Tropical Health Matters

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.

Rwanda’s First Malaria Forum has just concluded in Kigali, producing recommendations to help the country, which is already experiencing very low levels of malaria transmission, develop strategies for the path to malaria elimination. After a series of informative talks other countries in the region and international support organizations, working groups distilled the learning from the forum into suggestions for strategic planning. Below we present the deliberations of the Working Group on Surveillance, Monitoring and Evaluation. Group members included Irenee Umulisa, J. Bosco Ahoranayezu, John MacArthur, Arielle Mancuso, Aafje Rietveld, Eric Tongren, Anna Winters.

Preamble: A paradigm change is necessary within the national malaria surveillance system in order to take Rwanda from the stage of malaria control to pre-elimination. Stratification (epidemiological, entomological and environmental) will be used as the basis for applying different programme approaches in the different parts in the country, including surveillance approaches. In high burden strata, the quality of malaria control surveillance will be optimized. In low endemic strata, WHO recommended elimination surveillance approaches will be piloted and gradually introduced to field-try forms & procedures and build systems capacity.

Goals and Vision: By 2017, every febrile patient on the Rwandan territory will visit a health facility within 48 hours for diagnosis and treatment. Under 5s will be treated at community level within 24 hours. A microscopy and RDT quality assurance system (including external quality control) will be in place, ensuring reliable diagnosis at all diagnostic facilities. Every malaria case diagnosed with RDT and treated at community level will be reported to the health center level within 24 hours, accompanied by a microscopy slide for confirmation of diagnosis.

All malaria cases will be reported into one centralized HMIS, irrespective of the health providers who diagnosed and treated them (public, private, community, army, etc.) and irrespective of the way they were detected (ACD, PCD, surveys).

Health centers in low and moderate malaria burden strata will carry out “enhanced malaria surveillance” allowing foci investigation and classification. Health centers in endemic areas will forward line-listings of patients (ideally also with information about recent travel) to the district level with copy to the central level on weekly basis. Central level will compile from these data weekly updated mapping by village level and track cases against epidemic thresholds.

Strategic objectives and action points:

By 2012, update the stratification map of Rwanda’s malaria burden by including data from HMIS, SIS-COM and any other sources of malaria patient data that may be available. The objective is to be all-inclusive: in malaria elimination every case counts. A more in-depth stratification using entomological and environmental variables and intervention coverage will follow.

• Merge SIS-COM (community) data collection with existing HMI
• Use the map to identify 3-4 zones for stratification of surveillance and intervention methods based upon malaria burden.

By 2013, develop/update the surveillance plan to direct the MOH malaria surveillance strategies over the coming 5 years within the changing epidemiological settings, with a view to (a) attain malaria pre-elimination programme status in low and moderate burden strata by 2017; and (b) maintain and improve upon the current control achievements in higher burden strata.

• Improve and coordinate data management and timeliness.
• Include a plan for human resources necessary to undertake enhanced surveillance.
• Include a timeline to achieve strategic objectives and action points.

By 2014, set up the systems to enable and ensure that all suspected malaria cases (100%) are diagnostically confirmed using available tools and in a timely fashion within both public and private clinics.

• Develop (guided by OR) for each strata a clear case definition of a suspected malaria case who should be tested, ranging from a broad definition (fever) in highly endemic areas to a more restricted definition (perhaps including a travel history or additional symptoms) in low endemic areas. Communicate these definitions to all health care providers and the public in the various strata. The purpose is to ensure that every potential malaria case is promptly tested, without unduly overburdening the health workers in low endemic areas.
• Monitor the use of antimalarials by various health facilities against the numbers of cases diagnosed and reported.

By 2015, pilot “enhanced malaria surveillance” in 1-3 low endemic districts

• In low and moderate burden areas, begin line listing all confirmed malaria cases including travel history and household location with the goal to map cases (2015-2017). Focus initial line listing and case mapping within Kigali or another accessible low burden district (2013).
• By 2014, engage the private sector physicians in Kigali for cooperation in malaria surveillance activities (working with the Rwanda medical association). Enforce full cooperation of the private sector by 2017. Restrict availability of antimalarial medicines to registered facilities with access to diagnostic capacity.
• In low and moderate burden areas, begin collecting weekly malaria data at the health facility level.
• Gradually include immediate notification and due programme follow up (investigation, classification) of cases detected, starting with one district where this seems doable.
• Explore business/private coalitions to support a longer term vision of a malaria-free Kigali / tourism areas.

