Tropical Health Matters

In a relatively short period, 2003 – 2007, all malaria endemic countries in Africa adopted artemisinin-based combination therapy (ACT) drugs as their nationally approved first line treatment.  Unfortunately the uptake of ACTs in actually treating children remains extremely low. The Press Center at the Multilateral Initiative for Malaria 5th Pan-African Malaria Conference hosted a press conference to highlight efforts to promote and keep track of ACT use.

Suprotik Basu, Advisor to the UN Special Envoy for Malaria, moderated the panel and explained that the United Nations is promoting universal coverage of correct and prompt malaria treatment by the end of 2010 with a goal of ending malaria deaths by 2015. This is a huge challenge starting from a baseline in 2006 of only 3% of children who received any malaria treatment getting ACTs.

While there are efforts underway to ensure that more ACTs will be available at prices people can afford, including the new ‘experimental’ program Affordable Medicines Facility – malaria (AMFm), it is also important to have a mechanism in place to track what is happening with ACTs.

Des Chavasse, PSI’s Vice President for Malaria Control and Child Survival, is also heading up the ACT Watch project, funded by the Bill and Melinda Gates Foundation. ACT Watch is monitoring malaria medicine outlets – public and private – in 7 countries in Africa and Southeast Asia and conducting community surveys to achieve this goal of ACT tracking.

At its start, ACT Watch has documented that more than half of parents access malaria medicines for their children in private outlets, and where ACTs are available in these shops, a rare occurrence, they can cost 10 to 20 times more than the (ineffective) common treatments available. Many parents are not aware of ACTs as the new approved malaria medicine, but those who do are four times more likely to get ACTs at a private outlet.

While efforts are underway to promote and track ACTs, ACT Watch is also tracking the distribution of other antimalarials.  Peter Olumese who focuses on malaria case management at WHO’s Global Malaria Program, explained that due to cost and communication challenges, monotherapy artesunate drugs are often sold in the private sector. This will exacerbate the development of resistance of malaria parasites to artemisinin-based drugs. The availability of effective and cheap ACTs through programs like AMFm will hopefully drive the ineffective or dangerous antimalarials from the market.

Oliver Sabot from the Clinton Foundation shared that although US$ 180 million was now available annually to buy ACTs, but in the best situation only about 25% of children who receive malaria treatment get ACTs.  There needs to be a dramatic scale-up if even 80% coverage is to be achieved by the end of 2010. AMFm may make a dent if ACTs can actually reach the consumer at only 5% of current retail costs.

The most exciting aspect of the press briefing was a report by Ambrose Talisuna who represents Medicines for Malaria Venture in Uganda. Uganda has been experimenting with with subsidized ACTs in the private sector. Child doses are only 10 US cents and 40 cents for adults in contrast to $US 6-10 generally.  ACT market share has increased from below 1% to 50-60%, and consumers seem to like ACTs. At the same time share of ‘obsolete’ malaria medicines in the market has dropped by 50%.

AMFm will not be a magic bullet to achieve universal coverage since the first few pilot countries will not receive funding until 2010 at the earliest. AMFm will also operate for only 2 years until an evaluation will guide further work. In the meantime more efforts like those in Uganda are needed – nothing stops countries using their existing GFATM grants to subsidize ACT costs in the private sector as Nigeria is doing.

In order to count malaria out we need to learn as much as possible about the design and management of malaria control programs, especially setting up a functional monitoring and evaluation (M&E) system from which health workers, program managers and policy makers can learn and then plan improvements.

USAID’s Global Health eLearning Center is a great free online resource for agency staff and health team members to learn about maternal and child health issues, including malaria. Registration is free, and the format does not require much bandwidth, so should be more accessible to learners in developing countries.  As of World Malaria Day – 25 April 2009 – the 29th course will be added to the curriculum, that is a six-module learning activity on malaria in pregnancy (MIP) developed by Jhpiego.  This compliments the existing general malaria course available on the site.

