Tropical Health Matters

A May 28^th press release from the World Health Organization states that, “Togo eliminates trachoma as a public health problem.” The article explains that …

“Validation of trachoma elimination as a public health problem in Togo was based on evidence. Several population-based trachoma surveys were conducted starting from 2006 to 2017. The 2017 survey using WHO recommended methodology found that the prevalence of key indicators was below the WHO trachoma elimination threshold. There was also evidence that Togo’s health system is able to identify and treat new cases of late complications of trachoma.”

This raises the question, is Trachoma gone from Togo or does trachoma continue to exist at some low level whereby, as WHO notes, Togo has joined, “12 other countries that have been validated by WHO for having eliminated trachoma as a public health problem.”

This description of disease elimination contrasts sharply with the global concerns when “health authorities in Malawi have declared an outbreak of wild poliovirus type 1 after a case was detected in a young child in the capital Lilongwe. This is the first case of wild poliovirus in Africa in more than five years.” Wild polio virus had been declared eliminated in Africa, and just one case in one country grabs international attention.

Would one case of trachoma tomorrow receive the same concern in Togo? Apparently not according to the WHO definition, “Elimination of trachoma as a public health problem is defined as: (i) a prevalence of trachomatous trichiasis (TT) “unknown to the health system” of < 1 case per 1000 total population; and (ii) a prevalence of trachomatous inflammation-follicular (TF) in children aged 1–9 years of < 5%, in each formerly endemic district.”

So, while no cases of smallpox, guinea worm or polio would be tolerated after elimination has been declared, parents of a child who develops trachoma in Togo tomorrow would be told that your child’s case is only 1 in a 1000 and not of concern to public health. The caveat is though that “the health system (must be) able to identify and manage incident TT cases.” Presumably, if such management capacity does not exist, the disease in question could spread and elimination would be eliminated.

Another Neglected Tropical Disease, Lymphatic Filariasis, faces the same challenge in terms of elimination status. WHO explained in its guidance that, “In 1997, the 50th World Health Assembly resolved to eliminate LF as a public-health problem (resolution WHA50.29). In response, WHO proposed a comprehensive strategy for achieving the elimination goal that included interrupting transmission in endemic communities and implementing interventions to prevent and manage LF-associated disabilities The LF guidance stresses “Effective monitoring, epidemiological assessment and evaluation are necessary to achieve the aim of interrupting LF transmission,” or in a word Surveillance. There is clear concern for “absence of transmission” and worries about “recrudescence.”

While polio has a vaccine and guinea worm relies on providing safe community water, LF and Trachoma elimination depends on mass drug administration (MDA) at planned intervals until such time as transmission is reduced. All require a strong health system to implement, but the challenges of maintaining MDAs until such time as elimination has been validated is somewhat more challenging. In this context the communication is extremely important. Just because WHO validates the elimination of a disease as a public health problem, does not give policy makers license to ignore that disease. Advocacy is continually needed such that even after apparent elimination, neglected diseases will not be forgotten and health systems themselves not neglected.

Save the Children recognizes the importance of strong health systems to deliver malaria interventions. Here they arsharing a wealth of information on these efforts at the 2021 American Society of Tropical Medicine and Hygiene Annual Meeting. Here is an abstract from one of their malaria efforts. See Author List below.

Since 2010, Cote d’Ivoire has made significant progress in the fight against malaria; however, since 2016 progress has stagnated and malaria incidence is steadily increasing. The aims of this study were to assess knowledge, attitudes and practices among heads of households, pregnant women and caretakers of children under 5 years of age (U5) and IPTp-SP compliance.

A mixed-methods study was conducted in rural and urban areas in 20 health districts of Cote d’Ivoire. A total of 1,812 households composed of 8,813 members were surveyed using a structured questionnaire. Qualitative data were gathered through twenty focus group discussions. Data triangulation was used during analysis.

Fever was the main malaria symptom reported by heads of households (38.5%) followed by headache (25.5%). Additionally, many FGD participants also reported sadness as a symptom of malaria. The primary cause of malaria was mosquito bites, followed by fatigue, the sun, and salty water, 70.7%, 15.1% and 10.9%, 3.3% respectively. The main prevention methods reported were sleeping under an ITN (60.4%), spraying the house (25.9%), taking medication (5.8%), and using a fan (7.9%). In FGDs, additional means of prevention were discussed including sanitation of the environment, personal hygiene, and stopping alcohol consumption.

The majority of women with at least one child reported having attended at least three ANC visits in their last pregnancy (85.1%). The cost of ANC was a main factor affecting attendance.  Overall, 78.2% of them received SP and of these women, 98.1% said they received it during their ANC visits. However, only 55.4% received 3 doses or more of SP and 76.79% received SP free of charge. The reasons for not taking SP were stock outs, side effects, bitter taste, and preference for injections.

Our study revealed that knowledge of prevention measures (ITNs) and causes of malaria (mosquito bites) were high and in line with the targets of the National BCC Strategy 2021-2025. However, even though the majority of pregnant women would like to take SP, they were blocked by the health system unable to provide them with the drugs and others had to pay for them. These problems within the health system are likely to contribute to the high malaria incidence in Cote d’Ivoire.

AUTHOR LIST

Edouard C. Balogoun1, Manasse Kassi1, Philomène A. Beda1, Jacob Y. Agniman1, Serge B. Assi2, Florence Kadjo-Kouadio3, Michel N’da-Ezoa4, Aristide E. Kouadio1, Joel Koffi1, Apollinaire N. Kouadio1, Paul Bouey5, Sara Canavati5, Eric Swedberg5 — 1Save the Children, Abidjan, Côte D’Ivoire, 2Le Programme Nationale de Lutte contre le Paludisme (PNLP), Abidjan, Côte D’Ivoire, 3Médecin Spécialiste de Santé, Abidjan, Côte D’Ivoire, 4Socio-Anthropologue de la Santé, Abidjan, Côte D’Ivoire, 5Save the Children, Washington, DC, United States

PRESS RELEASE                                                 

New Partnership launched to accelerate elimination of relapsing P. vivax malaria that poses a risk to an estimated 2.5 billion people worldwide

• The Partnership for Vivax Elimination (PAVE) will support endemic countries in achieving their Plasmodium vivax (P. vivax) malaria elimination goals.
• PAVE will advance the development of quality-assured, child-friendly treatments for relapse prevention, and generate and consolidate evidence to support malaria-endemic countries in developing and implementing new strategies to eliminate P. vivax malaria.

