Cameroon, are already free of guinea worm. Niger to the north is also in the pre-certification phase, while active transmission is still occurring on a small scale in Chad. Prof. Molyneux explained that the concern about these neighbors to the north and northeast is the potential of imported cases through population migration, hence the need for continued strong surveillance as part of an overall national health surveillance system.

In the process of verifying information in the national report on guinea worm elimination and validating its contents the ICT visited 17 States and the Federal Capital Territory, 60 Local Governments, 136 villages and interviewed 1,630 people using standardized questionnaires. Prof. Molyneux said the team took each State into consideration as a separate entity since some are larger than whole countries that have previously been certified.

Surveillance that helped Nigeria document no new cases since 2008 included 1) regular reporting on multipurpose surveillance forms at all frontline clinics, 2) incorporation of case searches into community and house-to-house health activities such as national immunization days/child health days and ivermectin distribution for onchocerciasis control, and 3) radio advertisements/jingles that describe guinea worm and offer a reward of N25,000 (approximately $160) and subsequent follow-up of rumored reports that this stimulates. These activities need to continue as long as countries in the region may still harbor the disease.

The team also reviewed contributing factors to maintaining a guinea worm free Nigeria, in particular village water supplies. While they noted that access to safe water had increased in many rural villages, there was still a problem of maintaining various kinds of wells and water systems.  At the start of global guinea worm eradication efforts during the United Nations Water Decade (the 1980s) the importance of guinea worm being the main infectious disease transmitted only through poor water supplies was stressed.

The next steps after this informal briefing of the FMOH is transmission of the ICT report to the ICCDE. The decision of the ICCDE will then be sent to the Director General of WHO, who will then communicate the findings and recommendations to the Nigeria FMOH officially.  Hopefully before the end of 2013, Nigeria will be declared free of guinea worm, and as Prof. Molyneux said, strong vigilance and surveillance will need to stay in place, including cross-border collaboration to prevent reintroduction of the disease. (Photo shows two Nigeria Guinea Worm pioneers, Prof. Eka Braide on right and Prof Luke Edungbola on left who were among the original zonal coordinators for NIGEP)

Eradication of guinea worm will only be achieved once each endemic country is certified free of the disease.  The certification process is lengthy, thorough but absolutely necessary. Similar processes need to be strengthened for other infectious diseases.

Presented at Jhpiego’s Mini-University on 24 June 2013 in Baltimore by Marya Plotkin, Elaine Roman, and Maryjane Lacoste

Malaria in pregnancy (MIP) is a threat to the pregnant women, the unborn child and the newborn and infant. Intermittent Preventive Treatment during pregnancy (IPTp) is one of the few interventions available that specifically targets and protects pregnant women.  As malaria prevalence drops when countries aim at malaria elimination, we need to examine the continued role of IPTp and search for alternatives.

From August 2011 to September 2012, Jhpiego partnered with the Zanzibar Ministry of Health to conduct a study looking at the prevalence of placental malaria infection among women delivering in selected health facilities in Zanzibar who had not had IPTp during the course of their pregnancy. The community-level malaria positivity rate in Zanzibar declined from as high as 20% in 2005 to 1.6% in 2011. In Zanzibar as in the rest of Tanzania, IPTp coverage has been quite low, but pregnant women have access to long-lasting insecticide-treated nets (LLINs) and indoor residual spraying (IRS) is practised in the islands.

Midwives in six clinics in in Unguja and Pemba tested the women using PCR at delivery. Of the 1,356 women with no IPTp exposure enrolled in the study, only nine (0.6%) were found to have placental malaria (95% CI 0.2–1%). Thus, even without benefit of IPTp, other interventions appear to be protecting pregnant women to some degree.

Estimations of the costs of IPTp program put the annual expenditure at $114,678, while the annual cost of intermittent screening and treatment with RDTs (ISTp) would be $155,294.  Given the extraordinarily low prevalence of malaria in pregnancy, as well as pilot experience of testing in the ANC setting, there is a strong argument for adopting ISTp and dropping IPTp in Zanzibar.

To do so, the authors argue, thresholds of prevalence or incidence of malaria infection must be set in advance in order to trigger a reconsideration of the IPTp decision, and surveillance of malaria infection in pregnancy must be strengthened.

