Tropical Health Matters

As global financial support for malaria and other disease control efforts has faltered, there is a greater need for national malaria programs to pick up the slack. A look at Nigeria’s national health accounts does show that ‘foreign’ aid does play a relatively small role in health financing and expenditure in this oil-rich country, but ironically it is the common citizen who picks up the bulk of health financing through out-of-pocket expenditures.

The question of local initiative in the move toward elimination of malaria received a severe blow when the Nigerian Senate Committee on Health questioned the need for continued purchases of long lasting insecticide-treated nets (LLINS). The Guardian newspaper reported that the, “Chairman of the committee, Dr. Ifeanyi Okowa, wondered why Nigeria would still continue to cling to the strategy, which he said was not working, when country like Senegal that has manufacturing plants for LLINs was using other effective means to tackle malaria.”

The Senator’s views contrast with those of national experts and the WHO: “While the Minister of State for Health, Dr.Muhammad Ali Pate, said in January that the ministry proposed N1.8 billion for the procurement of LLINs for additional three states, a World Health Organisation (WHO)’s report shows that Nigeria would need one billion dollars (N158 billion) to stave off backsliding and resurgences of malaria in 2013 and 2014.”

It would seem that the Senator was reacting to perceived pressure from the international community to maintain a malaria control strategy that he thought was less effective than indoor residual spraying (IRS).  Of course one of the biggest challenges in disease control advocacy efforts is to educate policy makers. The Director-General of the Nigerian Institute for Medical Research, Prof. Innocent Ujah, tried to do this. He pointed out cultural factors that inhibit net use – and in fact lack of serious community follow-up efforts after massive net distribution over the past 2-3 years, can be traced as one reason why LLINs may have been wasted.

The Senator did not realize that malaria control leading toward elimination needs a multifaceted strategy. IRS can be part, but has its own limitations of which one is expense.  In highly endemic, stable and year-round transmission environments like Nigeria, spraying would be needed twice a year.  We forget that Nigeria has already once tried IRS a few decades ago and abandoned the effort in part due to the huge logistical challenges required.

Nigeria has tried selling LLINs/ITNs through the private sector, but coverage was low since not all Nigerians could or would buy them despite paying disproportionately out-of-pocket for treatment. If the government refuses to fund massive LLIN distribution, then we can expect the burden to fall on the common people who may die from malaria before they purchase a more costly net on the commercial market.

Some people love their spouse, some people love their new car, and apparently some people love DDT.

Love is not a particularly rational emotion, even more so when it comes to inanimate objects like cars and pesticides. Those who love DDT have now even equated stopping its use with population control in Africa.  One wonders where these same people stood when real ‘population control’ or genocide was happening in Rwanda and Darfur (to name a few of the more obvious human atrocities). Somehow one doubts banning of DDT can be equated with Darfur.

Long before DDT was banned, the malaria eradication efforts of the 1950s-60s were grinding to a halt in many African countries for the basic reasons that health systems could not support sustained efforts and donors were tiring of funding the project. There is also the not so simple matter of insects developing resistance when only one pesticide is being used.

One key lesson of the earlier eradication project was that relying on a single intervention technology was not enough to control, much less eradicate, a complicated disease like malaria.

Now that we have several proven tools (long lasting insecticide treated nets, artemisinin-based combination therapy, rapid diagnostic tests, intermittent preventive treatment AND indoor residual spray) in addition to new tools on the horizon (e.g. vaccines), we can apply those in combinations that best suit the epidemiological situation in each country and region of a country.

Yes, spraying was included above, and is an integral component of current malaria control and elimination efforts because it can now be targeted, as with the other interventions, in the most effective places such as areas that have more seasonal and unstable transmission and thus, where annual spraying can be effective. Yes, DDT is included in the WHO approved list of chemicals for indoor use, but for countries that want choice, there are a dozen alternatives.

Why annual spraying? DDT may be cheap, but the spraying operation is not. Nor is it convenient to the people whose homes are sprayed. Spraying more than once a year would be more time and cost consuming than present funding and community tolerance could support. Very high year-round malaria transmission settings are not so amenable to IRS as they would require more frequent spraying.  WHO recommends the following for appropriate IRS use in epidemiologically appropriate areas:

Achieving [the highest possible] level of coverage and timing spraying correctly – in a short period of time before the onset of the transmission season – are crucial to realize the full potential of IRS. IRS is indicated only in those settings where it can be implemented effectively, which calls for a high and sustained level of political commitment.