Global Health eLearning was originally designed to help update the knowledge of USAID health, population and nutrition staff. The website now has over 30,000 registered learners, and 80% of those are not directly affiliated with USAID. This means that the courses are filling a continuing education need for a wide variety of people.  Eventually there may be up to 50 courses, which may be organized into focused learning packages.

Another useful free eLearning site is he Open Course Ware (OCW) program of the Johns Hopkins Bloomberg School of Public Health. Lecture materials from approximately 80 of the School’s courses is available consisting of slides, handouts and other resources.  The course on Malariology …

Presents issues related to malaria as a major public health problem. Emphasizes the biology of malaria parasites and factors affecting their transmission to humans by anopheline vectors. Topics include host-parasite-vector relationships; diagnostics; parasite biology; vector biology; epidemiology; host immunity; risk factors associated with infection, human behavior, chemotherapy, and drug resistances; anti-vector measures; vaccine development; and management and policy issues.

Jhpiego has a Malaria in Pregnancy Resource Package (MRP) online.  The MRP contains all the materials needed to conduct training on malaria in pregnancy including a facilitator’s guide, sample slides, a brief tutorial, job aids and other reference documents. The training materials emphasize the M&E component of MIP service delivery.

Another key online learning resource is the Roll Back Malaria Toolbox. One can download a number of reference materials for planning and implementing M&E components to all aspects of malaria control services.

There is no excuse not to keep up-to-date on malaria control with all the free eLearning materials available online. Please share with us additional sources and links that foster eLearning on malaria.

 Jhpiego, an affiliate of the Johns Hopkins University, is planning several activities to recognize April as the month when World Malaria Day (WMD) is observed.  Jhpiego promotes the health of women, their children and their families, and will be featuring spotlights on its country efforts to protect women and children from malaria.

These spotlights will appear on a regular basis during April 2009 and will explain how Jhpiego, in keeping with the theme of this year’s WMD, is counting the efforts needed to count malaria out.  The spotlights will focus on keeping count of progress in the programs:

• Community delivery of malaria in pregnancy (MIP) control services in Nigeria
• Training the next generation of Ghanaian midwives in malaria in pregnancy control
• Scaling up in-service training on malaria to over one-third of the health facilities in Tanzania
• Improving the quality of monitoring and evaluation of MIP control in Angola leading to increased delivery of services
• Enhancing the malaria control skills of village health workers in Rwanda
• Building a strong malaria control team in Mali

In addition, Jhpiego will be hosting two noon-time seminars at its headquarters at Browns Wharf in Fells Point, Baltimore. One seminar will introduce the new e-Learning course on malaria in pregnancy that Jhpiego is developing for USAID (April 16). The second will explain the need and process of improving monitoring and evaluation of malaria control projects (April 24).

GlaxoSmithKline is going to be testing its malaria vaccine candidates in the very places where malaria is most endemic and “where people are actually suffering infection” – unfortunately these are often remote and lack communication access to the outside.  Chris Dannen reports that –

The solution to GSK’s connectivity problem: satellites. Each clinic site has a small satellite (dish) mounted on a concrete pad. Otherwise, the sites are relatively simple: a few outbuildings and gasoline generators for electricity. There are a handful of computers, one to run an x-ray machine, and another two or three serve as data collection points, where workers can also access e-mail and the Internet. The satellite connects back to GSK’s central data collection system …

We recently visited the Sege Health Center in Dangbe East District of Ghana and saw a satellite dish installed right outside the small outbuilding that served as the clinic’s records office.  Inside we found that health data were being entered in a computer and were told that the satellite connection enabled the staff to forward data to the regional authorities.  Included of course were data on IPTp and malaria case management at this rural outpost.

Cell phones are also connecting people with malaria messages. “MTN is planning to use its texting feature to remind people to use their bed nets and seek treatment for malaria, increase malaria education with a major ad campaign and distribute nets and malaria information at its cell phone sale centers.”

