Tropical Health Matters

Professor Lateef Akinola Salako was an accomplished leader in malaria and health research in Nigeria whose contributions to the University of Ibadan and the Nigeria Institute for Medical Research (among others) advanced the health of the nation, the region and the world. His scientific research and his over 140 scientific publications spanned five decades.

His research not only added to knowledge but also served as a mentoring tool to junior colleagues. Some of his vast areas of interest in malaria ranged from malaria epidemiology, to testing the efficacy of malaria drugs to tackling the problem of malaria in pregnancy. He led a team from three research sites in Nigeria that documented care seeking for children with malaria the acceptability of pre-packaged malaria and pneumonia drugs for children that could be used for community case management. Prof Salako was also involved in malaria vaccine trials and urban malaria studies.

As recent as 2013 Prof Lateef Salako, formerly of NIMR said: “It is true there is a reduction in the rate of malaria cases in the country, but to stamp out this epidemic there is the urgent need for a synergy between researchers, the government, ministries, departments and agencies and involved in malaria control. That will enable coordinated activities that will produce quicker results than what obtains at the moment.”

At least one website has been set up where people can express their condolences.  As one person wrote, “Professor Lateef Salako was an exceptional student, graduating with distinction from medical school; an unforgettable teacher, speaking as a beneficiary of his tutelage; an exemplary scholar, mentoring many others; an accomplished scientist, making indelible contributions to knowledge. May his legacy endure.”

Readers are also welcome to add their own comments here about Prof Salako’s contribution to malaria and tropical health.

Recently Professor Ayodele S Jegede of the Faculty of Social Sciences, delivered the 419^th Inaugural Lecture at the University of Ibadan, Ibadan, Nigeria, during the 2016/2017 academic session.  Below Prof. Jegede shares an abstract of his lecture.

Prof Ayodele S Jegede

Knowledge of individual actor’s behaviour is a reflection of the society as tree to the forest. As forest produces large quantities of oxygen and takes in carbon dioxide, society produces the needed resources for human beings to survive through culture. This inter-dependence between man and the environment is summarised by the Yoruba adage which says: “irorun igi ni irorun eye” (meaning: a bird’s peace depends on the peace enjoyed by the tree which harbours it).

Nigeria, a country with a population of about 187 million and a life expectancy of 53 years, 54% of the populace are living below the poverty line with limited access to health care services physically and economically. Although universal health coverage is vital to the achievement of the Sustainable Development Goals (SDGs) cultural perception of disease aside from loss of economic and low purchasing power makes people to attribute their illnesses to spiritual cause and therefore seek alternative health care services. This influences resistance to public health interventions in some African communities resulting in suspicion and distrust between health educators and the public.

Strengthening Health Information Systems

For instance, response to childhood immunizable diseases, mental illness, malaria and HIV/AIDS reported in this lecture was driven by how people define the diseases. Their response did result in delay in seeking modern health care until alternative care sources proved ineffective. This confirms W.I. Thomas (1929: 572) postulation that, “If men define situations as real, they are real in their consequences”.

Our stakeholders’ engagement interventions strategies strengthened by knowledge of how people construct their life, socially and culturally, proved to be a potent vaccine for preventing strain relationship between health workers and clients. Since society consists of individuals who constitute the stakeholders conducting health researches as well as management of epidemics and treatment during epidemics and disease episodes require appropriate ethical behaviours.

This suggests that adequate knowledge of the society is inevitable since a tree does not make a forest which confirms Marx Weber’s Action Theory postulation that an act does not become social unless it involves two or more persons. It is, therefore, that government should establish National Disease Observatory System (NDOS) to document diseases by type, location and related local practices for training health care professionals, clinical practice and emergencies preparedness.

Note also that the lecture was featured in the New Nigerian Newspaper with an emphasis on establishing a national disease observatory.  The Nigerian Tribune also featured the lecture stressing the importance of disease emergency preparedness.

