Tropical Health Matters

With the 2010 World Cup taking place in Africa, a great opportunity became available to highlight health and development issues on the continent. One of those issues was malaria and the message was carried by a consortium of groups who formed United Against Malaria.

UAM has continued its efforts to advocate for malaria elimination beyond the World Cup. Late last year five CECAFA national teams joined UAM during the CECAFA Tusker Cup in Dar es Salaam, Tanzania, from late November into December. The Ghana Football Association, as one example, featured its players in television documentaries about the devastating effects of the disease.

The very nature of competition among football clubs and associations requires travel within a country and among countries.  A news story out of Jamaica (which was declared malaria-free in 1966) yesterday highlights that football can also ‘transmit’ malaria between countries …

The Jamaican Ministry of Health has reported the confirmation of three cases of malaria among players of the Haitian under-17 football team who are in Jamaica to play in the CONCACAFUnder-17 championship in Montego Bay. The Haitian players are being treated. According to the Jamaica Observer, The Ministry of Health has recommended that in the circumstances they do not participate in the tournament and therefore return to Haiti. These arrangements are presently being made. The Ministry of Health has implemented mosquito control measures and a surveillance system to try to quickly identify any new cases.

Malaria truly has no borders, as stressed on World Malaria Day in 2008. Living on an island does not protect when both people and mosquitoes can travel.  Places like Jamaica and Mauritius need to be constantly vigilant – it is not just the high burden countries that need to worry about whether we can reach malaria elimination.

This is not Jamaica’s first brush with the risk of reintroduction of malaria. An upcoming Tropical Medicine and International Health article reported that in 2006 Jamaica successfully controlled an outbreak of Plasmodium falciparum with 406 confirmed cases. The outbreak highlighted the need for increased institutional capacity for surveillance, confirmation and treatment of malaria as well as effective prevention and control of outbreaks which can occur after elimination. Jamaica appears to have successfully eliminated malaria after its reintroduction.

The West Indian Medical Journal reminds us that, “All the essential malaria transmission conditions–vector, imported malaria organism and susceptible human host–now exist in most” Caribbean countries, this re-emphasizing the need for constant surveillance. The added saddness in the current story is that not only does Haiti continue to suffer from the devastation of last year’s earthquake, but itself has been the ‘victim’ of imported disease – cholera.

As long as people, including football teams and UN Peacekeepers, continue to move around the globe, the difficulty of eliminating diseases like malaria will remain. The lack of current cases of malaria in a country is not justification for complacency, especially if the environmental and vector conditions for transmission persist.

Three new articles in Malaria Journal plus a news release from the Commonwealth Games in India remind us that like any other organism, the malaria parasite will fight for survival.

Yvonne Lim and colleagues document a rare case of P. ovale imported into Malaysia. They note that local vectors are capable of transmitting this parasite as well as an “exponential increase in the number of visitors from P. ovale endemic regions.”

A Nigerian table tennis player at the Commonwealth Games in India withdrew after coming down with malaria. The Times of India implies that the illness may be a result of “The Capital’s dreaded mosquitoes.” Depending on when he arrived in India, Ekundayo Nasiru could have brought the disease with him. In either case the potential for importing and exporting malaria exists.

Now under way in several pilot countries, “The Affordable Medicines Facility-Malaria (AMFm) is a mechanism to increase access to quality assured ACT.” AMFm hopes that with approved and cheaper artemisinin-based combination therapy (ACT) drugs monotherapies will be driven from the market and the lifespan of ACTs will be prolonged, thus “reducing the likelihood of resistance to artemisinin.”

Unfortunately, another article in Malaria Journal reviews “Declining in clinical efficacy of artesunate-mefloquine combination has been documented in areas along the eastern border (Thai-Cambodian) of Thailand.” After identifying cases of recrudescence after treatment, the researchers concluded that …

Although pharmacokinetic (ethnic-related) factors including resistance of P. falciparum to mefloquine contribute to some treatment failure following treatment with a three-day combination regimen of artesunate-mefloquine, results suggest that artesunate resistance may be emerging at the Thai-Myanmar border.