WHO has recently issued new guidance recommending continuation of IPTp where it is currently being practiced, making Zanzibar’s decision to maintain or discontinue IPTp of particular interest to the malaria in pregnancy community. Better guidance is needed on MIP services as countries move closer to malaria elimination.

The efforts to eliminate guinea worm from Nigeria are coming to a close 28 years after the challenge was taken up at national conference in 1985. At the time there were over 650,000 cases in the country. In just eight years between 1988 and 1995 Nigeria saw a precipitous decline in cases down to 16,374 as seen in the attached map from the Carter Center.

1995 had been posited as the first target date for global guinea worm eradication (see countdown calendar page below), and while efforts came close to eliminating it in Nigeria, the process dragged on for 14 more years until we reached zero annual reported cases. Now there are only a few countries left. The last verifiable case in Nigeria was November 2008. What is the process of ensuring that guinea worm has been eliminated from Nigeria?

A major step over the past few years has been to maintain surveillance since guinea work thrives from neglect.  As Steve Dada from This Day reported, “WHO officials say finding and containing the last remaining cases of the disease is the most difficult stage of the eradication process, because cases usually occur in remote, hard-to-reach areas.” The communities were involved, as evidenced from a radio announcement heard in Jos, Plateau State last Saturday in which people were encouraged to keep looking for the disease.Surveillance efforts have even made use of events like national immunization days to seek out information on possible cases.

As reported recently in the Vanguard, “The Federal government is offering a cash reward of N25,000 (~$160) for every report of authentic new guineaworm cases in any part of the country. In 2011, a N10,000 reward was offered for a similar report.” So far no authentic case has been found, but indigenous beliefs about the disease has meant many false positives over the years, accounting for the many rumors reported by the Vanguard. These efforts are part of the program to prepare Nigeria for a visiting team from the World health Organization in June 2013 to certify elimination.

In preparation for eventual certification of all countries, WHO established in 1995 “an independent International Commission for the Certification of Dracunculiasis Eradication in 1995. The Commission comprises 12 public health experts from all six WHO regions.”  WHO explains that, “A country reporting zero cases over a period of 12 consecutive months is believed to have interrupted transmission of dracunculiasis and is classified as being in the pre-certification stage … After at least three years of pre-certification and consistent reporting of zero indigenous cases, a country becomes eligible for certification.”

What does all this mean for malaria? First, even though we are talking about a process in Nigeria that spanned nearly three decades, this is relatively short.  The characteristics of guinea worm disease (and even small pox, its predecessor in eradication) make it relatively easy to spot. Few people could confuse a worm emerging from one’s body, as seen in the photo from the Carter Center, with another disease. One does not need a microscope either.

We have been reminded recently that malaria parasites can even ‘hide’ at submicroscopic levels without causing any symptoms. Even with malaria symptoms there is easy confusion by the public with other diseases. We are certainly nowhere near the point of offering $100 rewards for detection of malaria cases.

There are a number of other key differences such as a ‘vector’ that stays in the pond for guinea worm, while malaria carrying mosquitoes can fly a few miles.  The key lesson therefore, is the need to adapt elimination efforts and timelines to the realities of each disease.  So while we will not be giving financial rewards for case detection just yet, we should continue to give recognition to Malaria Champions like President Joyce Banda of Malawi.

Another lesson is the fact that WHO established its guinea worm elimination certification process long before all countries were close to reaching goals.  This can help malaria program planners envision the surveillance processes they will need to out in place to eliminate the disease, especially since it will likely be, like guinea worm, hiding in the more remote and poor areas of a country.

Finally we must congratulate Nigeria in its guinea worm elimination success and hope this provides motivation for malaria elimination, too.

The 2015 Millennium Development Goals milestone of reducing malaria morbidity and mortality is sometimes hard to see from here because of the many carts that got ahead of the horses and clogged the road.  We discussed earlier this week about the big push for universal coverage with long lasting insecticide-treated nets that got ahead of thoughts and plans for disposing the net packaging as well as old nets in an environmentally sound way.

Only a few efforts are underway to find a solution to old net disposal. In fact the need to replace LLINs much sooner than expected because of less than desired durability in real life field settings was another cart that surprised some horses and may lead to stock-outs in the next few years as financial sources for nets are not as certain as before.