Approved use of any pesticide for public health comes with the following caution: “When implementing IRS, it is critical to ensure that adequate regulatory control is in place to prevent unauthorized and un-recommended use of public health pesticides in agriculture, and thus contamination of agricultural products. Pesticide contamination can have serious ramifications for trade and commerce for countries exporting agricultural products.”

Those who love DDT may not find these concerns expressed about the object of their affection very comforting. But then love is fickle. Maybe next year these same people will fall in love with BPA.

In Nigeria’s Rivers State the State’s Malaria Control Coordinator reports on “efforts to roll back malaria in Rivers State, (in which) the state government says it would carry out indoor residual spraying (IRS) to terminate mosquitoes, the causative agent as from this quarter.”

The Coordinator has set up a timeline: “According to her, plans were already underway to purchase and distribute chemicals that would be used for the house-to-house spraying. She also said that if done every six months in the next three years, Rivers State would be free from malaria.”

WHO explains that, “The application of IRS consistently over time in large areas has altered the vector distribution and subsequently the epidemiological pattern of malaria in Botswana, Namibia, South Africa, Swaziland and Zimbabwe.” These are countries with large areas of unstable or epidemic malaria where annual spraying is effective.  Rivers State, Nigeria, as its Malaria Coordinator notes, requires twice a year spraying since it is an area of stable, intense and year-round transmission.

When the US President’s Malaria Inititive planned IRS in Ghana it chose districts in the Northern part of the country where malaria transmission is more seasonal and IRS can be cost-effective when used only once a year. For most of the country PMI is planning to distribute more than a million long lasting insecticide-treated nets as the appropriate strategy.

The Rivers State effort, while recognizing the need to adapt IRS timing to its ecological/epidemiological setting will still face huge challenges including –

• dispersed, nearly inaccessible riverine communities
• coordination among neighboring states where mosquito control efforts may not be as strong
• ongoing civil disorder wherein “Militants in the Niger Delta attack pipelines and other oil facilities and kidnap foreign oil workers.”

Apparently the State is also relying on the bednet option, and “government had distributed four million insecticide treated bednets during the last immunisation campaign in the state. But this spraying option would ensure that even those who fail to clean their areas get the needed cover.” Nets can be distributed and monitored through a variety of community channels and last for 5 years if used properly.  This might be a safer and more viable vector control option for such a high transmission areas.

The National Academy of Sciences reports that, “The Ugandan government recently started spraying insecticides in homes and settlements to combat mosquitoes that spread malaria, the country’s leading cause of death.  A new report from a committee of the Uganda National Academy of Sciences (UNAS) says that as the spraying continues, the government needs to monitor mosquitoes for resistance to insecticides, and manage the spraying program in ways that minimize resistance.  UNAS is a participant in the African Science Academy Development Initiative, a joint effort of several African academies and the U.S. National Academies to advance science-based policy advice in Africa.”

The Committee that met to assess malaria vector resistance to insecticides used for indoor residual spraying in Uganda has looked at the strengths and weaknesses of the proposed “best practices” in IRS with an aim to maximize the effectiveness of DDT and other insecticides as well as identify contextual issues that would have a bearing on successful implementation of the “best practices.” In short the committee is not against IRS, but wants to ensure that it is carried out in the most safe and effective way.

The report of the Committee is available online. The report documents national policy and the fact that the Ministry of Health was authorized to begin IRS using DDT in August 2007 with support from the US President’s Malaria Initiative. Committee recommendations include establishment of sentinel surveillance sites, baseline entomological assessment, use a variety of factors ranging from susceptibility to cost and reliability of supply in selecting insecticides, and plan for long-term implementation, among others.

PMI’s updated Uganda profile states that, “To date, more than 4,000 local personnel have been trained on proper spraying technique. Spraying has covered almost every targeted household in Uganda and benefited more than 1.8 million people.” In addition PMI’s Malaria Operational Plan for Uganda documents that PMI established insecticide resistance monitoring to IRS in Kabale with a training course in 2006 on the use of the bottle bioassay for mosquito insecticide resistance testing. Additional training and capacity building was planned for 2007. As a result of these activities, “The NMCP intends to monitor the level of susceptibility of malaria vectors to the insecticides scheduled for use in 2008, 2010, and 2012,” in selected sentinel sites as well as consider rotating insecticides to slow the development of resistance.