These experiences show how important it is not only to document drug resistance and imported cases but also to help countries plan “Robust Malaria surveillance systems towards malaria pre-elimination and assessing Roadmaps achievements,” which is the theme of a meeting of the East Africa Regional Network (RBM) underway in Kigali. More technical assistance is needed in “strengthening Malaria surveillance in high and low burden countries,” if elimination goals are ever to be achieved.

The recent meeting of the African Leaders Malaria Alliance (Alma) as part of the African Union summit reconfirmed commitment to achieving universal coverage with long lasting insecticide-treated nets by the end of 2011. The President of Tanzania and Chairman of Alma, writing in The Guardian, explains that, “Successes in malaria control have been substantial. Mosquito-net coverage in 20 African countries is at least five times higher today than in 2000, leading to significantly fewer cases of disease and death.”

While some places like Zanzibar in Tanzania and Rwanda have made serious incursions in malaria morbidity and mortality by concerted efforts at LLIN and malaria medicine distribution, others are facing challenges to meeting the 31 December 2010 goal. Nigeria has completed its mass distribution in only about one-third of its states, and Burkina Faso is still awaiting shipments of the LLINs.

Even when the nets arrive and are distributed, we still need to be vigilant.  Aside from hanging up the nets and sleeping under them in one’s normal place of residence, we also need to be concerned about population movement.

Researchers from the University of Michigan found that, “The greatest risk factor for a child living in an urban area in Kenya was whether the child spent at least one night a month in a rural area. Those children were nine times more likely to contract malaria.”

Movement between rural and urban areas in Africa is quite normal as extended family members are divided between the two areas. Although urban areas are often more hostile to anopheles mosquito breeding and have variable malaria micro-environments, urban residents definitely get exposed to malaria-bearing mosquitoes when they return ‘home’ to the rural village for ceremonies and holidays. It is not uncommon to send children to stay with village grandparents during school breaks and vacations.

These children would not have acquired any malaria immunity in the city. Travel history is an important part of investigations when these children are back in the city and become sick.

The question arises – are there enough LLINs in the villages to accommodate these temporary visitors and protect them from malaria?

Guinea worm elimination efforts faced similar problems – people may have a well or a cloth filter at their main residence in the village but not at their farm hamlet/settlement. Were they to expected to carry their filters back and forth, possibly leaving from family members exposed to infested water supplies at one location or another, or be given at least two filters – one for each residence? Likewise, can we expect people to carry their nets around?

These may seem like insignificant questions when countries are still grappling with just getting and distributing enough LLINs to achieve universal coverage in the next 153 days, but ultimately for elimination to succeed, every case counts, and every preventive effort must be made.

The nomadic Maasai people of East Africa are certainly not immune to malaria. Research by Bussmann and colleagues shows a wealth of ethnomedical responses to the problem and points out that, “The Maasai pastoralists of Kenya and Tanzania use a large part of the plants in their environment for many uses in daily life.” Specifically, they reported that …

“Although malaria treatment is often available at health centers, the traditional use of herbs for the treatment of ‘malaria and fever’ is still common. The cures mostly involve the ingestion of purgative plant extracts, obtained by boiling plant material. In the Sekenani valley the most important species used to treat malaria were Achyranthes aspera, Warburgia salutaris, Combretum molle, Olea europaea, Sporobolus stapfianus, Teclea nobilis, Toddalia asiatica and Cissus quinquangularis.”

Likewise Koch and co-researchers learned from three Maasai healers the names of 21 indigenous herbs used to treat malaria. “Of the species tested, over half were antiplasmodial, and all but one displayed selectivity for the malaria parasite Plasmodium falciparum.”

