Category Archives: Health Education

The Weekly Tropical Health News 2019-07-06: Eliminating Malaria in Low Transmission Settings

This week started with articles that drew attention to the challenges of malaria in low transmission areas and with low density infections. Malaria Journal has provided several insightful articles toward this end.

Being an island has certainly helped Zanzibar make progress toward malaria elimination as witness the fact that malaria prevalence has remained below 1% for the past decade. Not only does Zanzibar still face threats of infection from the mainland, it may also experience an upsurge locally if residual transmission and the role of human behavior and community actions are not well understood. April Monroe et al. conducted in-depth interviews with community members and local leaders across six sites on Unguja, Zanzibar as well as semi-structured community observations of night-time activities and special events to learn more.

While there was high reported ITN use, there were also times when people were exposed t mosquitoes while being outdoors during biting times. This could be around the house, or at special night events like such as weddings, funerals, and religious ceremonies. Men spent more time outdoors than women. Clearly appropriate interventions and needed and should be promoted in culturally appropriate ways in order to further reduce and eventually eliminate transmission.

Angela Early and colleagues presented findings on a diagnostic process of deep sequencing for understanding the dynamics and complexity of Plasmodium infections, but stress that knowing the lower limit of detection is challenging. They present “a new amplicon analysis tool, the Parallel Amplicon Sequencing Error Correction (PASEC) pipeline, is used to evaluate the performance of amplicon sequencing on low-density Plasmodium DNA samples.”

The authors learned that, “four state-of-the-art tools resolved known haplotype mixtures with similar sensitivity and precision.” They also cautioned that, “Samples with very low parasitemia and very low read count have higher false positive rates and call for read count thresholds that are higher than current default recommendations.” Better understanding of the genetic mix of plasmodium infections as countries move toward low transmission and elimination is crucial for selecting appropriate interventions and evaluating their outcomes.

Hannah Edwards and co-researchers examined conditions for malaria transmission along the Thailand-Myanmar border in areas approaching malaria elimination. While prevalence may be less than 1%, residual transmission still occurs. Transmission occurs not only around residences but in the forests where people work. The researchers therefore looked at the behavior of both humans and insects. Overall, they found that, “Community members frequently stayed overnight at subsistence farm huts or in the forest. Entomological collections showed higher biting rates of primary vectors in forested farm hut sites and in a more forested village setting compared to a village with clustered housing and better infrastructure.”

While mosquitoes preferred to bite inside huts, their threat was magnified by those who did not use long lasting insecticide-treated nets (LLINs). While out in the farms and forests, people tended to wake early and increase their likelihood of being bitten. The authors discuss the challenges of dual residences in terms of LLIN ownership and even concerning the potential access to indoor residual spraying. The definition for universal net coverage needs to expand from one net per two people to include adequate nets wherever people are located.

The Amazonian area of Brazil is another area working toward malaria elimination, in particular, Plasmodium vivax. Felipe Leão Gomes Murta et al. also looked at the human side of the equation and identified misperceptions by both community members and health workers that could inhibit elimination efforts. They found, “many myths regarding malaria transmission and treatment that may hinder the sensitization of the population of this region in relation to the use of current control tools and elimination strategies, such as mass drug administration (MDA),” and LLINs.

Problematic perceptions included mention by both groups that the use of insecticide-treated nets, may cause skin irritations and allergies. Both community members and health professionals said malaria is “an impossible disease to eliminate because it is intrinsically associated with forest landscapes.” They concluded that such perceptions can be a barrier to control and elimination.

Efforts to eliminate malaria from low transmission settings are an essential to the overall global goals. These four articles tell us that close attention to and better understanding of humans, parasites and mosquitoes is still needed to achieve these goals.

Malaria funding may never be enough, but better program management should be possible

The World Malaria Report shows that malaria cases are up, and even though there are fewer reported cases in 2017 than 2010, the number is greater than 2016. So once again high burden countries are being targeted. Today this focus is on “High Burden to High Impact”, but in 2012-13 it was the “Malaria Situation Room” that also focused on 10 high burden countries.

