Category Archives: Eradication

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.

The Tail End of Eradication, an Elusive Goal

We are nowhere near eradicating malaria with hundreds of thousands of cases annually throughout the world.  It reappears in Greece, and in subclinical form stymies surveillance efforts in the Solomon Islands. But eventually we will close in on this parasite. What can we learn from eradication efforts of another scourge, polio?

Recently the Express Tribune published an article that provided some shock not only in Pakistan, where the issue was detected, but throughout the polio eradication community. “The Prime Minister’s polio cell, the World Health Organisation (WHO), and the United Nations Children’s Fund (UNICEF) confirmed … a newly-found strain of the polio virus.”

The technical reason for the new stain was explained by the international health agencies: cVDPV cases that cause type 2 poliovirus mutate and attain a form that can cause paralysis after passing through multiple children in environments with substandard sanitation. Fortunately polio associated with vaccines is extremely rare, but a more damning administrative explanation of why this may have happened in Pakistan is “poor routine immunization coverage” that enabled these mutations to occur.

Administrative problems include poor scheduling of the current immunization round during a sacred religious period resulted in four districts not participating, but on top of this was a more pressing problem,  “the global shortage of the oral polio vaccines especially as anti-polio campaigns are increasing .” This calls into question the upcoming second round of immunization in December. The problem is persistent since it was reported earlier this year that,  “Polio coverage (in Pakistan) remained sub-optimal during the past year in Islamabad, as revealed by an independent evaluation report on the post-polio campaign conducted by the World Health Organization.”

polio-cases-as-of-mid-november-in-2011-sm.jpgFour endemic countries remain as seen in the graph, and Pakistan’s performance to date is actually better than some of the others, but the situation is volatile, as is the civil/political situation in the remaining affected countries. Interestingly, another eradication-targeted disease, Guinea Worm, was down to 1058 cases in 2011 and remains in only 4 countries, but this is 17 years after the initial date set for its eradication.

Polio and Guinea Worm offer malaria some lessons for the present in countries approaching pre-elimination now and those who will hopefully join them over the next decade (if global funding levels are maintained). One lessons is that surveillance is an active part of current polio eradication efforts, otherwise these reports on progress and its challenges would not be published. But the key lesson is that regardless of the effectiveness of the technical intervention (e.g. a vaccine), deployment of the technical intervention is subject to human, administrative, managerial and social complications.

Polio focuses on a vaccine; malaria has treatment medicines, preventive medicines, insecticide sprays, treated bednets, diagnostic tests, and maybe also one day an effective vaccine.  It is not too early to plan on how to coordinate all this into achieving effective disease elimination, nationally, regionally and globally.

Reactive Malaria Case Detection – Tools for Elimination

Kelly M. Searle, ScM and her advisor at the Johns Hopkins Bloomberg School of Public Health, William J. Moss, MD MPH share the findings from her masters thesis: “Evaluation of Reactive Case Finding to Target Focal Malaria Transmission in Two Different Settings in Macha, Zambia.” They offer ideas on how we can move toward the challenging target of malaria elimination…

figure-1-rdt-zambia-sm.jpgWith malaria elimination in the minds of many, new methods of identifying and treating asymptomatic parasite carriers are being investigated. The current study evaluated reactive case detection as a malaria transmission intervention. Reactive case detection is the result of a malaria case being identified in a clinic by passive case detection, testing and treating that individual and their household contacts, and surrounding neighbors.

Survey sample data from different areas of Macha, Zambia in 2007 and 2008 were used to determine proportions of malaria infected individuals caught passively and reactively. Simulations were done to extrapolate this data to non-sampled households. Radii surrounding identified positive households (index households) were examined to determine the proportion of positive households in each radius.

In the 2007 transmission setting, screening 500 meters surrounding index households would have identified 89% of all households with an RDT positive resident and 90% of all RDT positive individuals. Screening 1 kilometer surrounding index households would have identified 95% of all households with an RDT positive resident and 94% of all RDT positive individuals (Figure 1). In the 2008 transmission setting, screening 500-meters surrounding index households would have identified 77% of all households with an RDT positive resident and 76% of all RDT positive individuals. Screening 1 kilometer surrounding index households would have identified 89% of all households with an RDT positive resident and 89% of all RDT positive individuals (Figure 2).

figure-2-rdt-zambia-sm.jpgReactive case detection has the potential to be an effective malaria intervention for populations of both moderate transmission settings and transmission settings transitioning (or that have recently transitioned) from moderate to low. With reactive case detection, a large proportion of malaria-infected individuals are accounted for using screening radius of 500 meters. A greater proportion of total households would have to be screened in the lower transmission setting, likely due to the overall lower numbers of cases existing. For reactive case finding to be most effective, it should be targeted at malaria foci and hotspots where transmission is greater than the overall area.

