Category Archives: Eradication

Malaria Mass Drug Administration: Ensuring Safe Care of Reproductive Age Women

The potential impact of mass malaria drug administration (MDA) on pregnant women was the focus of Symposium 146 at the recent 65th Annual Meeting of the American Society of Tropical Medicine and Hygiene in Atlanta. The symposium was co-chaired by Clara Menéndez and Larry Slutsker who opened the session with an overview.

mda-recommendations-whoAs malaria control interventions are scaled up and sustained and malaria transmission levels decline and prevalence falls, an increasing number of countries are starting to see elimination on the horizon. For pregnant women, the antimalarial antibodies that have provided some level of protection in moderate to high malaria transmission settings are reduced as malaria transmission declines.

Current evidence shows that as transmission levels decline, the consequences from P. falciparum malaria are even greater for pregnant women. As countries enter pre-elimination stage and move towards eventual elimination, it will be important to address the needs of pregnant women given their increased vulnerability.

To help achieve elimination, countries are exploring strategies involving widespread distribution of anti-malarials, primarily artemisinin-combination therapies (ACTs), to asymptomatic individuals, including both mass drug administration (MDA) and mass screen and treat (MSaT).

Animal studies have suggested potential embryo toxicity and teratogenic effects of artemisinin drugs in the first trimester of pregnancy.

Given the limited human data, ACTs are currently contraindicated in first trimester, except in documented cases of clinical malaria illness where quinine is unavailable. This poses a challenge in mass campaigns, as it requires the identification of women in early pregnancy who are not yet obviously pregnant. Screening including offering pregnancy tests and/or interview to ask a woman her pregnancy status directly may not work as many may not wish to reveal their pregnancy status.

Final Algorithm for Screening Prior to MDA in Mozambique

Final Algorithm for Screening Prior to MDA in Mozambique

While only about 5% of the population is pregnant at any given time, and only 1/3 of those are in the first trimester, approximately 20% of the population is comprised of women of reproductive age who may be pregnant. Thus, the number of women who need to be screened for pregnancy is substantial across countries. In addition to privacy issues, costs of screening processes are another barrier.

During the symposium Francisco Saúte from Mozambique and Samuel J. Smith from Sierra Leone shared experiences. Clara Menéndez addressed ethical issues involved in the potential risk of MDA with the ACT Dihydroartemisinin-Piperaquine (DHA-P). These two countries have addressed pregnant women in MDAs in two widely different contexts.

Mozambique is learning whether MDA is a valuable component to malaria elimination in the low transmission areas in the southern part of the country. In Sierra Leone MDA was seen as a lifesaving tool to prevent malaria deaths during the Ebola epidemic when taking blood samples for diagnosis was a major risk.

Over several rounds of MDA, Mozambique refined its pregnancy screening procedures over several rounds of MDA as seen in the attached slide.  Costs, confidentiality, convenience and efficiency entered into the equation that saw a greater focus on communicating with women rather that testing. Lessons learned from MDA in Mozambique included –

  • Screening for early pregnancy in the context of MDA is challenging, particularly among teenage girls where disclosing pregnancy can be problematic
  • Need to train field workers (preferably women) about the need to ensure confidentiality of pregnancy testing/results
  • Confidentiality is also crucial to ensure adherence to t
    MDA Rationale in Sierra Leone during Ebola Outbreak

    MDA Rationale in Sierra Leone during Ebola Outbreak

    he pregnancy testing

  • Women not accepting pregnancy test must be warned on risks/ benefits of ACTs in 1st trimester
  • Health authorities must understand that IPTp and MDA are not mutually exclusive

The Ebola epidemic in Sierra Leone and its neighbors, Liberia and Guinea, devastated the health workforce, and the availability of any sort of testing supplies was low.  The country experienced a major drop in utilization of clinic based MCH services including those for malaria during the period.

MDA Goals in Sierra Leons

MDA Goals in Sierra Leone

Because of initial similarities in presenting symptoms between Ebola and malaria, people were often fearful of going to the health center in case they were detained for Ebola care or were exposed to other patients who had Ebola. Community MDA seemed to be one way to protect the population from malaria in this emergency situation. The attached slide offers a rational for the MDA. A second slide explains Sierra Leone’s goal for MDA with Artesunate-Amodiaquine in the context of Ebola. Though not completely, the Sierra Leone MDAs were able to exclude pregnancy women in their first trimester.

