Category Archives: Integration

Tropical diseases need an integrated approach

A common critique of the Global Fund to Fight AIDS, TB and Malaria is that there are other major contributors to the burden of disease in tropical countries.  Some are infectious like pneumonia while others are non-communicable like injuries.

dscn1225sm.JPGFrom the standpoint of malaria, integration makes sense. From the start, the Roll Back Malaria Partnership made it clear that malaria control (end eventual elimination) could not succeed unless health systems were strengthened. These are the same systems that are supposed to control filariasis, helminthic diseases, diarrheal diseases, and pneumonia as well as promote maternal health, child growth and development as well as immunization programs. It was a weak health system that contributed to the failure of the first effort to eradicate malaria fifty years ago.

Two recent articles exemplify the need for integrated prevention and control services because tropical communicable diseases themselves are ‘integrated’ into the environment and the human host.

Abraham Degarege and colleagues examined Malaria and helminth co-infections in outpatients at Alaba Kulito Health Center in southern Ethiopia. Fifty-four percent of patients having malaria parasites also had at least one of three helminth infections including hookworm, A. lumbricoides and/or T. trichiura. Those with both worms and malaria (P. falciparum and/or P. vivax) had higher rates of anemia. These negative synergies require an integrated approach to patient management as well as to community prevention programs.

Marcia C. Castro and her co-researchers looked into local water sources for larval development of lymphatic filariasis and malaria vectors in Dar es Salaam, United Republic of Tanzania. Larvae of both anopheles and culex species were found in puddles, swamps, mangrove swamps, drains/ditches, human-made holes, water storage, agriculture, rivers/streams, and ponds.

Polluted urban environments are less conducive to anopheles breeding, and culex were more likely to be found in all these urban sites in Dar es Salaam, especially in drains/ditches, but again in this environment both types were found, meaning that both filariasis and malaria ‘co-existed’. Integrated control through larviciding and ITNs would help prevent both diseases.

If basic health services are well funded, staffed and supplied, no tropical disease needs to be neglected.

One Billion and Counting

As 2009 comes to an end, The Guardian lets us know that, “The baby’s name and nationality are not known. The child will grow up innocent of having a place in history. But somewhere, this year, that child became the billionth person in Africa, the continent with the fastest growing population in the world.”

With 45% of Africa’s current population living in urban areas, the billionth child was as likely to be born in Lagos or Nairobi as in a village. This paints an epidemiological picture where, “Deaths from smoking or car crashes will be a factor as much as the more familiar health issues of malnutrition, malaria and Aids. These citizens will also be vulnerable to droughts, floods and desertification caused by climate change.”

And while the population keeps growing, African children born in 2009 face the highest under 5 year old child mortality rates in the world. Afghanistan and Burma were the only non-African countries among those 38 with rates of 100 child deaths per 1000 live births or greater.

The life expectancy of that child is 55 years – 14 years younger than the world average. It could even be ten years less if the child was born in some of the areas highly endemic for HIV.

So what are we offering the cohort of children born in Africa during 2009? Many countries like Nigeria are in the midst of working toward universal coverage of insecticide treated nets, and just reported a successful campaign in Ogun State where 1.6 million of the proposed 63 million national total were just distributed.

africa-population-growth2.jpgWe have noted that the process of making appropriate malaria medications for children and intermittent preventive treatment for pregnant women (to protect the next cohort of African children as well as the mothers) is well below target. One-off Campaigns to get nets out to households are somewhat ‘easier’ than ensuring an integrated and functioning public, private and non-governmental health system that is needed to provide other routine preventive and treatment services.

We wish that when this one billionth child has a birthday in 2010, she or he will be fully protected from malaria with a net and have ongoing access to the services needed to keep malaria at bay.

