Tropical Health Matters

AK Adeneye, PO Ossai and TS Awolola are sharing with us a pilot study they conducted based from the Nigerian Institute of Medical Research in Yaba, Lagos.

With two years to the MDGs deadline, there is limited evidence of decreases in malaria-related mortality and morbidity in Nigeria. We therefore wanted to evaluate the awareness, accessibility and use of malaria control interventions among at-risk groups in Lagos State, Nigeria.

Lagos State Ministry of Health http://www.lsmoh.com/news/lagos-treats-300-for-malaria#.UmlR9RAQ5aw

In planning for a broader assessment we conducted a descriptive, cross-sectional pilot study of 80 consenting pregnant women and mothers of children below five years of age. It was carried out using a household survey questionnaire and observation in Ikotun and Ketu communities of Lagos State

All respondents identified mosquito as the malaria vector. Respondents’ preferred drugs for malaria treatment were as follows: sulphadoxine-pyrimethamine (31.3%); ACTs (20.2%); artemisinin monotherapies (15.0%); chloroquine (13.8); and analgesics (12.5%). Only (30.0%) had used ACTs, and 55.0% of these had practiced self-medication.

Nearly all knew of and had LLINs. From room observation, only 53.8% (31.5% mothers of under-five vs. 11.3% pregnant women) actually hung the LLINs. Reasons for non-use of LLIN included: “prefer house spraying” (28.8%) and “causes heat” (7.5%).

LLIN use was positively associated with education (p<0.05), ranging from 50.0% (no education) to 77.8% (post-secondary). Only 41.8% got their LLINs through house-to-house mass distribution. Women averaged washing their nets 3 times within an average of 21.7 months of use.

LLIN washing practices showed that 30.5% used toilet soaps compared to detergents and hard soaps (66.7%). Unfortunately, 19.4% sun dried their nets.

While 52.6% of the pregnant women were aware of IPTp, 42.1% actually had received at least one dose.

Results of this pilot showed high awareness but low and poor use of malaria control interventions in populations studied. A wider survey in the near future will inform public health education on the different malaria control interventions that need to be intensified among the women so they can benefit from improved pregnancy and child health outcomes. This is important if the malaria-related MDG targets are to be realized in Lagos and in Nigeria in general.

Smita Das and Douglas E Norris of the Johns Hopkins Bloomberg School of Public Health Department of Molecular Microbiology and Immunology and Johns Hopkins Malaria Research Institute have written our guest blog posting based on a poster they presented at the recent JHU Global Health Day.

As part of the International Centers of Excellence in Malaria Research (ICEMR) in Southern Africa project, mosquito collections are being conducted in Nchelenge District in Luapula Province, Zambia. Nchelenge experiences hyperendemic malaria despite continued implementation of indoor residual spraying (IRS) and long-lasting insecticide nets (LLINs) as control measures.

Center for Disease Control light trap (CDC LT) and pyrethroid spray catch (PSC) collections performed during the wet season in April 2012 revealed the presence of both Anopheles gambiae s.s. and An. funestus s.s. Both species were highly anthropophilic and the Plasmodium falciparum sporozoite infection rate in An. funestus was higher compared to An. gambiae.

In the dry season collections, An. funestus continued to be the dominant species with even fewer An. gambiae caught compared to the wet season.  Due to the abundance of An. funestus and high human malaria infection rates in Nchelenge, it is predicted that the human blood index and entomological inoculation rate for An. funestus is higher than that of An. gambiae in both seasons.

The multiple blood feeding behavior and insecticide resistance status of both malaria vectors will also be explored as this can give us an idea of estimating the transmission potential of these mosquitoes. The vector data in Nchelenge present unique opportunities to further our understanding of malaria transmission and the implications for malaria control in high-risk areas.

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.

A photo contest sponsored by the Swiss Malaria Group has stirred some controversy among colleagues. One photo shows a conical net suspended from a tree branch and covering a chicken on the ground, with rocks placed around the edges to ensure the chicken does not escape. The question arising is whether such photos do disservice to malaria control programs and discourage donors, when in fact the net pictured is most likely an old one being re-purposed. Fortunately only a few of the 712 photo entries depict this situation.

There are worries that such photos are fodder for untrained or unscrupulous journalists to derail malaria control campaigns.  In fact most of the material on net misuse is anecdotal and found in the press and on the web.  A quick search on PubMed found very few articles that directly addressed the problem. There is more on non-use than misuse.