By 2015, pilot line listing in one endemic district, increasing to all endemic districts by 2017

• Integrate training and data management into existing community health worker programs.
• Develop and deploy a system for active case detection (ACD) as part of case investigation at the community level.
• Map all confirmed cases which are passively and actively detected.
• Develop epidemic thresholds for comparison against weekly case loads.

By 2013, review and start to address the factors that contribute to malaria mortality in Rwanda.

• Conduct death audits for all reported malaria cases that occurred in 2012. The purpose is to identify risk factors for delays in treatment / inadequate treatment that can be addressed by NMCP programme interventions. Use this study to strengthen collaboration of the NMCP with the national school of public health (or equivalent) by engaging a team of university students / scientists in the study.
• Explore possibilities for increasing the use of pre-referral treatment with rectal artesunate, based on an understanding of the barriers and behaviours for accessing pre-referral treatment.
• By 2015, carry out death audits for all reported malaria deaths as they occur, to adjust and target programme interventions.

Continue drug and insecticide resistance monitoring to guide drug and insecticide policies.

Recommendations:

• By 2014, initiate “enhanced malaria surveillance” following WHO recommended strategies for the elimination phase in 1 low endemic district, increasing to 3 districts by 2015 and all low-endemic districts by 2017. This includes investigation, classification and mapping of cases and transmission foci.
• By 2015, institute line listing in one endemic district, increasing to all endemic districts by 2017.
• Encourage and facilitate information sharing among all partners in malaria control.
• Use available resources in a manner that allows continued high quality surveillance in endemic areas combined with gradual introduction of elimination approaches in low endemic districts. Adopt the philosophy of first building up enhanced surveillance systems and then expanding the system as resources and malaria burdens allow.
• Consider including Kigali within the first pilot districts for enhanced surveillance, given the low prevalence and focalized transmission patterns, and to encourage political will.
• Conduct death audits in order to measure progress towards the goal of zero malaria deaths.

Efforts to eradicate smallpox and guinea worm have taken generations.  In both cases there was a very clear and focal transmission pattern. Smallpox spread only among people and could be stopped with a very effective vaccine. Guinea worm again only infects humans and transmission can be stopped through safe water.

Unlike these other diseases malaria has no one silver bullet and transmission dynamics vary across many different environment types.  At present case containment that was successful in ending smallpox and is effective in guinea worm, is out of the question for malaria.  Malaria must deal with huge health systems challenges ranging from weak procurement and supply management systems to health workforce shortages.  Peak efforts at malaria control have also unfortunately coincided with a world economic downturn.

Documentation of malaria control progress is ongoing, if not perfect. A look at indicators from three national DHS/MIS surveys in Uganda make it possible to show how difficult it is to achieve and sustain coverage of the interventions we do have. To date the Roll Back malaria targets of 80% have not been achieved for any indicator, and in the cases of using insecticide treated nets (ITNs) and intermittent preventive treatment in pregnancy (IPTp), there have been drops.

There are a number of ways to measure indicators.  For example, the figures for people who slept under any kind of net are better than those using only ITNs. On the other hand, if we used the data on taking Artemisinin-based combination therapy (ACT) within 24 hours of fever onset, then the figures would be worse.  Of course these figures do not even include whether treatment occurred after a positive rapid diagnostic test.

What we can see is that even with a little more positive nudge, the data are not encouraging.  The guinea worm eradication effort has shown that stakeholders do tire of maintaining disease control efforts year after year.  Many endemic countries are still much too dependent on external assistance to go it alone in eliminating malaria. What will it take to get malaria control and elimination back on track so we can achieve zero malaria deaths by 2015?

Currently the Roll Back Malaria (RBM) Partnership’s Malaria in Pregnancy Working Group is meeting in Kigali, Rwanda. Seven country teams present have presented their progress and challenges, including most recent information on coverage/use of long-lasting insecticide treated nets (LLINs) and intermittent preventive treatment for pregnant women (IPTp).  Other working group members have also presented coverage data from other countries.

Two main challenges emerged. First, for the most part stable endemic countries that are using IPTp and reporting recent levels of coverage for this and for LLINs are hardly reaching the 2010 RBM targets of 80%.  The second challenge is that some countries have actually recorded recent drops in IPTp coverage.

Group members presented experience and research that help explain these challenges.  Coverage with the minimum two doses of IPTp has been hampered by the following:

• periodic stock-outs of sulfadoxine-pyrimethamine (SP) supplies
• complexity of the steps involved in providing IPTp properly as directly observed treatment at antenatal clinic
• poor dissemination of national malaria in pregnancy (MIP) policies and guidelines
• inconsistencies in IPTp guidelines between malaria control and reproductive/maternal health service units
• lack of coordinated planning between those two units

The second problem, as seen in the chart to the left may be due to the above mentioned factors, but also imply more serious health systems problems. SP has become a forgotten step-child in the essential medicines portfolio.  Once reduced treatment efficacy was observed with SP, countries began switching to artemisinin-based combination therapy (ACT) for case management. SP was, according to meeting participants, still efficacious for prevention, but the formal health sector has not always responded by keeping it in stock.

