Category Archives: Morbidity

Burundi: when will citizens see real protection from malaria?

Preliminary findings from Burundi’s 2015-16 DHS have been made available. The country has a long way to go to meet targets for basic control of malaria.

LLIN availability by household is an overall disappointing 32%. Ironically there is greater coverage of households in in urban areas (50%) than rural (30%). There is also great variation among the provinces with 52% coverage in Bujumbura metropolitan but only 19% in Canzuko. The overall average is less than one treated net per household.

A major concern is equity. The chart above shows a steep gradation from 19% coverage among the lowest fifth of the wealth quintile, up to 48% in the highest. Even in households that have at least one net, only 17% of of people slept under a net the night before the survey.

In terms of use by those traditionally defined as vulnerable, the DHS shows only 40% of children below 5 years of age overall slept under a treated net the night prior to the survey. Even in households that own at least one net, 78% of these children slept under one.

A similar pattern is seen for treated net use by pregnant women. Overall 44% slept under a treated net, and 84% did so in households that owned at least one treated net. The internal household dynamics of net use where one is available does appear to favor these two groups.

Overall coverage of Intermittent Preventive Treatment for pregnant women is very low. Less than 30% of pregnant women received even the first dose of SP. This decreased to 21% for two doses and 13% for three. In contrast to net coverage, more rural women (31%) received the first dose of IPTp than urban ones (19%).

Nearly 40% of children below five years of age were found to have had a fever in the two weeks preceding the survey. Among those care was sought for only two-thirds. Eleven percent of those with fever received an artemisinin-based combination therapy drug. The report did not mention whether these children had received any testing prior to treatment, so appropriateness of treatment cannot be judged. Prevalence testing of the children in the sample found 38% with parasitemia. Therefore one might assume that more children should have received ACTs.

Burundi still faces major political and social challenges. Even so Burundi is the recipient of malaria support from the Global Fund. For example 18 million LLINs were distributed in 2015 and 19 million in 2016.

Much work is needed to bring Burundi even close to universal coverage of malaria interventions. In today’s climate of questionable donor commitment, it is hoped that regional partners may play a role since malaria knows no boundaries.

Tanzania – Malaria Indicators Low, Still Need Work

Success in the war against malaria is not guaranteed. Two articles to that effect have appeared The Citizen of Dar es Salaam following presentation of findings from the most recent (2015-16) Tanzania Demographic and Health Survey (DHS)/Malaria Indicator Survey (MIS).

Slide2On Tuesday (21 June 2016) the news story noted the increase in malaria prevalence among children below the age of 5 years, which was attributed to “the decline in the use of mosquito nets and low distribution of nets to households.” Then in a Wednesday (22 June 2016) Editorial, the paper noted that this “backtracking” is a “worrisome situation, for malaria is a problem that puts such a heavy burden on the government and the country’s economy.”

Slide1A look at the preliminary DHS does confirm the concerns about insecticide treated nets (ITNs).  After nearly 10 years of progress, reported ITN availability in households declined. This was reflected in a drop in reported use by children below 5 years of age as well as pregnant women. It should be noted that targets set in 2000 in the Roll Back Malaria Abuja Declaration had been 80% by the year 2010, and those had almost been achieved in 2012, but the fall to around 50% in 2015-16 is discouraging.

Another preventive measure has also faced difficulty. Pregnant women should receive doses of Sulfadoxine-pyrimethamine (SP) as part intermittent preventive treatment (IPT) during antenatal care (ANC).  Until 2012 the recommendation was two contacts, but the World Health Organization has raised this to three or more depending on the number of times a woman attends ANC. So far IPT has not reached 40% or half of the Abuja target.

Slide3This low IPT coverage is ironic since most women attend ANC at least once in Tanzania. At present only 68% of women who had been pregnant received the first dose of IPT even though 98% registered for ANC. Granted that some may have registered in their first trimester when they would not yet be eligible for IPT, but the gap is quite large and signals missed opportunities, which are often caused by stock-outs. Even though the proportion of women attending up to ANC visits could be better, these attendances should produce better delivery of the 3rd IPT dose.