Pregnant women excluded from MDA in Sierra Leone

Pregnant women excluded from MDA in Sierra Leone

In conclusion MDA is a tool conceived primarily for countries and areas of countries as part of the pre-elimination strategy. It presents a variety of logistical challenges, but a major concern should also be the ethical issues of giving a potentially toxic drug to women in their first trimester of pregnancy. Alternative strategies to protect these women, including insecticide treated nets, must be explored.

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

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.

Guinea Worm, Inching Toward Eradication

Twenty-eight years ago efforts to eradicate guinea worm began in earnest. It was the UN Water Decade, and there was optimism that guinea worm could be the test case for success of the global effort to guarantee adequate and safe water for all.

gw_infographicAs can be seen in the CDC infographic, we have gone from 3.5 million cases to 148 during this time. As we reach toward the tail end of the worm, we find some challenges remain.

On the list of currently endemic countries one finds Chad. Chad was supposed to be in the pre-certification phase, but new cases appeared a few years ago.

Preliminary Guinea Worm Cases from 2011-13Sudan was the most highly endemic country until South Sudan gained independence and took the guinea worm cases with it. Recently a few cases have also appeared again in the Sudan itself seen in charts derived from CDC’s newsletter, Guinea Worm Wrap-Up.

Looking at the most recent data from early 2014, one can see that Mali is back to reporting no cases as have Ethiopia and Sudan for 2014. Caution is needed since transmission is more likely in the upcoming rainy season months than in the current dry period.

Preliminary Guinea Worm Cases from January to AprilWhat is common in these areas is either being in a state of conflict or bordering a conflict zone.  This makes efforts to detect cases and put interventions in place in a timely manner to prevent the next season’s transmission very difficult.

Unlike some other diseases, guinea worm has some relatively simple, epidemiologically appropriate and less expensive interventions like cloth water filters, abate/temephos for water source treatment and case containment.  Of course investments in improved water supplies will also solve the problem. But without easy access to the communities where transmission is occurring, the disease will persist at this incredibly low level.

Other disease elimination programs are equally affected by the problems of access and conflict, polio being a good example.  We know that malaria is also exacerbated in conflict situations, but in the locations where pre-elimination is near, like Swaziland, Botswana, South Africa and Namibia, the main concern is ensuring a strong health system to handle the additional surveillance tasks. Still we should not be complacent, because malaria is also endemic in these very sites where guinea worm stubbornly lingers.

Remembering a Pioneer in International Health and Health Systems: Tim Baker

Honoring people in their lifetime is important, and fortunately Prof. Timothy Baker and his wife Prof Sue Baker were jointly recognized for their many years of service, not only to the Johns Hopkins University Bloomberg School of Public Health, but generally to the fields of global health systems and management.  A portrait of the couple was presented and hangs at the School to remind all of their contributions. Unfortunately Tim Baker left us earlier this week.

DSCN1653While such departures are not often surprising when people have passed their three score and ten, Tim Baker at 88 was still active in teaching, research and service.  In fact we served together on the School’s MPH Admissions Committee where Tim Baker brought his wealth of experience and compassion for training students to bear at each meeting.  From the student’s point of view, I can saw that even though Tim Baker was not my adviser in during my DrPH at JHU (1989-91), he always looked after my academic progress and was the one to nominate me for Delta Omega (Public Health Honor Society) membership.

On the occasion of the portrait unveiling in 2011, the school shared these brief notes on Dr. Baker’s career: “

Timothy Baker, MD, MPH, a professor in International Health, joined the School as a faculty member in the Department of Public Health Administration and as an assistant dean. In 1961, he founded the School’s Division of International Health and served as acting director. Over the next five years, he was instrumental in building the Division into the Department of International Health. Baker’s fundamental contributions to the Department include faculty recruitment, curriculum development, student mentoring and fundraising. He was instrumental in establishing one of the School’s first endowed professorships—the Edgar Berman Professorship in International Health.

“In more than 50 years as a researcher and consultant, Baker—who holds joint appointments in Health Policy and Management and Environmental Health Sciences—worked in over 40 countries, focusing on health services and assessment of disease and injury burden. He also held leadership positions in several international public health agencies.”

