Tropical Health Matters

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.

The Uganda Malaria Indicator Survey for 2009 is now available for reading. The report helpfully provides charts that distinguish levels of key indicators from the 2006 Uganda Demographic and Health Survey with the current data. While there has been clear progress, most indicators fall below the 80% targets set by the Roll Back Malaria Partnership for 2010.

The chart of the right shows that sleeping under any insecticide treated bed net the night prior to interview tripled for children under five years of age and quadrupled for pregnant women, the 2009 levels do not achieve RBM goals.  Even when one looks only at households that actually possess these treated nets, one finds that use is less than ideal.

The report provides some reasons for low net usage…

The most common reason cited for non-usage was that the net was not hung (58 percent of households), especially in North East region (99 percent). Sixteen percent reported that the net was not used because it was too hot, and 11 percent said the net had too many holes or was too old.

There were also wide variations in ownership and use across different parts of the country, meaning that program managers need to look more indepth at possible regional factors that discourage access to and use of nets.

The East African countries were among the pioneers to introduce intermittent preventive treatment with sulphadoxine-pyrimethamine for pregnant women.  Again we see that RBM targets are far from being met in Uganda, although progress over 2006 is evident.

• 16% of pregnant women got two doses in 2006
• 45% got one dose in 2009
• 32% got two doses in 2009
• 95% of pregnant women attended ANC with a skilled provider at least once in 2009

Clearly problems of procurement, supply and stock keeping and missed opportunities are preventing achievement of this goal.

The malaria case management picture was not cheering. Among children under five years of age with a reported fever in the two weeks before the survey …

• 60% took any antimalarial drug
• 23% of took an ACT
• 14% took ACT same or next day
• Chloroquine and SP were still being used

Uganda is not in a unique situation. Even countries benefiting from the Global Fund, the US President’s Malaria Initiative and other major partners like Unicef, DfID and the WOld Bank are having a challenging time with managing commodities, improving service quality and attracting clients to avail themselves of malaria services.

2010 ends in 17 days. How many places will have achieved the RBM 80% targets? More importantly, what can the international partnership do to meet the needs?

The Center for Global Development developed a Millennium Development Goal trends report to coincide with the MDG Summit this week. The Report explains that …

The MDG Progress Index includes only 8 of the 60 progress indicators tracked and reported by the United Nations (see appendix I for complete list). We selected these 8 core indicators due to their (1) accuracy in capturing the original Millennium Declaration goals; (2) data availability; and (3) usage in the development literature.

The authors “… excluded … five malaria indicators because of the lack of available data – especially for baseline years.” Ideally the baselines should have been around 1990.  It was not until around the time that the Roll Back Malaria Partnership was formed that there was agreement on malaria indicators to be tracked and their actual measurement was done.

One of the excluded indicators was, “Proportion of children under 5 sleeping under insecticide-treated bednets.” Out of interest we examined DHS reports from three countries where ITN use was reported – Ghana, Nigeria and Zambia – as seen in the charts below with 2002/03 and 2008 information available.

These three countries present very different pictures, but none were approaching the 2010 RBM target of 80% coverage during their 2008 surveys.  Nigeria with the highest burden in sub-Saharan Africa was the farthest and had made the least progress. Zambia is said to be among the best performing countries and yet it was just a little over halfway to the 2010 target in 2008.

Maybe the move toward Universal Coverage will produce some major jumps in these indicators. But already some countries like Ghana have had to re-evaluate the feasibility of the 31 December 2010 Universal Coverage target due to net procurement challenges. Ghana now is aiming for 2011 to ensure there is at least one LLIN for every two people.

We may not have perfect data to track all MDG indicators, but we should use what is available to aid the planning and decision making to reach targets and sustain them.

Not all fevers are malaria. This should not be an earth shaking statement, but national treatment guidelines in malaria endemic countries often stress presumptive treatment for malaria, especially when children present with fever. Irin explains that even the World Health Organization has been hard pressed to recommend otherwise when accurate parasitological diagnostic resources are unavailable.

The concern about over-diagnosis of malaria is hitting home though because the current first line treatment, artemisinin-based combination therapy (ACT) is quite expensive, and additionally, health experts are concerned that overuse or misuse of these drugs may foster parasite resistance. To make this point even stronger Peter Gething and colleagues found that, “Of the 183 million children with malaria symptoms treated by public health clinics in 2007, only 43 percent were diagnosed with malaria, but many more most likely received anti-malarial medication (IRIN News).”

