Category Archives: Ivermectin

Leadership and Support for Malaria Pre-Elimination in Nepal

Emmanuel Le Perru, Jhpiego field staff in Nepal, shared his experiences in aiding the malaria pre-elimination efforts in the country during a retreat that preceded the 65th Annual Meeting of the American Society of Tropical Medicine and Hygiene in Atlanta. Here are some highlights of his talk.

risk-mapMalaria Pre-Elimination efforts are targeting 0 deaths as well as investigation of 100% of confirmed cases in Nepal. Systematic entomology investigation/interventions are required. Glucose-6-Phosphate Dehydrogenase deficiency (enzyme genetic defect causing hemolysis with primaquine) testing for Plasmodium vivax in high G6PDd prevalence communities is required. Cases should receive treatment within 72 hours of symptoms for Pf (to quickly prevent transmission and gametocyte reservoir). There is also a need to distinguish between indigenous and imported cases.

Jhpiego is providing technical assistance and capacity building for Nepal’s Ministry of Health pre-elimination efforts as follows:

  • Integrated Vector Management
  • Micro-stratification
  • Entomology curriculum to be conducted in medical college (need new positions)
  • Case-based Surveillance guidelines
  • Private-sector engagement (for increased reporting and product quality control/procurement such as Antigen RDTs)
  • Capacity Assessments in 9 health systems strengthening components at central and district levels (Jhpiego Malaria Implementation Guide)
  • Human resources: clear job descriptions and performance goals
  • Leadership & Management development program

gfatm-bednets-distProgram highlights include the fact that the Global Fund malaria grant rating improved from B2 (inadequate but demonstrating potential) in January 2016, but now A2 (meeting expectations) in November 2016. Concept note for operational research at 2 or 3 border check points has been developed in order to determine whether such intervention (communication & voluntary screening) is cost-effective and relevant to catch/target imported cases, raise awareness on malaria available services, detect/prevent sources of potential outbreaks. This will inform GFATM on the relevance to fund such intervention. A similar approach was done at the China-Myanmar border but was not recognized by not WHO.

Nepal's Global Fund Grant Indicators for Malaria Case Management

Nepal’s Global Fund Grant Indicators for Malaria Case Management

Although the National Malaria Strategic Plan refers to high risk groups (forest workers, national parks security personnel, refugees, prisoners, etc.) evidence is needed to back this up. A study or improved investigation forms are needed to identify such groups and use this information to design appropriate behavior change communications and other interventions.

Special Programming Highlights include proposing a focus on Closed/Isolated Settings/Foci (limited migration, duration and population) to WHO and GFATM. Considering a targeted mass drug administration (MDA) Plasmodium vivax (not yes recommended by WHO) with Primaquine/G6PD testing. Consideration is being given to new drugs in the pipeline such as Ivermectin. Molecular Testing using Polymerase Chain Reaction (PCR) to detect low parasitemia, asymptomatic or re-infection cases (Pv includes inactive/dormant sporozoites known as hypnozoites) is being proposed.

Community based testing as proposed in the Global Fund grant needs strengthening. Therefore RDT use by Female Community Health Volunteer is being considered. Active case detection is another possibility for those areas moving toward pre-elimination. As mentioned, there is also need for studies of asymptomatic infection.

Lessons learned so far for best practices for efforts in identifying specific pre-elimination interventions include the value of getting consensus at national level through the Malaria Technical Working Group. There is also need to challenge WHO recommendations and engage dialogue to get creative. At present there is a risk of a Catch 22 situation wherein the GFATM asks for innovative interventions but at the same time tries to adhere strictly WHO to existing guidance.

The Nepalese malaria program is in constant dialogue with the GFATM Fund Portfolio Manager and team on the local context and technical challenges in order to get them involved in looking for innovative solutions.

Challenges arise in malaria diagnostics. While systematic microscopy is the gold standard, quality can be poor because of low stain/re-agent quality, constant staff turnover and donor reluctance to fund additional training. Also microscopy confirmation and slide quality control are time consuming, and often this process is not clear or well followed. PCR require specific equipment, training and qualifications. Takes time to be operational.

There are opportunities moving forward.  Progress could be made if there were more “elimination experts” to position to influencer to WHO to seek and propose new interventions for the pre-elimination stage. Nepal provides an ideal opportunity to test new ideas. It will also be necessary for the national malaria program staff to receive regular technical updates on program issues such as new drugs (Ivermectin?) and on-going pilots of MDA.

Malaria, Lymphatic Filariasis and Insecticide-treated Nets

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Throughout Africa one of the main vectors that carry Lymphatic Filariasis (LF) is the Anopheles mosquito, which also carries the malaria parasite. The Carter Center has been promoting use of insecticide treated nets (ITNs) for many years as part of its LF control efforts, but others may not have gotten the message.

The global community is targeting LF for elimination in 2020. The primary strategy is mass drug administration annually with ivermectin and albendazole. The plan is that up to seven annual rounds of drug distribution in endemic communities where 90% of population coverage is achieved is necessary to stop LF transmission. The Carter Center explains that distribution of long-lasting insecticidal bed nets (LLINs) protects pregnant women and children who cannot take drug treatment.