On World Population Day (July 11) one often thinks of family planning. A wider view was proposed by resolution 45/216 of December 1990, of the United Nations General Assembly which encouraged observance of “World Population Day to enhance awareness of population issues, including their relations to the environment and development.”

A relationship still exists between family planning and malaria via preventing pregnancies in malaria endemic areas where the disease leads to anemia, death, low birth weight and stillbirth. Other population issues such as migration/mobility, border movement, and conflict/displacement influence exposure of populations to malaria, NTDs and their risks. Environmental concerns such as land/forest degradation, occupational exposure, population expansion (even into areas where populations of monkeys, bats or other sources of zoonotic disease transmission live), and climate warming in areas without prior malaria transmission expose more populations to mosquitoes and malaria.

Ultimately the goal of eliminating malaria needs a population based focus. The recent WHO malaria elimination strategic guidance encourages examination of factors in defined population units that influence transmission or control.

Today public health advocates are using the term population health more. The University of Wisconsin Department of Population Health Sciences in its blog explained that “Population health is defined as the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” World Population Day is a good time to consider how the transmission or prevention of malaria, or even neglected tropical diseases, is distributed in our countries, and which groups and communities within that population are most vulnerable.

World Population Day has room to consider many issues related to the health of populations whether it be reproductive health, communicable diseases or chronic diseases as well as the services to address these concerns.

Preliminary findings from Burundi’s 2015-16 DHS have been made available. The country has a long way to go to meet targets for basic control of malaria.

LLIN availability by household is an overall disappointing 32%. Ironically there is greater coverage of households in in urban areas (50%) than rural (30%). There is also great variation among the provinces with 52% coverage in Bujumbura metropolitan but only 19% in Canzuko. The overall average is less than one treated net per household.

A major concern is equity. The chart above shows a steep gradation from 19% coverage among the lowest fifth of the wealth quintile, up to 48% in the highest. Even in households that have at least one net, only 17% of of people slept under a net the night before the survey.

In terms of use by those traditionally defined as vulnerable, the DHS shows only 40% of children below 5 years of age overall slept under a treated net the night prior to the survey. Even in households that own at least one net, 78% of these children slept under one.

A similar pattern is seen for treated net use by pregnant women. Overall 44% slept under a treated net, and 84% did so in households that owned at least one treated net. The internal household dynamics of net use where one is available does appear to favor these two groups.

Overall coverage of Intermittent Preventive Treatment for pregnant women is very low. Less than 30% of pregnant women received even the first dose of SP. This decreased to 21% for two doses and 13% for three. In contrast to net coverage, more rural women (31%) received the first dose of IPTp than urban ones (19%).

Nearly 40% of children below five years of age were found to have had a fever in the two weeks preceding the survey. Among those care was sought for only two-thirds. Eleven percent of those with fever received an artemisinin-based combination therapy drug. The report did not mention whether these children had received any testing prior to treatment, so appropriateness of treatment cannot be judged. Prevalence testing of the children in the sample found 38% with parasitemia. Therefore one might assume that more children should have received ACTs.

Burundi still faces major political and social challenges. Even so Burundi is the recipient of malaria support from the Global Fund. For example 18 million LLINs were distributed in 2015 and 19 million in 2016.

Much work is needed to bring Burundi even close to universal coverage of malaria interventions. In today’s climate of questionable donor commitment, it is hoped that regional partners may play a role since malaria knows no boundaries.

June 14th is World Blood Donor Day. This year’s theme stresses the importance of donating now before a disaster strikes. This requires good storage facilities (and strong systems) in countries where disasters may occur,  which may not always be the case.  We know that blood donation facilities are concerned about testing for infectious diseases like HIV and Hepatitis C. What of malaria?

Studies have found that when people return to a non-endemic setting from malaria endemic countries, “Semi-immune individuals are more likely to transmit malaria as they may be asymptomatic” and serological data, not just circumstantial epidemiological information are also needed that if transmission through blood donations are to be prevented. There is also concern about the longevity of malaria infection depending on the species of Plasmodium in different parts of the world.