One well known article appeared in Malaria Journal in 2008 and even had pictures of nets spread on the shored of Lake Victoria as platforms for drying fishing catches. The authors reported that, “The most popular reasons were because the bed nets were inexpensive or free and because fish dried faster on the nets.” They also noted that excess nets had been distributed in the area due to lack of planning and coordination among agencies.

Another article about nets after a major state-wide campaign in Rivers State Nigeria had misuse in its title.  All houses in the villages had nets after the campaign, but only 72% had any hanging at the time of the survey.  Twenty percent of these were hung as window curtains (which is in fact another legitimate, though in this care unintended use of insecticide treated materials). Only 38% of children below five years of age had actually slept under a net the night before the survey. In this case non-use was more of an issue that misuse.

The third article dealing with the concept of misuse appeared in PLoS Medicine in 2011.  The authors faulted the one article they found in peer reviewed publications (the Lake Victoria study mentioned above) for methodological reasons. The authors conclude that, “Inaccurate news stories of widespread ITN misuse should be rebuked directly through the dissemination of empirical data contradicting anecdotal reports and in rebuttal editorials in newspapers and journals.”

Yes, there does need to be better systematic documentation to determine the extent to which new nets are misused and old nets are re-purposed in communities (or even a combination of practices).  Unfortunately we do have pictorial evidence from the field not long after the 2010 mass distribution of LLINs in Akwa Ibom State where we also had a malaria in pregnancy control program in several local government areas.

The two photos shown here were taken a few months after the campaign and showed clear signs of misuse. This was not a question of re-purposing old nets, since hardly any existed prior to the campaign, and again the staff inspected these directly. In addition to the uses seen here we found new nets being used to cover vegetables to keep off insects as well as used in making goat pens.

Our project in Akwa Ibom had trained volunteer community health workers (CHWs) to provide malaria in pregnancy control services, and they were directly involved in the larger net distribution campaign. These misuse problems were not found in the communities with CHWs.  The clear lesson to us is that mass distribution without clear follow-up plans in place will result in both non-use and misuse of nets.

Unless donors demand that local health authorities build in a community follow-up component to net distribution, they will indeed be wasting their funds. In the meantime we need to be vigilant and carefully document whether nets in strange places are in fact misused new nets or re-purposed old nets. Re-purposing has an important role to play since safe disposal of old nets is a major environmental concern.

In 1998 Fred Binka and colleagues published an article that showed the value of living near someone with an insecticide treated net (ITNs), even if you did not have your own net. They documented a 6.7% increase in likelihood of malaria mortality in children for each 100 meter shift away from a house with ITNs the non-user was located.

Then Otten et al. looked at the effects of a short campaign in 2006 to distribute ITNs to children during immunization campaigns and ACTs through CHWs in Rwanda. Eight months later 60% ITN coverage was documented. The interventions resulted in a greater than 50% decline in inpatient malaria cases and outpatient laboratory confirmed malaria cases among children even with less than optimal intervention coverage.

Now, these hints of success in net use have been modeled mathematically to achieve a more realistic target for net coverage instead of relying solely on arbitrary estimates like 80% or 85%. Agusto and colleagues have published their findings which propose that, “If 75% of the population were to use bed-nets, malaria could be eliminated.”

“We conclude that more data on the impact of human and mosquito behavior on malaria spread (are) needed to develop more realistic models and better predictions.”  Of particular concern is learning more about how human handling and mishandling of nets affect these estimates.

So what progress toward this potential target of 75% have we made? The attached chart was derived recent from Malaria Indicator and Demographic and Health Surveys.  Except for the preliminary results of the Tanzania survey, most countries were not even close to the RBM target of 80% coverage for 2010, let alone a slightly more modest 75%. A frustrating trend is the fact that even in households that posses at least one net, children are not sleeping under them.

Now that we have more realistic targets, planning should be easier. Even so after all the push towards universal coverage since 2009, we still have a long way to go to reach targets, let alone talk of elimination.

Elizabeth Kubo has written this guest blog posting that originally appeared in SBFPHC Policy and Advocacy.

Malaria is a leading cause of morbidity and mortality in many developing countries, where children and pregnant women are the most vulnerable groups. In Kenya, the disease is responsible for 34,000 under five child deaths annually. About 70% of Kenya’s total population is at risk for malaria.