A classic example ‘carthorsology’ is the roll out of artemisinin-based combination therapy medicines long before appropriate, easy to use diagnostic procedures were in place. Certainly we needed to save lives, but while most endemic African countries replaced first line drugs to which parasites had developed resistance with ACTs between 2005 and 2008, there was no alternative to clinical diagnosis in place.

Hopes that net use and other preventive measures would bring down the demand for ACTs were thwarted when health workers had to rely on their clinical judgment and continued to prescribe the more expensive ACTs presumptively just as they had done for the cheaper chloroquine and sulphadoxine-pyrimethamine. When RDTs finally became more common, there was an uphill battle to convince health workers that their clinical diagnosis was no longer acceptable.

In actuality, RDT supplies are still not matching need – i.e. enough to test all fevers and suspected cases of malaria. So in hindsight we are rushing to invest more heavily in RDTs and health worker diagnostic training and trying to find ways to safely dispose old nets.

Processes like RoapMap planning sponsored by RBM and WHO are certainly moving us in the right direction that views holistically the totality of the malaria intervention package intervention. One wonders though if any other carts lie unforeseen ahead to block our horses.

One example of needed foresight is the development of appropriate strategies for end game pre-elimination and elimination.  In particular are appropriate surveillance systems in place?

Donors, especially the Global Fund seem reluctant to support the challenges of pre-elimination in countries like Swaziland, Namibia, Solomon Islands and others who are on the frontline of the elimination effort.  Fortunately the Clinton Health Initiative is one of those with foresight.  Hopefully we can keep investing in the forward march without additional unforeseen diversions in the RoadMaps.

A new article by Wickramage and Galappaththy raises numerous challenges facing a country like Sri Lanka that is approaching malaria elimination.  Human trafficking takes people from a malaria free zone, transits them through malarious areas in West Africa, and then in this case they are rescued and returned home, some carrying malaria parasites.

Other island nations are also addressing the problem of preventing future reintroduction of malaria, but they are not in a post-conflict situation that creates what Wickramage and Galappaththy euphemistically called “irregular migrants.” Seychelles has addressed both vector control as well as provision of malaria chemoprophylaxis and health education to outbound citizens.

Trafficked citizens would obviously and unfortunately miss the opportunity to get prophylaxis (as well as many other opportunities in life).  In Sri Lanka those returning from trafficking transit in West Africa were screened at the airport and treated. Seychelles could learn from this experience.

Mauritius has not had an indigenous malaria case in over a decade although the vectors are still present. Mauritius actively screens people return from malaria endemic areas at both airport and seaport.

Malaria Journal reports that in Sao Tome and Principe “A steep decline of ca. 95% of malaria morbidity and mortality was observed between 2004 and 2008 with use of the combined control methods. Malaria incidence was 2.0%, 1.5%, and 3.0% for 2007, 2008, and 2009, respectively. In April 2008, a cross-sectional country-wide surveillance showed malaria prevalence of 3.5%, of which 95% cases were asymptomatic carriers.”

So yes, countries approaching elimination must have a surveillance system that finds both obvious clinical cases as well as asymptomatic infections among residents and people returning to or visiting from the outside.  Island nations are among the first to put this process to the test.  But the bigger lesson from Sri Lanka’s ‘irregular migrants’ is that as long as conflicts, human trafficking and human rights violations persist, malaria will be difficult to eliminate.  Malaria demonstrates that no man or woman is an island.

In 1998 Fred Binka and colleagues published an article that showed the value of living near someone with an insecticide treated net (ITNs), even if you did not have your own net. They documented a 6.7% increase in likelihood of malaria mortality in children for each 100 meter shift away from a house with ITNs the non-user was located.

Then Otten et al. looked at the effects of a short campaign in 2006 to distribute ITNs to children during immunization campaigns and ACTs through CHWs in Rwanda. Eight months later 60% ITN coverage was documented. The interventions resulted in a greater than 50% decline in inpatient malaria cases and outpatient laboratory confirmed malaria cases among children even with less than optimal intervention coverage.

Now, these hints of success in net use have been modeled mathematically to achieve a more realistic target for net coverage instead of relying solely on arbitrary estimates like 80% or 85%. Agusto and colleagues have published their findings which propose that, “If 75% of the population were to use bed-nets, malaria could be eliminated.”