Geneva/Seattle, 14^th July 2021 –

The new Partnership for Vivax Elimination (PAVE) launching today, will support countries in the elimination of P. vivax – a complex and persistent type of malaria that poses a risk to more than one-third of the world’s population.

As part of PAVE, Medicines for Malaria Venture (MMV), PATH, Menzies School of Health Research, and Burnet Institute will work with in-country partners to conduct feasibility studies looking at the best way to use different P. vivax relapse treatments and diagnostics at different levels of the healthcare system in endemic countries including Brazil, Ethiopia, India, Indonesia, Papua New Guinea, Peru and Thailand.

PAVE will also continue to support countries, including Cambodia, Colombia, Lao PDR, and Vietnam, with market analytics and readiness planning for new tools and approaches as they seek to optimize P. vivax case management according to World Health Organization (WHO) guidance and accelerate progress towards their malaria elimination goals.

PAVE is led by MMV and PATH and combines a new investment of USD 25 million from Unitaid with work under existing grants from the Bill & Melinda Gates Foundation (BMGF), the UK Foreign, Commonwealth and Development Office (FCDO) and MMV core funding.  Consolidating these projects under PAVE will ensure coordination of efforts and clear communications with partners around the world. Recognizing that even more work is needed, PAVE will provide a vehicle for advocacy to bring further attention and resources to the challenge of eliminating P. vivax malaria.

Accounting for between 5.9 and 7.1 million estimated clinical cases every year, P. vivax is the most common type of malaria outside of sub-Saharan Africa. It presents a major challenge to achieving global malaria targets because of the difficulties in eliminating hypnozoites, a form of the parasite that remains in a person’s liver even after successful blood-stage treatment, leading to malaria relapses and contributing significantly to transmission.

Tackling P. vivax, by treating both the blood- and liver-stages of infection – known as radical cure – is essential to achieve the WHO 2030 targets of reducing global malaria case incidence by at least 90% and eliminating malaria transmission in 35 countries; as well as target 3.3 of the Sustainable Development Goals: end the epidemics of AIDS, TB and malaria by 2030.

PAVE will continue to work closely with WHO, National Malaria Control Programmes, and country-based partners to support the introduction and use of effective diagnostics and treatments for P. vivax malaria, including shorter-course primaquine and single-dose tafenoquine liver-stage treatments and better point-of-care glucose-6-phosphate dehydrogenase (G6PD) diagnostics needed to identify patients that are at risk of having adverse reactions to the class of drugs currently used for liver-stage treatments. Patients with the genetic disorder known as G6PD deficiency need to be screened because they are at risk of developing haemolytic anaemia when taking these drugs.

GSK and MMV have developed a paediatric version of tafenoquine, which iscurrently under review by regulators. PAVE aims to add to this and complete the full set of relapse prevention treatments suitable for children by supporting, with funding provided by Unitaid, the development of a quality-assured, child-friendly formulation of primaquine.

“Malaria elimination is one of the main objectives of the Ministry of Health of Peru. For this reason, MINSA appreciates the support of the PAVE initiative to find new tools for an optimized radical cure for the treatment of P. vivax malaria. This will contribute to the National Malaria Elimination Program’s “Plan Malaria Cero”. Said Veronica Soto Calle, Executive Director of the Directorate for the Prevention and Control of Metaxenic Diseases and Zoonoses, Ministry of Health of Peru (MINSA). “In this sense, we salute the launch of PAVE, an expansion of the VivAccess initiative, and its commitment to supporting endemic countries in their efforts to eliminate malaria.”

“With COVID-19-related interruptions threatening progress against malaria, investing in game-changing innovations remains one of our best chances to advance the frontier towards the elimination of malaria in all countries. By accelerating the adoption of a shorter radical cure and better diagnostics, we can reduce the burden of P. vivax malaria and draw the line against this disease,” said Philippe Duneton, Executive Director of Unitaid.

“We are thrilled to further expand this important work,” said Elodie Jambert, Director, Access and Product Management at MMV. “Families and communities affected by relapsing malaria have been suffering for too long. The new paediatric treatment options, and the real-world evidence that we will generate as part of PAVE, will represent a big step forward in eliminating this disease.”

“PATH is excited to continue our close engagement with MMV started under the VivAccess grant in working to generate evidence that will support scale-up of life-saving drugs and diagnostics for P. vivax malaria” said, PATH’s Ethiopia Country Director, Tirsit Grishaw. “By combining efforts with the National Malaria Elimination Program as well as the National Malaria Elimination Strategy, PAVE will help shift the paradigm for P. vivax case management.”

We are sharing the abstract of a just published article by Moussa Sangare and colleagues entitled, “Factors hindering health care delivery in nomadic communities: a cross-sectional study in Timbuktu, Mali,” that appears in BMC Public Health. As COVID-19 has been disrupting health services generally, we need greater awareness of the serious barriers faced by more vulnerable populations even in better times.

Background: In Mali, nomadic populations are spread over one third of the territory. Their lifestyle, characterized by constant mobility, excludes them from, or at best places them at the edge of, health delivery services. This study aimed to describe nomadic populations’ characteristics, determine their perception on the current health services, and identify issues associated with community-based health interventions.

Methods: To develop a better health policy and strategic approaches adapted to nomadic populations, we conducted a cross-sectional study in the region of Timbuktu to describe the difficulties in accessing health services. The study consisted in administering questionnaires to community members in the communes of Ber and Gossi, in the Timbuktu region, to understand their perceptions of health services delivery in their settings.