Scale-up Meets Resistance

News this week from The Lancet confirming suspicions of malaria parasite resistance to artemisinin-based drugs deals a double blow to malaria control efforts coming just a few months after announcements by Global Fund to cancel Round 11 funding.  Pressure on malaria drugs is nothing new, especially since the same problem has arisen in the same region of the world for two previous and cheaper mainstays of malaria case management.

In all our hopes for rolling back malaria over the past 14 years, did we tell ourselves that such resistance was this time not inevitable?   Unlike in previous waves of resistance, this time we should have been better prepared with effective anti-vector measures. BUT this assumes that we have met our RBM targets and are happily progressing toward 2015 expecting no more malaria deaths.

We get reports that scale-up and case reduction are occurring, such as a recent newspaper article from Jigawa State in Nigeria, but basically we have not achieved our 2010 scale-up targets – so what will come first – 2015 success or the wave of parasite resistance spreading out from Southeast Asia?

The hopes of the current RBM effort were based on the fact that by 2000 we had 3-4 effective anti-malaria interventions, unlike the reliance on mainly one during the first stab at eradication.  Unfortunately the question is still the same as it was in the 1950s-60s – are our health systems strong enough to deliver the goods? More effective interventions that do not reach people will not present a strong bulwark against spreading drug resistance.

mali-net-given-to-community-health-agent-2.jpgFrustration may mount even more when we realize that all the insecticide treated nets distributed over the prolonged period of campaigns from 2009-2012 will need to be replaced, mostly well before 2015.  Our coverage to date has not been adequate, our funding is threatened – what guarantees that we can keep up with adequately containing malaria before the resistant strains of the parasite reach Africa where the bulk of cases and deaths occur?

Some of our ‘easy’ eradication targets like guinea worm and polio are still flaunting their capacity to harm.  These like other previous efforts are at risk from donor fatigue.  Malaria, which is more complex than those two diseases, is at even greater risk. The RBM Partnership needs to develop a serious and workable strategy to get well ahead to the resistance wave NOW.

Closing in on Malaria Elimination in the Asia Pacific Region

malaria-distribution-in-asia-pacific-region-sm.jpgThe Asia Pacific Malaria Elimination Network (APMEN) is starting a workshop entitled ‘Building Competence in Connnunity Engagement for Malaria Elimination,’ tomorrow (22 November) in Chiang Mai, Thailand. APMEN includes 11 countries that are making clear progress to malaria elimination in the region.

The meeting will feature discussions on topics such as …

  • Lessons from 60 years of community participation in communicable disease control and elimination
  • Going to scale with community engagement for malaria elimination (models for equitable access and sustainability)
  • Experiences and challenges in achieving synchronous cross‐border community engagement for malaria elimination
  • Embedding community engagement for malaria elimination in comprehensive Primary Health Care delivery: A systems strengthening approach

Country case studies will be shared by Bhutan, China, Indonesia, Malaysia, Philippines, Republic of Korea, Solomon Islands, Sri Lanka, Thailand and Vanuatu. Discussions will focus on identifying intervention, training and research strategies to support elimination efforts.  Reports on the meeting will begin tomorrow.

How important are target dates?

If target dates were realistic, there would have been no more guinea worm in the world as of 1995. As it stands today

“Ghana appears to have broken Guinea worm transmission! With 7 consecutive months of zero cases reported since May 2010, and 14 months after reporting its last known uncontained case in October 2009, Ghana might have conquered Guinea worm disease! Surveillance continues while the Guinea Worm Eradication Program waits and watches. Currently, only four countries continue to report cases of Guinea worm disease: Southern Sudan, Mali, Ethiopia, and Chad.”

Sixteen years after the supposed eradication date approximatelt 376 cases were documented in the first four months of 2011.