PEPFAR Could Build Bridges to Malaria Programs

Under its new strategy, “PEPFAR patients will also be treated for tuberculosis, malaria and previously untreated tropical diseases,” according to a Washington Post editorial.  This is possible because, “PEPFAR 2 has three pillars: prevention, integration and improved health-care systems.”

pepfar.jpgThe Post further explains that with PEPFAR 2, “The goal is to make the services a routine part of each nation’s health offerings.” The Post quotes Eric Goosby, the U.S. global AIDS coordinator, as saying that, “We need to transition them into being more embedded in the countries’ infrastructure and for the countries to have true ownership of them.”

Research in Rakai, Uganda, has found, “Excellent self-reported retention and appropriate use of ITNs distributed as a part of a community-based outpatient HIV care programme. Participants perceived ITNs as useful and were unlikely to have received ITNs from other sources.” What PEPFAR 2 appears to be calling for is a more integrated systems approach that through the new US Global Health Initiatives that ensures that mothers, children and families get the full range of services they need from an improved and sustainable local health service.

Even before this greater focus on MCH, health professionals like Walensky and Kuritzkes, have noted the “massive direct and indirect benefits PEPfAR has achieved already for mothers and children. It may be that PEPfAR—by providing health infrastructure, HIV prevention, parental survival, and the opportunity to sustain economic growth.”  Though not stated directly, these views describe an environment that is also more favorable to malaria control.

There are those who see global health programs like PEPFAR and GFATM as “distracting governments from coordinated efforts to strengthen health systems and re-verticalization of planning, management and monitoring and evaluation systems.” Biesma et al. note that there is much more that donor programs “could do much more to promote country ownership through aligning their objectives with comprehensive national health.” The Washington Post editorial indicates that this is exactly where the new PEPFAR strategy is aiming.

Integrated community case management (ICCM) – a way forward

ccm-in-onileekaa.jpgICCM was the theme of a symposium at the MIM 5th Pan-African Malaria Conference last week. The organizers defined ICCM as a ‘strategy that delivers to the most vulnerable groups anti-malarials, antibiotics and a combination of oral rehydration therapy and zinc at the community level by trained community health workers.’ during the course of discussion CHWs were defined as people not only from the community, but also working in the community.

A little leeway has been taken with the latter definition in an ICCM study from Ghana where RDTs, ACTs, Amoxicillin and Paracetamol were availble for use by Community Health Officers posted in village health services known as Community Health Planning (CHPs) compounds.  Having both the RDTs and alternative treatment for pneumonia in the case of negative tests resulted in less overall drug use in the 8 intervention CHPs compounds compared with the 8 controls. Integration can only happen when health workers have all the materials they need to do appropriate case management.

Documentation of ICCM policy and program implementation for 68 countries was reported to the symposium. Only 55% of countries had a CCM policy for malaria, 50% for diarrhea, 30% for pneumonia and none for neonatal infections. Some countries were implementing without policies. Less than half had integration of three diseases – malaria, diarrhea and poneumonia.

Even with policies, not all countries implement CCM on a national basis, though there were examples of implementation across many or just a few pilot districts.

Potential barriers to CCM policy and implementation were identified through interviews with Ministry of Health officials from the selected countries. Common concerns were the ability to guarantee quality of care, incentives, supplies, monitoring and evaluation, training and supervision.

Ethical concerns were raised as to whether CCM really provides quality care to the poor.  In contrast, presenters working in post-conflict areas found that these situations provided opportunities for creative thinking on how to reach disenfranchised communities.

The session did not have time to get into the role of the informal private sector – especially patent medicine vendors – in CCM.  Also the focus on individual CHWs tended to divert attention away from the word ‘community.’ It is hoped that CCM can take a leaf from the Community Directed Interventions process and focus on strengthening community leadership and systems to take charge of health matters, and not rely solely on an individual CHW who may be here today and gone tomorrow.

NOTE: ICCM training materials and job aids are being consolidated by WHO/Unicef. The CORE Group also has a set of CCM training materials under development.