Results: We interviewed 520 individuals, all members of the nomadic communities of the two study communes. Their median age was 38?years old with extremes ranging from 18 to 86?years old. Their main activities were livestock breeding (27%), housekeeping (26.4%), local trading (11%), farming (6%) and artisans (5.5%). The average distance to the local health center was 40.94?km and 23.19?km respectively in Gossi and Ber. In terms of barriers to access to health care, participants complained mainly about the transportation options (79.4%), the quality of provided services (39.2%) and the high cost of available health services (35.7%). Additionally, more than a quarter of our participants stated that they would not allow themselves to be examined by a health care worker of the opposite gender.

Conclusion: This study shows that nomadic populations do not have access to community-based health interventions. A number of factors were revealed to be important barriers per these communities’ perception including the quality of services, poverty, lifestyle, gender and current health policy strategies in the region. To be successful, future interventions should take these factors into account by adapting policies and methods.

A variety of malaria and related issues have arisen over the past two days. A media coalition for malaria elimination formed in Ghana. A Nigerian NGO stresses the importance of addressing malaria on Nigeria’s 60th Independence Day (October 1). An innovative technology foundation is supporting various malaria and NTD treatment and diagnostic research efforts. Click on links below to read the details.

Media Coalition for malaria control and elimination launched

A Media Coalition comprising of selected journalists and editors, has been launched in Ghana under the umbrella of the “Zero Malaria Starts with Me” campaign to eliminate malaria by 2030. The Coalition, which aimed to enhance the quality and quantity of malaria coverage, and support broader advocacy efforts, was launched at a workshop in Accra organized by the National Malaria Control Programme (NMCP), in collaboration with the African Media and Malaria Research Network and Speak Up Africa, an advocacy and communication Organisation based in Senegal.

The workshop brought together media personnel from across the regions, who nominated their Regional Executives, with two National Co-Chairpersons coming from Greater Accra. The Members of the Coalition, made a firm declaration of their commitment towards the elimination of malaria in Ghana by the year 2030, by championing the fight, taking responsibility for their roles through proactive, regular, accurate, and high-quality media output of news on malaria.

Chinwe Chibuike Foundation Set To Flag-off Full Scale Malaria Eradication Program On Independence Day

A Nigeria indigenous and international non-governmental organization, envisioned to create a conducive environment towards the accessibility of healthcare facilities and improved educational opportunities, has joined the fight against the bizzare challenges of Malaria. The renowned Nigeria-USA humanitarian organization, Chinwe Chibuike Foundation is collaborating with other organizations to flagoff a full scale malaria eradication exercise tagged “Nigeria at 60 Malaria Eradication Project”, on the 1st of October 2020.

According to the founder and President of Chinwe Chibuike Foundation, Ms Gloria Chibuike, during an interview session with Pulse TV few days ago, she noted the forthcoming Nigeria At 60 Malaria Eradication Program will be different and of more impact, especially with the full scale approach and introduction a new Malaria repellant Band.

While emphasizing on the extensive features of the project, Ms Gloria described Malaria as one of the biggest problems in Africa at the moment, considering the increased number of recorded deaths and infection. She narrated that the discovery of the new malaria repellent band was timely and off-course very efficient, especially with testimonies from few persons who have already tried the brand.

Drugs and Diagnostics: Malaria and NTDs

The Global Health Innovative Technology (GHIT) Fund announced today a total of 1.37 billion yen (US$13 million*) to invest in seven partnerships to develop new lifesaving drugs and diagnostics for malaria, Buruli ulcer, Chagas disease, leishmaniasis, schistosomiasis, and soil-transmitted helminths (STH). This includes three newly funded projects and four that will receive continued funding. The RBM Partnership is planning on how to monitor and provide technical support for ITN programs. Click the links within each section to read details.

As of September 29, GHIT’s portfolio includes 50 ongoing projects: 26 discovery projects, 16 preclinical projects and eight clinical trials (Appendix 3). The total amount of investments since 2013 is 22.3 billion yen (US$211 million).

Support the Improvement of Operational Efficiency of ITN Campaigns

The Alliance for Malaria Prevention (AMP) is a workstream within the RBM Partnership to End Malaria. With malaria indicators stagnating and intense pressure to improve access and use of effective ITNs, WHO has renewed focus on stratifying vector control strategies in countries. Along with the introduction of new, more expensive ITNs, countries are now challenged to determine where they should deploy different ITN types to manage insecticide resistance within limited funding envelopes, as well as to identify more efficient ways to implement mass ITN distribution.

Countries that have accessed AMP technical assistance have significantly improved their capacity to modify and update strategies and tools to increase ITN access, use and accountability. They have also continued to identify further gaps and look for effective ways to address them. Now AMP planning to support update and finalization of ITN tracking tool, aligned with priorities across major partners (GF, PMI, RBM).

Today’s stories cover three continents including Surveillance for imported malaria in Sri Lanka, community perceptions in Colombia and Annual Fluctuations in Malaria Transmission Intensity in 5 sub-Saharan countries. In addition there is an overview of microscopy standards and an Integrated Macroeconomic Epidemiological Demographic Model to aid in planning malaria elimination. We also see how COVID-19 is disturbing Seasonal Malaria Chemoprevention activities in Burkina Faso. Read more by following the links in the sections below.

Will More of the Same Achieve Malaria Elimination?

… Results from an Integrated Macroeconomic Epidemiological Demographic Model. Historic levels of funding have reduced the global burden of malaria in recent years. Questions remain, however, as to whether scaling up interventions, in parallel with economic growth, has made malaria elimination more likely today than previously. The consequences of “trying but failing” to eliminate malaria are also uncertain. Reduced malaria exposure decreases the acquisition of semi-immunity during childhood, a necessary phase of the immunological transition that occurs on the pathway to malaria elimination. During this transitional period, the risk of malaria resurgence increases as proportionately more individuals across all age-groups are less able to manage infections by immune response alone. We developed a robust model that integrates the effects of malaria transmission, demography, and macroeconomics in the context of Plasmodium falciparum malaria within a hyperendemic environment.