Researchers at UCLA are exploring ways that cell phones can be integrated into malaria diagnostics. The researchers “envision people one day being able to draw a blood sample into a chip the size of a quarter, which could then be inserted into a (Specially-)equipped cell phone that would quickly identify and count the cells within the sample. The read-out could be sent wirelessly to a hospital for further analysis.” This would become a ‘medical lab in the palm of your hand.’

The US President’s Malaria Initiative is promoting cell phones for data reporting in Zanzibar:

Using a cell phone, each health facility reports data on a weekly basis via a customized text messaging menu developed by Selcom Wireless, in collaboration with ZMCP (Zanzibar Malaria Control Program). The malaria data are transmitted to a server, where they are processed and presented in two formats. First, a summary of each week’s surveillance data (for Unguja and Pemba separately) is sent via a single text message to the ZMCP program manager, district medical officers (DMOs), and other Ministry of Health authorities. Second, for easy viewing of malaria trends over time, the server automatically generates graphical images viewable on a secure Web site.

These experiences show that it is not enought to deliver malaria control services. Systems must be in place for reporting on these activities and on malaria surveillance in a timely manner so that better progrmmatic and policy responses can be made to count malaria out.

With the theme of the second World Malaria Day being counting progress, RBM Partners are highly challenged. “The international malaria community has merely two years to meet the 2010 Abuja targets and achieve universal coverage with all malaria interventions.” Partners will never know if they are meeting targets unless accurate and timely local data are generated in endemic countries.

Data in UNICEF’s 2009 State of the World’s Children Report has provoked the ire of Nigeria’s new Minister for Information and Communications.  The Punch explains that, “Prof Dora Akunyili, was reported to have expressed strong reservations over the damning statistics released by the United Nations Children‘s Emergency Fund (UNICEF) on three critical health indicators in the country.”  The ‘dismal’ national performance led to the following response seen in the Punch:

However, no sooner was the report made public than the Minister picked holes in the figures, describing it as unacceptable and unfair ”especially at this time when the country is trying to rebrand and project a new image”. And, without an alternative locally-generated data at her disposal to counter the supposed ‘unfair” figures, a visibly peeved Prof Akunyili … stressed that ”The figures for maternal mortality, infant and Exclusive Breast Feeding cannot be correct when put side by side with the great feat achieved by Nigerians in the area of salt iodization and vitamin A fortification, both of which enhance child and maternal survival and well being.”

The lack of up-to-date national statistics is especially important for judging progress toward RBM targets.  The most recent national figures come from the 2003 Nigeria Demographic and Health Survey (co-sponsored by the National Population Commission and USAID).  Most countries do perform a DHS only about every 5 years, and the 2008 Nigeria DHS is still being completed.  In the 2003 version –

• 6% if Nigerian children under 5 years of age had slept under a bednet the previous night
• 1% of these children had used an ITN
• 34% of suspected malaria cases had been treated with an appropriate antimalarial drug

Since that time Malaria control has been intensified in 18 of 36 states with support from the Global Fund and in a few other states with help from USAID and DfID.  Additional support from DfID, World Bank, Global Fund and USAID to cover the remaining states is slowly forthcoming.

In the absence of more recent national survey data some studies have reported increases in net use, but these data are still far below targets.  A 2008 article in Malaria Journal found in 12 states that ownership of any net was 23.9% and utilization of any net by children under-five was 11.5%. A follow-up article in 2009 found that even after a major net distribution campaign, the number of  under 5 years aged children sleeping under nets was only 40%.  Importantly, the proportion was three times higher in southern than in northern states even though all areas had been equally targeted with nets.

The availability of these local data should make the Minister happy, but traditionally there has been poor communications between researchers and government officials. Government needs to reach out more effectively to the research community and be willing to learn.

