Tropical Health Matters

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?

The American Journal of Tropical Medicine and Hygiene published a unique article in its May 2007 issue that documents how the timing and number of malaria infections during pregnancy influences child birth weight outcomes in Burkina Faso. Infection after 6 months of pregnancy was the strongest factor associated with low birth weight (LBW), but LBW was also associated with infection in early pregnancy. The challenge in determining the latter is that women in the study, as is the case in much of Africa, tended to register for antenatal care later in pregnancy. Fortunately in this study one-third of the women enrolled had first attended ANC in the first trimester and could be followed longer. This helped provide information for another important finding, that LBW is also more likely when women are infected with malaria multiple times during pregnancy.

These findings highlight the challenges of reaching pregnant women in a timely manner with malaria prevention measures including insecticide treated nets (ITNs) and intermittent preventive therapy during pregnancy (IPTp). The authors note the value of a full course of IPTp in preventing LBW, but lament that there are currently no safe drugs to use for IPTp in the first trimester. An additional challenge is that many women register for ANC too late or attend too infrequently to benefit from at least two doses after quickening at one month apart.

This points to the need to ensure that all ANC clinics have ITNs to give women on their very first visit. For those who attend and are not yet eligible for IPTp, ITNs too, prevent LBW and will provide the protection for the early infections that lead to LBW. Then if a woman gets a net early in pregnancy, she will be less likely to suffer multiple malaria infections, another risk factor for LBW.

The challenge if one of policy versus logistics. Although most malaria endemic countries point to guidelines that say a pregnant should sleep under an ITN, few have figured out the logistics of guaranteeing a regular and dedicated supply of ITNs for ANC clinics. At present ITN distribution favors campaigns as opposed to integration into routine Maternal and Child Health services. While this may favor achieving large targets among children under five years of age, it usually bypasses pregnant women.

Last week a colleague at JHPIEGO suggested that all women of reproductive age should be given an ITN. This would certainly help keep them safe from malaria whenever they get pregnant. Are donors willing to take up this challenge?

Last year EM Kamau wrote about “the enormous potential that exists between (the HIV and the Malaria) initiatives that seek to address closely related issues and targeting the same populations at risk within a fairly well defined geographical setting”  in the African Journal of Health Sciences. These synergies are not always found in practice. The HIV/AIDS project of the Nigerian NGO Mothers’ Welfare Group targets orphans and/or children affected by HIV. They provide specialized VCT for children and young adolescents and medical care for opportunistic diseases such as malaria. Even though they are working in Kaduna State, which receives support from the Nigeria’s Global Fund Malaria grant, they have found difficulty in obtaining ACTs and ITNs for the vulnerable and HIV-infected children in their care.

The US President’s HIV/AIDS program, PEPFAR, does talk about the need to provide malaria services for people affected by HIV. “PEPFAR-supported interventions to optimize survival of HIV-exposed and -infected children include provision of basic preventive care, including support for infant and young child nutrition, immunizations and prevention of infections such as malaria, tuberculosis, and pneumonia. The pediatric preventive care package includes life-saving interventions, such as cotrimoxazole prophylaxis to prevent opportunistic infections, including diarrheal disease; screening for tuberculosis and malaria; prevention of malaria using long-lasting insecticide-treated mosquito nets; and support for nutrition and safe water.” Under PEPFAR pallitive care shoud include “Provision of the following drugs and commodities: cotrimoxazole; isoniazid; insecticide-treated bed nets; point-of-use water treatment and safe-water storage vessels; soap; and hand – washing instructions for HIV-exposed and -infected children.” PEPFAR even sets reportable indicators around malaria: “PEPFAR indicators for palative care include: Number of service outlets/programs providing malaria care and/or referral for HIVinfected clients (diagnosed or presumed) as part of general HIV-related palliative care. This number is a subset of the number of service outlets/programs providing general HIV-related palliative care.”

Conversely, the US President’s Malaria Initiative acknowledges the need to target PLWHAs as a vulnerable group in malaria prevention and control. As seen in the PMI country action plan for Uganda, “This will be achieved by reaching 85% coverage of the most vulnerable groups-children under five years of age, pregnant women, and people living with HIV/AIDS-with proven preventive and therapeutic interventions, including artemisinin-based combination therapies (ACTs), insecticide-treated nets (ITNs), intermittent preventive treatment (IPT) of pregnant women, and indoor residual spraying (IRS).”

PEPFAR and PMI program planners are consciously thinking about the synergistic possibilities in addressing malaria in HIV.  Other donor efforts and national disease control programs should collaborate more on these two crucial health problems.