Slide4Malaria can also be controlled through prompt and appropriate treatment. While testing and treatment of children with appropriate artemisinin-based combination therapy (ACT) has increased, this are is still problematic. In particular, while WHO recommends that all cases of fever should be tested, less than a third received a test (rapid diagnostic test – RDT or microscopy). Testing helps distinguish malaria from other fevers, and ACTs should not be given unless malaria is confirmed. We can see that more ACTs are provided than the number who were tested, so treatment based solely on signs and symptoms is still the norm. Again there is need to explore the availability of both RDTs and ACTs as factors that have made these targets difficult to achieve.

Tanzania continues to receive support from the Global Fund and the US President’s Malaria Initiative, among other partners. It is incumbent on all partners, global and national, to use these results as a wake up call to to plan for better delivery of malaria services and thus a reduction of both the economic and health burden of malaria in Tanzania.

 

Attaining and Sustaining – malaria targets

Recent reports on the Global Burden of Disease with a focus on Millennium Development Goal #6 has stressed the improvement in malaria morbidity and mortality indicators since the Abuja Declaration of 2000. In particular, “Global malaria incidence peaked in 2003, with 232 million new cases, subsequently falling by about 29% to 165 million new cases in 2013.”

The improvements are attributed in part to the large increase in funding. The remaining challenge derives in part from the fact that four countries, India, Nigeria, Democratic Republic of the Congo and Mozambique account for nearly two-thirds of the global case load. Global progress in reducing disease has been achieved despite the fact that in these and many other countries, achievement of 2010 targets for malaria intervention coverage (80%) have lagged. In some cases national surveys have shown some declines in coverage (e.g. Nigeria).

DSCN7147Ghana provides a good example of the challenges. National surveys in 2006, 2008 and 2011 have shown mixed results in the use of insecticide treated nets by children below the age of 5 years.  While the proportion rose from 20% to 39% between the first two surveys, it stayed steady in 2011. A new survey in underway, but as of 2012 there were still areas of the country that needed nets, and we know that nets wear out in between distributions  and need to be replaced through routine services as seen in the photo.

Ghana 2006,8,11 Child sleep under netThe three surveys so far in Ghana paint a mixed picture as seen in the attached graph.  In six of the ten regions, net coverage for young children declined and in four it increased over the period.  This on balance led to the lack of overall improvement.

Thinking back to the reduced burden of disease overall, one can surmise that even some level of malaria intervention can impact on incidence of the disease, but the goal was no mortality for 2015, just one year from now.  If the trend seen in Ghana (which is reflective of other countries) continues, we will pass 2015 without attaining the 2010 coverage targets and still experience an unacceptable malaria disease burden.  Malaria elimination looks farther away each day.

Ronald McDonald House Charities Awards Jhpiego Grant to Reach Thousands of Children with Lifesaving Malaria Services

masthead JhpiegoFOR IMMEDIATE RELEASE
Contact: 410.537.1829; www.jhpiego.org

Baltimore, Md. (January 28)—Jhpiego, an affiliate of Johns Hopkins University, received a $150,000 grant from Ronald McDonald House Charities (RMHC) to strengthen and expand malaria prevention and treatment services to vulnerable pregnant women and children in Chad.

DSCN0540aJhpiego, a global health non-profit working in more than 50 countries, was among nine organizations selected by the global office of RMHC to improve the skills of health care workers through innovative approaches that directly benefit the health and welfare of vulnerable children around the world. The RMHC grant will build on Jhpiego’s current work in Chad to reduce deaths from malaria, the leading cause of death of children under five in the central African country.

“Jhpiego is thrilled to begin this new relationship with RMHC to ensure that children receive quality health care services in Chad and survive,’’ said Leslie Mancuso, President and CEO of Jhpiego. “More children under five in Chad die from malaria than from any other cause. In cooperation with the government, we will build the capacity of community health volunteers to educate families on malaria prevention and promote home use of insecticide-treated nets. These volunteers who go door to door are often the first line of care in many countries, providing basic health messages and connecting families to health facilities.”