Why Pneumonia Matters (Guest Blog)

world-pneumonia-day-logo.gifA big thanks to Bill for inviting me over to Malaria Matters.

In less than a week, child health advocates around the world will commemorate the first ever World Pneumonia Day. November 2nd will be bring greater attention—through conferences and events spanning 6 continents—to this disease, which takes the lives of 2 million children every year.

As Bill has written in Malaria Matters on previous occasions, we need integrated approaches to pneumonia and malaria control, especially as both killers often present as febrile illness in young children. A misdiagnosis can lead to inappropriate treatment, wasting valuable time, and putting the child’s life at risk. Integrating control efforts can include training community health workers to distinguish the two diseases, distributing bed nets during immunization days, promoting breastfeeding and adequate nutrition, and educating mothers on the danger signs of both diseases.

Why then, am I promoting World Pneumonia Day and not World Pneumonia and Malaria Day?

Besides a question of verbosity, the lack of awareness and funding for pneumonia is a serious threat to child survival. Less than 5% of Americans surveyed identified pneumonia as the leading cause of child death. And although pneumonia is responsible for nearly 20% of all deaths in young children, it receives only 1.3% of R&D funding for neglected diseases.

As Bill effectively argued, we need to make the pie of child health resources bigger, not compete for a bigger slice. My hope is that World Pneumonia Day will raise awareness and additional funds for the fight for child survival.

There are three simple things you can do to support World Pneumonia Day

  1. Take our online pledge. Add your voice to the growing call for action against pneumonia
  2. Wear blue jeans on November 2nd. Bring attention to this neglected disease by wearing your favorite pair to the office.
  3. Email Congress. Urge your Representative to co-sponsor the Newborn, Child and Mother Survival Act.

It’s not a question of stopping malaria or pneumonia. We have to do both.

Dr. Orin Levine, Executive Director of PneumoADIP

Malaria and Pneumonia – collaboration, not competition

Nicholas Kristof in the New York Times in a column entitled, “Pssst. Pneumonia. Pass it on,” is rightfully implying that while there has been much attention to malaria, HIV and tuberculosis, it is almost as if the international health community were keeping childhood killer diseases like pneumonia a secret.  Kristof goes on to explain that –

One of those active in the malaria campaign is Lance Laifer, and he’s now plotting a new effort to take on pneumonia. Respiratory tract infections are a huge problem in the developing world and kill vast numbers of kids, and so some attention could make a huge difference. More power to him and others trying to focus on pneumonia.

The answer to the problem is not trying to decide which disease is a worse killer, but how to tackle both diseases in an integrated way.

About eight years ago I was part of the Nigerian team in a four-country project sponsored by WHO/TDR to look at how home management of febrile illness could be managed in the community using prepackaged drugs.  Prior to this time most children were treated by breaking adult dose drugs into pieces or giving syrups, which could be unstable over time.  Parents did not like breaking the drugs and doubted their skills in doing so correctly.  The project therefore developed child dose pre-packs of drugs for both malaria and pneumonia and tested whether these would be acceptable and used correctly.

The reality was that both malaria and pneumonia presented with fever in children, and that both parents and front line health workers could become confused when selecting a course of treatment.  Training of village health workers, patent medicine vendors and front line health staff on distinguishing the two conditions went along with providing them the age-appropriate pre-packs of chloroquine (the malaria drug used on those days) and cotrimoxazole (for pneumonia). WHO explains that –

As a result of these studies, HMM has become a cornerstone of malaria case-management and, more generally, of malaria control in sub-Saharan Africa. Many countries have incorporated HMM (home management of malaria) in their strategic plans to roll back malaria, or in their successful applications to the Global Fund to fight AIDS, Tuberculosis and Malaria, and are now moving to large-scale implementation of HMM.