In endemic countries malaria antibodies can be present in basically all of asymptomatic adult blood donors. Unfortunately currently available screening assays appear unsuitable to minimize transfusion malaria.

Researchers in Brazil reported that, “The real-time PCR with TaqMan probes enabled the identification of P. vivax in a high proportion of clinically healthy donors, highlighting the potential risk for transfusion-transmitted malaria. Additionally, this molecular diagnostic tool can be adopted as a new laboratory screening method in haemotherapy centres, especially in malaria-endemic areas.”

Knowing the seasonal prevalence of malaria among blood donors in Bamako, Kouriba et al. suggest “A prevention strategy of transfusion malaria based on the combination of selection of blood donors through the medical interview, promoting a voluntary low-risk blood donation and screening all blood bags intended to be transfused” to vulnerable groups.

So while we recognize the life saving importance of adequate blood donations and supplies for transfusion, we also stress the importance of blood safety and expand our horizons to the possibility that malaria may be one of the potential problems shared with blood.

The Demographic and Health Surveys has released a brief on key indicators from the Ghana Malaria Indicator Survey of 2016. While much of the malaria community is discussing the elimination framework and processes, the reality is that many high burden countries are still trying to scale up basic interventions to achieve universal coverage.

The overall prevalence across the country in children aged 6-59 months at the time of the survey was 27% using Rapid Diagnostic test and 20% using microscopy.  Among children reporting fever in the previous two weeks care/advice was sought for only 72%. Although only only 30% received some sort of blood based diagnostic test, 61% of the febrile children were given the antimalarial artemisinin-based combination therapy drugs.

Children are still being treated without the benefit of parasitological testing, a key procedure highlighted in WHO case management guidelines. Presumptive treatment for malaria without testing means that a child could inappropriately receive antimalarial drugs and die of another underlying febrile illness. Appropriate testing and adherence to test results is one of the main areas of focus of Ghana’s grants from the US President’s Malaria Initiative. Improved testing is also an important element in Ghana’s current Global Fund support. Clearly more value for money is needed from these inputs.

Preventive measures as documented in the MIS fare somewhat better., but at present only 73% of households own an insecticide treated bednet. When considering the recommended 1 net for every 2 household members, the indicator drops to 50%. Concerning the typical ‘vulnerable’ populations, we see that only 52% of children below the age of 5 years slept under an ITN the night before the survey; only 50% of pregnant women did likewise.

Malaria prevention in pregnancy results reflect the fact that Ghana has promoted at least three IPTp doses for around ten years. Most pregnant women (78% ) had received the previously recommended minimum of two doses, and now 60% have received at least three doses.

One of the important issues stressed in WHO’s new malaria elimination framework is stratifying the country by prevalence to the lowest level possible in order to plan appropriate interventions. Fortunately the Ghana 217 MIS key indicator brief does stratify prevalence and intervention coverage by region.  Prevalence through RDT testing ranges from nearly 5% in the urbanized greater Accra area to 44% in the Central Region. Interestingly ITN use is nearly 20% higher in Central than greater Accra.

Hopefully future planning in Ghana will build on this stratification. Better mobilization of donor, national and private sector resources will address likely issues of stock-outs and increase the likelihood of universal coverage of basic interventions that is needed to move the country along the road to malaria elimination.

Below is an abstract of a poster presentation today at the American Society of tropical Medicine 65th Annual meeting in Atlanta. The presentation was prepared by Jhpiego’s Angola team including Jhony Juarez, Margarita Gurdian-Sandoval, Julio Bonillo, and William R. Brieger. Please join us at the Late-breaker’s session at noon.

CONTEXT

• Angola has three major belts of malaria transmission
• The north is high transmission and borders on the heavy burden country of the Democratic Republic of the Congo
• The mid-section of the country is meso-endemic
• The south is considered low endemic
• This low endemic area brings Angola into the Southern African Elimination 8 countries.