Dr Baker touched many lives. Prof. Peter Winch, Director of International Health’s Social and Behavioral Interventions Program expressed the following in his e-mail to colleagues:

Tim Baker passed away today at the age of 88. I first met him in 1987 as an MPH student when he lectured in Introduction to International Health. It is truly impossible to summarize all of his contributions to the Department of International Health, and to the field of Global Health. This is a quick of superficial overview of his contributions. It is always difficult to know who originated any given idea. But if Tim was not the first one to push the elevator button, he was definitely at the ground floor before the elevator went up. So here is my partial list of his conceptual contributions. This is my paraphrasing of his thinking. He usually expressed such ideas in a more circuitous manner, or did not make a statement at all but rather demonstrated the idea through his actions.

  1. Public health professionals from low and middle-income countries need training not only on disease prevention and control, but also the design of health systems, management and supervision, leadership and advocacy.
  2. A central task of global health spending by the US government in low and middle-income countries needs to be capacity-building of local institutions and health professionals. If we don’t do good capacity building, the investments will not yield any lasting results.
  3. Health systems in low and middle-income countries need to address not only infectious causes of morbidity and mortality, but also occupational health, environmental health, injuries and chronic disease.
  4. Health workforce development is a complex matter, and warrants high-quality planning, evaluation and research.
  5. Our School of Public Health benefits from a dynamic, multi-disciplinary, problem-based Department of International Health. Such a Department is an asset to other more disciplinary departments, rather than a threat or a problem.
  6. Finally: There are no problem students. Every student is an asset. If the faculty identify a student as a problem, there is a good chance the problem lies with the faculty.

Likewise Prof. Adnan Hyder, Director of the Health Systems Program with which Dr. Baker was most recently associated expressed these thoughts:

It is with great sadness that I email you to announce that our beloved Dr. Tim Baker passed away yesterday. This is an incredible loss for our program, the department, and the school to start; but really the entire global health community. As the founder of our department, he was a powerhouse of knowledge, inquiry, and persistence; as a teacher and mentor he was a giant in the field; and as a proponent of the poor and vulnerable, he hid a warm and glowing heart under his witty exterior. So many of us were fortunate to be his students, colleaugues and friends; and how lucky we were to receive his wisdom, insight and sharp advice. Not a man to appreciate praise, he always cut it short; not one to stand pomp and ceremony he often avoided it; and not one to accept failure he believed in the power of humanity to succeed. We will dearly miss him, his humor, his flowers (for ladies only) and his raisin bread – and always remember that he asked us to work harder, and better than anyone else in the world for the cause of social justice and international health.

Let us make sure we never forget his legacy.

Although tropical diseases per se were not Tim Baker’s primary focus, he was concerned about the health systems implications of control programs. In 1962 as the first global effort to eradicate malaria was underway, Tim Baker made the following observations in the American Journal of Public Health:

Malaria eradication “contributes to our own protection. Malaria can be reintroduced into the United States, as several local epidemics have conclusively proved. Just as in the case of yellow fever, where our shores were not safe from imported epidemics until the disease had been controlled in the major ports throughout the world, so it is with
malaria; the world is not safe from the threat of disastrous epidemics until malaria has been eradicated everywhere.” Dr Baker was well aware of challenges that still face us today when he noted that, “widespread development of insecticide resistance lends overwhelming urgency to the completion of eradication.”

He further explained that, “health workers are presented with the opportunity of developing and proving a new method of attack on disease that has tremendous economic import.” The economic impact of malaria remains today one of the driving forces behind efforts to eliminate the disease.

More recently (2007), Dr Baker demonstrated the importance of maintaining a long term perspective. Concerning India’s efforts at controlling malaria from its first through 10th five-year plan, Dr Baker drew on 50+ years of experience to comment that, “The drop from a million to a thousand deaths underscores the value of the malaria program.” It may be another 50 years until malaria is truly eradicated, but if we keep a critical long term view as exemplified by Dr Baker we will be alert to both the challenges and opportunities to bring malaria to an end.

After Dramatic Decline in Malaria Deaths in Africa, Scientists Plan for Final Eradication

MIMPRESS RELEASE: Thursday, 10 October 2013 at 12:00pm SAST (GMT+2)

After Dramatic Decline in Malaria Deaths in Africa, Scientists Plan for Final Eradication: How to win the Endgame Against an Ancient Foe?