Nigeria has been a place where much innovative malaria implementation research has taken place.  The question is whether the health system enables such research to be taken to scale.  The Punch is doubtful and scolds the government for allocating less that 5% of its annual budget when WHO recommends 15% and is skeptical that the existing system can deliver the goods:

Obviously, the country‘s neglect of primary health care service delivery as well as government‘s tardy response to health matters in the country seem to have, among other things, accounted for such evidently unpleasant reality. As a matter of fact, Nigeria ‘s primary health care system, responsible to anchor, as it were, maternal and infant health services, is currently in complete and total disarray, as a visit to the various health centres across the country will show. This explains why routine immunization programme that could have helped mitigate the spread of such child-killer diseases like polio, meningitis and others are difficult to be effectively implemented.

It is likely that the lack of national budgetary resources for health makes it difficult for the health system to conduct the monitoring and evaluation needed show Nigeria’s progress toward RBM indicators in a better light. Also some light needs to shine on current health systems challenges leading to soul searching and honest commitments to saving lives.

With about 2 months and 3 days to go until World Malaria Day 2009 partners are encouraged by RBM to start preparing to tell their own stories “to show the international community how far it has come – and how far it needs to go to reach its global malaria response.” Our target now for 2010 is 100% – universal coverage – with hopes of bringing malaria deaths near zero by 2015.

Its good to set targets and timetables – just as long as these are realistic – and do not ultimately discourage people. Guinea worm was supposed to have been eradicated in 1995, but remains in Sudan, Nigeria, Ghana, Burkina Faso, Niger, Togo and Ivory Coast according to a BBC report in December.  Donor fatigue sets in.  And in these days of economic downturn, even if donors are not tired, their purses are not as deep.  Counting funds and resources also needs to be part of the RBM countdown.

Nigeria is a high burden country and a good place to keep watch on progress toward targets. The National Malaria Control Program and colleagues has been good at publishing progress.

• An article last summer pointed out that by October 2005 only 13% of children under 5 years of age slept under any kind of net the night prior to the survey.
• Another article this month based on August 2007 survey data shows progress with 51% having slept under a net.

In both cases there were regional disparities – children in the south were more likely to sleep under a net than those in the north. This was not for lack of trying, since the recent article also documents net distribution in the study areas over a 12-month period.  It will be interesting how and if RBM partners will rally to help Nigeria double its net coverage rates in the next two years.

The Nigeria studies reported on number of children who slept under nets the night before the study, which is one of the key indicators of Roll Back Malaria success.  Counting alone will not be helpful in documenting progress towards universal coverage and eventual elimination unless all partners use standard measures. RBM’s Monitoring and Evaluation Reference Group has provided guidelines and toolkits, which all partners should read and use when reporting on their own progress.

When “Counting Malaria Out” on 25 April 2009, RBM encourages partners to, “Make 2009 the start of the countdown. Make the lives of every man, woman and child count as the international community intensifies its battle against malaria.” This will definitely require a well funded and coordinated effort.

The Washington Post reports that, “Many of the world’s poorest countries have for decades routinely exaggerated the number of children being immunized against disease, apparently driven by political pressure and, more recently, financial incentives. That is the finding of a huge analysis (by Christopher Murray and colleagues) that has provoked heated discussion even before its publication in the Lancet.”

Kenya’s The Nation explained that, “Researchers analysed independent surveys and found gaps between actual rates of immunisation and estimates reported to the World Health Organisation and the UN Children’s Fund.” This gap can be seen in the chart above.

The Post article suggests that the “pay for performance” approach of the Global Alliance for Vaccines and Immunizations (GAVI) may have contributed to the exaggerated performance reports. Specifically, “The study also found that the GAVI ISS program, which pays countries US$20 for each additional child that countries report to have immunized, leads to over-reporting in two out of three countries.” The Washington Post continues by saying that, “GAVI performs ‘data quality audits’ that test the validity of official counts by following the data trail in four health districts per country.” But that is not sufficient to detect over-reporting, Murray and his colleagues concluded according to a press release.