A recent AFP report focuses on the village of Sauri near Lake Victoria in Kenya. Sauri is one of the first 12 Millennium Development Villages (MDVs) in Africa and has been making strides using an integrated development approach. The Millennium Development Goals (MDGs) focus broadly on improving income, food supply and education, enhancing women’s empowerment, improving health, reducing disease, protecting the environment and encouraging partnership in addressing all these issues. These goals are now being pursued by many nations, but are specifically being addressed in a total of 80 MDVs.

In Sauri both women and men are producing more on their farms after learning new techniques, are sending more of their children to school, and are able to feed themselves. These results are interrelated since improved farming improved diet and makes children more alert in school. School attendance and school performance ranking in the district have risen. To round out the development efforts a free clinic has opened and free ITNs have been distributed in the village. Villagers attribute better school attendance to reduced malaria burden in their children.

Villagers also raise the question about sustaining these achievements. They ask whether the government will maintain the improvements. Some talk of a slow weaning process of donor support for village improvements as a way to ensure the village can stand on its own. In the meantime more people are moving in as they see the benefits enjoyed by their neighbors.

Questions arise. Can we achieve MDGs one village at a time? Can economic improvements enable villagers themselves to maintain the improvements, e.g. through revolving funds to guarantee continued supplies of malaria drugs and nets? Can all the thousands of villages in Africa become MDVs?

According to the President’s Malaria Initiative (PMI), one in seven children under five years of age dies in Mozambique, and at least 20% of these deaths are caused by malaria. Brentlinger et al. report on a project that attempted to save these lives using ITNs in the central part of the country.  These nets were sold through local shops and community leaders, although the latter channel proved to be ineffective. By the end of the 2-year project ITN ownership was still low at 40% and even lower (20%) for a net treated within the past 6 months.  Ownership was positively associated with higher socio-economic class and urban residence.

PMI selected Mozambique for attention in mid-2006 and since then has contributed to a mass ITN re-treatment campaign, with a goal of re-treating approximately 500,000 nets, protecting up to 1 million people. Upcoming plans will use Long Lasting Insecticide-treated Nets (LLINs) distributed through Antenatal Clinics.  Hopefully lessons learned about the low coverage achieved from selling nets will inform future national and PMI efforts to ensure that nets reach the rural poor at little or no cost.

Ghana, like other countries in the region, is reported to be revising its national malaria strategy. Most countries developed a new strategy document around 2001, at the beginning of the Roll Back Malaria Partnership, that reflected the goals of achieving 60% coverage of the core interventions (ITNs, IPT and appropriate and timely case management).  This level was supposed to have been achieved by 2005, and then new targets of 80% coverage took effect for the 5-year period starting 2006.  Many changes occurred between 2001 and 2006 including the availability of artemisinin-based combination therapy (ACT), long-lasting insecticide treated nets (LLINs), and the re-emergence of indoor residual spraying (IRS).

Some shifts in policy have occurred, and it is natural for a new strategy to be developed to account for these. The Global Fund for Fighting AIDS, TB and Malaria (GFATM) noted that Ghana switched to ACTs, and now the country needs to embody this in their malaria strategy. Ghana was given permission to use artesunate-amodiaquine as its ACT rather than the pre-qualified drug artemether-lumefantrine.  Drug quality issues resulted in serious side effects that eroded the public trust. The Food and Drugs Board took action, and as the GFATM noted, the PR worked hard “to overcome the bad publicity around the launch of ACTs.” Therefore the new malaria strategy needs a strong health education component to overcome and remaining public skepticism about the intentions and quality of the national malaria control effort.

Another challenge of the new malaria strategy will be to prevent the diversion of nets into the private sector. This problem likely arose in part due to the fact that cost was a major issue that prohibited net ownership before the start of the GFATM grant.

Ghana is also considering IRS, which is possible now that Ghana has been designated a PMI country. The challenge with IRS is determining the appropriate insecticide because of varying resistance of vectors in different regions of the country.

Overall the biggest challenge in revising the malaria strategy is determining Ghana’s own national malaria control needs and then coordinating the input of donors to meet those needs rather than developing a strategy based solely on what the donors expect.

The Tropical Disease Research (TDR) program of UNDP/World Bank/WHO/UNICEF piloted Community Directed Intervention (CDI) for ivermectin distribution for onchocerciasis (river blindness) control in 1995, and found that it provided greater coverage than distribution efforts organized by only the health authority. With CDI communities made decisions when and how to collect their annual ivermectin supplies, about the preferred mode of distribution (house-to-house, central), and days when distribution would occur, and who would be their volunteer Community Directed Distributors (CDDs). This model was adopted by the African Program for Onchocerciasis Control (APOC) and has become possibly the largest community participatory disease control mechanism in Africa, and possibly the world, reaching millions residents in isolated villages who often rarely see the formal health service. While the health system provides training, supervision and commodities, it is the villagers themselves that organize their own ivermectin distribution.