In fact the private sector still stocks SP because customers demand this cheaper alternative to ACT, even though such unregulated use may add to the problem of parasite resistance.  Also donor programs, recognizing that SP is relatively cheap, often rely on endemic countries to purchase their own SP stocks, which some are reluctant to do.

IPTp saves lives in countries with stable malaria. The pregnant woman herself may not ‘feel’ the results of malaria that is concentrated in her placenta, but the fetus is deprived of nourishment and may be spontaneously aborted, stillborn, or born with low birth weight that increases the likelihood of neonatal mortality.

The 2012 World Malaria Day Theme of Sustain Gains, Save Lives: Invest in Malaria, could not be more timely in light of the charts seen here.  First we still have to make the gains in many countries, especially in respect to protecting pregnant women.  We need to sustain gains, not backslide.  This can only be done if donors and health ministries continue to fund MIP control activities and health program managers in both malaria control and reproductive health sincerely collaborate.

We recently suggested that malaria elimination efforts learn from guidelines and manuals developed for the elimination of lymphatic filariasis. Today at the American Society for Tropical Medicine and Hygiene meeting, a presentation from the South Africa National Department of Health and its partners outlined how they are “Strengthening Malaria Information Systems in South Africa: Moving Towards Elimination.”

The presentation stressed that, “locally transmitted malaria cases have declined by 92% and malaria deaths have declined by 82% in 2010 as compared to 2000.” This serious drop in malaria cases is spurring the need recognize the transition from control strategies to efforts appropriate to the pre-elimination phase.

Currently malaria is endemic in only 3 provinces, Kwazulu Natal, Mpumalanga and Limpopo, with over 90% of cases in the latter. Thyere is a lack of standardized malaria information across these three provinces, absence of timely notification and lack of information that could aid targeting of interventions.  The national program is addressing this by identifying seven key components of an information tracking system that focuses on –

1. Rapid Diagnostic Tests
2. Geographic Information System
3. Parasitology
4. Entomology
5. Indoor Residual Spraying
6. Case Investigation
7. Notification

The three provinces have some but none has all of these embedded in a comprehensive and systematic information system that does more than track epidemics.  In addition there is emphasis on ensuring adequate human resources to undertake these tasks.

South Africa recognizes that political and financial commitment is needed in the country. There is a realistic expectation that the country cannot depend on donors to sustain their malaria information system.  Hopefully these efforts will also be adopted by the other front line malaria elimination target countries in Southern Africa.

Sessions at the current American Society of Tropical Medicine and Hygiene in Philadelphia have focused on progress in the global elimination of lymphatic filariasis (LF). Filariasis and malaria have some elements in common, such as some mosquito vectors, and possibly malaria elimination efforts could learn from LF elimination.

The duration of a typical filariasis elimination program might span around 10 years, much shorter than expected for malaria, where Roll Back Malaria has already been working hard for 13 years. Even with this difference LF elimination has important surveillance tools needed for the end game that can be adapted for malaria. As the figure here shows, the first step is mapping which can take at least a year.

Then there are at least five annual mass drug administrations (MDA) with ivermectin or DEC and albendazole.  Monitoring goes along with distribution, and as pointed out at a panel presentation at ASTMH, determines whether the program can enter Step 3 (three rounds of annual surveillance) or complete a few more MDA rounds.  Eventually the project site is certified as having eliminated filariasis.

An ASTMH symposium highlighted the challenges: “The decision to implement a mass drug administration (MDA) program for LF is based on convenience sampling to demonstrate that the prevalence of infection is greater than 1% in a selected district or implementation unit. Making the decision to stop MDA has been a challenge for countries,” when prevalence drops below 1%.

Fortunately those involved in LF have tools and guidelines to focus their efforts. These guide initial mapping and choice of diagnostic tools, ongoing program monitoring and endline Transmission Assessment Surveys (TAS)  The purpose of the guidelines is …

“Effective monitoring, epidemiological assessment and evaluation are necessary to achieve the aim of interrupting LF transmission. Th is manual is designed to ensure that national elimination programmes have available the best information on methodologies and procedures for (i) monitoring MDA, (ii) appropriately assessing when infection has been reduced to levels where transmission is likely no longer sustainable, (iii) implementing adequate surveillance aft er MDA has ceased to determine whether recrudescence has occurred, and (iv) preparing for verifi cation of the absence of transmission.”