With funding predominantly from international donors and development partners, the country has adopted and implemented multiple malaria control strategies, resulting in a remarkable decline in the national all-cause under 5 mortality. Despite the gains, a slight downward trend was noted in the proportion of households with at least one insecticide treated net (ITN), the proportion of children under five years old who slept under an ITN, and the proportion of pregnant women who slept under an ITN between 2008 and 2010.

The Global Fund for AIDS, Tuberculosis and Malaria, the Department for International Development (DfID), and the US President’s Malaria Initiative have confirmed funding for the 2013 implementation period, but this falls short of the expected need. Despite repeatedly reiterating its commitment to the fight against malaria, the Kenyan government has previously played a minor role in financing the control efforts.

There is an urgent need to intensify scale-up of targeted interventions in order to reverse the downward trend and attain universal targets. It is possible to close the funding gap through greater in-country resource mobilization. Government commitment to malaria control needs to be reflected in ministry of health budgetary allocations. Civil society organizations also have a role to play. It is possible to have a malaria free Kenya.

Preliminary results of the Tanzania indicator survey for HIV and Malaria have been released. This makes it possible to track over time some of the basic indicators for success in malaria programming using various Demographic and Health as well as Malaria Indicator Surveys.  The trends recall concerns of more than a decade ago when USAID organized the Malaria Action Coalition to address the relative ‘neglect’ in malaria case management and malaria in pregnancy program components.  At least in Tanzania, ten years on, the problem persists.

We can see clear progress in insecticide treated net use by vulnerable populations over time. The push for universal coverage since 2009 seems to have paid off in Tanzania.  We hope this victory is sustainable, but more and more we are receiving reports that the duration of the long lasting aspect of LLINs is far from the hoped for 5 years.  Eighteen months is more realistic.

So after a major campaign to achieve the targets seen in the attached figure we have to ask whether Tanzania is positioned to do massive replacement, either through routine services like immunization programs and antenatal care, over the next several years.

A depressing finding is the last of progress in intermittent preventive treatment for pregnant women as seen below.

• 2008 – 30%
• 2010 – 26%
• 2012 – 32%

Reports over the years have singled out procurement and supply problems arising after Tanzania switched from sulphadoxine-pyrimethamin (SP) to ACTs as its first line antimalarial drug. SP fell off the radar in many places.  One wonders also what this says about Tanzania’s overall commitment to maternal health.

Case management is similarly in the doldrums. This is ironic because Tanzania was one of the beneficiaries of the Affordable Medicines Facility malaria (AMFm) pilot effort that was generally credited with enhancing access to quality malaria drugs.  Tanzania has also pioneered an accredited drug outlet program aimed at upgrading the quality of the typical patent medicine shop.

As is often the case, much soul searching is needed to look at the health systems – especially those delivering child health and maternal health services – to find the bottlenecks to this problem.  Neighboring countries like Rwanda that want to move toward pre-elimination will find it difficult if their neighbors fall behind in implementing the basic malaria interventions.

Recently Matt Lynch of the Johns Hopkins Center for Communications Programs and the USAID NetWorks Project was asked about the challenges of disposing old ITNs. His response has been shared on Malaria Update, but we thought readers on Malaria Matters, who are not Update subscribers, could also learn from Matt’s Ideas. Matt urges that each country and community needs to find its own economic and ecological solutions as seen below.

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I would urge a careful look at all the options (including leaving the nets in the households) before leaping into actions which may end up with worse consequences than no action at all.

Much that I have heard on this topic begins with the assumption that nets must be collected – this is not necessarily true, and no one has been able to adequately describe to me exactly what the problem of leaving the used nets for households to re-purpose might be.  They are, on the other hand, very ready to describe the massive costs associated with collecting the nets, and the problems which will follow from concentrating enough old nets in one spot to actually have insecticide and plastic concentrations which do become quantifiable problems.

As far as I can tell from asking the manufacturers, most pyrethroids decay when exposed to UV light, and are broken down by soil bacteria.  This is why pyrethroids are so popular in agriculture – they don’t persist in the environment.  They are apparently quite toxic to fish, so that’s worth exploring in the island environments.  Dumping them into the sea is probably not a great idea.

In Africa, one frequently sees old, holed nets being used to cover plants, chicken coops, or to screen windows.  Such uses, as far as I can tell, do no harm and probably some good (who knows, the residual insecticide may help control chicken mites?).  In addition, they provide an opportunity for the UV light and soil bacteria to begin breaking down the insecticides.