The authors analyzed the potential for existing interventions, alongside economic development, to achieve malaria elimination. Simulation results indicate that a 2% increase in future economic growth will increase the US$5.1 billion cumulative economic burden of malaria in Ghana to US$7.2 billion, although increasing regional insecticide-treated net coverage rates by 25% will lower malaria reproduction numbers by just 9%, reduce population-wide morbidity by ?0.1%, and reduce prevalence from 54% to 46% by 2034. As scaling up current malaria control tools, combined with economic growth, will be insufficient to interrupt malaria transmission in Ghana, high levels of malaria control should be maintained and investment in research and development should be increased to maintain the gains of the past decade and to minimize the risk of resurgence, as transmission drops. © The American Society of Tropical Medicine and Hygiene [open-access]

Microscopy standards to harmonise methods for malaria clinical research studies

Research Malaria Microscopy Standards (ReMMS) applicable to malaria clinical research studies have been published in Malaria Journal. The paper describes the rationale for proposed standards to prepare, stain and examine blood films for malaria parasites. The standards complement the methods manual(link is external) previously published by the World Health Organization and UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR). The standards aim to promote consistency and comparability of data from microscopy performed for malaria research and hence to strengthen evidence for improvements in malaria prevention, diagnostics and treatment.

Microscopy is important in both malaria diagnosis and research. It is used to differentiate between Plasmodium species and stages and to estimate parasite density in the blood – an important determinant of the severity of disease. It is also used to monitor the effectiveness of drugs based on the rate at which parasites recrudesce or are cleared from the blood.

While rapid diagnostic tests have replaced microscopy in some contexts, microscopy remains an essential tool to support clinical diagnosis and research. The standardisation of methods allows direct comparisons from studies conducted across different points in time and location. This facilitates individual participant data meta-analyses, recognised as the gold standard approach to generate evidence for improvements in interventions and hence patient outcomes.

Estimating Annual Fluctuations in Malaria Transmission Intensity and in the Use of Malaria Control Interventions in Five Sub-Saharan African Countries

RTS,S/AS01E malaria vaccine safety, effectiveness, and impact will be assessed in pre- and post-vaccine introduction studies, comparing the occurrence of malaria cases and adverse events in vaccinated versus unvaccinated children. Because those comparisons may be confounded by potential year-to-year fluctuations in malaria transmission intensity and malaria control intervention usage, the latter should be carefully monitored to adequately adjust the analyses. This observational cross-sectional study is assessing Plasmodium falciparum parasite prevalence (PfPR) and malaria control intervention usage over nine annual surveys performed at peak parasite transmission. Plasmodium falciparum parasite prevalence was measured by microscopy and nucleic acid amplification test (quantitative PCR) in parallel in all participants, and defined as the proportion of infected participants among participants tested. Results of surveys 1 (S1) and 2 (S2), conducted in five sub-Saharan African countries, including some participating in the Malaria Vaccine Implementation Programme (MVIP), are reported herein; 4,208 and 4,199 children were, respectively, included in the analyses.

Plasmodium falciparum parasite prevalence estimated using microscopy varied between study sites in both surveys, with the lowest prevalence in Senegalese sites and the highest in Burkina Faso. In sites located in the MVIP areas (Kintampo and Kombewa), PfPR in children aged 6 months to 4 years ranged from 24.8% to 27.3%, depending on the study site and the survey. Overall, 89.5% and 86.4% of children used a bednet in S1 and S2, of whom 68.7% and 77.9% used impregnated bednets. No major difference was observed between the two surveys in terms of PfPR or use of malaria control interventions. © The American Society of Tropical Medicine and Hygiene [open-access]

Community perception of malaria in a vulnerable municipality in the Colombian Pacific

Malaria primarily affects populations living in poor socioeconomic conditions, with limited access to basic services, deteriorating environmental conditions, and barriers to accessing health services. Control programmes are designed without participation from the communities involved, ignoring local knowledge and sociopolitical and cultural dynamics surrounding their main health problems, which implies imposing decontextualized control measures that reduce coverage and the impact of interventions. The objective of this study was to determine the community perception of malaria in the municipality of Olaya Herrera in the Colombian Pacific.

A 41-question survey on knowledge, attitudes, and practices (KAP) related to malaria, the perception of actions by the Department of Health, and access to the health services network was conducted. In spite of the knowledge about malaria and the efforts of the Department of Health to prevent it, the community actions do not seem to be consistent with this knowledge, as the number of cases of malaria is still high in the area.

Use of a Plasmodium vivax genetic barcode for genomic surveillance and parasite tracking in Sri Lanka

Sri Lanka was certified as a malaria-free nation in 2016; however, imported malaria cases continue to be reported. Evidence-based information on the genetic structure/diversity of the parasite populations is useful to understand the population history, assess the trends in transmission patterns, as well as to predict threatening phenotypes that may be introduced and spread in parasite populations disrupting elimination programmes. This study used a previously developed Plasmodium vivax single nucleotide polymorphism (SNP) barcode to evaluate the population dynamics of P. vivax parasite isolates from Sri Lanka and to assess the ability of the SNP barcode for tracking the parasites to its origin.

A total of 51 P. vivax samples collected during 2005–2011, mainly from three provinces of the country, were genotyped for 40 previously identified P. vivax SNPs using a high-resolution melting (HRM), single-nucleotide barcode method. The proportion of multi-clone infections was significantly higher in isolates collected during an infection outbreak in year 2007. Plasmodium vivax parasite isolates collected during a disease outbreak in year 2007 were more genetically diverse compared to those collected from other years. In-silico analysis using the 40 SNP barcode is a useful tool to track the origin of an isolate of uncertain origin, especially to differentiate indigenous from imported cases. However, an extended barcode with more SNPs may be needed to distinguish highly clonal populations within the country.

Coronavirus rumours and regulations mar Burkina Faso’s malaria fight

By Sam Mednick, Thomson Reuters Foundation: MOAGA, Burkina Faso – Health worker Estelle Sanon would hold the 18-month-old and administer the SMC dose herself, but because of coronavirus she has to keep a distance from her patients. “If I am standing and watching the mother do it, it’s as if I’m not doing my work,” said Sanon, a community health volunteer assisting in a seasonal campaign to protect children in the West African country from the deadly mosquito-borne disease.

Burkina Faso is one of the 10 worst malaria-affected nations in the world, accounting for 3% of the estimated 405,000 malaria deaths globally in 2018, according to the World Health Organization (WHO). More than two-thirds of victims are children under five. Now there are fears malaria cases could rise in Burkina Faso as restrictions due to coronavirus slow down a mass treatment campaign and rumours over the virus causing parents to hide their children, according to health workers and aid officials.