In fact many organizations have taken the concept of HMM to a broader level of community case management (CCM). This includes the two febrile conditions – malaria and pneumonia – and other conditions.  The Core Group is bringing together the lessons learned in 27 countries to develop an operations manual for organizing CCM. The draft manual offers the following definition/description:

Community case management (CCM) is a strategy to deliver life-saving curative interventions for common, serious childhood infections. Priority infections are those that cause the most child death in developing countries: pneumonia, diarrhea, malaria, and newborn sepsis. The interventions are: antibiotics for pneumonia, dysentery and newborn sepsis; oral rehydration therapy; antimalarials; zinc; and Vitamin A. The CCM strategy targets children because they are the most vulnerable to these infections and, once infected, the most likely to die.

WHO/TDR has also tested community mechanisms for treating malaria and providing preventive services through the Community Directed Interventions (CDI) approach that has made onchocerciasis control successful in tens of thousands of villages throughout Africa. CDI encourages communities to make decisions about how they will manage the supply of basic health commodities and results in better coverage than facility-based services alone.

In summary, models exist for integrating the management of a number of health problems at the community level.  We need to ensure that community committees and volunteers have access to all that is necessary to save their children’s lives, including drugs for malaria and pneumonia and also ITNs, supplements like Vitamin A and zinc and other essential health commodities.

Integration may address NTDs – example of lymphatic filariasis

lf4ib-sm.jpgLymphatic filariasis (also known as elephantiasis) is another mosquito borne disease that plagues much of the population in malaria endemic areas. In fact is is the same anophelene species of mosquitoes which carry malaria that also transmit lymphatic filariasis in much of Africa. With talk of integration of disease control programs, one wonders what are the potential synergies of combining efforts against malaria and lymphatic filariasis?

Both share the preventive measure of bed nets, which is a major strategy for malaria control, but the main approach to eliminating filariasis is Mass Drug Administration (MDA). Two drugs in combination, ivermectin (or diethylcarbamizine citrate) and albendazole, are given annually. These annual doses kill the microfilaria and have some effect on the adult worms. Success as measured by prevalence below 1% can b achieved after 6 rounds of MDA depending on 1) initial level of LF endemicity; 2) effectiveness of vector mosquitoes; 3) MDA drug regimen; 4) population compliance.

If the two diseases share geography and in some cases a vector, have there been any actual attempts at a joint effort? At least two countries have attempted such within the context of their global fund grants for malaria, Togo and Papua New Guinea (PNG). Togo’s Round 4 GFATM grant aimed at “demonstrating the synergy effect of MDA on the impact of malaria control activities” in co-endemic areas. This was based in part of research that showed a negative impact of helminths on malaria infection.

An innovation in the PNG GFATM proposal is “Training of field staff to disseminate information about malaria and HIV/AIDS (who) will also be used for annual mass drug administration for lymphatic filariasis elimination.”

An NGO example of integration has been piloted by the Carter Center. “In 2004, the Carter Center-assisted Lymphatic Filariasis Elimination Program received 57,000 bed nets from the Nigerian Ministry of Health in a combined effort to prevent the spread of lymphatic filariasis, being addressed by the Center, and malaria, a project of the health ministry. The nets are treated with the insecticide deltamethrin, which is safe for humans yet kills the mosquitoes that are the carriers of both diseases in rural Africa. The bed nets have been distributed in four local government areas of Plateau and Nasarawa states in Nigeria, which are endemic for both diseases.”

The Carter Center has been using the same community distribution system found effective for onchocerciasis control. “Community volunteers distributed 38,600 insecticide-treated bed nets, while simultaneously treating 150,800 persons with ivermectin/albendazole.” A 30-cluster survey found a 9-fold increase in bednet ownership compared to baseline. “This first linkage of insecticide-treated bed net distribution with mass drug administration resulted in substantial improvement in insecticide-treated bed net ownership and usage, without adversely affecting mass drug administration coverage. Such integration allowed two programs to share resources while realizing mutual benefit, and is one model for rapidly improving insecticide-treated bed net coverage objectives.”