Progress was being made up to around 2015-16, it then started to reverse. The challenge was not just funding. As the WHO Director General noted in the foreword to the 2018 World Malaria Report (WMR), “Importantly, ‘High burden to high impact’ calls for increased funding, with an emphasis on domestic funding for malaria, and better targeting of resources. The latter is especially pertinent because many people who could have benefited from malaria interventions missed out because of health system inefficiencies.”

Over the years there have never been enough pledged funds to fully achieve targets, but as funding has never reached desired levels, attention is now being drawn more and more to the source of that funding (more emphasis on domestic/endemic countries) and especially how the health system functions to use the funds that are made available. In 1998 during one of the early meetings establishing the Roll Back Malaria Partnership, a speaker stressed that malaria control could not succeed without concomitant health systems strengthening and reform. That 20-year-old thought was prescient for today’s dilemma.

First, what is the funding situation? As outlined in the World Malaria Report …

  • In 2017, an estimated US$ 3.1 billion was invested in malaria control and elimination efforts globally by governments of malaria endemic countries and international partners – an amount slighter higher than the figure reported for 2016.
  • Governments of endemic countries contributed 28% of total funding (US$ 900 million) in 2017, a figure unchanged from 2016.
  • Funding for malaria has remained relatively stable since 2010
  • To reach the Global Technical Strategy 2030 targets, it is estimated that annual malaria funding will need to increase to at least US$ 6.6 billion per year by 2020

The question remains – does investment lead to results. The WMR shows, for example, that “Between 2015 and 2017, a total of 624 million insecticide-treated mosquito nets (ITNs/LLINs), were reported by manufacturers as having been delivered globally. This represents a substantial increase over the previous period 2012–2014, when 465 million ITNs were delivered globally”.

At the same time the report states that, “Households with at least one ITN for every two people doubled to 40% between 2010 and 2017. However, this figure represents only a modest increase over the past 3 years, and remains far from the target of universal coverage.” Is it simply a matter of funding to reach the other 60% of households, or are there serious management problems on the ground?

Then there is the issue of using nets. The WMR traces new ownership and use from 2010 to 2017, and we can see that overall the proportion of the population at risk who slept under a net increased from around 30% to 50%, but only 56% of those with access to a net were sleeping under them. This can be attributed in part but not completely to the adequacy of nets in a household.

We should ask are enough nets getting to the right places, and also are efforts in place to promote their use. Behavior change efforts should be a major component of malaria program management. Even the so called biological challenges to malaria control have a human element. Monkey malaria transmission to people results from deforestation. Malaria parasite resistance to medicines comes from poor drug management on individual and systems levels.

The target year 2030 will be here before we know it. Will malaria still be here, or will countries and donors get serious about malaria financing AND program management?

Targeting Children as the Primary Audience for Public Health and Malaria Programs

Our second Guest Posting by Erica Kuhlik examines important questions on the relationship between communicable and non-communicable diseases.

blog-posting2-kuhlik-pic1.jpgTargeting children of primary school age with health education and behavior change interventions is essential in developing countries.  Due to the success of illness prevention programs targeting children under the age of five in developing countries, more children survive longer than ever before.[1]  This is an incredible achievement for public health, but also means there are more older children at risk of illness and death from diseases like malaria.

For instance, one study in Kenya found that despite living through the most vulnerable first five years, children of primary school age still suffered an average of 25 episodes of illness over the 30-week study period.[2]  Our photo shows an application of this idea where members of the malaria club prepare to present their skit about malaria at Jolly Mercy Primary School in Wakiso District.

The result of chronic illness on children is tragic.  Repeated bouts of malaria can cause anemia, increased susceptibility to other diseases, and long-term neurological problems.[3]  Chronic illness also causes children to miss school and reduces their capacity to succeed.[2] The extent of serious illness among children in developing countries makes them prime targets of health interventions.

Such interventions are met with success because children of primary school age are at a stage in their lives when they are both impressionable and beginning to develop new habits.[4]  Children are open to learning healthy habits and behaviors that will help prevent the diseases to which they are vulnerable, like malaria. Additionally, the aforementioned study showed that in 19% of the illness episodes, children were self-treating using herbal remedies and Western medicines.2

blog-posting2-kuhlik-pic2.jpgThese results show that children have the capacity to take responsibility for their health and also suggest that health education programs can target children with information on disease prevention and treatment.  Children can share what they learn as seen in our photo where a student at Nakatunya Primary School in Soroti District displays her malaria message.

