Tropical Health Matters

In wars in malaria endemic areas, malaria can cause more damage than what occurs on the battlefield. The United States just observed its annual Memorial Day where those who died serving the country are remembered. Wing Beats, the journal of the Florida  Mosquito Associations reported on the status of malaria vectors in the state of Georgia and stressed the damage malaria did during the US Civil War:

• “From 1861 to1866 malaria was the second most commonly diagnosed ailment – diarrhea/dysentery was first – among Union troops, with over 1.3 million cases. Although sold iers native to the South were much more likely to have experienced malaria growing up, they also suffered deaths and incapacitation that affected the timing and outcome of battles.”

During the Korean conflict, “paragonimiasis, malaria, and amoebiasis were the most fatal parasitic diseases during the early 1950s in the Korean Peninsula,” and consequently were responsible for deaths of prisoners of war. The U.S. military received a severe damage during World War II in the Pacific where it was said that “more soldiers were lost by malaria than by battle itself.” The experience led to hundreds of units specialized in controlling malaria in Korea.

In Europe during World War II, people in concentration camps and prisoners of war were used in experiments. “In Dachau Professor Claus Schilling tested synthetic malaria drugs and injected helpless prisoners with high and sometimes lethal doses.” Malaria as a biological warfare agent was demonstrated in Italy where “The German army’s 1943 flooding of the Pontine Marshes south of Rome, which later caused a sharp rise in malaria cases among Italian civilians, has recently been described by historian Frank Snowden as a unique instance of biological warfare and bioterrorism.”

Today malaria continues to produce death in conflict zones. “The area of Walikale in North Kivu, Democratic Republic of Congo, is intensely affected by conflict and population displacement.” The most frequently reported cause of death among the local population was fever/malaria at 34.1% .

During the civil war in Côte d’Ivoire “the availability and use of protective measures against mosquito bites and accessibility to health care infrastructure deteriorated.” A study of resettlement camps of displaced families after the Angolan civil war “Malnutrition was the leading cause of death (34%), followed by fever or malaria (24%) and war or violence (18%).”

Some of the most highly malaria endemic countries in the world still experience conflicts. Malaria kills directly, it can be used as a weapon, and war disrupts efforts to control it. If we are to “end malaria for good,” we might also think about trying to end war and conflict, too.

What it is that makes a disease “eradicable,” or more correctly what makes it possible to eliminate malaria in each country leading to the total eradication world-wide. Bruce Aylward and colleagues identified three main sets of factors by drawing on lessons of four previous attempts to eradicate diseases (including the first effort at malaria eradication in the 1950s and ‘60s).[1]

1. biological and technical feasibility
2. costs and benefits, and
3. societal and political considerations

So far smallpox is the only success because as Aylward et al. pointed out biologically, humans were the only reservoir and on the technical side a very effective vaccine was developed. The eradication campaign was promoted in clear terms of economic and related benefits. While the early malaria eradication efforts started with political will and recognition of the potential economic benefits of malaria eradication, the will was not sustained over two decades. On the technical side at that time there was only one main tool again malaria, indoor residual insecticide spraying, and mosquitoes quickly developed resistance to the chemicals. Are we better able to meet the three eradication criteria today?

Today’s technical challenges are embodied in intervention coverage problems. The World Malaria Report of 2015[2] (WMR2015) explains that the problem is most pronounced in the 15 highest burden countries, and consequently these showed the slowest declines in morbidity and mortality over the past 15 years. Use of insecticide treated nets and intermittent preventive treatment for pregnant women hovers around 50%, while appropriate case management of malaria lags well below 20%, a far cry from the goals of universal coverage. A further explanation of the technical challenges as outlined in the WMR2015 lies in “weaknesses in health systems in countries with the greatest malaria burden.”

The economic benefits criteria should be most pronounced in the high burden countries, but these are also generally ones with low personal income. Ironically, the WMR2015 points out that it is the high costs of malaria care and the malaria burden that further weaken health systems. More investment is needed in order to see more economic benefits.

Biological challenges to elimination are also identified in the WMR2015. Examples of existing and arising biological difficulties include –

• Plasmodium vivax malaria which requires a more complicated regimen to affect a cure.
• “Since 2010, of 78 countries reporting (insecticide resistance) monitoring data, 60 reported resistance to at least one insecticide in one vector population.
• “P. falciparum resistance to artemisinins has now been detected in five countries in the Greater Mekong subregion.” Historically chloroquine and sulfadoxine-pyrimethamine resistance spread from this area and now artemisinin resistance marks a ‘Third Wave” of resistance emanating from the region.[3]
• “Human cases of malaria due to P. knowlesi have been recorded – this species causes malaria among monkeys in certain forested areas of South-East Asia,” and so far human-to- human transmission has not been documented.