The guideline manual provides general guidance to national programmes but reminds program managers that each program is unique and may require further technical guidance.

Several countries, especially in the Asia-Pacific Region and Southern Africa are working toward malaria elimination. Such tools adapted to malaria program needs are required. One of the challenges for the TAS is that while countries have received donations of medicines to eliminate LF, they have found it harder to find or allocate funds to do the necessary surveillance to know when to stop interventions and verify elimination. This also rings true for malaria – donors and governments should not stop funding malaria elimination until certification has been achieved.

The publication this week by African Leaders Malaria Alliance (ALMA) of progress reports of African nations toward controlling and eliminating malaria and other maternal and child health problems has been both enlightening and helpful for advocacy and planning.  If one combines these data with reports by the Roll Back Malaria Partnership (RBM) on progress towards country Roadmap targets, a good picture emerges of the steps needed to reduce malaria deaths by 2015.

The time frames of the two indices are different – RBM is looking at overcoming gaps laid out by national malaria programs in 2010, while ALMA – but they are close enough to highlight the main logistical, process and input challenges facing endemic countries. The ALMA scorecard does have one outcome indicator – operational coverage of long lasting insecticide-treated nets (LLINs) – but one needs to consult surveys such as the Malaria Indicator Survey to get more accurate coverage data, and such surveys are scheduled less frequently.

Several key issues arise from these two reports.  For example, the ALMA Scorecard shows that eight countries do not have a policy that enables community case management of malaria, a strategy that is essential for achieving universal and timely coverage of malaria treatment. Though not indicated clearly, such a policy should include the use of rapid diagnostic tests (RDTs) and the community level.

Sixteen countries do not have full funding for purchasing the RDTs they need. RDT supply problems also appear in the RBM Roadmap analysis. Eighteen countries lack full financing for their LLIN needs.  Unfortunately, if not enough funding is available to achieve universal coverage now, what will happen in three years when most of the recently distributed nets may need replacing?

Of course there are hopeful signs. The Scorecard shows that ten countries have reduced malaria deaths by more than 50%, and another seven have made substantial progress. It is unfortunate that the remaining countries are left blank implying that there are inadequate data to make such calculations.  We will have trouble eliminating malaria is our monitoring and evaluation systems cannot measure progress towards our goals.

Hopefully such tools as the Roadmap analysis and the Scorecard will spur some friendly competition among malaria endemic countries in Africa that will save more lives and boost national economies.

If target dates were realistic, there would have been no more guinea worm in the world as of 1995. As it stands today …

“Ghana appears to have broken Guinea worm transmission! With 7 consecutive months of zero cases reported since May 2010, and 14 months after reporting its last known uncontained case in October 2009, Ghana might have conquered Guinea worm disease! Surveillance continues while the Guinea Worm Eradication Program waits and watches. Currently, only four countries continue to report cases of Guinea worm disease: Southern Sudan, Mali, Ethiopia, and Chad.”

Sixteen years after the supposed eradication date approximatelt 376 cases were documented in the first four months of 2011.

Even the famous smallpox eradication effort could not achieve its targets until a paradigm shift occurred that changed intervention approaches from from maintaining high vaccine coverage to case containment that focused on outbreaks – vaccinating in a radius around cases until the disease disappeared.

Another set of goals – 80% coverage with key malaria interventions by the end of 2010 – has come and gone. The country with the largest burden of disease, Nigeria, was able to achieve around 67% of its insecticide treated bednet distribution target by 31 December 2011, let alone actual use by 80% of the population.  Nigeria is not alone in this situation.

The website, Global Atlanta, headlines that “U.S. Works to End Malaria by 2015”. While not technically true, the headline is followed by the actual goal – “The U.S. government is leading the way in ending malaria-related deaths by 2015, the head of the President’s Malaria Initiative said at a youth leadership conference organized by Usher’s New Look Foundation.”

The 2015 date refers to the Millennium Development Goals. Many countries find themselves lagging in in the interrelated MDGs (see picture). Our ability to reduce malaria mortality (if not morbidity) depends so much on health systems issues – procurement, supply, distribution, access, and use.

We have to be careful with public goal statements lest we create and then deflate expectations, with the unwanted side-effect of scaring away donors and national financial commitment.  Goals are a public relations tool – just be careful that they are realistic and don’t backfire.

Surprise – the latest in the Rupert Murdoch scandal concerns malaria.  Yesterday Metro Online headlined a story: “Cheryl Cole’s ‘phone hacked while she was suffering from malaria.'”  The claims are still at the level of rumors, and thus investigators are still “looking into claims that her voicemails were hacked while she was hospitalised.”