DSCN0492aThe goal of the project funded by RMHC is to allow more children under five and pregnant women to receive much-needed services by training 10 Master Trainers, who will then educate and train 100 community health volunteers in malaria prevention activities. This approach will build a sustainable method for serving pregnant women and children in their communities. Jhpiego will target 109,571 children under five and 25,466 pregnant women who live in malaria-endemic districts in the East Logone region of Chad.

Through its Global Grants and matching grants program to local U.S. RMHC Chapters, the Charity has awarded nearly $97 million in grants in the last 11 years. “Child mortality rates around the globe continue to be alarming. There is a need to invest in resources and training to create lasting change,” said David C. Herman, MD, MSMM, President and CEO, Vidant Health, and RMHC Board of Trustees member. “For 40 years, RMHC has been part of the solution in helping to eliminate some of the barriers that make it more difficult for families and children to get the health care they need.”

For more information about Jhpiego and its lifesaving mission, contact Melody McCoy, 410-537-1829 or melody.mccoy@jhpigeo.org.

About Jhpiego: Jhpiego (pronounced “ja-pie-go”) is an international, non-profit health organization affiliated with Johns Hopkins University. For 40 years, Jhpiego has empowered front-line health workers by designing and implementing effective, low-cost, hands-on solutions to strengthen the delivery of health care services for women and their families. For more information, go to http://www.jhpiego.org.

About Ronald McDonald House Charities: Ronald McDonald House Charities® (RMHC®), a non-profit, 501 (c) (3) corporation, creates, finds and supports programs that directly improve the health and well-being of children. Through its global network of local Chapters in 58 countries and regions, its three core programs, the Ronald McDonald House®, Ronald McDonald Family Room® and Ronald McDonald Care Mobile®, and millions of dollars in grants to support children’s programs worldwide, RMHC provides stability and resources to families so they can get and keep their children healthy and happy. All RMHC-operated and -supported programs provide access to quality health care and give children and families the time they need together to heal faster and cope better. For more information, visit www.rmhc.org, follow us on Twitter (@RMHC) or like us on Facebook (Facebook.com/RMHC Global).

The following trademarks used herein are owned by McDonald’s Corporation and its affiliates: Ronald McDonald House Charities, Ronald McDonald House Charities Logo, RMHC, Ronald McDonald House, Ronald McDonald Family Room and Ronald McDonald Care Mobile.

Mosquito Nets – are we ready to restock?

The 2012 Millennium Development Goals annual report/update has been released. Progress for malaria has been noted, but below target. In summary the report notes that …

“The estimated incidence of malaria has decreased globally, by 17 per cent since 2000. Over the same period, malaria-specific mortality rates have decreased by 25 per cent. Reported malaria cases fell by more than 50 per cent between 2000 and 2010 in 43 of the 99 countries with ongoing malaria transmission.”

mdg-report-2012-net-progress-a.jpgWhile the overall tenor of the report veers toward the positive, the authors had to explain that, “Although these rates of decline were not sufficient to meet the internationally agreed targets for 2010 of a 50 per cent reduction, they nonetheless represent a major achievement.”  Ironically, the map at the right, taken from the report does not even include a shading for 80% and higher – the Roll Back Malaria target for 2012. Inadequate intervention coverage and the financial and health systems weaknesses contributed to the coverage gap, in spite of calls for universal coverage in 2009.

The big push toward universal coverage did result in more nets, but some countries are still in the process of trying to get the first round of mass distribution finished.  In light of Global Fund Round 11 cancellation and the world economic crisis, fears exist that replacement nets, likely needed by 2013, can be bought. The MDG report echos this concern: “There are worrisome signs, however, that momentum, impressive as it has been, is slowing, largely due to inadequate resources.”

Fortunately there is a bight light. Rwanda just announced that –

Over six million treated mosquito nets will be distributed to households in 2012 and 2013 and around 500,000 Long Lasting Insecticidal Nets (LLINs) will be given to pregnant women and children under five years in 2012, the National Malaria Control Program Director, Dr. Corine Karema, has said. “Currently we are in the phase of replacing the Long Lasting Insecticidal Nets (LLINs) distributed in 2010,” Dr Karema said, adding that families which didn’t receive them in 2010 will be assessed so that they can also get nets.