At world’s largest meeting of malaria experts, evidence of elimination work underway at edge of disease distribution; focus now turns to malaria heartlands

DURBAN, SOUTH AFRICA (10 OCTOBER 2013)—With widespread use of insecticide-treated nets, indoor spraying and potent malaria medications credited with dramatically reducing malaria deaths in Africa, experts at a major malaria conference discussed the potential to use this progress as a springboard for achieving eradication of a disease that still kills some 660,000 people each year—most of them young African children.

“For the first time we have achieved very large-scale vector control coverage in Africa, and these interventions have prevented a large number of deaths and greatly reduced the burden of transmission,” said Jo Lines, a malaria expert with the London School of Hygiene & Tropical Medicine who previously led the Vector Control Unit of the World Health Organization’s Global Malaria Program. “So while there is a lot of attention still rightly focused on how we can win the battles of today or next week or next year, we can start turning our attention to the longer-term and think about what is needed to win the war.”

Lines was one of several malaria experts discussing the road to malaria eradication in Africa at the Sixth Multilateral Initiative on Malaria (MIM) Pan-African Malaria Conference—the world’s largest gathering of malaria experts—taking place in Durban, South Africa, 6-11 October 2013.  Presentations at MIM, including the symposium Lines chaired on “planning for the endgame in Africa,” highlighted how scientists are transitioning from eradication as a lofty aspiration to one that involves an operational plan on the ground.

For example, researchers from South Africa discussed efforts to develop a web site dense with data on local malaria infections, part of the country’s effort to fight practically case by case to achieve its goal of eliminating malaria from the country by 2018. And researchers from Namibia presented the results from a joint effort to police malaria with neighboring Angola, an example, they said, of the cross-border initiatives that will be needed across Africa to eliminate malaria from the continent. Other researchers offered new approaches to malaria control they believe may be more “sustainable.”

According to an abstract by Chistopher Plowe with the Howard Hughes Medical Institute, vaccines are likely to be essential to malaria elimination, given that vaccines have been part of “nearly all successful” infectious disease eradication efforts and “absent from all unsuccessful campaigns.”

THE ELIMINATION CONUNDRUM: MAKING MALARIA GET OUT AND STAY OUT

Lines said that eliminating malaria in Africa requires confronting a range of confounding questions. For example, he noted that increasing access to things like insecticide treated nets and artemisinin combination therapies (ACTs), while crucial to saving lives and reducing disease transmission, comes at a cost: the more they are used, the faster mosquitoes and parasites are likely develop resistance. Also, he said that while malaria transmission patterns are “changing radically” across Africa, it’s not always clear why.

For example, he said his research has documented that there was a significant decrease in malaria transmission in parts of Tanzania before these areas saw widespread use of insecticide treated nets. Meanwhile, in parts of Uganda and Malawi, he said transmission has remained intense despite aggressive use of bed nets and better access to effective medications.

“We don’t know why these interventions are not working equally well in all places in Africa or why in some areas, like Tanzania, the fight against malaria appears to be aided by some other process,” he said. “We do know that when we look back at areas that have eliminated malaria, like the Southern US and Europe, we see that things like land use change, housing and human behavior played a part—potentially a very large part—in conquering the disease.”

Lines said eliminating malaria in Africa requires a better understanding of the different factors affecting transmission and also more attention to disease surveillance. Such work is crucial, he said, to ensuring that once malaria is eliminated from a particular region, it doesn’t simply re-establish itself when an infected individual migrates from areas where malaria is still common.

“The lesson you want to learn from areas that have eliminated malaria is not just how did you drive it out but how did you keep it out,” he said. He said elimination might ultimately need to involve some way of reducing the capacity of mosquitoes or humans to transmit the parasite.

For example, there is work underway today to develop a vaccine that would interrupt the life-cycle of the malaria parasite by preventing it from passing from humans back to mosquitoes. Other efforts have focused on the potential of genetically modified mosquitoes that are rendered incapable of passing along the parasite.

EYES ON THE PRIZE: ELIMINATION VIA DISEASE SURVEILLANCE

In South Africa, which hopes to eliminate malaria by 2018, tracking the total number of infections, recording where they are occurring and following-up to confirm details such as travel history and symptoms is a cornerstone of the country’s elimination strategy. South Africa’s intensive malaria surveillance program includes a website that is constantly updated and features an outbreak alert system and an automated mapping program that can depict malaria cases down to the local level.