A new NGO, Maasailand Health Project (MLHP) based in Washington State, USA, is trying to bring current anti-malaria technologies to a Maasai community in Tanzania. The project focuses on six boma or villages in an approximately 200 square mile area in which nearly 500 people live. MLHP’s “first shipment of 100 nets, 50 blood test kits, 30 treatments of medication, and training,” took place last month.

The group has been in touch with USAID and the Tanzanian Ministry of Health, so hopefully this effort can be integrated with the overall national malaria control program and thus be sustained. Integration of programming for nomadic people is crucial since none of the currently operating Global Fund malaria grants in either Tanzania or Kenya explicitly mention outreach to the Maasai.  The US President’s Malaria Initiative Malaria Operations Plans for both countries are also silent on the needs of the pastoralists.

Unfortunately Kenya’s unsuccessful Global Fund Round 9 malaria proposal intended to involve the Maasai Pastoralist Development Foundation. “This organization has an extensive community network which will be mobilized as part of BCC-Community Outreach. Its capacity will be built through the dual track PR as part of Community Systems Strengthening.”

National and cross-border malaria control efforts need to plan for and finance efforts to protect nomadic, migratory and minority populations from malaria. Without attention to the needs of these populations, malaria cannot be eliminated.

Malaria – a disease without borders. That was the theme of World Malaria Day in 2008.  What does this mean in practical terms?  There are definitely countries that share mosquito breeding sites on their borders, but it is the human movement across borders that has caused concern recently in Malaysia.

The New Straits Times reports from KUALA LUMPUR that, “Migrant workers, many of whom are here illegally, are the source of the spread of malaria in six states.” The Health minister is quoted as complaining that, “‘In some of these states, the increase in cases is due to migrant workers, many of whom are illegal, coming from countries where malaria is still endemic …’ In addition, he said, these workers were mobile and posed a challenge to the ministry’s efforts to ensure they completed their treatment.”

A different aspect of migration also threatens our ability to control malaria – brain drain. AllAfrica.com shares a story from Burkina Faso: “UNESCO is expanding a scheme that aims to slow the brain drain of African and Arab researchers by giving them access to global scientific networks and computing power.” Additionally, “UNESCO and Hewlett-Packard say they plan to include 100 more universities in the scheme by the end of 2011, with help from additional partners.”

Although the article does not address malaria directly, similar efforts by the international research community to strengthen endemic country research capacity hope to enable African researchers to contribute directly on the ground to solving their countries’ malaria problems. For example, see the work of the Malaria in Pregnancy Consortium.

The timing of these migration concerns – whether illegal migrants entering a country or high level brainpower departing – coincide with the observance this month of the tenth International Migrants Day. This observance recognizes the “human rights and fundamental freedoms of migrants.”

Migration is a basic reality of human existence. We should not blame migrants for the challenges posed by malaria but acknowledge, if we are to eliminate malaria world-wide, that migrants need access to basic malaria control services, whether they come to Malaysia, Guyana or Kazakhstan.

We should also realize that the issue of migration and malaria shows how intertwined the control of the disease is with national development. By improving employment opportunities, health systems and research capacity in malaria endemic countries, we might stem the tide of some migration and enable all levels of the national workforce to contribute in their own ways to controlling malaria at home.

The New Vision of Uganda reports that according to the 2009 Human Development Report, “THE majority of Ugandans who migrate to other countries are among the higher educated group. And those who migrate, whether within their own country or abroad, are doing better in terms of income, education and health than those who stayed where they were born.”

Health workers are among those educated emigrants, but the factors behind their movement are complex.

Citing the case of health workers deserting Africa, (the World Development Report) explains that this is being caused by poor staffing levels and poor public health conditions. “Migration is more accurately portrayed as a symptom, not a cause, of failing health systems.”  It notes that improving working conditions at home might be a better strategy to stop the brain-drain than restricting emigration.