Not only does Rwanda’s effort represent replacement of the old nets, but also recognizes the need to provide nets in an ongoing manner during routine health services like antenatal care. Let’s hope that this sets a good example for other countries to make a commitment to find the funds – locally and/or internationally to ensure that the MDG for malaria morbidity and mortality reduction will not be sidetracked.

Investing and Sustaining: Lessons from Rwanda on World Malaria Day

Rwanda on track to zero deaths from malaria by 2015

By Dr. Corine Karema

Today, April 25th, the world will be commemorating Malaria Day as stipulated in the Abuja Declaration of 2000. Just like the previous years, Rwanda will join the rest of the world in commemorating this day by highlighting achievements in controlling Malaria while also renewing commitment of achieving zero targets of malaria related deaths by 2015.

The theme for this year’s World Malaria Day is “Sustain Gains, Save Lives: Invest in Malaria”, a theme that is testimony to the renewed global commitment of finding lasting solutions for eliminating Malaria from our midst.  For Rwanda, a country that has registered significant progress in combating Malaria, this commitment is a shared vision for which we attach greater value.

Coming up with sustainable and investment solutions for Malaria control is a new discourse which underlines the importance of continued investment in combating this disease with the view of propelling malaria-endemic countries along the path of achieving the health and poverty related Millennium Development Goals by 2015. Here in Rwanda, the battle against Malaria has not been an easy one. It has called for strategic interventions, committed leadership of our government and support from development partners to register progress that we see today across the country.

I will share with you some of the outstanding achievements we have registered over the past years, many of which are captured in the recently released 2010 Demographic Health Survey (DHS). The recent scaling up of interventions has made significant progress:

  • reductions in morbidity by 87% from 1,669,614 malaria cases in 2005 to 212,200 cases in 2011 and
  • reduced mortality by 76% from 1,582 deaths in 2005 to 380 deaths in 2011.

dscn7129asm.jpgThis reduction is as a result of scaling up of preventive measures especially coverage and use of long lasting insecticidal nets (LLINs) which according to the 2010 DHS results…

  • 82% of households have at least one LLIN
  • 72% of pregnant women slept under their nets and
  • 70% of children under-five years were using bed nets

Previously and as the case is in most developing countries, Malaria is treated based on signs and symptoms. However, Rwanda is one of the few countries in the world today where up to 94 percent of Malaria cases are laboratory through microscopy or rapid diagnostic tests at all levels of health care structure including the community level.

The involvement of Community Health Workers (CHWs) in early diagnosis and treatment of children Under-five years has also had an impact on malaria incidence throughout the country as currently 95% of children are tested and treated for malaria within 24 hours of symptoms onset.

In addition, Malaria control activities have been integrated and decentralized at all levels including –

  • a strong CHWs network which facilitates community involvement and participation,
  • the community health insurance scheme also known as Mutuelles de Sante and
  • a strong Health Management Information Systems (HMIS) including the web based community health information system (SIS.com)

The above interventions are strengthened by use of mobilisation and sensitisation campaigns using different channels of communication. The advocacy and social mobilisation is oriented towards intensifying different efforts to sustain the gains made as the country moves towards pre-elimination phase of malaria as outlined in the new Malaria Strategic Plan (2012-2017).

To emphasize on the importance of the World Malaria Day, this year’s event will be held during the scheduled Rwanda Malaria Forum that will be held in Kigali in mid June 2012. The Forum will bring together malaria experts from international community who will deliberate on the challenges African countries and in particular, Rwanda, face in malaria control and how to overcome them.

The recommendations of the forum will guide our sector in finalizing the new Malaria Strategic Plan that outlines Rwanda’s strategies from malaria control to pre-elimination phase by 2017. A series of activities to run for a week have also been planned to reach community levels where different interventions of promoting awareness on preventive measures will be discussed with input from community leaders.

Therefore, as we mark this day in Rwanda, we take pride of our achievements but also remain mindful and conscious of the challenges ahead a in realising the ambitious target of having a Rwanda that is free from Malaria.