It would appear that the scientific, programmatic and donor communities are poised to deliver a safe and effective IRS intervention in Uganda. We would feel a bit more comfortable knowing whether Uganda is achieving some of the early milestones implied above – deployment and support of trained personnel, establishment of sentinel centers and conduct of baseline, for a start.

Nine companies engaged in organic farming in Lango sub-region’s districts of Oyam, Apac and Lira are suing the government of Uganda over the use of DDT for indoor residual spraying according to the Monitor. The Monitor reports the case as filed states that, “The decision by the government to introduce DDT in the districts is illegal as it contravenes the provisions of the Stockholm Convention on persistent organic pollutants of 2001.” WHO does clarify that the Convention says DDT can be used for public health purposes, but the question is, who defines the public’s health?

The farmers have logical fear that if DDT spraying inside houses is not done with proper precautions, their crops and livelihoods as organic farmers could be imperiled. Those pressing the suit claim that the agency contracted to do the work is in fact not following precautions and thus opening the potential to contaminate their crops. Let’s look at what is at stake.

In an overview of organic farming in Uganda, the International Trade Center explains that, “Uganda has the most developed sector of certified organic production in Africa. About 33,900 farmers manage 122,000 hectares of land using organic methods, an area that accounts for 1% of Uganda’s arable land (IFOAM & FiBL, 2006). Although still small and far below the increasing global demand, the country’s export of organic agricultural produce has been growing substantially in recent years. In Uganda, which has one of the lowest agro-chemical usages in Africa, the majority of farmers practice de facto organic agriculture without being certified yet (ACODE, 2006). Since no significant domestic market exists, certified organic agriculture targets mainly export markets in Europe and North America.”

In fact, the Monitor reported in 2007 that, “Organic farming has become a means of generating income for farmers and consequently fighting poverty.” Furthermore, “On the world market, Uganda’s export share of organic products has increased considerably and is the highest in Africa. The coordinator of Nogamu, Mr Moses Muwanga says 38 percent of organic agricultural production in Africa is from Uganda, with over 50,000 certified organic farmers. This makes Uganda one of the countries with the highest comparative advantage for organic production in Africa.”

Tiki-OneWorld.net takes us to an organic farm in Tororo District and with pictures and text concludes that a Tororo farmer could, “teach farmers in Europe or America a thing or two. His type of farming — sustainable and organic — produces lots of food and lots of varieties of food. And it doesn’t need huge tractors, diesel fuel, artificial fertilisers and chemical poisons. As I said earlier, nothing is wasted.”

The Kulika Charitable Trust Uganda “has set up a sh800 million agricultural training institute at Lutisi, 37km on the Kampala-Hoima highway,” (AllAfrica.com). In short, there have been major investments in capacity building for organic farming in Uganda. “The core of Kulika’s Community Development Programme is training of farmers in sustainable organic agriculture which focuses on experiential learning, practical work, on-farm experimentation and demonstrations to improve the skills of farmers (see photo from Kulika).”

The economic issue here may be confusing – a chicken and egg debate. Does malaria control promote economic development or does economic development strengthen societies to control malaria. Assuming it is the latter scenario, we need to think twice about interventions that will affect the livelihoods of thousands of Ugandan farmers, specially when alternative control measures are available.

WHO recognizes that, “When implementing IRS, it is critical to ensure that adequate regulatory control is in place to prevent unauthorized and un-recommended use of public health pesticides in agriculture, and thus contamination of agricultural products. Pesticide contamination can have serious ramifications for trade and commerce for countries exporting agricultural products.” The organic farmers in Uganda question whether adequate control is possible.

In light of the current world food crisis the BBC has re-examined the experiences of the Green Revolution. This high tech approach to increasing farm output appears on the surface to be a success in the Punjab of India. The BBC’s David Loyn reported on the experiences of one farmer: “Before Mr Singh’s father died young of cancer in 1992, none here suspected that the technology that had brought wealth to these farmlands in the 1970s might have a downside as well.”

Mr. Loyn looked more closely into the issue of the pesticides required by these crops. “The sprays all have instructions demanding that they should only be used with face masks and protective clothing. But the farm workers here do not use protective equipment, and they spray far more than the recommended amount. The cause of cancer is always a contentious issue, but a new study from the Punjabi University at Patiala ruled out other potential factors like age, alcohol intake and smoking, concluding that the way the sprays are used is causing cancer.”