Since the Global Fund programs have yet to focus on neglected tropical diseases, these examples of integration between malaria and lymphatic filariasis, may be the best way to ensure parasite-free populations in endemic areas.

Anemia: another place to focus on integration within antenatal care

Anemia in pregnancy is responsible not only for threats to a woman’s health, but ultimately the survival of the child. Hotez and Molyneux in a PLoS Neglected Tropical Diseases editorial explain that …

“… most of the 7.5 million pregnant women infected with hookworm likely live in areas of sub-Saharan Africa that place them at risk for malaria. At the same time, malaria control and NTD control have each been shown to reduce anemia both in children and in pregnant women. Therefore, combining malaria and NTD control practices in a unified anemia framework affords one of the best opportunities to reduce the huge burden of morbidity and mortality that results from anemia in sub-Saharan Africa.”

detect-and-prevent-anemia-in-pregnancy2.jpgEach disease presents its own challenges. Guyatt and Snow report that, “Although the vast majority of women with malaria infections during pregnancy remain asymptomatic, infection increases the risk of maternal anemia and delivering a low-birth-weight (LBW) baby.” Furthermore, “It is estimated that in areas where malaria is endemic, around 19% of infant LBWs are due to malaria and 6% of infant deaths are due to LBW caused by malaria. These estimates imply that around 100,000 infant deaths each year could be due to LBW caused by malaria during pregnancy in areas of malaria endemicity in Africa.”

Addressing hookworm during pregnancy in Peru, Larocque and colleagues found that pregnant women, “infected with moderate and heavy intensities of hookworm infection and those with moderate and heavy intensities of both hookworm and Trichuris infections were more likely to suffer from anemia than women having no or light intensities. These results support routine anthelminthic treatment within prenatal care programs in highly endemic areas.”

Positive experiences on anthelminthic control were also reported from Nepal in the Lancet. During prenatal care  “… women received albendazole twice during pregnancy. Women given albendazole in the second trimester of pregnancy had a lower rate of severe anaemia during the third trimester. Birthweight of infants of women who had received two doses of albendazole rose by 59 g , and infant mortality at 6 months fell by 41%. Antenatal anthelmintics could be effective in reducing maternal anaemia and improving birthweight and infant survival in hookworm-endemic regions.”

We reported from Mozambique that PMTCT and IPTp for malaria in pregnancy control are integrated into antenatal care in many clinics.  One can see metronidazole in addition to SP and AZT in the picture among the preventive medicines available for pregnant women. Countries can make their choices of anthelminthics, including albendazole, but the meassage that Hotez and Molyneux convey is the need to control NTDs like soil transmitted helminths should be an integral part of services for pregnant women.

Malaria at the XVII International HIV conference

Malaria is estimated to kill over 1 million people a year, mostly children, while the annual death toll from HIV/AIDS approaches 2 million. Where these diseases overlap, “Malaria contributes synergistically with HIV/AIDS to morbidity and mortality in areas where both infections are highly prevalent, such as in Africa south of the Sahara. In addition to providing immediate health benefits, prevention and treatment of malaria may lessen transient increases in HIV viral load during malaria episodes and thus help limit the progression,” according to the World Malaria Report.

iasmexico_banner.gifWith the clear public health links between the two diseases, one would have expected to see more reports about malaria in HIV within the XVII International AIDS Conference in Mexico. Search at the conference website on malaria as a key word turned up only four abstracts or session outlines that actually addressed malaria, not just presentations that happened to spell out the full title of the Global Fund, and thus inadvertently mentioned malaria.

An abstract by Imani et al. reported that, “HIV infection was significantly associated with cerebral malaria in children admitted to Mulago Hospital and the prevalence of HIV infection among those with cerebral malaria was 9%.
Recommendation: Malaria prevention should be an important component of education and counselling of HIV infected children and their caretakers. A large study is recommended to establish whether there is a correlation between the level of HIV immunosuppression and cerebral malaria.”