A study by Bridget M. Shandukani with South Africa’s National Department of Health found that this type of meticulous surveillance, while costly and labor-intensive, is essential to finishing off malaria in countries like South Africa that have reduced malaria transmission to relatively low levels. She and her colleagues reported that during the 2012-2013 season, all nine of the districts in South Africa at risk for malaria entered into elimination mode, “reporting local case incidences of less than one case per one thousand population at risk.”

Meanwhile, researchers from Namibia presented a study that highlights the importance of cross-border initiatives for countries targeting elimination. They noted that most of the malaria cases in northern Namibia are “imported from southern Angola.” The study examined the effectiveness of a program—the Trans Kunene Malaria Initiative—that implemented a host of interventions in a 20-square kilometer region on both sides of the Namibia-Angola border.

The interventions included long-lasting insecticide treated bed nets, rapid diagnostic tests, community education and case management. Also, both governments agreed to remove customs duties from malaria “commodities,” including bed nets and chemicals used for indoor spraying programs.

The study, presented at MIM and led by Constance Njovu with the JC Flowers Foundation’s Isdell:Flowers Cross Border Malaria Initiative, noted that both areas targeted achieved a significant reduction in malaria.  “These results show that cross-border work is both critical to elimination of malaria and possible despite (involving) different national governments with language and cultural differences,” the scientists reported.

Meanwhile, researchers from the University of Pretoria focused on developing “sustainable” tools for malaria control, which they view as crucial to creating more durable reduction in illness and death and thus a more stable platform from which to pursue malaria eradication.

A study by Leo Braack with the University’s Center for Sustainable Malaria Control (CSMC) investigated night-time mosquito biting behavior outdoors, which, given the effectiveness of bed nets, are where an increasing proportion of malaria infections occur. The study found that most bites happen at or near ground level. Braack and his colleagues concluded that simply wearing mosquito-repellent anklets “holds the potential to lower malaria incidence.”

The CSMC’s Taneshka Kruger along with colleagues at the University’s Institute of Applied Materials sought to address limits to bed nets and indoor spraying as control measures: one has to be sleeping under a bed net to enjoy its protection, they noted, while indoor spraying is costly and raises fears of exposure to toxic chemicals. They found that lining interior doors with a mesh fabric treated with a slow-releasing insecticide was a safe, effective and potentially inexpensive form of long-lasting malaria control.

The Multilateral Initiative on Malaria (MIM) (http://www.mimalaria.org/eng/), launched in Dakar, Senegal in 1997, is an international alliance of organizations and individuals seeking to maximize the impact of scientific research against malaria in Africa to ensure that research findings yield practical health benefits. The MIM conference in Durban follows successful conferences held in Yaoundé, Cameroon, in November 2005, and in Nairobi in October 2009. The MIM Secretariat is currently hosted by the Biotechnology Centre of the University of Yaoundé I/Amsterdam Medical Centre.

Media Contacts:
South Africa
Louis Da Gama:  +44-7990810642,  ldagama@gmail.com
Jessica Rockwood:  +27-793517881,  jessicarockwood@verizon.net
Geoffrey So:  +27-728367853,  gso@rbmny.org
Jennifer Jackson:  +27.835987778,  jennifer.jackson@mrc.ac.za
Keletso Ratsela:  +27.828048883,  keletso.ratsela@mrc.ac.za

Senegal: Fara Ndiaye:  +221.773328863,  fara.ndiaye@speakupafrica.org

France: Michel Aublanc:  +33-608719795,  michel.aublanc@orange.fr

Switzerland: Pru Smith:  +41-227914586, smithp@who.int

United Kingdom: Alex Fullem:  +44-7787404884,  afullem@path.org

USA: Geoffrey So:  +1-3479320820,  gso@rbmny.org
Trey Watkins:  +1-6466266054,  kwatkins@rbmny.org

Follow the conversation on social media! #MIM2013 @MIMConf2013

Disease Eradication: Somalia Then and Now

In 1978 the US Centers for Disease Control and Prevention reported that, “As of April 14, 1978, no cases of smallpox have been reported to the World Health Organization (WHO) from anywhere in the world since the last case had onset of rash on October 26, 1977, in Merka town, Somalia. However, a total of 2 years of effective surveillance must elapse before this last endemic area can be confirmed to be smallpox-free.” Thirty-five years later Somalia is linked with difficult efforts to eradicate another disease, polio.