A variety of febrile illnesses, especially from mosquito-borne diseases, occur in the same community. A news report from Vapi, India states that, “During the (previous week), 13 cases of chikungunya, six of dengue and 25 of malaria have been reported from in and around Vapi with Nehru Street being the most affected. The outbreak of mosquito transmitted diseases has made the health officials in the district rush to the city to initiate measures for vector control.”

A serological-epidemiological household survey in Sudan after a yellow fever outbreak found, “serologic evidence of recent or prior chikungunya virus, dengue virus, West Nile virus, and Sindbis virus infections.”

Källander and colleagues stressed the challenges of clinical diagnosis to differentiate malaria and pneumonia and reported that, “Of 3671 Ugandan under-fives at 14 health centres, 30% had symptoms compatible both with malaria and pneumonia, necessitating dual treatment. Of 2944 ‘malaria’ cases, 37% also had ‘pneumonia’.”

Gething’s group did find that 72% of those febrile cases that actually were malaria were found in locations that had higher parasite prevalence. Possibly clinicians in more highly endemic areas can presume correctly more often that a fever is malaria, but this still does not stop the wastage of ACTs, which will continue until the parasitological testing gap is closed with adequate supplies of rapid diagnostic tests and microscopes (and the skills to use these).

Gething and colleagues stress the need for countries to develop appropriate strategies by adapting the statistical models they developed with more country based data. They sadly conclude that, “Unfortunately, inadequacies in national health management information systems across Africa are in part a cause of the present imperfections in essential  commodity demand and burden estimation.”

It would be even sadder if much of the treatment commodity supplies distributed in 2010 to achieve universal coverage of malaria interventions were wasted on non-malaria fevers.

RBM’s second report in the Progress and Impact Series provides us with the following data:

• Annual donor support for malaria control has increased dramatically (approximately 10-fold) between 2004 and 2009, estimated to have reached nearly $1.8 million in 2009
• Global production of ITNs has increased 5-fold since 2004, rising from 30 million to 150 million in 2009
• Six of the eleven countries with data collected in 2008 or 2009 showed >50% household ownership of nets, although the highest was 62%
• Averaging across 26 African countries (with 71% of <5 year child population), use of ITNs by children rose from 2% in 2000 to 22% in 2008

What do these figures tell us? First, money and commodities do not translate easily into indicators of success. Even household possession of the commodities does not guarantee use. And the best net coverage results achieved in 2008 or 2009 barely reach the RBM target of 60% for 2005, let along the 80% goal for 2010.

Some malaria community members have become cynical. “‘These are meaningless input measures that tell us only (the UN) is effective at spending other people’s money,’ said Philip Stevens, a health-policy expert at the London think-tank International Policy Network.”

C.Health also reports that, “Richard Tren, director of Africa Fighting Malaria, an Africa and US-based advocacy group, said measuring malaria spending and the numbers of drugs bought did not always mean more Africans had access to them.”

Obviously inputs are needed, but UNICEF reports that “available funds are still far short of the estimated $6 billion needed worldwide for effective malaria control in 2010.”

Partners are anxiously considering that the ‘Decade to Roll Back Malaria‘ comes to a close on 31 December 2010 and hope for success, but so far only Eritrea, Ethiopia, Equatorial Guinea’s Bioko island, Gambia, Ghana, Zambia, the Tanzanian island of Zanzibar and Sao Tome and Principe have scaled up malaria interventions and have observed marked reduction (30-95 percent) in morbidity and mortality indicators.

What can we expect from high burden countries like Nigeria and DRC where over a third of Africa’s malaria occurs? Nigeria is in the midst of distributing over 60 million LLINs, although there is still a gap of 9 million. Preliminary reports shared at a recent debriefing session on malaria progress in Abuja estimated that up to 25% of LLINs were ‘lost’ during distribution in one state.

Clearly nets produced for and acquired by countries is not the ultimate indicator we need to determine a decade’s success. We should not feel guilty about ‘spending other people’s money’ to eliminate malaria, but we should be accountable.

Since this year’s World Malaria Day continues last year’s emphasis on ‘counting malaria out’, we need to think about the availability of timely data to know if progress is being made toward universal coverage. The best bet for reliable and comprehensive information on coverage has often been the Malariaa Indicator Surveys. The challenge is that such national surveys are expensive, take time to analyze and do not give us the needed snapshot to help direct and redirect intervention.