Around a dozen insecticides are approved for use in Indoor Residual Spraying. WHO cautions that, “When implementing IRS, it is critical to ensure that adequate regulatory control is in place to prevent unauthorized and un-recommended use of public health pesticides.” Safety should be a major concern –

Another major consideration when selecting an insecticide is safety. Insecticides recommended by WHO are deemed safe for public health use under the recommended conditions of use. Concerns over the safety of DDT, a persistent organic pollutant, have also been comprehensively addressed in the framework of the Stockholm Convention on Persistent Organic Pollutants (POPs). The Convention bans the use of DDT, except for public health purposes. Therefore, DDT can be used for IRS where it is indicated, provided that stringent measures are taken to avoid its misuse and leakage outside public health.

In a comparison of the cost advantages of various insecticides that can be used for IRS, Walker (2000) emphasizes that safety measures must be included in the cost calculations. Even in the re-treatment of ITNs, WHO recommends that, “The use of rubber gloves is essential; mouth and nose masks should be worn when dipping large numbers of nets, especially with emulsifiable concentrate formulations.” The document also stresses that people who pack, mix and spray insecticides should also wear protective devices/clothing.

We hope that with proper care, supervision and protection of malaria workers, the community members they serve and the environment, we will see the history of today’s malaria control efforts written without the downside as experienced in the Green Revolution.

World Malaria Day is time for hope, and the United Nations Secretary-General, Ban Ki-moon, is not disappointing. The BBC reports that, “In a video message for a UN World Malaria Day event, the Secretary-General announces an initiative offering household sprays and bed nets treated with insecticide “to all people at risk, especially women and children in Africa” by the end of 2010.”

This is an almost unbelievable though desirable goal, much over the 80% RBM targets for 2010. The Secretary-General prefers to call this goal “bold, but achievable.” Even with help from GFATM, PMI, the World Bank Booster program, UNITAID and others, many countries are struggling to meet the 2005 target of 60% coverage of vulnerable populations with ITNs and medicines. The new UN malaria envoy, Ray Chambers has done the math –

• 500 million additional people
• 250 million additional ITNs/LLINs
• less than 1,000 days to achieve this
• “That’s four-to-five times what we’ve done in the past”

While this effort will push us toward eradication, Chambers is realistic in stating that the goal of complete elimination of the disease will depend on vaccine development, which is still some years away.

Reuters News also adds a note of realism by quoting a statement from the U.S. National Institutes of Health which said that malaria has proven to be “remarkably resilient, resurging because of the emergence of drug-resistant parasites and insecticide-resistant mosquitoes.” Reuters also mentions the unknowns created by global warming for consideration. These concerns add a sense of urgency that simple mentioning of 2010 may not confer.

Ironically, targeting these new malaria intervention and coverage goals comes on the heels of concern that African countries, where malaria is endemic, are unlikely to meet the Millennium Development Goals, which include malaria reduction. Clearly there are serious challenges in terms of finance and health systems issues to achieving universal overage in under 1,000 days – we hope all partners will heed this challenge on World Malaria Day and work together to meet it.

The VOICES website features a success story on corporate responsibility and contribution to malaria control in Ghana – the efforts by AngloGold Ashanti to organize state of the art indoor residual spraying in the district of Ghana where they have their mining operations.  The case study showed that from the start in early 2005 until near the end of 2006, hospital cases of malaria in the district droped by 50%.  Recent updates show continued progress as seen in the attached chart.

The IRS program in Obuasi district started its fifth round of bi-annual spraying in March 2008. Since the start of the program, major drops in clinic attendance for malaria have been seen. Some parasitological studies were done at baseline and once since the start, and showed a similar trend, but these surveys need to be done more regularly to provide definitive proof of the intervention’s effectiveness.

A recent report to Ghana’s National Malaria Coordinating Committee on the project showed 1) positive community acceptance, 2) wide use of a variety of education and information channels, 3) the addition of larviciding, and 4) the functioning of a Malaria Control Center that monitors activities, provides training and receives visitors from partners around the region. The project has created 128 jobs in the community. Other mining companies in the country are apparently considering a similar venture into corporate responsibility.