Now unfortunately, “Somalia hadn’t had a case of polio for nearly six years. But in the past few months, the virus has come back,” according to National Public Radio (NPR)  In fact the 73 cases reported from Somalia so far this year, surpasses the 59 cases reported in the rest of the world. NPR further notes that, “Somalia has the rate of polio vaccination in the world after Equatorial Guinea, according to the World Health Organization.”

Thirty-five years ago, challenges hampering disease eradication were the natural environment. “During October and November surveillance in Somalia has been severely hampered by heavy rains that have made it difficult or impossible to travel by vehicle. Since work has had to be continued on foot, there have been some delays in reporting and incomplete search coverage in certain areas,” CDC reported.

Today it is human conflict, not the weather, that inhibits control. NPR’s report notes that, “The Somali government directs the campaigns, but it doesn’t control or have access to vast swaths of the country. Some of the most recent polio cases have occurred in areas that are considered off limits to vaccination teams.” Conflict in Pakistan in December-January also tried to create off limits areas by killing polio workers.

Because polio is a fecal-oral disease it spreads with people. Not surprisingly, cases are appearing in Somali refugee camps in Kenya.  All countries in the region are on alert as extra vaccination efforts will be needed. And as NPR observes, this may draw resources from countries like Nigeria that are very close to eliminating the disease.  Ironically the polio virus strain found in Somalia was traced to Nigeria.

pf_mean_2010_som-sm.jpgPolio cannot be easily compared with malaria which has a vector, and also an larger arsenal of effective tools – insecticide treated nets, indoor residual spraying, chemo-prevention drugs, rapid diagnostic tests and effective medicines.  But the diseases face similar challenges that are more often human than deriving from the natural environment.  Human conflict deters malaria control in eastern Democratic Republic of the Congo, in the Central African Republic and in South Sudan.

Unlike for polio, we are not even close to numbering malaria cases in the dozens, but the as the recent Abuja Summit has shown, we must have the political will to rise above conflict and inefficient health systems and face down these devastating diseases.

(PS – fortunately as we can see in the attached map, malaria is not a pressing problem in Somalia.)

900 Days Left to Make a Big Difference in Malaria as African Ministers of Health Learn in Abuja

A Breakfast Briefing was given to African Ministers of Health and Foreign Affairs on 13th July 2013 in Abuja, Nigeria to review progress in Africa’s fight against malaria and to announce a new initiative to support 10 high-burden countries as part of the Special African Union Summit on HIV/AIDS, Tuberculosis and Malaria.

final-eng-invite-abuja-mohs-malaria-session-09-07-2013-sm.jpgDr Fatoumata Nafo-Traoré, Executive Director, Roll Back Malaria (RBM) Partnership in her welcome address) acknowledged the high level of commitment of partners and the high level of leadership from endemic countries over the past decade in the fight against malaria resulting on 44 countries seeing a > 50% reduction in malaria cases, but we cannot rest in the face of financial and technical challenges.

Dr Mustapha Sidiki Kaloko, the African Union Commission’s Commissioner for Social Affairs in his opening remarks reminded us that external funding has never been guaranteed, and as it is ebbing we need to scale up domestic financial support. The AU will work with all stakeholders to help close the $4b gap and not let gains reverse. In order not to lose momentum innovative domestic funding models are needed.

Joy Phumaphi, Executive Secretary of the African Leaders Malaria Alliance (ALMA) delivered the ALMA Scorecard update. She noted that the scorecard provides a roadmap and pushes countries to demonstrate results. Very positive results in terms of adopting policies that oppose artemisinin monotherapies and promote community case management are the norm now.

art-mono-banned.jpgThe challenge is the low scores on public sector management and effective use of existing resources. Efficiency gains could deliver up to 40% more services with available money. Continued scorecard success also depends on global attention remaining focused on Africa as post MDG goals are being set.

Dr Robert Newman, Director of the WHO Global Malaria Programme (WHO-GMP) introduced the new Larval Source Management (LSM) Manual. He told the gathering that the new LSM Manual was a result of advocacy by Nigeria’s Minister for Health.  IRS and ITNs have been success stories, but we need to use all available tools in appropriate manners. LSM has a unique niche where one finds discrete, fixed and definable water bodies as opposed to water in multiple diffuse sources like cattle foot prints on a rutted road that come and go over days.