“COVID-19 has the potential to worsen Burkina Faso’s malaria burden,” said Donald Brooks, head of the U.S. aid group Initiative: Eau, who has worked on several public health campaigns in the country.  “If preventative campaigns can’t be thoroughly carried out and if people are too scared to come to health centres … it could certainly increase the number of severe cases and the risk of poor outcomes.”

During peak malaria season, from July to November, community health workers deploy across Burkina Faso to treat children with seasonal malaria chemoprevention (SMC). This is the second year the campaign will cover the whole country with more than 50,000 volunteers going door-to-door, said Gauthier Tougri, coordinator for the country’s anti-malaria programme. Logistics were already challenging. Violence linked to jihadists and local militias has forced more than one million people to flee their homes, shuttered health clinics and made large swathes of land inaccessible. Now the coronavirus has made the task even harder, health workers said.

People in Cape Verde evolved better malaria resistance in 550 years

Yes, we are still evolving. And one of the strongest examples of recent evolution in people has been found on the Cape Verde islands in the Atlantic, where a gene variant conferring a form of malaria resistance has become more common.

Portuguese voyagers settled the uninhabited islands in 1462, bringing slaves from Africa with them. Most of the archipelago’s half a million inhabitants are descended from these peoples. Most people of West African origin have a variant in a gene called DARC that protects.

Deadly malaria and cholera outbreaks grow amongst refugees as COVID pandemic strains health systems.

Apart from the strain on health facilities during the pandemic, in some countries such as Somalia, Kenya and Sierra Leone, we are seeing that a fear of exposure to COVID-19 has prevented parents from taking their children to hospital, delaying diagnosis and treatment of malaria and increasing preventable deaths. COVID restrictions in some countries have also meant pregnant women have missed antimalarial drugs. Untreated malaria in pregnant women can increase the risk of anaemia, premature births, low birth weight and infant death. According to the World Health Organization (WHO), 80% of programs designed to fight HIV, tuberculosis and malaria have been disrupted due to the pandemic and 46% of 68 countries report experiencing disruptions in the treatment and diagnosis of malaria.

Today we learn about malaria-carrying A. stephensi invading African cities, how malaria outpaces COVID-19 in Central African Republic, and the need to examine malaria service delivery in the context of strong health services. Malaria Journal looks at ITN use in Uganda and malaria genetic variability even at the household level. Click on links to read full articles.

Spread of city-loving malaria mosquitoes could pose grave threat to Africa

An Asian malaria-carrying mosquito that has adapted to urban life has the potential to spread to dozens of cities across the African continent, a new modeling study suggests.
The mosquito species, Anopheles stephensi, poses a serious new threat for African cities, says Francesca Frentiu, a geneticist at the Queensland University of Technology who was not involved in the research. She praises the work as “an important effort, underpinned by robust methods.” A. stephensi hopped from Asia to the Arabian Peninsula between 2000 and 2010 and then made another jump to the Horn of Africa; scientists first discovered it in Djibouti in 2012, then later in Ethiopia and Sudan.

In times of COVID-19, malaria remains the number one killer of children in CAR

Since the beginning of the year, MSF teams have treated 39,631 malaria cases in Batangafo, compared to 23,642 in the same period last year. The hospital in Batangafo – a town of 31,000 people, including 22,000 displaced from elsewhere in the Central African Republic – is bustling with activity. While a particular focus has been placed on infection prevention and control measures to identify and isolate people with suspected cases of COVID-19, another deadly disease has a much heavier impact on the lives of people living here.

September is the rainy season, when malaria becomes more deadly than ever in the Central African Republic each year. It is the leading cause of death for children under five in the country. During periods when malaria transmission is high, eight out of ten paediatrics consultations in the hospital supported by Médecins Sans Frontières (MSF) in Batangafo are due to complications from malaria, including anaemia and dehydration.

Assessment of health service delivery parameters in Kano and Zamfara States, Nigeria

In 2013, the Nigeria Federal Ministry of Health established a Master Health Facility List (MHFL) as recommended by WHO. Since then, some health facilities (HFs) have ceased functioning and new facilities were established. We updated the MHFL and assessed service delivery parameters in the Malaria Frontline Project implementing areas in Kano and Zamfara States.

In 2016, the US Centers for Disease Control and Prevention (CDC), in collaboration with the Nigeria National Malaria Elimination Program (NMEP), established a 3-year intervention project, Malaria Frontline Project (MFP), with the objectives of strengthening the technical capacity of LGA-level health workers, improving malaria surveillance and facilitating evidence-based decision-making. The project was implemented in Kano and Zamfara States.

Some deficiencies in the list of facilities in DHIS2 and MHFL were uncovered making it difficult to submit and access malaria program data. Also, some facilities were still using the old version of register which did not collect all indicators required by DHIS2. In addition there were a small number of non-functional facilities. Finally the low number of facilities within the PHC category meeting the minimum HR requirement will hamper the countries effort to achieve its goal of universal health coverage. From the foregoing, the study identifies several areas to improve delivery of malaria services specifically and universal coverage in general.

Individual, community and region level predictors of insecticide-treated net use among women in Uganda: a multilevel analysis

ITN use attributable to regional and community level random effects was 39.1% and 45.2%, respectively. The study has illustrated that ITN policies and interventions in Uganda need to be sensitive to community and region level factors that affect usage. Also, strategies to enhance women’s knowledge on malaria prevention is indispensable in improving ITN use.

Genetic diversity and complexity of Plasmodium falciparum infections in the microenvironment among siblings of the same household in North-Central Nigeria

These findings showed that P. falciparum isolates exhibit remarkable degree of genetic diversity in the micro-environment of the household and are composed mainly of multiclonal infections, which is an indication of a high ongoing parasite transmission. This suggests that the micro-environment is an important area of focus for malaria control interventions and for evaluating intervention programmes.

