Tropical Health Matters

The New Vision (Kampala) reported on Sunday the abuse of a free ITN program in Tororo, Uganda. Not only was the paper concerned that, “The fight against malaria in Tororo district is facing setbacks as residents use mosquito nets, which are intended to control the spread of the disease, to make wedding gowns.” They were also appalled that members of the local council, “cannot support voluntary programs if there is no kitu kidogo (bribe).” Concern even extended to the health workers who manage the project and who were warned not to “use the project’s bicycle or motorcycle to take your wife or children for leisure rides.” This raises the age old question of whether people appreciate things they receive for free.

In contrast, Noor et al., in PLoS Medicine make the case for free distribution of nets as not only being pro-poor (equitable) but also effective in increasing coverage in neighboring Kenya. Their conclusions are in keeping with WHO’s Global Malaria Program in a recent position paper stated its preference for net distribution as follows:

“In most high-burden countries, ITN coverage is still below agreed targets. The best opportunity for rapidly scaling-up malaria prevention is the free or highly subsidized distribution of LLINs through existing public health services (both routine and campaigns). LLINs should be considered a public good for populations living in malaria-endemic areas. Distribution of LLINs should be systematically accompanied by provision of information on how to hang, use and maintain them properly.”

The Tororo experience contrasts with expectations in Benin Republic according to Aplogan and Ahanhanzo (Bull Soc Pathol Exot. 2007; 100(3): 216-7) where, “The major expectations of the households are supply of impregnated bed nets free of charge.” The key to successful ITN distribution and utilization rests on thorough community involvement, demand creation and culturally appropriate health education.

Providing an insecticide treated bednet (ITNs) for all pregnant women as early in pregnancy as possible is a key malaria control strategy that not only protects the woman from malaria but improves birth outcomes and child survival. Ideally ITNs for pregnant women should be a routine service provided through antenatal care (ANC) since in many countries over 80% of pregnant women attend ANC at least once.

A major problem in achieving this goal is that in many malaria endemic communities, pregnant women who do attend ANC do not register until well into their third trimester after many months of exposure to malaria transmitting mosquitoes. At the same time, campaigns to distribute ITNs in the community usually target children under 5 years of age, not pregnant women.

A number of social and cultural factors explain poor access and timely acquisition of ITNs by pregnant women. In some cases pregnancy is considered normal and thus there is no need to register early for ANC. Pregnant and unmarried teens,who are among the most vulnerable to the effects of malaria in pregnancy (MIP), are often embarrassed to register and thus make their pregnancy publicly known.[1,2] ANC requires payments in some countries, and even when free, attendance at ANC has indirect economic costs when women miss work.

Poor service quality is another issue that keeps many women from attending ANC early or often. Finally a cultural issue that has been documented in many countries, is the reluctance of revealing one is pregnant until ‘it shows’ due to fears that jealous or evil people may curse or damage the pregnancy.[3-6]

One solution to this problem of ensuring that pregnant women get and sleep under ITNs is to give all women of reproductive age an ITN. This would make access easier and would also avoid any embarrassments or cultural fears that would come from singling out a pregnant women for a net. The Global Fund has created the capacity to distribute ITNs to over 30 million people by mid-2007. This ITN capacity should be extended to include all women.

References:

1. Sow F. To be a woman in Africa. On the danger of being a mother. Mortality [Article in French] Vivre Autrement. 1994 Oct:13-4.
2. Magadi MA, Agwanda AO, Obare FO. A comparative analysis of the use of maternal health services between teenagers and older mothers in sub-Saharan Africa: evidence from Demographic and Health Surveys (DHS). Soc Sci Med. 2007; 64(6): 1311-25.
3. Ndiaye P, Dia AT, Diedgiou A, Dieye EH, Dione DA. Socio-cultural determinants of the lateness of the first prenatal consultation in a health district in Senegal [Article in French] Sante Publique. 2005; 17(4):531-8.
4. Morse JM. Cultural variation in behavioral response to parturition: childbirth in Fiji. Med Anthropol. 1989; 12(1): 35-54.
5. Beninguisse G, De Brouwere V.Tradition and modernity in Cameroon: the confrontation between social demand and biomedical logics of health services. Afr J Reprod Health. 2004; 8(3): 152-75.
6. Chapman RR.Chikotsa–secrets, silence, and hiding: social risk and reproductive vulnerability in central Mozambique. Med Anthropol Q. 2006; 20(4): 487-515.