How are we sure that the same problems of over-reporting do not afflict statistics from projects supported by GFATM, PMI or the World Bank Booster, to name some of the major players?  “The Global Fund follows the principles of performance-based funding in making funding decisions. The aim is to ensure that investments are made only where grant funding is managed and spent effectively on programs that achieve impact in the fight against HIV/AIDS, tuberculosis and malaria.” and accomplishes this through Local Fund Agents.

The US President’s Malaria Initiative 2008 Annual Report recognizes “The need to strengthen monitoring and evaluation systems for malaria so that national malaria control programs and partners can monitor the progress of their activities, make adjustments, and report on their results.” The World Bank Booster program addresses results-based monitoring and evaluation.

This does not mean that malaria programs are immune from data quality problems. Vigilance is always needed to ensure that the best quality data are gathered and that these inform program decisions.

“Incidence of malaria in Gambia has plunged thanks to an array of low-cost strategies, offering the tempting vision of eliminating this disease in parts of Africa, a study published Friday by The Lancet said,” according to AFP. The Gambia now joins four countries featured in the World Malaria Report that “reduced the malaria burden by 50% or more between 2000 and 2006–2007.” The four, Eritrea, Rwanda, Sao Tome and Principe, and Zanzibar (in the United Republic of Tanzania), are distinguished by “relatively small populations, good surveillance, and high intervention coverage.”

Reuters explained that, “Providing pregnant women and children with insecticide-treated bed nets has sharply cut malaria deaths.”  The findings raise hopes that, “Other parts of Africa could eliminate the disease as a public health problem in a region where malaria kills a child every 30 seconds.”

Gambia News carried a caution in comments by David Conway, one of the authors of the Lancet article who said, “We have seen that it has gone down and stayed down. There is no evidence of an upsurge but we are aware that with an infectious disease you can never know for sure.” This caution is relevant bearing in mind this year’s World Malaria Day theme – a disease without borders.

Achievements in the Gambia have been facilitated by grants in Rounds 3 and 5 from the Global Fund in which its performance has been ‘A’ and ‘B1’ respectively. Neighboring Senegal also had Global Fund malaria grants, but it experienced serious grant performance problems not long ago, reinforcing the caution that malaria is waiting at the Gambia’s borders.

While the Gambia may not be able to eradicate malaria all by itself, as implied in a February 2008 article in The Observer, it is certainly on track for elimination using available control technologies.  Even though eradication is not on the immediate horizon, the government official quoted in The Observer was on target when she said, “My government has therefore not relented in waging a continuous war against the disease. We have also embraced all policies and implemented all programmes formulated by the WHO and its sister UN agencies on malaria prevention and control.” Other nations with larger malaria burdens need to be as vigilant as The Gambia.

Malaria cases are dropping according to a United Nations press release described in the British Medical Journal. “… the figures show that the fund has delivered 59 million bed nets impregnated with insecticide to families at risk of catching malaria, almost double the number that were issued a year ago. Michel Kazatchkine, the fund’s executive director, said there was now clear evidence that mortality rates from the disease among children younger than 5 years of age had fallen sharply in 10 sub-Saharan countries, and, in Zanzibar, malaria had been almost eradicated as a public health problem.”

Likewise, Destination Sante exclaims that, “Rolling back malaria really is possible ! Between 2005 and 2007, the authorities in Rwanda and Ethiopia succeeded in reducing the number of cases of malaria and deaths from the disease on their territory by 60%. This victory is the result of close coordination with international sponsors.”

• Le Rwanda par exemple, a réduit de 64% le nombre des infections et de 66% les décès chez les enfants de moins de 5 ans. (In less than two years, Rwanda, for example, reduced the number of infections by 64% and deaths among the under-5s by 66%.)
• En Ethiopie voisine, les succès sont tout aussi encourageants : 55% de transmissions en moins, et 60% de morts évitées. (In neighbouring Ethiopia, the story is just as encouraging: 55% fewer transmissions and 60% of deaths avoided.)