METHODS: Field visits were made to six northern high burden provinces. Health information system (HIS) data were collected from each provincial health department. Supplementary HIS information was collected from the national malaria control program

FINDINGS: Data from the six high burden provinces reveal an overall upward trend in confirmed malaria. Cases from 2011, but with a jump of over 130,000 confirmed cases from 2014 to 2015. This occurred despite support from government and major malaria partners over the past decade. Overall cases in the country have risen from 2.73m in 2011 to 3.25m in 2015

NATIONAL MALARIA EFFORTS

• Between 2012 and 2015 2 million Long Lasting insecticide treated nets were distributed to a population of approximately 5 million in the 6 provinces
• This exceeded the desired 2 people per net ratio
• Intermittent preventive treatment in pregnancy reached only 59% of women registering for antenatal care in 2015
• Only 44% and 18% of women received the second and third IPTp doses respectively.

CHALLENGES

• A dual challenge makes performance of malaria indicators difficult
• The Global Fund grant had expired for more than a year
• The oil-based economy also suffered from the major global drop in prices

THE WAY FORWARD

• Angola requires concerted efforts by government and partners to scale up malaria control interventions
• Universal coverage targets must be sustained if these high burden northern provinces are to begin seeing a decline in the disease

The malaria work of Jhpiego will be featured in 8 posters and two symposia during the upcoming 65^th annual meeting of the American Society of Tropical Medicine and Hygiene in Atlanta from 13-17 November 2016. Below are titles of the posters and descriptions of the symposia along with session information that will help people find the presenters. We will share abstracts closer to the actual time of presentation. Follow the conference on twitter through #TropMed16.

Poster Presentations

1. Collaborative efforts to improve prevention of malaria in pregnancy in Burkina Faso through use of IPTp-SP. Mathurin Dodo, Stanislas Paul Nebie, Ousmane Badolo, Thierry Ouedraogo Presentation No. 304 Poster Session A
2. The Improving Malaria Care (IMC) Project’s Contribution to follow up a Pilot to Use Rapid Diagnostic Tests (RDTs) at the Community Level in Burkina Faso. Ousmane Badolo, Stanislas P. Nebie, Moumouni Bonkoungou, Mathurin Dodo, Rachel Waxman, Danielle Burke, William Brieger Presentation No. 218 Poster Session A
3. Building Capacity to accelerate IPTp uptake through the adoption of 2012 WHO IPTp guidance in Malawi. John Munthali Presentation No. 393 Poster Session A
4. Rwanda Towards Malaria Pre-Elimination: Active case investigation in a low endemic district. Noella Umulisa, Angelique Mugirente, Veneranda Umubyeyi, Beata Mukarugwiro, Stephen Mutwiwa, Jean Pierre Habimana, Corrine Karema Presentation No. 310 Poster Session A
5. The Challenge of Reducing Malaria in Angola. Jhony Juarez, Margarita Gurdian-Sandoval, Julio Bonillo, William R. Brieger Presentation No. LB-5113 Poster Session A
6. Joint efforts, a key to success for the Malaria in Pregnancy Program in Luanda, Angola. Jhony Juarez, Adolfo Sampaio, William R. Brieger, and Domingos F. Gueve Presentation No. 982 Poster Session B
7. Improving pregnancy outcomes: Alleviating stock-outs situation of sulfadoxine pyrimethamine in Bungoma, Kenya. Augustine M. Ngindu, Gathari G. Ndirangu, Waqo Ejersa, David O. Omoit, Mildred Mudany Presentation No. 815 Poster Session B
8. Community health: Improving start of IPTp early in second trimester through promotion of MIP at the community level in Kenya. Augustine Ngindu Presentation No. LB-5383 Poster Session C

Symposia

1. Global Call to Action to Increase Coverage of Intermittent Preventive Treatment in Pregnancy: Progress and Lessons Learned. Symposium 87 Tuesday, November 15, 2016  1:45 PM /  3:30 PM Sponsors: PMI and MCS