Last year we reported on the second year results of the UNICEF/UNDP/World Bank/WHO Tropical Disease Research (TDR) Program’s Community Directed Intervention (CDI) Multi-Country study. CDI was originally developed for annual distribution of ivermectin as part of the African Program for Onchocerciasis Control. The current study tested whether the community and the volunteer distributors selected by the community could manage additional health interventions. Included in the trial were ITNs for children and pregnant women, home management of malaria with Coartem, Vitamin A and TB case detection.

At the end of the second year of the study “Malaria home management coverage doubled, Bednet coverage doubled to quadrupled, Vitamin A coverage was significantly higher, and TB case detection rate doubled.” One of the seven research team leaders, Richard Ndyomugyenyi of Uganda, explained that, “… if we involve them (the community) as stakeholders right from the beginning, and they are following up what you are doing, it becomes easy for them to implement, because those results would also be theirs.”

Richard further noted that, “The main reason this works seems to be that this process [CDI] empowers the communities to own the process and the programme. So they actively participate in deciding how these interventions should be delivered – so they take an interest in their own program, and it increases coverage”

According to Elizabeth Elhassan, the team leader from Kaduna, Nigeria, “Once you empower people, and they realise it is for their own benefit, it becomes a priority for the communities.” Of course community participation must be coupled with availability of commodities. “The study went well, particularly in 2006 as we had a reasonable supply of materials: nets, antimalarials, and vitamin A, to both the study and the comparison arms,” Elizabeth told RealHealthNews.

The seven teams from Nigeria, Cameroon and Uganda just completed their third year and final data analysis last week in Douala.  Interventions were added to the existing ivermectin distribution each year to observe how communities could handle the extra responsibilities. In control arms normal ivermectin distribution occurred but the other interventions were provided to the district health authorities to distribute through their ‘normal’ channels. The CDI process used in the research is described on the TDR website where a short video clip from the team that worked in Taraba State, Nigeria can be found.
The accompanying graphs show that the results have maintained a positive direction.  The study arms that received the malaria interventions by the second year had higher coverage than those in the other two arms in year two and by the third year those who had received the interventions in either year did better than the control districts/arms.  ITN coverage for pregnant women and home management of malaria showed the best results.  The improvements in ITN coverage for children were still below RBM targets, and qualitative results indicated that better follow-up by the volunteer distributors in reminding people to use the nets is needed.

Clearly the community directed participatory approach can help get basic health commodities to people living in remote and rural areas. Qualitative results found that the malaria interventions were particularly successful because communities see malaria as a serious problem that affects everybody.

The research teams are now planning advocacy meetings with policy makers in their countries, while TDR staff are sharing the results internationally to encourage other countries and donors to adopt the CDI approach.

The 2006 Demographic and Health Survey report for Uganda is now available. It was possible to compare the malaria indicators with the survey done in 2000-01. Some progress can be seen in the attached picture. The definition of the indicators is somewhat different between the two periods. For example IPTp did not begin as a national policy/program until 2002, so the comparison indicator in 2000 was the proportion of women who received antimalarial prophylaxis at Antenatal Clinic. Likewise, distinctions between types of nets were not reported for all users in 2000.

While there have been increases in all the indicators, none reached the 2005 RBM targets of 60%. Uganda has been fortunate to receive donor support for its malaria efforts. Uganda’s $23m Round 2 Global Fund Grant started in 2004, and by September 2006 over 91% of the funds had been disbursed. The final grant progress report (2006) indicates that 15% of children under 5 years had slept under an ITN the night before, compared to 9.7% in the 2006 DHS. The progress report shows that 35% of pregnant women had received IPTp2 compared to 16.2% in the DHS. The Global Fund Round 4 Grant in Uganda focused primarily on treatment with ACTs.

Uganda is also fortunate to be one of the first recipients of the US President’s Malaria Initiative. PMI selected Uganda in part because it envisioned potential synergies and scale ups because of the presence of GFATM efforts. Now that RBM targets are 80%, it is incumbent on Uganda to make the most of this multiple donor funding achieve better and faster results while the opportunity exists.

We are lucky that there are various monitoring tools like the DHS to compare reported achievements from progress reports to donors. Other countries should take similar advantage of such tools in order to monitor and improve their malaria control performance.

