Tropical Health Matters

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.

The Daily Times of Malawi has reported that, “The Malaria Control Program has said the new malaria drug, artemisinin combination therapy (ACT)—commonly known as LA—is the best drug against malaria, even though patients have complained of unpleasant side effects. Some patients have complained of persistent headaches and itching whilst others have said some of their body parts swell after taking the drug.” One assumes that “LA” means lumefantrine-arthemeter. In contrast in neighboring Zambia researchers found that after the new treatment policy of ACTs was introduced there were high levels of acceptability, and “it was not surprising to see high levels of compliance.”

Itching and fatigue have definitely been associated with amodiaquine. But according to Malawi’s Global Fund Round 7 Malaria Proposal, “AL (artemether- lumefantrine) was chosen over other ACTs due to its co-formulation which is expected to improve compliance while artesunate+amodiaquine (AA) was chosen as second line for the management of the uncomplicated malaria.” A recent review of ACTs by Nosten and White reported that, “except for occasional hypersensitivity reactions, the artemisinin derivatives are safe and remarkably well tolerated. The adverse effect profiles of the artemisinin-based combination treatments are determined by the partner drug.”

Just because a drug is effective, it may not be acceptable. As was found with AA in Ghana in 2005, first the drug needs to be formulated correctly. Various other factors affect acceptability including cost, packaging, provider-client communication and drug color in addition to side-effects. It is quite important to test all these factors with consumers, not just drug efficacy.

Perceived problems with drugs do interfere with compliance, and poor compliance will lead to development of drug resistance. Monitoring of acceptability and compliance must be an integral part of any malaria control program.

In the meantime there is need to keep searching for new anti-malarial drugs. That is why the news is sad that after nearly a decade’s work put into developing LapDap, the drug was ultimately pulled from the market because of links with anemia. This was a good example of public-private collaboration, and hopefully such ventures will continue.

The 2006 Demographic and Health Survey report for Uganda is now available. It was possible to compare the malaria indicators with the survey done in 2000-01. Some progress can be seen in the attached picture. The definition of the indicators is somewhat different between the two periods. For example IPTp did not begin as a national policy/program until 2002, so the comparison indicator in 2000 was the proportion of women who received antimalarial prophylaxis at Antenatal Clinic. Likewise, distinctions between types of nets were not reported for all users in 2000.

While there have been increases in all the indicators, none reached the 2005 RBM targets of 60%. Uganda has been fortunate to receive donor support for its malaria efforts. Uganda’s $23m Round 2 Global Fund Grant started in 2004, and by September 2006 over 91% of the funds had been disbursed. The final grant progress report (2006) indicates that 15% of children under 5 years had slept under an ITN the night before, compared to 9.7% in the 2006 DHS. The progress report shows that 35% of pregnant women had received IPTp2 compared to 16.2% in the DHS. The Global Fund Round 4 Grant in Uganda focused primarily on treatment with ACTs.

Uganda is also fortunate to be one of the first recipients of the US President’s Malaria Initiative. PMI selected Uganda in part because it envisioned potential synergies and scale ups because of the presence of GFATM efforts. Now that RBM targets are 80%, it is incumbent on Uganda to make the most of this multiple donor funding achieve better and faster results while the opportunity exists.

We are lucky that there are various monitoring tools like the DHS to compare reported achievements from progress reports to donors. Other countries should take similar advantage of such tools in order to monitor and improve their malaria control performance.