The Canadian Medical Association Journal explains the problem thus:

You can’t force someone to stay and attempt to work in a place that  is lacking even minimum provisions for them to do their job. “If you tell them they can only hand out band-aids and aspirin, no  one will stay,” says Dr. Otmar Kloiber, secretary general of the  World Medical Association. “People should have the privilege to  migrate. For medical workers it’s important to have exchanges in  order to learn and to work. You can’t put someone on a dead end road and ask them to build a health care system.”

WHO also reminds us that health workforce maldistribution and migration occurs within countries, too. “Approximately one half of the global population lives in rural areas, but these  people are served by only 38% of the total nursing workforce and by less than a  quarter of the total physicians’ workforce.” Health workers locate in urban centers to gain greater economic, educational and social opportunities for themselves and their families.”

The loss of health workers is a major impediment in implementing malaria coverage targets and making progress toward disease elimination even when malaria commodities are provided in adequate amounts. More generally, WHO notes that, “Without available, competent, and motivated health workers, the potential for  achieving the Millennium Development Goals, and for effective, efficient use of  the financial and other resources committed to achieving the Goals, remains  extremely limited.”

The solution, according to the comments above is not simply finding more people to deliver malaria services in isolation, but ensuring that malaria control services are integrated into a well functioning health system. Donors who provide malaria and other health and development support are also cautioned to become aware of how their own programs, policies and activities can disrupt the health workforce in the countries receiving aid.

In Guyana Stabroek News reports that, “Minister of Health Dr Leslie Ramsammy has thrown down the gauntlet to pharmacies to desist from selling the single dose artemisinin malaria drug by the end of this year or he would instruct officers from the Food & Drugs Department to size the drug from their shelves.” Guyana has been promoting ACTs since 2004.

In Guyana, the coastal areas are considered to be malaria free while the interior areas are considered to be high-risk malaria areas. Guyana therefore, may not me among the most endemic countries for malaria, but all endemic countries need to take the disease seriously, like Guyana’s Minister of Health, in order for global elimination to succeed.

Guyana has seen success in promoting malaria control. In endemic areas bednet use by children under 5 years of age increased from 7% to 70% between 2000 and 2006, according to the Multiple Indicator Cluster Survey.

Guyana’s Round 7 Global Fund proposal also aims to decrease malaria incidence by 70%. Included in the strategies are diagnosis and treatment with the intention that all health facilities (including the private sector) would be appropriately trained and equipped with microscopes and have adequate amounts of drugs and rapid tests. This is why the need for appropriate treatment with ACTs, not monotherapy drugs is being stressed.

As we have mentioned before, Guyana’s malaria control efforts are complicated by migrant miner populations in the endemic areas. It is such populations that may help drive the demand for cheaper, though inappropriate malaria medicines like artemisinin monotherapies.

An interesting irony is that WHO lists Guyana among the 16 countries that have never registered artemisinin monotherapy drugs. This implies that the availability of such medicines in Guyana is truly against the law and also shows how slippery the pharmaceutical import business can be.

WHO as of 16 November 2009, lists 33 endemic countries as not taking adequate steps to stop the sales of monotherapy artemisinin drugs.  Another 29 have “taken regulatory measures to withdraw the marketing authorization of oral artemisinin-based monotherapies after implementing ACT policy.” The approach of these 29 does not mean the immediate withdrawal of monotherapies, as some like Nigeria are simply letting the current registration of these drugs run out – meaning they may be on the market for another 2-3 years.

Unless all endemic countries take action like that proposed in Guyana, we may not be proceeding along the pathway to elimination, but down the road to drug resistance.

The Americas have the lowest rates of malaria among the major endemic areas of the world. So when concerns are raised that Guyana may not be able to keep its total cases in 2009 below 10,000, countries like Nigeria, Tanzania and DRC may wonder what the fuss is all about. We must remember therefore, that for malaria eradication to succeed, the disease must be eliminated in EACH endmic country, no matter how few the number of current cases appears to be.