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.

The US Embassy in Tanzania has announced a donation of about 50 insecticide-treated nets to HIV/AIDS orphans. While this is a relatively small effort, it sets a good example for possible synergies between HIV and Malaria programming and funding.

The attached map from WHO shows the geographical overlap of the two diseases. According to WHO’s Global Malaria Program, “The resulting co-infection and interaction between the two diseases have major public health implications.

• HIV-infected people must be considered particularly vulnerable to malaria;
• Antenatal care needs to address both diseases and their interactions;
• Where both diseases occur, more attention must be given to specific diagnosis for febrile patients.”

It is important therefore that ITNs are not only given to orphans, but all HIV infected people, particularly pregnant women. Malaria enhances transmission of HIV to the child, and therefore ITNs are an important component of PMTCT. Therefore, all donor programs that have both malaria and HIV components need to plan together to serve those in need and not think only in vertical control paradigms.

PS – Thanks for your support and interest. This is our 100th malaria blog.

UNICEF has just announced the results of surveys that show a major reduction in child mortality between 1990 and 2006. While it appears that immunization programs have contributed the most to this progress, the role of increased malaria intervention is important. According to UNICEF malaria currently accounts for 8% of child deaths worldwide, and to date insecticide treated nets have made the main contribution to mortality reduction. For example at present over 50% of households own at least one ITN in Malawi.Treatment is also becoming an important component, and since the start of the Global Fund to Fight AIDS, TB and Malaria and other partnership efforts is recognized. For example, to date the GFATM has helped to…

• finance 109 million bed nets to protect families from transmission of malaria, thus becoming the largest financier of insecticide-treated bed nets in the world
• deliver 264 million artemisinin-based combination drug treatments for resistant malaria

Dr. Robert Black of the Johns Hopkins Bloomberg School of Public Health stressed the importance of recognizing regional differences in tackling the challenge of reducing child mortality in the Washington Post. For example pneumonia remains a major force in South Asia, while Malaria is more of a threat to children in sub-Saharan Africa.

As seen in the attached chart from UNICEF at BBC News, child morbidity rates worldwide dropped from 55/1000 live births to 27 between 1990 ans 2006. It is in sub-Saharan Africa where the challenge of child mortality is the highest and where over half of child deaths occur. Malawi, for example, saw a fall in under-five mortality of 29 per cent between 2000 and 2004, and there were reductions of more than 20 per cent in Ethiopia, Mozambique, Namibia, Niger, Rwanda and Tanzania. So, while there were reductions in countries surveyed sub-Saharan Africa the problem remains unacceptably high.

We have addressed the issues of financing, partnership and political commitment before, but these are what it takes to solve the malaria problem. These somewhat hopeful results from UNICEF provide a further opportunity to encourage all partners take all actions needed to remove malaria from the list of major child killers in Africa.

Thursday the 16^th of August 2007 marked a dual launching of two related malaria documents in Nairobi. WHO released its new guidance on insecticide-treated bed nets, and the Ministry of Health (MOH) in Kenya shared its impact report on malaria control interventions. Both stressed the importance of mass distribution of free Long Lasting Insecticidal Nets to achieve coverage of vulnerable populations. WHO explained that Kenyan evidence on net distribution modalities and improvements in malaria morbidity and mortality reinforced the need eventually to cover the entire population in endemic areas to achieve maximum health and economic benefits.

The Washington Post reported that the WHO guidance may put to rest the argument between proponents of free nets and those who believe that, “people who spend their own money on them are more likely to value them and use them properly.” Both documents indicated that equity in reaching the poorest portion of the population was best achieved by providing free nets, but that highly subsidized nets through clinic voucher programs and social marketing may play some role in improving access to LLINs in the poorer segment of society.

Data from the Kenya document seen in the attached picture show that over the past three years the gap between the higher and lower income quintiles of the population has been narrowing. This is an indication of how malaria control can contribute the goal of reducing health inequalities enshrined in Kenya’s National Health Sector Strategic Plan for 2005-10.

WHO also commended Kenya for implementing its national malaria strategy through a broad based international partnerships including DfID, UNICEF, USAID, GFATM, WHO and the Wellcome Trust among others. As the Times reported, donor funding helped make it possible for Kenya to give free nets.