Angola is a case in point. The last MIS was done in 2006. All coverage indicators – ITN use, ACT access and consumption and IPTp distribution were low. Since that time major donor input from the US President’s Malaria Initiative and Global Fund have help speed up intervention. We know challenges exist, especially from a logistical point of view, in getting services and commodities out to people, but at this point we cannot easily pinpoint areas that are in most need.

Another MIS is being planned for late 2010 or early 2011 in Angola, and this will certainly let us know how close we came to universal coverage. We know from experience that distribution of a commodity alone does not guarantee its use, but for the present we may have to rely on such distribution data as a proxy until the impact indicators can be measured.

Also it would help if all donors required and provided simply surveys as part of their grants – whether they be an oil company or a bilateral agency.  At least one could thereby learn more quickly on a province or district level what is working or not.

We cannot eliminate malaria unless we take counting seriously – in short without counting we will never know if we have reached our targets.

PS – we have been offline for the past couple weeks while our website is ‘migrating’ within the JHU system. We are still testing the result, hence this quick posting.

The 2009 World Malaria Report was launched with ‘cautious optimism.’  The WMR “found that the increase in international funding commitments (US$ 1.7 billion in 2009 compared to US$ 730 million in 2006) had allowed a dramatic scale up of malaria control interventions in several countries, along with measurable reductions in malaria burden.”

These figures represent a jump from only $0.3 billion in 2003. The improvements still fall short of the estimated $5 billion needed annually to reach Millennium Development Goals by 2015.

The WMR says that, “In countries that have achieved high coverage of their populations with bed nets and treatment programmes, recorded cases and deaths due to malaria have fallen by 50%.” The five countries referred to do not fit the overall picture of endemic counties where only 24% of children under 5 years of age had slept under an insecticide treated bednet and only 15% of such children had received artemisinin-based combination therapy to treat malaria.

With efforts to find more funds it “scale up for impact” by the end of 2010 in all endemic countries, a new large scale evaluation of child survival interventions appearing in the Lancet, awakens us to the need to be ‘cautious’ but maybe not ‘optimistic. The study evaluates UNICEF’s Accelerated Child Survival and Development ACSD program in Benin, Ghana and Mali that took place between the years 2001-05. ACSD package was supposed to include –

• Routine immunisation and periodic measles catch-up and mop-up
• Vitamin A supplementation to children twice yearly
• Distribution and promotion of insecticide-treated nets for children and pregnant women, and re-dipping of bednets every 6 months
• Intermittent preventive treatment of malaria with sulfadoxine-pyrimethamine for pregnant women
• Tetanus immunisation during pregnancy to prevent maternal and neonatal tetanus
• Supplementation with iron and folic acid during pregnancy and with vitamin A post partum
• Promotion of exclusive breastfeeding up to 6 months, timely complementary feeding
• Improved and integrated management (at the health facility, community, and family levels) of children with pneumonia† malaria, and diarrhoea
• Promotion of household consumption of iodised salt

Unfortunately mortality reduction in the ACSD districts did not achieve the 25% target, and in Benin and Mali there was greater reduction in the non-ACSD districts (Ghana did not have comparison data).  There was variability in introducing the package of interventions. Contextual factors such as worsening economic conditions at the community level and broad national level policy and programming technical assistance by donors may have affected outcomes.

A Lancet editorial concluded that, “The results of this evaluation do not match with the extravagant claims UNICEF made about the programme in 2005, but show potential for advantages if sufficient resources are directed to interventions addressing the major causes of death.”

The research team also observed that, “The analysis showed that child survival was not accelerated in Benin and Mali focus districts because coverage for effective treatment interventions for malaria and pneumonia were not accelerated, causes of neonatal deaths and undernutrition were not addressed, and stock shortages of insecticide-treated nets restricted the potential effect of this intervention.”

Instead of going away from their analysis discouraged, the researchers actually did take an optimistic view that such evaluations provide valuable lessons for improving service delivery.  Likewise a comment in The Lancet stressed that such large scale evaluation can, “create generalisable knowledge that can accelerate child survival by bridging the know-do gap.”

So what are the lessons of the ACSD evaluation for scaling up malaria control to reach the MDGs? Decreasing funding for fear of failure is certainly not an option.  Instead the evaluation study tells us to pay attention to how the funds are spent, to address structural and contextual barriers to effective implementation and coverage, and to ensure that there is enough funding for proper monitoring and evaluation to give us continual feedback for improvement.