On the positive side greater political support to elimination efforts has been expressed by the African Leaders Malaria Alliance (ALMA) who met at the African Union Leaders Summit in Addis Abba early in 2015 and resolved to eliminate malaria by 2030.[4] This call to action was backed up with an expansion of ALMA’s quarterly scorecard rating system of African countries’ performance to include elimination indicators.[5]

In conclusion, political will exists, but needs to be backed with greater financial investment in order to produce economic benefits. Time is of the essence in taking action because biological and technical forces are pressing against elimination. 2030 seems far, but we cannot wait another 15 years to take action against these challenges to malaria elimination.

[1] Aylward B, Hennessey KA, Zagaria N, Olivé J, Cochi S. When Is a Disease Eradicable? 100 Years of Lessons Learned. American Journal of Public Health, 2000; 90(10): 1515-20.

[2] World Health Organization. World Malaria Report 2015. WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland, 2015.

[3] IRIN (news service of the UN Office for the Coordination of Humanitarian Affairs). “Third wave” of malaria resistance lurks on Thai-Cambodia border. August 29, 2014. http://www.irinnews.org/report/100549/third-wave-of-malaria-resistance-lurks-on-thai-cambodia-border

[4] United Nations Secretary-General’s Special Envoy on MDGs. African Leaders Call for Elimination of Malaria by 2030. Feb. 3, 2015. http://www.mdghealthenvoy.org/african-leaders-call-for-elimination-of-malaria-by-2030/

[5] African Malaria Leaders Alliance. ALMA 2030 Scorecard Towards Malaria Elimination, December 2014. http://alma2030.org/sites/default/files/sadc-elimination-scorecard/alma_scorecards_poster_english.pdf

Chulwoo (Charles) Park who has been undertaking the Masters of Science in Public Health at the Johns Hopkins Bloomberg School of Public Health is sharing herein his experiences with the LiST tool in African countries.

The Lives Saved Tool (LiST) is a computer-based tool that estimates the impact of scaled up health intervention packages in a quantitative manner. By modeling complex mathematical relationship of coverage difference among interventions for maternal, neonatal and child health (MNCH), LiST shows us quantitative results, such as mortality rates, incidence rates, number of cases averted, percentage of stunting and wasting, number of cause-specific death and lives saved.

Especially, LiST can project and run multiple scenarios for subnational target population in the country not only to evaluate existing MNCH project but also prioritize investments for the future based on the quantitative results. World Vision International (WVI) has implemented LiST analysis to strengthen its evaluation and strategic planning methods for MNCH projects since 2013.

Recently, the mid-term evaluations for Access to Infant and Maternal (AIM)-Health project in Kenya, Mauritania, Sierra Leone, Tanzania, and Uganda were conducted through mixed methods analysis, both qualitative research (in-depth interview and focused group discussion) and quantitative research (LiST) from June to September of 2014.

Subsequently, LiST was solely utilized to quantify the retrospective impact of Water, Sanitation, and Hygiene (WASH) project in Southern Africa Region (SAR), Malawi, Mozambique and Zambia between 2010 and 2014. The significant impact indicates that the combined effect of all five WVI WASH interventions (improved water source, home water connection, improved sanitation, hand washing with soap, and hygienic disposal of children’s stools) have prevented 989,745 diarrhoeal cases among the under-five target population of 506,019 children.

In other words, every single young child prevented 1.96 cases of diarrhea, and prevention rate for diarrhoea was 13% throughout the implementation period. Another results indicate that WVI’s WASH project contributed a 209% mean increase in percentage of under-five lives saved and 15.5% mean decrease in under-five mortality rates across SAR.

• Chulwoo (Charles) Park, MSPH ’15
• Johns Hopkins Bloomberg School of Public Health, Department of International Health, Division of Global Disease Epidemiology and Control
• For more information write to e-mail: park@jhmi.edu

The largest portion of infant deaths occurs in the neonatal period. During those first 28 days, the child is at risk from a variety of problems arising from delivery complications, infections and simply not being kept warm.

In malaria endemic areas there is the small but important problem of malaria transferred from mother to child, or congenital malaria. The problem occurs with both Plasmodium vivax and falciparum.

Congenital malaria in the newborn is often hard to detect. There may be fever, but other signs and symptoms might include anaemia, jaundice, paleness, diarrhoea, vomiting, and general weakness.