These malaria and related news and abstracts stress the importance of sentinel surveillance systems, strong political and systems commitment to disease elimination, malachite green loop-mediated isothermal amplification for better malaria detection, and the threat of neglected fungal infections. An article from The Lancet shows that it is not just money that is needed to eliminate malaria, but better management and systems. Finally a bit of history from 18th Century North Carolina is shared. Click the links in each section to learn more about each topic.

Implementation of a malaria sentinel surveillance system in Togo: a pilot study

Since July 2017, 16 health facilities called sentinel sites, 4 hospitals and 12 peripheral care units located in 2 epidemiologically different health regions of Togo, have provided weekly data on malaria morbidity and mortality for the following 3 target groups:?<?5-years-old children,???5-years-old children and adults, and pregnant women. Data from week 29 in 2017 to week 13 in 2019 were analysed.

Each sentinel site provided complete data and the median time to data entry was 4 days. The number of confirmed malaria cases increased during the rainy seasons both in children under 5 years old and in children over 5 years old and adults. Malaria-related deaths occurred mainly in children under 5 years old and increased during the rainy seasons. The mean percentage of tested cases for malaria among suspected malaria cases was 99.0%. The mean percentage of uncomplicated malaria cases handled in accordance with national guidelines was 99.4%. The mean percentage of severe malaria cases detected in peripheral care units that were referred to a hospital was 100.0%. Rapid diagnostic tests and artemisinin-based combination therapies were out of stock several times, mainly at the beginning and end of the year. No hospital was out of stock of injectable artesunate or injectable artemether.

These indicators showed good management of malaria cases in the sentinel sites. Real-time availability of data requires a good follow-up of data entry on the online platform. The management of input stocks and the promptness of data need to be improved to meet the objectives of this malaria sentinel surveillance system.

Evaluation of the colorimetric malachite green loop-mediated isothermal amplification (MG-LAMP) assay …

… for the detection of malaria species at two different health facilities in a malaria endemic area of western Kenya. Prompt diagnosis and effective malaria treatment is a key strategy in malaria control. However, the recommended diagnostic methods, microscopy and rapid diagnostic tests (RDTs), are not supported by robust quality assurance systems in endemic areas. This study compared the performance of routine RDTs and smear microscopy with a simple molecular-based colorimetric loop-mediated isothermal amplification (LAMP) at two different levels of the health care system in a malaria-endemic area of western Kenya.

Patients presenting with clinical symptoms of malaria at Rota Dispensary (level 2) and Siaya County Referral Hospital (level 4) were enrolled into the study after obtaining written informed consent. Capillary blood was collected to test for malaria by RDT and microscopy at the dispensary and county hospital, and for preparation of blood smears and dried blood spots (DBS) for expert microscopy and real-time polymerase chain reaction (RT-PCR).

Results of the routine diagnostic tests were compared with those of malachite green loop-mediated isothermal amplification (MG-LAMP) performed at the two facilities.
A total of 264 participants were enrolled into the study. At the dispensary level, the positivity rate by RDT, expert microscopy, MG-LAMP and RT-PCR was 37%, 30%, 44% and 42%, respectively, and 42%, 43%, 57% and 43% at the county hospital. Using RT-PCR as the reference test, the sensitivity of RDT and MG-LAMP was 78.1% (CI 67.5–86.4) and 82.9% (CI 73.0–90.3) at Rota dispensary.

At Siaya hospital the sensitivity of routine microscopy and MG-LAMP was 83.3% (CI 65.3–94.4) and 93.3% (CI 77.9–99.2), respectively. Compared to MG-LAMP, there were 14 false positives and 29 false negatives by RDT at Rota dispensary and 3 false positives and 13 false negatives by routine microscopy at Siaya Hospital. MG-LAMP is more sensitive than RDTs and microscopy in the detection of malaria parasites at public health facilities and might be a useful quality control tool in resource-limited settings.

Terminating Trachoma. How Myanmar eliminated blinding trachoma.

Download the book  from WHO New Delhi: World Health Organization, Regional Office for South-East Asia; 2020. Licence: CC BY-NC-SA 3.0 IGO.  Myanmar’s three-phase approach to eliminating trachoma has been a great success, which will certainly continue. The country’s visionary National Eye Health Plan 2017-2021, which is closely aligned with international policies for prevention of blindness, gives confidence that Myanmar will maintain its elimination status. This book chronicles how a combination of good leadership, effective partnerships, health-care facilities and hardworking health-care personnel helped Myanmar eliminate trachoma as a public health problem.

Health sector spending and spending on HIV/AIDS, tuberculosis, and malaria, and development assistance for health, SDG Progress

Although the progress towards Sustainable Development Goal (SDG) 3, which aims to “ensure healthy lives and promote well-being for all at all ages”, has been assessed in various works, there is less research focusing on tracking spending towards this goal. In this study, spending estimates were used to determine progress in financing the priority areas of SDG3, examine the correlation between outcomes and financing, and identify where resource gains are most required to attain the SDG3 indicators for which data are available.

From 1995 to 2017, domestic health spending was determined, disaggregated by source (government, out-of-pocket, and prepaid private) for 195 countries and territories. Outcomes suggest a global rise in total health spending since the state of the SDGs in 2015, reaching $7·9 trillion (7·8–8·0) in 2017, and is estimated to rise to $11·0 trillion (10·7–11·2) by 2030, although with substantial disparity across countries. Per estimates, low-income and middle-income countries, in 2017, had an estimated spending of $20·2 billion on HIV/AIDS, $10·9 billion on tuberculosis, and $5·1 billion on malaria in endemic countries.

Although there is an increase in both domestic government and DAH spending, across these three diseases, variation in the accompanied changes in outcomes was observed. Malaria was noted to have the most consistent reductions in outcomes across countries as spending has raised. Findings thereby suggest mixed progress towards meeting the SDG3 targets; the progress varied by country and by target. The evidence on the scale-up of spending and improvements in health outcomes suggest a nuanced relationship, such that outcomes do not always improve with increases in spending.

Although more resources may be required by the countries to achieve SDG3, there will also be a necessity for addressing other constraints in the broader health system such as inefficient allocation of resources across interventions and populations, weak governance systems, human resource shortages, and drug shortages.