Two years ago, TDR embarked on new research that tested whether other health interventions could be integrated within the CDI model. Thus, in selected districts in Cameroon, Nigeria, Tanzania and Uganda CDDs are also promoting home management of fever with antimalarials drugs, distributing insecticide treated nets, undertaking case detection for TB, and giving Vitamin A, in addition to annual ivermectin doses. One new intervention was introduced at each site in each of four trial districts, while the fifth serviced as control (offering only ivermectin as usual). A second intervention was added in year two. In the third and final year, all five interventions will be taking place in the four study districts at each site. Effort was made to ensure that the district health departments had supplies of all commodities, but only in the intervention districts were the commodities made available through the CDI approach.

The research teams recently completed a data analysis workshop on progress made by year two. ITN ownership, net use and timely and appropriate home management of malaria episodes in children under five years of age showed significant progress over baseline and compared with the control areas where only ivermectin distribution was provided through the CDI approach.

The key lesson is that even though malaria commodities are supplied to district health services, they do not always reach people unless the community is involved. Some countries are including community volunteers in their malaria strategy, such as Role Model Mothers in Nigeria. We hope that with the preliminary results of TDR’s CDI study, more countries will take seriously the need to get communities actively involved in their own malaria control efforts.

The Global Fund to Fight AIDS, TB and Malaria (GFATM) has delivered more than 18 million insecticide-treated bed nets as of December 2006. In Malawi alone, UNICEF reports nearly 4 million nets distributed since 2002 from various sources. During a campaign in May 2006, 2 million nets were distributed in Niger through IFRC, CIDA and GFATM support. It is hard to know exactly how many ITNs/LLINs have been distributed in Africa, but in any given year nearly 50 million children under five years of age and pregnant women need protection from malaria.

But is counting nets distributed the right approach? The ultimate test is whether those for whom the nets are intended actually sleep under them.  One of the most crucial problems facing Global Fund grantees is monitoring and evaluation, not only of nets purchased, but generally keeping track of malaria interventions in their countries.  Integrated and functional national health management information systems are rare.

Monitoring is possible though, and on the positive side the President’s Malaria Initiative reported that in early 2006, PMI and the Global Fund distributed more than 230,000 ITNs in Zanzibar, which subsequently saw a dramatic decrease in reported malaria cases and quicker recovery for those infected. According to PMI, the number of confirmed malaria cases on Pemba Island dropped 87% from January to September in 2006.

On the negative side, not long after the net campaign in Niger, the LLINs distributed began appearing for sale in the markets of Kano, Nigeria, just to the south. In addition social research in Ghana and Nigeria revealed that communities often believe that working adults, particularly males, are more vulnerable to malaria, more severely affected and thus, more in need of nets. These perceptions threaten net access within households.

Two key issues must be addressed to ensure bednets reach the intended beneficiaries. First is donor coordination, and second is community education and follow through. Many groups are getting on the malaria bandwagon these days. The newly formed “Malaria No More” featured prominently at the White House Malaria Summit from where it solicited donations for bednets. A visit to its website shows that fortunately MNM is not going it alone, but will be working through UNICEF and IFRC, which already have the infrastructure in endemic countries to get nets to those in need.  Similarly JICA channels most of its net donations through UNICEF.  These efforts help get nets into endemic countries in a coordinated fashion. Likewise on the ground, coordination is needed among the various players. Reports from Zambia, Malawi and Tanzania show that events such as national Child Health Weeks provide an opportunity for all partners to work together to provide nets.

The second issue, education and follow through, links directly with the need for accountability in achieving Roll Back Malaria usage or coverage indicators, which now aim for 80% of vulnerable groups sleeping under nets by 2010.  IFRC provides a toolkit (worksheet) for local chapters involved in net distribution that includes key messages about malaria and nets as well as directives on the need to demonstrate appropriate use to community members. The toolkit guides volunteers to monitor net use and report results.  Recently we reported here that using community-directed intervention with local volunteers produces substantially better net acquisition and use than typical health department distribution efforts. Local volunteers selected by the community are better able to communicate and monitor health interventions because they live with the people and understand culturally appropriate ways to communicate health information including issues of vulnerability to malaria.

Recently the Executive Director of Church World Service addressed the intentions of governments and donors by noting that, “For those children who suffer the ravages of malaria, promises that come and go mean absolutely nothing, only action makes a difference.” Hopefully by this time next year we are not counting promises to distribute nets ¾ or not even counting nets distributed ¾ but counting the number of children and pregnant women actually sleeping under those nets and lives saved.