The Lancet, where this information was published earlier, asks how these successes happened and what lessons can be learned for scaling up elsewhere. Chambers et al., in The Lancet explain that, “The case of Ethiopia is especially informative, because this is the first time such significant achievements have been recorded over such a large geographical area in sub-Saharan Africa.” They identified four key components of success that made scale-up in three years possible:

1. a catalytic moment,
2. demand for universal coverage,
3. pragmatic donor response, and
4. innovative problem-solving

The authors offer this crucial piece of advice: “Donors must also be willing to assume greater risk by encouraging and funding ambitious programmes while showing increased flexibility in their processes and procedures. And both parties must plan early for the maintenance and eventual elimination phases so that donor support does not flag as malaria deaths are reduced.”

Finally it is important to observe that these claims of progress could not be made without a system of monitoring and evaluation.  Are the interventions reaching the people? Are they actually using the nets and medicines? Are health systems employing the correct diagnostic tools to determine whether cases of malaria are really dropping?  The Global Fund, being performance based, provides tools to answer these questions.  We encourage all countries who are not writing their Round 8 Global Fund proposals to take advantage of these tools and write strong monitoring and evaluation components into their grants.

World Malaria Day means that the malaria situation in more countries outside Africa will be getting attention. The Daily Times of Pakistan has observed that “Pakistan reported 3.5 million suspected malaria cases in 2007 and 0.13 million of them were later confirmed, says an official of Directorate of Malaria Control (DOMC),” but also expressed concern that WHO “claims that high incidence of suspected malaria cases is exaggerated and the figure couldn’t be more than 1.6 million because malaria has yet not reached epidemic proportions in Pakistan.”

Better data are needed. The website ‘fitfortravel‘ can compose a map to guide travelers on the need for antimalarials, but this is not intended as an accurate picture of the country’s malaria situation. That said, malaria is obviously a recognized problem in the country because the Global Fund to fight AIDS, TB and Malaria has awarded Pakistan three grants to fight the disease.

The Round 3 proposal to Global Fund explained that, “The plasmodium falciparum is on the rise and in 2001 as many as 25 districts had a P. falciparum ratio of more that 30 percent. The parasite has developed RI & RII level resistance to chloroquine in many areas.” The proposal also reports that the annual parasite incidence reaches 18 per 1000 in certain districts, but also says that only abouy 21% of the population use government health facilities were data could be collected. Therefiore it is not surprising that the Daily Times reports that, “The DOMC official said only 20 percent of the total population had access to malaria treatment.”

Some published data comes from hospitals, which of course would not reflect the general situation in the population, but at least is a step in the direction of documentation. Idris et al. from the Ayub Medical College in Abbotabad studied nearly 2000 febrile patients and found that over 7% had malaria parasites. While most cases were P. vivax, 24% were P. Falcuparun and 3% were mixed. In Karachi, Beg et al. documented among over 500 patients hospitalized that P. vivax and P. falciparun were found in almost equal measure (52% and 46%). They expressed concern that many were treated with inappropriate medicines, showing a need for updating pre-service and in-service training.

Bhatti et al., looked at malaria in pregnancy in Karachi. The findings they reported included the following: “Two patients had an abortion. One of the following complications including, threatened abortion, preterm labour, ARDS or Cerebral malaria, was observed in one patient each. Mean weight of babies born to cases was 2.8 kg (range 1.4-3.8) and of control babies was 3.2 kg (range 2.5-4.0 kg).” P. falciparum was identified as one of the risk factors for poor pregnancy outcome.

Among the 28 malaria Global Fund grants approved for Round 7, half came from regions outside Africa. As international attention is turning more to malaria all over the world, it is important for all endemic countries to seek better population based data about their malaria situation so that appropriate interventions can be targeted most effectively.