The Author is Head of Malaria and Other Parasitic Diseases Division Rwanda Biomedical Center/IHPDPC, Follow: Twitter @ckarema

When the media goes home

The malaria threat to Haiti may not be as immediate as the terrible injuries and potential infections from inadequate water and waste disposal. Malaria will be lurking – but will anyone be paying attention when it arises?

Anderson Cooper of CNN was quoted in the New York Times as saying “We all know what’s going to happen. People are just going to lose interest in this as a story. They’re going to stop watching.” Already today the BBC has only one small headline on its world news homepage referring to Haiti and one feature piece far at the bottom of the page.

newspapers-in-kenya.JPGMore importantly, according to the Times, the major news organizations also have ‘money worries’ about the extensive coverage. The costs of coverage, and the boost it gives to donor organization efforts to raise funds, were outlined by the Times as follows: “News outlets rushed to charter airplanes and snap up extra seats on aid flights, but that was the easy part. Upon arrival, they had to establish supply lines, mostly through the neighboring Dominican Republic.”

News executives acknowledge that the media can move in and out of Haiti quickly, but efforts to scale back are already in evidence. One network reported on running out of water for its staff twice.  Overall it was estimated that each news organization would be spending $US 1.5 million on its Haiti coverage.

Well recognized media figures like Dr. Sanjay Gupta have been serving an advocacy role encouraging potential partners to reach difficult areas and provide better quality services.  The Times recognizes the importance of the visual element in this advocacy process.  Will scaled back coverage reduce this advocacy avenue?

Over 150,000 people have been confirmed dead so far in Haiti, and final estimates reach as high as 200,000.  The World Malaria Report still estimates over 800,000 malaria deaths world wide annually. These deaths may not occur in as dramatic a fashion as a natural disaster, but they add up and are still disastrous to families and nations.

The media has been an essential partner in highlighting malaria interventions and progress at all levels, especially as we count down to universal coverage.  We need all partners to ensure that the media spotlight remains on malaria, and especially right now on malaria in Haiti.

As morbidity reduces and we get closer to malaria elimination, this task may become harder – but media advocacy will be needed up to the very end to ensure adequate funding to maintain surveillance and certify elimination even when malaria seems less pressing.

The Gambia joins small club of reduced incidence countries

“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 reduced … through better statistics

For years the standard figure of malaria morbidity has been half a billion cases a year. Now, “The World Health Organization halved its estimate of the number of people who get malaria each year, saying Thursday that better measurement techniques had cut the number from 500 million people to 247 million.”

world-malaria-report-2008.jpgPrevious figures apparently were based on estimates that mapped where people were likely to be exposed to malaria, but data collection is deemed to be more accurate in 2006, the most recent information as presented in the new World Malaria Report 2008.  Even with reduced morbidity, “WHO left unchanged the figure of malaria deaths. An estimated 881,000 people were killed by malaria in 2006 — most of them were children under 5.” But even with better data, “Less than one-third of the agency’s 192 member countries have acceptable registration of malaria cases and deaths.”

Science Magazine cautioned that, “the report’s authors say that the drop isn’t a sign we’re winning the battle, just that the methodology of gathering data is better.” Health statistics are challenging. Science also noted that, “Determining the burden of malaria is notoriously hard because many patients don’t seek or receive medical attention, and even if they do their case may not be lab-confirmed or entered into government statistics. One result is that WHO’s numbers have huge error bars: For instance, the estimate for Kenya ranges from 5 million to 19 million cases.”

Robert Snow of the University of Oxford, U.K. and the Kenya Medical Research Institute in Nairobi was quoted by Science as sayingthat “WHO still relies too heavily on weak government data, resulting in too rosy a picture.” Fortunately donors are recognizing more and more the importance of strengthening malaria data and monitoring and evaluation (M&E) capacity in endemic countries.

The Global Fund offers M&E guidance and encourages countries to write into their proposals means for strengthening their health information systems. Countries do not always take full advantage of these health system strengthening components. Partners should therefore, continue to provide guidance and encouragement to countries to improve their M&S and health statistics so that the next World Malaria Report will truly reflect both reality and hopefully progress.

Counting down the cases

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.”

m-and-e.jpgFinally 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.