Larvicides are expensive and labor intensive and need regular monitoring. People need to remember that environmental management is another larva control tool.  With all vector measures “commodities don’t deliver themselves”, but require commitment and action of people at all levels form the national to the community.

Dr Richard Kamwi, Hon. Minister of Health, Namibia, shared that in the 1990s there were 7,000 malaria deaths in his country annually, but only 4 in 2012. Namibia has a mixed strategy especially in the northern border area, and is close to pre-elimination.

Dr Robert Newman, Director of WHO-GMP gave a presentation on the Malaria Situation Room concept and explained that even though progress has been made and millions of lives saved, there are over 219 million cases of malaria annually and 660,000 deaths/ A disproportionate burden of malaria deaths even now is in African children under five years of age. We have responsibility for these children.  This burden is focused on 10 countries which account for 70% of malaria cases in Africa and 56% globally.

The Malaria Situation Room will be a way to collate data on funding, intervention, commodities and results.  International partners will continue to support all endemic countries, but malaria elimination will remain elusive unless more coordinated action is aimed at high burden areas.

With only 900 days left before the MDGs reach their target date (end of 2015), we want to anticipate and prevent problems like stock-outs, but wait to hear that there have been no antimalarials in clinics for over a month. We want to be proactive in the face of potential dis-investment to protect 10 years of progress which could be undone in only one malaria transmission season.

dscn3310-sm.jpgDr Alexandre Manguale, Hon. Minister of Health, Mozambique noted that his country is one of the ten in the “situation room.” Mozambique has made great progress in case reduction in the south with support from the cross border Lubombo Spatial Development Initiative. The rest of the country poses special challenges with logistics and weather (flooding). Under these circumstances partners need to coordinate and be flexible in response to gaps and bottlenecks. Information gathered and shared through the situation room will make this possible.

At this point Dr Newman, Dr Nafo-Traoré and Dr Kaloko officially launched the Malaria Situation Room with a ribbon-cutting. Now the work begins to make this ‘room’ a pro-active place to eliminate malaria.

certifying elimination of guinea worm – lessons for malaria

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.

nigeria-erad-chart-line-2009-zero-sm.jpg1995 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.

dscn0361-a.jpgIn 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.

foot-close-up2-sm.jpgWe 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.

South Africa at the Forefront of Malaria Elimination

South Africa as just hosted the 2013 Africa Nations Cup (AFCON) football finals. At the launching of the United Against Malaria (UAM) campaign in collaboration with Confederation of African Football (CAF), RBM (MAWG), and SARN among other partners, the Minister of Health for South Africa explained his country’s commitment to eliminating malaria. Excerpts from the meeting, kindly provided by Daniso Mbewe, summarize the Minister’s remarks.

malaria-profile-south-africa-sm.jpg“We are so excited to host 2013 AFCON. We love to have visitors come to our beautiful country. One of the advantages to coming to South Africa for the African Cup is the much reduced risk of getting malaria. We are proud to be among the first African countries to be working on eliminating malaria. There are less than 10,000 cases of malaria a year, and they are in an area that we are monitoring closely. Ten years ago, we couldn’t talk about eliminating malaria on the African continent and be taken seriously. Even 5 years ago, many would have never believed it. Today, we have the data to help us tell this story.

“In recent years, we have learned about how a robust health system, with close monitoring of malaria cases can give us the information we need to correctly diagnose and treat each case of malaria. You can’t believe how important it is to track each case down, and be sure that treatment is successful and complete.

“Here in southern Africa; there are already four leading countries well on their way to malaria elimination including provinces and districts in the remaining E8 countries (Botswana, Namibia, Swaziland and South Africa in tier one, and Zimbabwe, Angola, Zambia and Mozambique in tier two) However, for us to stay on track and for other countries to reach sustained malaria control like we have, it required investments and commitments from all sectors. Then and only then, will the malaria map shrink. ”

Of interest, Dr Pakishe Aaron Motsoaledi, the Minister of Health, was born in Phokwane Village in Limpopo – one of the few regions where malaria remains, though at a steadily diminishing rate. The Ministry’s commitment to eliminating malaria is therefore not surprising. In fact South Africa has shown leadership in the region through participation in two cross-border malaria elimination efforts. This is an example of political will that all countries on the continent need to follow.