Ignored fungal infections kill more people annually than HIV and malaria combined

Carolina Pohl-Albertyn says that, “You may also know that there are other infections causing great concern, such as HIV (690 000 deaths/year), tuberculosis (1.5-million deaths/year), and malaria (405,000 deaths/year). But what would be your reaction if you knew that fungal infections (ranging from skin and mucosal infections (e.g. vaginal or oral thrush) to deadly systemic and organ infections (e.g. candidiasis, cryptococcal meningitis, and bronchopulmonary aspergillosis]) affect more than one-billion people each year, of which more than 150-million cases are severe and life-threatening and cause 1.7 million deaths per year?”

Malaria was once scourge in Chowan County, North Carolina

Nicole Bowman-Layton (Editor) provides some history of malaria. It’s fascinating to think that less than 100 years ago this disease was still a major scourge in Chowan County. I’ve wanted to write about this topic for a long time since the coronavirus popped up but was a bit concerned about writing about a somewhat depressing topic.

According to NCPedia malaria came to North Carolina in the 1500s from some of the first European explorers who were bitten by our friendly Anopheles mosquitoes and then transmitted to the native population. And as we well know, we live in a very damp environment surrounded by sitting water which certainly increases the harvest of mosquitos. Some of the most prominent Revolutionary Edentonians suffered from the “Ague” during their lives. Declaration signer Joseph Hewes suffered from “intermittent fever and ague” throughout his life which were certainly symptoms of malaria.

The German traveler Dr. Johan Schoepf wrote in his book Travels in the Confederation, 1783-1784, of “…the sickliness of the inhabitants, especially prevalent in the low, overflowed, and swampy parts of this country, and giving the people a pale, decayed, and prematurely old look. This is the case not only about Edenton, but along the entire low-lying coast, which this fall, from Virginia to South Carolina, was visited with numerous fevers.

Today’s updates are brief and look at Vietnam in Southeast Asia and South Sudan in Africa. Both are concerned with health systems issues. Please click on links to read more details.

Malaria Week 2020 – Why Integration Could Be the Key to Elimination

Hosted by the Government of Vietnam, Malaria Week 2020 (7-11 September) brings together government officials and diverse partners to drive forward the elimination of malaria from Asia Pacific by 2030. This year’s theme centres on the three I’s – Inclusion. Integration. Innovation – and captures the ambition to unite the region and harness innovation as efforts intensify to eradicate malaria globally and in Asia Pacific. Key topics in the series this week include surveillance systems, sustaining health financing, and innovation within the malaria landscape.

Given the backdrop of COVID-19 to this year’s event, discussions will have a focus on sustaining health financing and in particular malaria interventions during a pandemic, the critical role of community-based approaches in health systems strengthening and the need for strong surveillance and timely reporting, in addition to the role of innovation and private provider engagement in accelerating malaria elimination and strengthening health security.

Healthcare in South Sudan: A Fractured System

A limited access to healthcare facilities, medical supplies in South Sudan results in high number of preventable deaths. high rates of tuberculosis, HIV/AIDS, malaria, and diarrheal diseases in country.

The South Sudanese population has very limited access to healthcare facilities, with only 44% of the population living within a one-hour walk of a medical center. This adds an extra burden on those in need of medical attention as the majority of the population has to walk for an extended time to reach a medical center. During a time of civil unrest, traveling for an extended period comes with increased exposure to the risk of ambushes and looting.

Below we highlight some of the news we have shared on our Facebook Tropical Health Group page during the past week.

Polio Persists

If all it took to eradicate a disease was a well proven drug, vaccine or technology, we would not be still reporting on polio, measles and guinea worm, to name a few. In the past week Afghanistan reported 2 wild poliovirus type 1 (WPV1) cases, and Pakistan had 3 WPV1 cases. Circulating vaccine-derived poliovirus type 2 (cVDPV2) was reported in Nigeria (1), DRC (4) and Ethiopia (3) from healthy community contacts.

Continued Ebola Challenges

In the seven days from Saturday to Friday (June 28) there were 71 newly confirmed Ebola Cases and 56 deaths reported by the Democratic Republic of Congo’s Ministry of Health. As Ebola cases continue to pile up in the Democratic Republic of the Congo (DRC), with 12 more confirmed Thursday and 7 more Friday, a USAID official said four major donors have jump-started a new strategic plan for coordinating response efforts. To underscore the heavy toll the outbreak has caused, among its 2,284 cases, as noted on the World Health Organization Ebola dashboard today, are 125 infected healthcare workers, including 2 new ones, DRC officials said.

Pacific Standard explained the differences in Ebola outbreaks between DRC today and the West Africa outbreak of 2014-16. On the positive side are new drugs used in organized trials for the current outbreak. The most important factor is safe, effective vaccine that has been tested in 2014-16, but is now a standard intervention in the DRC. While both Liberia and Sierra Leone had health systems and political weaknesses as post-conflict countries, DRC’s North Kivu and Ituri provinces are currently a war zone, effectively so for the past generation. Ebola treatment centers and response teams are being attacked. There are even cultural complications, a refusal to believe that Ebola exists. So even with widespread availability of improved technologies, teams may not be able to reach those in need.

To further complicate matters in the DRC, Doctors Without Borders (MSF) “highlighted ‘unprecedented’ multiple crises in the outbreak region in northeastern DRC. Ebola is coursing through a region that is also seeing the forced migration of thousands of people fleeing regional violence and is dealing with another epidemic. Moussa Ousman, MSF head of mission in the DRC, said, ‘This time we are seeing not only mass displacement due to violence but also a rapidly spreading measles outbreak and an Ebola epidemic that shows no signs of slowing down, all at the same time.’”

NIPAH and Bats

Like Ebola, NIPAH is zoonotic, and also involves bats, but the viruses differ. CDC explains that, “Nipah virus (NiV) is a member of the family Paramyxoviridae, genus Henipavirus. NiV was initially isolated and identified in 1999 during an outbreak of encephalitis and respiratory illness among pig farmers and people with close contact with pigs in Malaysia and Singapore. Its name originated from Sungai Nipah, a village in the Malaysian Peninsula where pig farmers became ill with encephalitis.