Prevalence of congenital malaria in Ghana, for example, ranged from 2% by microscopy to 12% using polymerase chain reaction (PCR). In India microscopy revealed a prevalence of 3% with cases of both vivax and falciparum.

One would hope this problem could be avoided if prevention of malaria in pregnancy was practiced using insecticide treated nets, intermittent preventive treatment (IPTp) and prompt and appropriate case management, but studies still find placental and cord parasiteamia in countries where such interventions are supposed to be integrated into antenatal/prenatal care. In Colombia, “An association was found between congenital malaria and the diagnosis of malaria in the mother during the last trimester of pregnancy or during delivery, and the presence of placental infection.”

Countries are in the process of shifting to the relatively new WHO guidance on IPTp that encourages monthly doses of sulfadoxine-pyrimethamine from the beginning of the second trimester up until delivery. Countries are also trying to ensure universal coverage of ITNs so that women will be using nets prior to even becoming pregnant.

We still have trouble administering to take just two doses of IPTp, but if we want to prevent congenital malaria, we need to ensure that women are protected from malaria in their placentas and are free from parasites right up until they give birth and thereby prevent another cause of neonatal mortality.

Much of the discussion around global health and post-Millennium Development Goals focuses on non-communicable diseases (NCDs) including cardiovascular problems, diabetes, cancers and the the like.  While it is important to recognize that low income nations are not plagued with both communicable and non-communicable diseases, we do not want the greater focus on NCDs in richer countries to overshadow the problems of malaria, pneumonia, TB, diarrhea and other child killers in poorer countries.

A major reason for us not to lose focus on communicable diseases was recently reported from the Wellcome Trust on research they have supported in Malawi. The researchers found that the malaria parasite, Plasmodium falciparum, is able to “cause inflammation in blood vessel walls, making them more sticky so that the infected red blood cells can cling to the sides. Being able to stick to the blood vessels in vital organs allows the parasite to hide away from the immune system, a process called sequestration. When it occurs in the brain it causes a more severe form of the disease called cerebral malaria, associated with seizures, coma and sometimes death.”

The researchers also surmised that if this complication does not kill people in childhood, the damage to blood vessel walls can have more long lasting effects. In particular they noted that, “Chronic changes to the blood vessels like these could an important contributing factor to cardiovascular disease later in life.”

The link between malaria and Endemic Burkitt lymphoma (eBL) continues to be explored. Recently adding to this long history of eBL research, Peter Aka and colleagues reported that. “Anti–HRP-II (Plasmodium falciparum histidine-rich protein-II) antibodies suggest that recent malaria infection triggers the onset of eBL.”

In a review of intrauterine growth retardation (IUGR) Demicheva and Crispi observed that, “Several clinical and experimental studies showed that IUGR fetuses present signs of cardiac dysfunction in utero that persist postnatally and may condition higher cardiovascular risk later in life.” In endemic regions, malaria in pregnancy is a major cause of IUGR and thus low birth weight.

Preventing malaria therefore saves lives now and in the future. Ignoring malaria now adds greater burdens to the health system and national productivity tomorrow. We need to maintain our investments in malaria both globally and in and by endemic countries themselves.

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.”

While 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.

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.

This 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

Recent research has stressed the increase risk of death from malaria that elderly tourists face. Mortality from P. falciparum malaria increased steadily with increasing age with case fatality rate peaking in the group aged over 65 years. The authors explain that, “These data are supported by previous reports of increased case fatality and higher levels of parasitaemia in elderly people,” but the three studies cited focus only on travelers and tourists back in the UK, not adults and elderly people living in endemic regions.

This leads on to wonder about the risks malaria poses to elderly people in endemic countries, especially as populations throughout the world are aging.

While the recent controversial study that suggests that malaria deaths in adults have been underestimated world-wide, it does not specifically address the suspected prevalence of malaria morbidity and mortality in older adults. Specifically the authors “estimated more deaths in individuals aged 5 years or older than has been estimated in previous studies: 435 000 (307 000-658 000) deaths in Africa and 89 000 (33 000-177 000) deaths outside of Africa in 2010.”

Concerning the “outside Africa” component mentioned above, a study of adult and child malaria mortality (both falciparum and vivax) in India published in 2010 did report a higher malaria mortality risk in persons over 60 years of age.

More documentation on malaria morbidity and mortality in persons over 60 years in age in endemic countries is needed. Although portions of this segment of the population may no longer be in their productive years, they do consume health care resources, and as grandparents play important roles in child care.

In addition there is need to ascertain reasons for any differing patterns that may be detected. The study on tourists did not think that co-morbidity in elderly patients was responsible but instead implied that older people on holidays may forget to take their prophylaxis.