The LF strategy often builds on and integrates with onchocerciasis control efforts where these diseases overlap. The community directed treatment with ivermectin (CDTI) model pioneered by the African Program for Onchocerciasis Control  (APOC), wherein communities or villages plan together the distribution process including selecting their own community directed distributors (CDDs). This model has also been used to distribute ITNs.

20160818_100110-1A second component of the LF strategy is morbidity management which focuses on enhanced personal hygiene or cleaning of the parts of the body that experience lymphedema. Another aspect uses surgery to address some of the worst effects, hydrocele.  While this component does not ‘control’ LF, it is a necessary effort to reduce suffering and the negative stigma from the disease.

To judge whether transmission has stopped and elimination has been achieved Transmission Assessment Surveys (TAS) are conducted with rapid diagnostic tests on young children after at least 5 years of MDA in a community.  Specifically WHO recommends an implementation unit must have completed five effective rounds of annual MDA defined as achieving rates of drug coverage exceeding 65% in the total population.

For example the Carter Center in Support of the Nigerian Federal Ministry of Health worked in Plateau and Nasarawa States through community health education, delivery of long lasting insecticide-treated nets (LLINs) and 33 million drug treatments for lymphatic filariasis and river blindness between 2000 and 2011. “In 2012, it was confirmed (through TAS) that lymphatic filariasis transmission had stopped. Post-treatment surveillance is currently underway to assure that the parasite is not reintroduced into the area.”

Another component of the assessment process is yet to be fully realized. That is the testing of mosquitoes for the presence of microfilariae. This indirectly implies an important role in preventing human-vector contact as would be achieved through the use of ITNs as well as indoor residual spray (IRS).

Vector control can benefit more than one disease. Integrated vector management is seen as a key tool to prevent reintroduction of LF in areas where anopheles mosquitoes carry the disease and where ITN campaigns are successful.

Ultimately the key to benefiting from the disease control synergies provided by insecticide-treated nets is an understanding what if any effect nets have on transmission. This poses a challenge in terms of separating it from the effect of MDAs as well as the fact that MDAs are time-limited. As MDAs are still underway in many places it is incumbent on program managers to monitor and evaluate the impact of all activities, treatment and vector control, over the next decade to determine the success of eliminating LF and hopefully malaria, too.

Malaria, Onchocerciasis and Ivermectin – Possibility of Eliminating Two Diseases

Many tropical diseases are co-endemic in a given country and environment. Therefore, it only makes sense to learn whether there can be common strategies and synergies in disease control and elimination efforts. Onchocerciasis or River Blindness is carried by the black fly (simulium damnosum) that breeds along the banks of fast flowing rivers and malaria are examples.

Onchocerciasis was eliminated in many settings in the Sahel through the process or aerial spraying of these riverbanks to kill the black fly larvae. Though the insecticide used was often the same as used for malaria larviciding, the habitats differed and no synergies were achieved then.

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Merck donates ivermectin to achieve control and elimination of onchocerciasis

Through subsequent programs using community directed treatment with ivermectin (Mectizan ®) interventions sponsored by the African Program for Onchocerciasis Control (APOC) it was learned that ivermectin also had beneficial effects on malaria transmission.

Ivermectin had been used in agriculture not only for internal parasites of animals. The agricultural community has long known that ivermectin kills both internal parasites (worms) but is also effective against some external parasites (lice and ticks).

Around 2010 scientists began to consider the anti-mosquito effects ivermectin might have when humans consumed it. It turns out that after a mass distribution in a community of ivermectin for onchocerciasis that mosquitoes feeding on people who had recently swallowed ivermectin would die. This was demonstrated when mosquitoes bit volunteers who took ivermectin of the first few days after consumption died there was no effect in the group not taking the drug.

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Ivermectin distribution sessions in a Cameroonian village

Of particular interest was the fact that people who had consumed ivermectin would contribute to mosquito mortality even when they were outdoors. While the effect was not long lasting, the onchocerciasis control programs in the Americas have shown that it is safe to administer the drug two or four times a year.

Research that looks at the malaria parasite concluded that, “it is likely that ivermectin treatment is arresting parasite growth.” The researchers note that, “given the prior use of ivermectin and its safety record in humans and animals, it can be considered in combination therapy with other antimalarials.” The issue of dosage would need to be tested further.  Ivermectin at sub-lethal concentrations even inhibits the sporogony of P. falciparum in An. Gambiae.

Because of the need to find new and complementary tools to eliminate malaria the Malaria Policy Advisory Committee (MPAC) of the World Health Organization’s Global Malaria Program considered at its recent meeting the role of endectocides including ivermectin in the future of malaria control and elimination and the importance of further research.

The future of malaria elimination requires finding new tools to integrate with and the strengthening of existing tools. If these efforts also benefit the control and elimination of other diseases, the public’s health will benefit.