A recent human outbreak in southern India has been followed up with a study of local bats. In a report shared by ProMED, out of 36 Pteropus species bats tested for Nipah, 12 (33%) were found to be positive for anti-Nipah bat IgG antibodies. Unlike Ebola there are currently no experimental drugs or vaccines.

Climate Change and Dengue

Climate change is expected to heighten the threat of many neglected tropical diseases, especially arboviral infections. For example, the New York Times reports that increases in the geographical spread of dengue fever. Annually “there are 100 million cases of dengue infections severe enough to cause symptoms, which may include fever, debilitating joint pain and internal bleeding,” and an estimated 10,000 deaths. Dengue is transmitted by Aedes mosquitoes that also spread Zika and chikungunya. A study, published Monday in the journal Nature Microbiology, found that in a warming world there is a strong likelihood for significant expansion of dengue in the southeastern United States, coastal areas of China and Japan, as well as to inland regions of Australia. “Globally, the study estimated that more than two billion additional people could be at risk for dengue in 2080 compared with 2015 under a warming scenario.”

Schistosomiasis – MDA Is Not Enough, and Neither Are Supplementary Interventions

Schistosomiasis is one of the five neglected tropical diseases (NTDs) that are being controlled and potentially eliminated through mass drug administration (MDA) of preventive chemotherapy (PCT), in this case praziquantel. In The Lancet Knopp et al. reported that biannual MDA substantially reduced Schistosomiasis haematobium prevalence and infection intensity but was insufficient to interrupt transmission in Zanzibar. In addition, neither supplementary snail control or behaviour change activities did not significantly boost the effect of MDA. Most MDA programs focus on school aged children, and so other groups in the community who have regular water contact would not be reached. Water and sanitation activities also have limitations. This raises the question about whether control is acceptable for public health, or if there needs to be a broader intervention to reach elimination?

Trachoma on the Way to Elimination

Speaking of elimination, WHO has announced major “sustained progress” on trachoma efforts. “The number of people at risk of trachoma – the world’s leading infectious cause of blindness – has fallen from 1.5 billion in 2002 to just over 142 million in 2019, a reduction of 91%.” Trachoma is another NTD that uses the MDA strategy.

The news about NTDs from Dengue to Schistosomiasis to Trachoma is complicated and demonstrates that putting diseases together in a category does not result in an easy choice of strategies. Do we control or eliminate or simply manage illness? Can our health systems handle the needs for disease elimination? Is the public ready to get on board?

Malaria Updates

And concerning being complicated, malaria this week again shows many facets of challenges ranging from how to recognize and deal with asymptomatic infection to preventing reintroduction of the disease once elimination has been achieved. Several reports this week showed the particular needs for malaria intervention ranging from high burden areas to low transmission verging on elimination to preventing re-introduction in areas declared free from the disease.

In South West, Nigeria Dokunmu et al. studied 535 individuals aged from 6 months were screened during the epidemiological survey evaluating asymptomatic transmission. Parasite prevalence was determined by histidine-rich protein II rapid detection kit (RDT) in healthy individuals. They found that, “malaria parasites were detected by RDT in 204 (38.1%) individuals. Asymptomatic infection was detected in 117 (57.3%) and symptomatic malaria confirmed in 87 individuals (42.6%).

Overall, detectable malaria by RDT was significantly higher in individuals with symptoms (87 of 197/44.2%), than asymptomatic persons (117 of 338/34.6%)., p = 0.02. In a sub-set of 75 isolates, 18(24%) and 14 (18.6%) individuals had Pfmdr1 86Y and 1246Y mutations. Presence of mutations on Pfmdr1 did not differ by group. It would be useful for future study to look at the effect of interventions such as bednet coverage. While Southwest Nigeria is a high burden area, the problem of asymptomatic malaria will become an even bigger challenge as prevalence reduces and elimination is in sight.

Sri Lanka provides a completely different challenge from high burden areas. There has been no local transmission of malaria in Sri Lanka for 6 years following elimination of the disease in 2012. Karunasena et al. report the first case of introduced vivax malaria in the country by diagnosing malaria based on microscopy and rapid diagnostic tests. “The imported vivax malaria case was detected in a foreign migrant followed by a Plasmodium vivax infection in a Sri Lankan national who visited the residence of the former. The link between the two cases was established by tracing the occurrence of events and by demonstrating genetic identity between the parasite isolates. Effective surveillance was conducted, and a prompt response was mounted by the Anti Malaria Campaign. No further transmission occurred as a result.”

Bangladesh has few but focused areas of malaria transmission and hopes to achieve elimination of local transmission by 2030. A particular group for targeting interventions is the population of slash and burn cultivators in the Rangamati District. Respondents in this area had general knowledge about malaria transmission and modes of prevention and treatment was good according to Saha and the other authors. “However, there were some gaps regarding knowledge about specific aspects of malaria transmission and in particular about the increased risk associated with their occupation. Despite a much-reduced incidence of malaria in the study area, the respondents perceived the disease as life-threatening and knew that it needs rapid attention from a health worker. Moreover, the specific services offered by the local community health workers for malaria diagnosis and treatment were highly appreciated. Finally, the use of insecticide-treated mosquito nets (ITN) was considered as important and this intervention was uniformly stated as the main malaria prevention method.”

Kenya offers some lessons about low transmission areas but also areas where transmission may increase due to climate change. A matched case–control study undertaken in the Western Kenya highlands. Essendi et al. recruited clinical malaria cases from health facilities and matched to asymptomatic individuals from the community who served as controls in order to identify epidemiological risk factors for clinical malaria infection in the highlands of Western Kenya.

“A greater percentage of people in the control group without malaria (64.6%) used insecticide-treated bed nets (ITNs) compared to the families of malaria cases (48.3%). Low income was the most important factor associated with higher malaria infections (adj. OR 4.70). Houses with open eaves was an important malaria risk factor (adj OR 1.72).” Other socio-demographic factors were examined. The authors stress the need to use local malaria epidemiology to more effectively targeted use of malaria control measures.

The key lesson arising from the forgoing studies and news is that disease control needs strong global partnerships but also local community investment and adaptation of strategies to community characteristics and culture.