What differences in health behavior might be found in elderly populations in malaria endemic countries – maybe greater reliance on less efficacious indigenous concoctions? Are there differences in terms of perceptions of severity and seriousness of illness? Are there differences in care access?

The respect and quality of care we give the elderly says a lot about the societies in which we live.

Attention has recently focused on the news that malaria deaths are reducing and therefore, we may actually experience no malaria deaths by 2015 in line with the Millennium Development Goals. The excitement has been generated by a new report in the Progress and Impact series that documents great increases in malaria funding. Optimism helps spur action, but occasionally caution is needed so that slight disappointments do not grind action to a halt.

Two recent publications should encourage a little caution without dampening enthusiasm.

A headline in Ghana Business News states that, “Ghana risks missing some MDGs by 2015.”  The article explains that “… a study jointly conducted by the Ministry of Health and Ghana Health Service (GHS) has revealed … certain bottlenecks and organisational weaknesses …”  These weaknesses include –

• absence of integration of programmes
• general health service financial resources at national levels
• weak community participation in health planning and management
• increasing sense of frustration and neglect on the side of community volunteers

These are health systems and management issues – the very framework on which good malaria interventions are built.  Even the MDG website itself encourages us that “efforts must be sustained to win the battle.”

The Demographic and Health Survey (DHS) has published the preliminary results of the Nigeria 2010 Malaria Indicator Survey (MIS). Because of its large population Nigeria is the bellwether for controlling malaria on the continent with the overall highest number of malaria cases. Compared to the 2008 DHS, the 2010 MIS shows an increase from 17% to 44% of households that own any kind of bednet.  Gains are greatest in states supported by special programs such as the World Bank Booster, but are smaller than needed for achieving the 2010 Roll Back Malaria targets.

Speaking of targets, the proportion of young children sleeping under any kind of bednet in 2008 was 12% and rose to only 30% in 2010.  The figures are lower for insecticide treated bednets. Even in households with a net, only 59% of children slept under them.

Once can argue that Nigeria did not complete its net distribution for universal coverage in 2010 as hoped, but this gets back to the health systems bottlenecks mentioned in Ghana. Further caution is needed when one realizes that these millions of nets distributed up through 2010 will likely need replacement before 2015.

At present 51.5% of the children under five years of age tested with Rapid Diagnostic Tests in the 2010 Nigeria MIS tested positive for malaria.  We can certainly reduce mortality even if bednets are not used, but only 6% of this age group who had fever in the two weeks preceding the MIS had received the recommended artemisinin-based combination therapy.

Funding increases for malaria commodities alone will not achieve the desired reductions in malaria mortality, not will funding alone be able to tackle the health systems bottlenecks identified in many high prevalence countries.  A change in attitude is needed from top level political will to front line health worker perceptions.  If primary health care generally is not working, not reaching the people, malaria will still kill.

Over 40% of child deaths are now due to neonatal mortality, according to National Public Radio (NPR). NPR was commenting on a new article published in PLoS Medicine that examines neonatal death trends between 1990 and 2009. Although reducing child deaths is a key component of the Millennium Development Goals, neonatal mortality rates have actually increased in eight African countries, many of which are endemic for malaria.

Malaria contributes to neonatal mortality in two ways.  First, malaria in pregnancy leads to stillbirth and low birth weight babies who are more prone to death that those of normal weight. In a recent review, Ishaque and colleagues reported that, “The clearest evidence of impact in stillbirth reduction was found for adequate prevention and treatment of syphilis infection and possibly malaria.” Low birth weight can be prevented by using intermittent preventive treatment during pregnancy (IPTp).

The second contribution of malaria to neonatal mortality is congenital and neonatal malaria. A recent study in Nigeria has re-emphasized the connection between placental malaria and congenital malaria. Again, IPTp has be found effective in reducing neonatal cases of malaria.

Published research from Mozambique confirm that, “IPTp-SP was highly cost-effective for both prevention of maternal malaria and reduction of neonatal mortality in Mozambique.” Ironically, IPTp coverage is one of the key malaria indicators that is lagging as we have passed the RBM 2010 target of 80% coverage with two doses minimum for each pregnant woman in stable transmission areas.

Sufphadoxine-pyrimethamine, the drug used for IPTp, is cheap.  Many women attend antenatal care clinics where IPTp is (or should be given), yet Demographic and Health Survey results show few countries nearing even the 60% coverage mark for two IPTp doses.  There are no excuses in 2011 for pregnant women suffer and their newborns die because of malaria in pregnancy.