The Obuasi model is expensive relative to what typical government programs can afford, in part because ecological conditions require bi-annual spraying. The Malaria Center is an additional cost, but a valuable contribution to the national malaria control effort. The US President’s Malaria Initiative is in the process of building on the Obuasi experience and expanding IRS into five districts further north where once a year spraying will be appropriate and thereby test the feasibility of wider IRS use as part of the Ghana National Malaria Control Program.

Ghana had applied to the Global Fund for IRS activities in Round 7, but was unsuccessful. If IRS is going to be rolled out fully in the ecologically appropriate districts (at least 50), the levels of funding support possible from GFATM are needed. Hopefully partners will rally to ensure that Ghana is successful in its malaria proposal for Round 8.

A new report on the implementation of Indoor Residual Spraying (IRS) by the World Health Organization begins with the following ‘historical’ perspective: “In the 1950s and 1960s the WHO led malaria eradication campaign eliminated the risk of malaria infection for about 700 million people mainly in Europe, Asia and Latin America within a period of about 20 years using IRS as a major tool. In the 1980s, following the global consensus to replace malaria eradication campaign by a long term control program, use of IRS was significantly reduced. In Africa, the intervention was abandoned except in some countries in southern and eastern Africa where IRS remained the corner stone of the malaria control strategy.” The report goes on to expound on the return of IRS and its potential for success throughout Africa.

The above statement makes it sound like the world community just woke up one day and decided, “Let’s stop IRS”, with little reference to problems faced by famed Malaria Eradication Program (MEP). Fortunately Randall Packard has also recently published a book on the history of malaria that helps set the record straight on the MEP.

Technically the MEP was launched in 1955 and came to an official close in 1969, but even before it started, its main technical intervention, IRS with DDT, had already shown signs of mosquito resistance. A number of factors including low levels of economic development, poor health system infrastructure and donor fatigue led to the close of MEP. It truly was a daunting task given the limited tools and difficult environment in many countries.

Today there are more tools, but some are more expensive, e.g. ACT compared to chloroquine. There is also a greater choice of insecticides, though again, cost is a consideration. The new WHO report brushes on some of these challenges, especially the low levels of health system capacity in some of the most endemic countries. But as Packard points out these tools alone are not enough unless programs address the basic underlying social and economic factors that continue to ‘protect’ the persistence of this killer disease.

A press release yesterday announced that, “Research in Zanzibar, Tanzania has found a remarkable fall in the number of children dying from malaria. Within a three-year period (2002 to 2005), malaria deaths among the islands’ children dropped to a quarter of the previous level and overall child deaths to half.”

Zanzibar is an island, and that makes control of any disease special. Mabaso, Sharp and Lengeler conducted a historical review of malaria control in Africa and looked especially at IRS efforts between the 1940s and 1960s. They noted that, “IRS was not taken to scale in most endemic areas of the continent with the exception of southern Africa and some island countries such as Reunion, Mayotte, Zanzibar, Cape Verde and Sao Tome.” Malaria has returned to some of these islands, and the authors warn that IRS by itself is not a magic bullet.

A key feature of the effort in Zanzibar was the use of ACTs and LLINs together. These interventions have been supported by both the US President’s Malaria Initiative and the Global Fund to Fight AIDS, TB and Malaria, which has provided assistance for both treatment and LLINs specifically to Zanzibar in Rounds 1 and 4.

Progress on Bioku Island in Equatorial Guinea is happening, but not at the same rate as Zanzibar. Marathon Oil has helped with IRS and ExxonMobil with nets. Marathon reports that annual insecticide spraying campaigns started February 2004., and the program achieved “44% reduction of malaria parasites in children and 95% reduction in malaria transmitting mosquitoes.” Researchers have also documented “42% fewer infections occurring in 2006 compared with baseline (2004)” and reduction associated with recent house spraying or net use. They also stressed the need for comprehensive monitoring of coverage and correct use of IRS and ITNs, as there were variations in mosquito populations on the island.

Sao Tome also experienced a drop in malaria prevalence after a successful pilot ITN program. Currently Sao Tome is using GFATM money to implement a mixed method strategy and scale up free distribution of insecticide-bed nets, community-based management of malaria, provision of information, education and communication (IEC) about malaria, Intermittent Preventive Treatment (IPT), and artemisinin-based combination therapies (ACTs).

While disease control on an island may appear simple, the process is obviously a microcosm of the challenges faced on the mainland. Lessons from the eradication days show that one strategy alone may not yield long term results. Hopefully Zanzibar’s lessons of mixed approaches to malaria control will guide other national malaria control programs.