“We conclude that more data on the impact of human and mosquito behavior on malaria spread (are) needed to develop more realistic models and better predictions.”  Of particular concern is learning more about how human handling and mishandling of nets affect these estimates.

So what progress toward this potential target of 75% have we made? The attached chart was derived recent from Malaria Indicator and Demographic and Health Surveys.  Except for the preliminary results of the Tanzania survey, most countries were not even close to the RBM target of 80% coverage for 2010, let alone a slightly more modest 75%. A frustrating trend is the fact that even in households that posses at least one net, children are not sleeping under them.

Now that we have more realistic targets, planning should be easier. Even so after all the push towards universal coverage since 2009, we still have a long way to go to reach targets, let alone talk of elimination.

The First Rwanda Malaria Forum was organized by the National Malaria Programme from the 26th to 28th September 2012 in Kigali Rwanda. The aim of the Forum was to recommend actions that Rwanda should take to accelerate the attainment of zero malaria deaths. The forum brought together experts from Rwanda, East Africa, Southern Africa, the United States of America and Europe. WHO was prominently represented by the Director Disease Prevention and Control on behalf of the Regional Director WHO AFRO.

The Forum recognized the remarkable progress Rwanda has made in reducing malaria morbidity and mortality and recommended that by 2017 Rwanda should aim to achieve zero deaths due to malaria and achieve pre-elimination status. The following were the key recommendations:

A) Maintain the remarkable achievements and further reduce malaria morbidity to pre-elimination levels countrywide

• Increase funding to the fight against malaria (domestic and external)
• Achieve 90% coverage of the population at risk of malaria with locally appropriate vector control interventions based on evidence
• Improve malaria case diagnostics to 100% and treatment at all levels including the private sector.
• Develop a comprehensive advocacy, communication and social mobilization aimed at shifting the understanding of malaria pre-elimination by the leadership and other policy makers, the community and all levels of the health system.
• Develop capacity for malaria pre-elimination including in entomology and epidemiology
• Conduct operational research to support programme implementation and robust documentation of the process

B) Achieve zero malaria deaths by 2017

• Strengthen prompt access to treatment of severe malaria
• Conduct malaria death audits for all cases

C) Investigate and classify all cases and foci in low endemic districts

• Gradually, strengthen epidemiological, entomological and therapeutic surveillance
• Strengthen malaria stratification for local and eventually imported malaria cases
• Further strengthen the health system in readiness for pre-elimination using the WHO 6 pillars
• Strengthen an integrated quality assurance and control system for diagnosis and treatment of malaria cases.

D) Develop and strengthen local and international collaborative and partnership initiatives to accelerate malaria control and pre-elimination in Rwanda and the region.

• Strengthen linkages with other players in the health non-health sectors within the country
• Create a multi-sectoral malaria pre-elimination group
• Develop, with other East African Countries, a cross border strategy to accelerate malaria control and pre-elimination in the region

A key focus of the recently completed First Rwanda Malaria Forum was on cross-border initiatives to help eliminate malaria.  The two most malaria-endemic districts in Rwanda are situated at borders with other malaria endemic countries. Nyagatare borders Uganda and Tanzania, while Gisagara borders Tanzania and Burundi.  The Democratic Republic of Congo, which has some of the highest malaria burden in the world, shares a long border with Rwanda, too.

The Working Group on Cross Border Planning and Initiatives consisted of Nancy Mock (Tulane), Charles Paluku, Okui Albert Peter (Uganda), James Banda (WHO/GMP), Carol Asiimwe, Harriet Pasquale  (South Sudan), Simon Kunene  (Swaziland), Dorothy Memusi (Kenya), Corine Karema (Rwanda), Felicien Ndayizeye (Burundi), Patrick Moonasar ( Rapporteur), Georges A. Ki-Zerbo (WHO/AFRO).  Their overall strategic considerations are found in the table below.

Key action points focused on defining the problem and drafting a concept paper. Defining the problem would require Two meetings with all 5 countries supported by RBM’s East Africa Regional Network (EARN)Earn Support. The first meeting would focus on a conducting situational analysis and drafting of framework for data collection (before 15 December 2012). The second meeting would bring evidence based on Framework for collaboration in moving towards malaria elimination and a draft concept paper (March 2013).