One might expect polyethylene nets to pose more of a problem in terms of solid waste, but I have not seen any reports of drains being blocked by old bednets (plastic bags, frequently!).  Polyester nets are even more difficult to imagine as a serious solid waste problem – after all, there were millions of pretty toxic-looking polyester leisure suits sold in Africa through the 1980’s and no one seems concerned about their disposal…

So, I don’t mean to trivialize the issue;  I think we need a clear description of precisely what the problem is with letting households dispose of their worn-out nets through their usual practices.  There may well be harmful disposal practices that need to be addressed, but I do think we need a clear description of the problem before we rush into complicated, expensive and potentially hazardous “solutions”.   I personally doubt the optimal solution will be to collect the nets.

When we think about safety matters and insecticide treated bednets our first thoughts often go to the chemicals.  As Jamali has observed, “Pyrethroids form the mainstay of preventive measures due to their efficacy and safety in mammals.” Barlow and colleagues pointed out some time ago that while deltamethrin may have some dermal effects, the rick was much lower than the benefit.

More recently there has been concern expressed about health and environmental implications of disposing or re-purposing old nets. One approach has been to treat an old net, even is it has little effective insecticide left, just like a used pesticide container. In reality the potential effects of nets used for unintended purposes, or large collections of nets in community disposal sites are not well researched yet.

A recent article from Uganda in The Observer has drawn our attention to an important and seemingly neglected aspect of net safety – fire. One of the doctors interviewed shared that a “majority of the cases of burns he handles are as a result of mosquito nets catching fire. He says although rarely talked about, nets are the worst agent of fire that can burn children.” The article further explained …

“Mosquito nets made of polyester are particularly dangerous; when it catches fire and wraps around someone, it causes deep, severe burns. When distributing free mosquitoes nets in the fight malaria campaign, no one is teaching people about safety and how dangerous they are with fire.”

There are many sources of open fire in village homes – lanterns, candles, stoves. Living, cooking and sleeping space may be at a premium and rooms may serve multiple functions, increasing potential fire exposure.

There is a lot we need to do to educate net owners about their nets – even the basics of how to hang and net and when to use are often forgotten in the rush to hand out thousands of nets during a campaign.  In this case we need to be extra vigilant to ensure that a commodity intended for protection from harm does not itself become a death trap.

The 2012 Millennium Development Goals annual report/update has been released. Progress for malaria has been noted, but below target. In summary the report notes that …

“The estimated incidence of malaria has decreased globally, by 17 per cent since 2000. Over the same period, malaria-specific mortality rates have decreased by 25 per cent. Reported malaria cases fell by more than 50 per cent between 2000 and 2010 in 43 of the 99 countries with ongoing malaria transmission.”

While the overall tenor of the report veers toward the positive, the authors had to explain that, “Although these rates of decline were not sufficient to meet the internationally agreed targets for 2010 of a 50 per cent reduction, they nonetheless represent a major achievement.”  Ironically, the map at the right, taken from the report does not even include a shading for 80% and higher – the Roll Back Malaria target for 2012. Inadequate intervention coverage and the financial and health systems weaknesses contributed to the coverage gap, in spite of calls for universal coverage in 2009.

The big push toward universal coverage did result in more nets, but some countries are still in the process of trying to get the first round of mass distribution finished.  In light of Global Fund Round 11 cancellation and the world economic crisis, fears exist that replacement nets, likely needed by 2013, can be bought. The MDG report echos this concern: “There are worrisome signs, however, that momentum, impressive as it has been, is slowing, largely due to inadequate resources.”

Fortunately there is a bight light. Rwanda just announced that –

Over six million treated mosquito nets will be distributed to households in 2012 and 2013 and around 500,000 Long Lasting Insecticidal Nets (LLINs) will be given to pregnant women and children under five years in 2012, the National Malaria Control Program Director, Dr. Corine Karema, has said. “Currently we are in the phase of replacing the Long Lasting Insecticidal Nets (LLINs) distributed in 2010,” Dr Karema said, adding that families which didn’t receive them in 2010 will be assessed so that they can also get nets.

Not only does Rwanda’s effort represent replacement of the old nets, but also recognizes the need to provide nets in an ongoing manner during routine health services like antenatal care. Let’s hope that this sets a good example for other countries to make a commitment to find the funds – locally and/or internationally to ensure that the MDG for malaria morbidity and mortality reduction will not be sidetracked.