The Kenyan MOH reported that the donor partnership has made one-quarter of a million US dollars available for malaria control since 2002. This amount should be viewed in the light of estimated budgetary needs of US $105 million for the current year alone. The fight against malaria in Kenya requires not only continued donor support, but also greater Kenyan government contributions and wise management of donor support to achieve the greatest health and equity impacts.

A malaria control curiosity appeared in the news this past week – vaporized lighting. The concept seems simple enough – using the heat of a light bulb to vaporize and disperse insecticides. While we encourage multiple vector control efforts, the feasibility of finding functioning light bulbs among the must vulnerable populations gives pause to the quest for ever more clever mosquito control innovations.

In contrast Jeffrey Sachs and colleagues draw us back to the basics by asking whether we can get insecticide treated nets to everyone and make a real impact on malaria. He stresses the importance of long lasting insecticide-treated nets (LLINs) as both an individual and a community protection intervention. What is unique in Sach’s call for action is asking donors to get serious about providing nets for ALL people in endemic communities, not just children, not just pregnant women, not just those who can afford subsidized socially marketed nets. This gets at the heart of the supply and demand problem. As long as there are inadequate nets to cover the whole population (and working adults also need nets to prevent malaria and increase their economic productivity) then there will always be loss and leakage from the supplies intended to serve the most vulnerable.

The practicalities of getting nets out to all is addressed by Grabowsky et al. (2007) who examine a dual approach of using both campaigns and routine health services as complimentary methods for net distribution. In this way malaria control programs can both ‘catch-up’ and ‘keep-up’ with need.

Finally Charles Griffin of the Brookings Institute calls on donors, large and small, as well as national malaria control programs to take the long term view to preventing malaria. He calls on donors and governments not only to make a long term commitment to sustain efforts but at the same time to strengthen the ability for local industry to produce and sustain supplies for malaria commodities and to enhance the role of the private sector in protecting its workforce.

the foregoing ideas require an unprecedented level of donor-government-private sector collaboration – but without such cooperation we will not achieve nets for all.

Debate has gone back and forth as to whether malaria is a serious urban health problem or not. This issue itself is important to consider since the world’s population continues to urbanize, making it very necessary to understand the nature of urban health problems for better planning.

The key issue is the anopheles mosquito, which likes relatively clean collections of water, like puddles, exposed to sunlight. The crowding and pollution characteristic of urban areas does not favor anopheles mosquitoes, and yet studies continue to document some degree of malaria prevalence in urban communities of endemic countries.

Lagos, Nigeria represents anopheles scarcity. As far back as 1946 Muirhead Thomson observed an inhospitable environment for the breeding of anopheles. USAID partners revisited three neighborhoods in Lagos in 1998 and found malaria parasites in only 0.9% of over 900 children between 6 and 60 months of age. A. gambiae mosquitoes were not found in knockdown and human baiting studies, and a larval breeding density of only 0.3 was detected. The predominant mosquitoes were culex. Ironically in these neighborhoods, local shops were selling over US$ 3,000 per week in antimalarial drugs. Residents still perceived that they had ‘malaria’ and expressed similar cultural beliefs and perceptions as the outlying rural communities from where they had emigrated.

Clearly some level of malaria prevalence in the cities arises from traveling back and forth between rural and urban areas for economic and social obligations, for example the traders who travel back and forth guaranteeing food supplies for the cities. Urban health services therefore do need some stocks of antimalarial drugs to treat people coming in from the rural areas who are incubating a malaria infection.

A more complex issue is the nature and extent of urban malaria transmission. A recent study in Ghana found that malaria in urban areas displayed a heterogeneity and complexity that differed from the rural environment. Marked intra-city variation indicated the need for targeting specific areas, especially neighborhoods of the urban poor. A major contributory factor to malaria prevalence in many cities is urban agriculture, an informal economic activity of the urban poor.

Urban areas present a special challenge for ITN distribution. Epidemiological and entomological studies are recommended to map each city to determine target areas, and yet such targeting may be seen as discrimination by the general population who do not distinguish among types of mosquitoes and febrile illnesses. It may be politically necessary to provide ITNs in all poor neighborhoods regardless of mosquito ecology. In the area of treatment, health providers can be a bit more focused through using laboratory or rapid diagnostic tests to reduce inappropriate use of expensive antimalarials. As cities grow, are urban planners and health policy makers ready for the problem of urban malaria?