TropIKA.net is one of the latest to comment on the World Malaria Report and data from specific countries that show a drop in malaria cases that are ‘believed’ to be a results of stepped up intervention. Zambia, which is reporting a 50% drop in cases, is contrasted with Sierra Leone where there is a reported increase coupled with malaria control program implementation challenges.

In another part of the world, often known as a seed bed for malaria drug resistance, an increase is also reported. In Cambodia …

Figures for malaria cases in 2009 are still being tallied, said Ministry of Health and World Health Organization officials, but are already higher than in 2008, when there were 58,887 cases and 209 deaths. In 2009, 60,157 recorded malaria cases led to 213 deaths from January through September.

In either situation – more malaria or less – the real question is how do we know?  Diagnostics, monitoring, documentation and evaluation systems are not strong yet in most countries.  Until these are improved we may not recognize malaria elimination when we achieve it – or worse, falsely claim victory.

The Herald of Zimbabwe reports that, “NEW vaccines for meningitis, hepatitis, malaria and diarrhea among other diseases that had no vaccines before are on the cards as the world moves to effectively reduce cases of infant mortality and morbidity in view of attaining the World Millennium Development Goals.”

The Herald’s article is using the common metaphor, “on the cards,” or as said in the US, “in the cards”, to refer to a predictable or likely future event.  In essence the article expresses expectations that new vaccines will be incorporated into national health programs in the near future.

The metaphor is likely based on the fact that cards, as in the kind used to play games or Tarot cards, have been used for centuries to divine the future. But there is another kind of card that is crucial for determining the success of health programs generally and malaria interventions specifically. That is the record card that shows the health services a client has received.

Unfortunately, malaria interventions are not always “on the cards” that one finds at public health service centers.  In Ghana, for example, the antenatal card (actually a small booklet) for pregnant women does have a place to write if she has received IPTp and the number of doses, but there is no official place to record whether she has been given an ITN.

The ANC cards in common use in Burkina Faso do not even have a formal place to record IPTp doses.  In Nigeria many ANC cards as seen at the left, had no place to enter whether a woman was given an ITN or received IPTp doses. Several malaria in pregnancy projects had to print new ANC cards and clinic registers to make it possible to mark accurately the delivery of malaria control services. One wonders how accurate service and coverage data can be obtained to show progress toward achieving national malaria targets and indicators without such cards.

With no place to mark malaria interventions provided, health record cards are incomplete. No amount of divining will be able to give us proper information on whether we are achieving our malaria targets without these.

The Malaria Advocacy Innovation Grants have recently issued a report on their activities. The grants were expected to support “ideas and partnerships that reached new audiences in creative ways and tackled difficult issues such as equity, transparency and accountability.” The 3-year program reached 16 African countries and did involve audiences ranging from the expected civil society groups to government leaders, business people and researchers.

The challenge with advocacy efforts is what do we measure as success? By way of results or indicators, the Malaria Advocacy Innovation Grants “aimed to boost advocacy efforts to improve Africa-to-Africa accountability for response to malaria suffering on the continent as well inspire African civil society organizations and media to become “leaders” in the fight against malaria.”

Examples of success reported by these “mobilizing for malaria” projects include:

• Nigeria: the partner substantially boosted the capacity of local civil society by organising a five-day malaria advocacy training session. 35 people representing 28 CSOs were trained
• Tanzania: 37 MPs were trained in a workshop, and became instrumental in forming a first-of-its kind coalition of Tanzania Parliamentarians Against Malaria (TAPAMA)
• Ghana: a magazine Eyes on Malaria was created, connecting malaria research findings and policy with day to day issues
• Mozambique: a project focused on mobilizing and engaging government representatives and businesses resulted in several enterprises starting to plan malaria control interventions as part of their social responsibility programmes

According to WOLA, Bread for the World and CEDPA, “Aspects (of advocacy) to be evaluated include the execution of strategies, the impact of the initiative in solving (or not solving) the specific problem, its contribution to the empowerment of the group and of civil society, and consequences for democracy.”

The Malaria Advocacy Innovation Grants have just concluded, and hopefully we can expect more in terms of evaluation from the project. In the meantime we have some key outputs documented. Ultimately we would like to learn how these advocacy efforts impacted on malaria programming and whether the CSOs who were trained become sustainable themselves and continue to contribute in a meaningful way to fighting malaria in their countries and regions.