The draft a concept paper would cover the following key issues:

• Disease burden in all neighboring districts
• Coverage target in all neighboring countries  and other factors e.g. demographic and social factors.
• Rational for initiative
• Objectives
• Activities
• Budget
• Coordination mechanism
• Recommendations
• Action plan

Facilitators for this effort should be WHO and EARN. Because of Swaziland’s experience with such cross-border efforts the working group identified its National Malaria Control Program Director, Simon Kunene, as an expert who could provide technical assistance.

In summary key recommendations arising from the Working Group deliberations include:

• A cross border initiative meeting including target district leaders
• WHO/EARN to provide oversight TA, invite target NMCP managers and District Health Management Teams
• Each country shall initiate internal discussions on cross border initiatives
• Each member country to ensure inclusion of Cross-Border initiatives into national strategic plans and share data collection tool at country meetings

A second working group at the recently completed First Rwanda Malaria Forum examined issues around “Malaria Prevention and Vector Control.” A key message from the Forum was the need to protect existing vector control technologies (IRS and LLINs) and well as develop and test new ones in the local setting. These can be deployed in a focused manner as better entomological and epidemiological data are available on district, sub-district and cross-border areas.

Members of the group included – Hakizimana Emmanuel, MOPDD-Rwanda; Abraham Mnzava, WHO/HQ; Beata Nukorugwiro, JHPIEGO; Cait Unites, PSI; Beatus Cyubahiro, RBC-MOPDD; Dunia Mwuyakango, RBC-MOPDD; David Wainaina, Bayer; Arielle Mancuso, PMI/RFHP; Moses Turyazooka, CREST Technologies; Richmond Ato Selby, Networks; Christine Ochieng, Vestergaard Frandsen; Tessa  Knox, Vestergaard Frandsen; Levin Nsabiyumva, USAID/Burundi; Kagabo Jean Bosco, World Vision Rwanda; Athanase Munyaneza, RBC/KFHIK; Duschuze Clemence, RBC/MOPDD; Sangala Freddy, Nyagatare Hospital; John Githure, MOPDD/RBC; Francisco Saute, USAID/PMI

The group suggested the following Strategic Objectives to be achieved by or before 2017 …

1. Generate local evidence to guide optimization and diversification of available vector control interventions
2. Build sustainable capacity for entomological  monitoring and vector control at national, district and community levels
3. Formulate policies and procedures for effective and sustainable mobilization of vector control activities
4. 90% of the population at risk of malaria will have access to locally appropriate vector control  interventions based on evidence
5. Establish harmonized mechanism for cross border collaboration on vector control interventions

Key Actions For Strategy 1:

• Establish a national entomological profile (vector ecology and behavior, species composition and distribution, susceptibility to insecticides)
• Re-enforce and expand entomological  surveillance sentinel sites
• Determine the appropriateness of vector control interventions – including new tools
• Conduct operational research on the effectiveness of vector control interventions

Key Actions for Strategy 2:

• Recruit and train entomologists for deployment at district level for vector control interventions and entomological surveillance
• Strengthen and expand field lab/insectary facilities for entomological monitoring at sentinel sites
• Collaborate with the existing Dept. of Environmental Health at the KHI to include medical entomology programme
• Empower the communities through training on vector control

Key Actions for Strategy 3:

• Develop insecticide resistance management plan
• Establish regulatory processes to support timely deployment of existing and new tools as they become available
• Develop a transition plan for decentralization of vector control activities
• Re-orient IEC/BCC strategy to better support pre-elimination efforts
• Evaluate human and other factors influencing the effective lifespan and acceptability of vector control tools

Key Actions for Strategy 4:

• Maintain universal coverage with LLINs in the population at  risk
• Rational deployment of IRS in prioritized risk areas
• Evidence-based deployment of other supplementary vector control interventions (e.g. repellents, screening, LSM) where appropriate

Recommendations

• Establish a national inter-sectoral steering coordination mechanism for planning and implementation of  integrated vector management (IVM)
• Enhance entomological capacity in moving towards pre-elimination phase
• Integrate vector control within district development plans and operational targets
• Long term financial commitment of Government of Rwanda and development partners is essential to achieve and sustain the gains in malaria prevention