A year ago when Ms Cole’s bout with malaria hit the news, The News of the World was mentioned as a source. One online posting noted that Ms Cole, “is believed to have lost half a stone during her battle with malaria. A source told the News of the World that the Girls Aloud beauty is now just over 7 stone. The insider told the newspaper that medics have said that it could be six months before Cole is allowed to perform her strenuous dance routines.”

Similarly another website reported last year that, “A source told the News of the World: “We nearly lost her and the battle is far from over. She is so weak and this horrible illness has taken complete hold of her. ‘It got so bad she was literally only hours from death’s door. Thank goodness she was diagnosed in time.'”

Now a year later MTV UK published that, “Cheryl’s lawyers are investigating claims by a former News of the World journalist, who stated that the Geordie’s voicemails were listened to “while she underwent treatment for malaria.”

Fortunately most use of mobile phone technology these days helps promote malaria control and elimination. In Nigeria for example, mobile phone SMS has been used to track bednet distribution.  A UNICEF spokesperson who is involved in promoting such innovations explained that …

In Africa, we are finding there are systemic failures in public health and supply in terms of getting reliable information quickly from the field. Ninety percent of the developing world has access to a cell phone, so we’re experimenting with the use of instant messaging to make a difference. We’re finding that we can train people in villages to be data collectors and help us by using cell phones to text information to central authorities; we and governments can then respond faster to specific needs. In some places, it takes months just to get a piece of paper from the field. Mobile phones and SMS technology can help surmount that hurdle.

Recently the Business Standard reported that, “The University of Glasgow has received a grant from the Bill & Melinda Gates Foundation to further help in the diagnosis of malaria. The $100,000 award would go towards developing a device which uses mobile-phone derived technology to detect and separate red blood cells infected with malaria parasites.”

A study by Caroline Asiimwe and colleagues in Uganda has shown SMS improves the timeliness in reporting of specific, time-sensitive information on RDT positivity rates and ACT stockouts at modest cost, while by-passing current bottlenecks in the flow of data. Likewise in Tanzania “A multinational computer, technology and IT consulting company, IBM, in partnership with Novartis and Vodafone, together with Roll Back Malaria and Tanzania’s Ministry of Health and Social Welfare have reaped from the technology dubbed ‘SMS for Life’. The system tracks movement and the supply of anti-malaria drugs in sub-Saharan Africa.”

People have argued that technology itself is ethically neutral – it is how people use it that has ethical ramifications. In the case of malaria hopefully we will see more uses that help save lives instead of illegally spying on and disrupting them.

Todd Jennings of MACEPA (Malaria Control and Evaluation Partnership in Africa, PATH)
and the National Malaria Control Centre, Lusaka, provides us with an update on the newly completed Malaria Indicator Survey from Zambia.

Earlier this month Zambia’s Ministry of Health released results from their 2010 National Malaria Indicator Survey (MIS).  The full report, summary and technical brief are available on the National Malaria Control Center website.

Zambia is the first African country to have conducted three of these surveys, continuing a trend in benchmarking progress and providing evidence for decision makers to guide malaria control needs.  First the good news:

• The use of insecticide-treated mosquito nets increased for children under the age of five increased to 50%, and to over 60% in household that owned nets in 2010.
• Over 70 percent of Zambian households are now covered by at least one treated mosquito net or recent indoor residual spraying.  This represents a 69 percent increase since the 2006 survey.
• Pregnant women are more protected from malaria with 70% receiving at least two doses of preventive anti-malarial medicine during pregnancy.
• Among children using anti-malarials for treating fever, more children are receiving Coartem®, the first line treatment for malaria, rising from 30% in 2008 to 76% this year.

These figures are among the best in Africa. Better diagnostics nationwide, especially with rapid tests to confirm malaria parasitemia, mean fewer patients with symptomatic fever are being given anti-malarial drugs and more receive better treatment counseling based on the rapid and accurate results.

But these encouraging figures are tempered with news that Luapula, Northern and Eastern Provinces reported higher levels of malaria and severe anaemia.  This can partly be attributed to heavy, late rains that possibly extended the length and intensity of the transmission season and partly because net ownership and use of nets in Luapula and Northern Provinces saw a marked decrease since 2008.

The MIS is a powerful tool needed to maintain predictable funding streams to sustain levels of commodity coverage.  Gains are fragile; any interruption in supply, e.g. bednets, can quickly result in a malaria comeback.  Zambia and partners are already taking steps to address the country’s gap in bednet coverage. Other countries could benefit from more timely surveys and stronger partnership responses.