Success in Guyana has been mixed, with great reduction in some target communities, but now “There are areas in the country which did not have a problem now, but are not recording measurable and or moderate levels of malaria.” In the Omai area, “hundreds of small miners have appeared on the scene.” They are not paying attention to environmental control, but instead are responding to the increasing price of gold on the world market.

Guyana has received Global Fund grants from Round 3 and 7 for malaria control. Though the country has around three-quarters of a million people, the proposals focused on the more endemic regions. For example, Regions 7 and 8 are populated mostly by a little over 20,000 Native American peoples. These regions have also been inundated by another 20,000 informal miners and loggers.

The GFATM performance report on case management in the Round 3 grant shows that while appropriate malaria drugs are available in all target communities, actual appropriate treatment of vivax and falciparum malaria hovers around only 60% of cases. (Round 7 was signed only in May 2009 so a detailed progress report is not yet available.)

Community participation indicators also show high marks, but then one needs to consider that the non-indigenous miners and loggers may not really be part of a community.

The 2006 Multiple Indicator Cluster Survey found that sleeping under bednets by children under five years of age increased from 6.5% to 70% between 2000 and 2006. Of course this leaves open the question of whether adult migrant miners are using nets and are harboring the disease. Palmer and colleagues describe one typical mining camp in this region –

The mining camp … was approximately 400 km inland from Georgetown, the capital of Guyana, in the heart of the Amazon region of the country. It was typical of many of the mining camps in the jungle. Men sleep in rows of 20 to 40 hammocks strung underneath a large tarp-like covering. The tarp coverings are not enclosed, but the men usually sleep under mosquito netting, as malaria infection is a constant problem.

If Guyana is to meet its 2012 target of only 8,000 annual cases of malaria some serious thinking is needed about strategies to reach the diverse populations in the endemic regions.  The indigenous peoples have their community structures, and it appears that these have been reached.

The challenge then is to distinguish the other residents of these endemic regions and organize malaria control activities that will be appropriate to their social context, recognizing at the same time that their mining practices may be detrimental to the environment and the elimination of malaria.

Mobile population importation of drug-resistant infections and diseases is a focus of the November 2009 issue of Emerging Infectious Diseases. In that issue, MacPherson and colleagues cite, “Many examples of imported multidrug-resistant (MDR) infectious diseases are associated with migrant populations, e.g., MDR Plasmodium falciparum malaria in immigrants, tourists, and returned foreign-born travelers.”

Parasites travel –

• According to Monge-Maillo, malaria accounted for nearly 10% “of 2,198 immigrants referred to the Tropical Medicine Unit of Ramón y Cajal Hospital over a 20-year period” in Spain.
• “CDC received reports of 1,324 cases of malaria, including four fatal cases, with an onset of symptoms in 2004 among persons in the United States or one of its territories. This number represents an increase of 3.6% from the 1,278 cases reported for 2003,” as reported in MMWR by Skarbinski and colleagues.
• In the Netherlands 5043 laboratory cases of imported malaria were confirmed between 2000 and 2003 according to Klein and Bosman.

The problem is worse when drug-resistant parasites travel. Chan and co-researchers have been examining archival human sera “to explore the origin and evolution of Plasmodium falciparum chloroquine resistance in the Pacific.”

In 2002 Afghan refugees brought malaria into northwestern Pakistan. They experienced a 28% treatment failure rate when chemically substandard locally manufactured sulfadoxine-pyrimethamine was used for routine treatment. This is a potential way of producing drug resistance that could be carried back home by returning refugees

MacPherson and colleagues demand what they call, “Pharmaceutical security systems for standard and quality medicines,” in an effort to combat “commonly substandard or counterfeit” drugs in endemic countries.  Progress in eliminating malaria in Zanzibar, Rwanda and Zambia can easily be threatened if resistant parasites cross their borders. These parasites don’t need passports and visas.