Description: The aim of the symposium is to review country progress in sub-Saharan Africa (SSA) in increasing intermittent preventative treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP).  The symposium will expand the knowledge base among Ministries of Health, donors and partners who are working to increase IPTp-SP coverage to address malaria in pregnancy (MiP). In this symposium, speakers from WHO and the President’s Malaria Initiative will describe how they are prioritizing support to scale up MiP interventions including IPTp-SP across SSA.  Burkina Faso, Malawi and Tanzania will present and discuss how they were able to dramatically scale up IPTp-SP through a health systems approach that addresses MiP from community to district to national level.

2. Malaria Pre-Elimination: Ensuring Correct Care of Reproductive Age Women. Symposium 146 Wednesday, November 16, 2016 1:45 PM /  3:30 PM

Description: This symposium will present experiences from four countries – Mozambique, Sierra Leone, Brazil, and Dominican Republic; specifically, looking at how these countries have addressed pregnant women in their malaria pre-elimination strategies. Further the symposium will discuss the important ethical considerations that should be reviewed as countries contemplate standard diagnosis, notification and treatment vs. MDA. The lessons learned shared can be disseminated to guide other countries where these strategies are being considered.

Colleagues[1] from the Ministry of Health Angola, Jhpiego and the Johns Hopkins Bloomberg School of public Health are presenting a poster at the 64^th ASTMH Annual Meeting in Philadelphia at noon on Monday 26^th 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 (November 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.

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

Colleagues[1] from the Rwanda Ministry of Health, Jhpiego and the Johns Hopkins Bloomberg School of public Health are presenting a poster at the 64^th ASTMH Annual Meeting in Philadelphia at noon on Monday 26^th October 2015. Please stop by Poster 315 and discuss the results as presented in the Abstract below.

Malaria in pregnancy (MIP) is a serious health risk for the pregnant woman and fetus and associated with mortality in the perinatal period. In Rwanda there has been no accurate national estimate of malaria prevalence among pregnant women. In 2011, a cross-sectional study of 6 districts in 3 malaria transmission zones (low, medium and high) in Rwanda was conducted to estimate the prevalence of peripheral parasitemia in pregnant women. Data were collected from consenting women presenting to antenatal clinics (ANC) for the first time in their current pregnancy including age, parity, gestation, ITN availability and use.

Blood was obtained for malaria testing using microscopy, rapid diagnosis tests and polymerase chain reaction (PCR). A total of 4,037 pregnant women were recruited with median age of 27 years, and 3,781 (93.7%) had usable PCR samples. The prevalence of MIP by PCR was 5.6%.

Nearly 20% of women’s families did not have a net, and 8.7% of these tested positive compared to 4.9% of women whose family owned an ITN. For those who did not sleep under an ITN the previous night, 8.1% tested positive compared with 4.8% who slept under an ITN. Malaria prevalence by parity ranged from 5.5% (parity 0-1), to 5.4% (parity 2-3), and 6.5% (parity 4 or more). The two districts that bordered highly endemic countries had MIP prevalence rates of 10% and above. Those testing positive were treated according to national guidelines.

Despite a significant decline of 86% in malaria prevalence in the general population from 2005 to 2011, MIP prevalence remains high, especially in border districts. Our study also showed that ITN ownership and use among these pregnant women is below the national target. In order to address this gap, ITN distribution to achieve universal access, and educational campaign targeted at pregnant women on the use of ITN are recommended. Furthermore, early detection and treatment of MIP at ANC and regional collaboration to reduce cross-border malaria transmission should be prioritized.

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[1] Corine Karema, William R. Brieger, Irenee Umulisa, Aline Uwimana, Jeremie Zoungrana, Beata Mukarugwiro, Rachel Favero, Elaine Roman, Barbara Rawlins, Tharcisse Munyaneza, Fidele Ngabo, David Sullivan, Jean Baptiste Mazarati, Rukundo Alphonse, Agnes Binagwaho