Even the famous smallpox eradication effort could not achieve its targets until a paradigm shift occurred that changed intervention approaches from from maintaining high vaccine coverage to case containment that focused on outbreaks – vaccinating in a radius around cases until the disease disappeared.

Another set of goals – 80% coverage with key malaria interventions by the end of 2010 – has come and gone. The country with the largest burden of disease, Nigeria, was able to achieve around 67% of its insecticide treated bednet distribution target by 31 December 2011, let alone actual use by 80% of the population.  Nigeria is not alone in this situation.

The website, Global Atlanta, headlines that “U.S. Works to End Malaria by 2015”. While not technically true, the headline is followed by the actual goal – “The U.S. government is leading the way in ending malaria-related deaths by 2015, the head of the President’s Malaria Initiative said at a youth leadership conference organized by Usher’s New Look Foundation.”

nigeria-mdg5.jpgThe 2015 date refers to the Millennium Development Goals. Many countries find themselves lagging in in the interrelated MDGs (see picture). Our ability to reduce malaria mortality (if not morbidity) depends so much on health systems issues – procurement, supply, distribution, access, and use.

We have to be careful with public goal statements lest we create and then deflate expectations, with the unwanted side-effect of scaring away donors and national financial commitment.  Goals are a public relations tool – just be careful that they are realistic and don’t backfire.

Net coverage; how much is enough?

We are unlikely to eliminate mosquitoes, according to Tanya Russell and colleagues, but she notes that this should not stop us from implementing all available interventions. Specifically their study of malaria vectors in Tanzania found that the at reduced densities of mosquito populations, they try to reproduce more, meaning we may never get below 10% mosquito elimination.

Instead, a member of the National Malaria Control Program in Tanzania says our goal “should be to reduce, and eventually halt, transmission of the parasite, rather than eliminating the vector.” If we can achieve no more than 90% elimination of mosquitoes, what is a realistic coverage figure for malaria interventions?

Applications of net and case management strategies in Rwanda and Ethiopia have definitely shown that major drops in malaria incidence are possible.  But the RBM targets of 80% coverage (85% for the US President’s Malaria Initiative) are elusive.  Demographic and malaria surveys from Senegal, Liberia and Nigeria show that even in homes that own nets, net use among people at most risk, does not reach this target.

Are we really sure that 80% is the right target?

Fred Binka was one of the first to demonstrate that people living in homes without nets can be protected by their neighbors’ nets, which kill mosquitoes in the community. ITNs “provided very good personal protection to children using them, and also protected nonusers in nearby compounds. Among nonusers, the mortality risk increased by 6.7% with each additional shift of 100 m away from the nearest compound” with nets. This led the researchers to speculate on the need to study whether the “mass effect from a small number of highly dispersed nets would provide equivalent protection to complete coverage.”

A few years later William Hawley and co-researchers reported that, “protective effect of ITNs on compounds lacking ITNs located within 300 meters of compounds with ITNs for child mortality, moderate anemia, high-density parasitemia, and hemoglobin levels.”

As part of the move toward universal coverage, Killeen and colleagues examined the importance of considering all household members, not just the ‘vulnerable.’ The group condluded that …

Using field-parameterized malaria transmission models, we show that high (80% use) but exclusively targeted coverage of young children and pregnant women (20% of the population) will deliver limited protection and equity for these vulnerable groups. In contrast, relatively modest coverage (35%–65% use, with this threshold depending on ecological scenario and net quality) of all adults and children, rather than just vulnerable groups, can achieve equitable community-wide benefits equivalent to or greater than personal protection.

Barat has called for ‘data driven decision making‘ in the effort to eliminate malaria. Using data in models as done by Killeen is a further important step. The onchocerciasis control community has been working with such models for over 15 years now. New data are fed into the Onchosim model based on program progress such that it is possible to forecast that onchocerciasis could be eliminated from areas with high initial prevalence if 65% coverage of ivermectin treatment were maintained for at least 25 years.

Unlike onchocerciasis control, malaria elimination rests on multiple interventions.  This makes modeling much more urgent, as outlined by malERA’s research agenda for eradication. Since universal coverage unfortunately does not mean universal usage, we need to seek valid data and models to help us plan for distribution of malaria interventions more strategically in ways that are affordable and can be maintained and at the same time can achieve maximum reductions in morbidity and mortality.