Oloo and colleagues presented on “Strengthening HIV/AIDS programs for transport sector workers through a regional trade union approach in East and Central Africa.” Among their recommendations was the importance of providing “integrated reproductive health, malaria and family planning services to transport workers through the resource centers.”

A workshop is being organized on, “Uniting and Empowering Civil Society on CCMs: How AIDS, TB, and Malaria Organizations Can Work Together on CCMs and in GFATM Advocacy,” and is crosscutting on the three diseases.

Finally, Raposo et al., presented the topic, “Counseling and testing in health: a public health approach to increase access to health promotion in Mozambique.”  They stressed the need for linkages with other health services. A model for better integrated services was described that included, “Additional counseling is provided for malaria prevention, environmental health, uptake of antenatal care during early pregnancy, and institutional delivery.”

Better integration of disease control and prevention efforts is needed to better serve those in endemic communities. Integration should also be evident in advocacy efforts such as international conferences. We can’t afford the medical model that looks at diseases only, not the people who suffer from multiple problems.

Malaria, HIV – integration into Antenatal Care in Mozambique

Infectious diseases during pregnancy put both the mother and the unborn child at risk.  According to WHO’s Global Malaria Program, co-infections with HIV and malaria put pregnant women at special risk. WHO is also concerned that opportunities to address infectious diseases like HIV and malaria are often missed during antenatal care (ANC).  WHO therefore recommends a minimum 4-visit focused ANC package as follows:

For antenatal care to be effective, all pregnant women need a minimum of four visits, at specific times and with evidence-based content. Care for women during pregnancy improves health by preventive measures, and by prompt detection and management of complications. Essential components of a focused antenatal-care package include screening for and treatment of disorders (such as anaemia, abnormal lie, hypertension, diabetes, syphilis, tuberculosis, and malaria); provision of preventive interventions (such as tetanus immunisation and insecticide-treated bednets); and counselling about diet, hygiene, HIV status, birth, emergency preparedness, and care and feeding of babies. Since antenatal care has good coverage, it provides a platform to increase the interventions provided during antenatal visits, including HIV care for the mother, prevention of maternal to child transmission (PMTCT) of HIV, and support for feeding choices. However, this opportunity must be weighed against the risk of overloading services that are already stretched.

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It is encouraging to see that the Ministry of Health in Mozambique is taking the integration of malaria control and PMTCT into its antenatal care services.  The picture above shows an ANC nurse’s desk in one of the more that 500 health facilities that offer PMTCT. There is almost what one could call a one-stop-shop for pregnant women in terms of getting their preventive medicines – sulfadoxine-pyrimethamine (SP) for intermittent preventive treatment of malaria (IPT), and AZT and neviraprine for PMTCT prophylaxis, among others.

Some challenges to this integration remain.  The policy for IPT was adopted only in 2006 after pilot testing in two provinces, and needs to be disseminated more fully. PMTCT is presently offered in only about one-half to one-third of health facilities where ANC is offered. ITNs are not yet available in all routine service points, but there is a strong commitment to contiunue work toward integration.

The Round Six Global Fund application for Mozambique summarizes the vision of integration: “The HIV/AIDS component supports provision of comprehensive antenatal care (ANC) to pregnant women, consisting of provision of anaemia, syphilis and HIV tests; iron, folic acid and vitamin A supplementation; Intermittent Preventive Tretament (IPT) of malaria in pregnant women; de-worming, health education & counselling on breastfeeding , nutrition, HIV and hygiene. The delivery by the malaria component of ITNs through routine ANC will reinforce this comprehensive care. Early data from applying the model in Inhambane Province has also shown increased use of ANC when ITNs are made available; this will enhance uptake of the other services.”

We hope other countries take this as a model of ANC integration to emulate.