Taken together, children represent a population that can be highly vulnerable to disease, in need of health interventions, and in an impressionable stage of their lives, thus allowing for the opportunity to introduce healthy habits and behaviors to reduce their burden of disease.


All pictures were taken by the author with permission from August to October 2012.

  • [1] Bundy, D., Shaeffer, S., Jukes, M., Beegle, K., Gillespie, A., Drake, L., Lee, S. F., Hoffman, A., Jones, J., Mitchell, A., Barcelona, D., Camara, B., Golmar, C., Savioli, L., Sembene, M., Takeuchi, T., & Write, C. (2006). School-Based Health and Nutrition Programs. In D. Jamison, J. Breman, A. Measham, G. Alleyne, M. Claeson, D. Evans, P. Jha, A. Mills, & P. Musgrove (Eds.), Disease Control Priorities in Developing Countries (pp. 1091-1108). New York City: Oxford University Press.
  • [2] Geissler, P. W., Nokes, K., Prince, R. J., Achieng’ Odhiambo, R., Aagaard-Hansen, J., & Ouma, J. H. (2000). Children and medicines: self-treatment of common illness among Luo schoolchildren in western Kenya. Social Science & Medicine 50, 1771-1783.
  • [3] Malaria Consortium
  • [4] Harre, N., & Coveney, A. (2000). School-based scalds prevention: reaching children and their families. Health Education Research, 15(2), 191-202.
  • For more information see: Kolucki, B., & Lemish, D. (2011). Communicating with Children: Principles and Practices to Nurture, Inspire, Excite, Educate and Heal. UNICEF.

Uganda: The Stop Malaria Project’s School Health Program

Our Guest Posting by Erica Kuhlik describes a project in which she was involved for the MSPH degree requirements at the Johns Hopkins Bloomberg School of Public Health. STOP Malaria is a USAID funded project managed by JHU’s Center for Communications Programs.

Schools have been found to to be an ideal place for young people to learn about malaria. The Stop Malaria Project (SMP) in Uganda has been using an exciting approach to combat the high prevalence of malaria in rural communities: a school health program that teaches children about malaria and empowers them to act as agents of change in their communities. Previous study in Kenya has shown that school children can learn about malaria and other common diseases and have an influence on their peers and families.

blog-posting1-kuhlik-pic1.jpgThe program uses active and participatory learning techniques to teach children about malaria transmission, infection, diagnosis, treatment, and prevention. Participatory learning methods show children how certain behaviors can reduce malaria and also allow children to practice the behaviors, thereby improving their self-efficacy to perform them.  A “Talking Compound” as seen in the photo is one way to help students learn. In these ways, participatory learning empowers children to adopt the promoted behaviors.

The students are also encouraged to share the malaria messages with their peers and families, effectively acting as change agents in their communities.  By empowering children to act as agents of change, school health programs can reach secondary audiences in the community at little or no cost.   Taken together, the use of active learning methods to teach and encourage children to be agents of change is known as the child-to-child approach.

blog-posting1-kuhlik-pic2.jpgDespite its recent launch, the Stop Malaria Project’s malaria education program already has significant reach.  In its fourth year alone, SMP reached over 350,000 students across Uganda through thousands of health education sessions using the child-to-child approach (The Uganda Stop Malaria Project Annual Performance Report: 2012 Year 4. Kampala, Uganda).

Discussions with these children have shown them to be highly knowledgeable of SMP’s malaria messages about prevention, diagnosis, and treatment and can demonstrate correct insecticide-treated net use as seen here.  Their teachers have used participatory learning techniques by integrating the malaria information into songs, poetry, drama plays, drawings, and posters.  Some children have even reported behavior change in their households as a result of sharing the malaria messages with their parents.

blog-posting1-kuhlik-pic3.jpgThe experience of the Stop Malaria Project demonstrates that school health programs using the child-to-child approach can be implemented in developing countries.  As we can see, the children have developed their own malaria messages. These programs offer the opportunity to reach vulnerable children and their families with valuable health information to improve the local health conditions.

[All pictures were taken by the author with permission from August to October 2012.]