Tropical Health Matters

Another World AIDS Day has come and passed. Sarah Boseley has commented on the information overload that comes this time of year on the disease and the range of basic health programming and valiant efforts to control it. This led to thoughts on whether there are any new developments concerning the connections between Malaria and HIV.

A quick look at the most recent PubMed listings for “Malaria AND HIV” mostly yielded sentences with the common theme of “AIDS, TB and Malaria” that considered the big disease funding efforts and the combined global burden of disease but few new insights on how each disease affects the other. Some interesting examples were uncovered.

On the biological side, Jiang and colleagues in the journal Vaccine (2010 Nov 23;28(50):7915-22) observed that, “Malaria and human immunodeficiency virus type 1 (HIV-1) infection overlap in many regions of the world.” Using mouse models they found that, “important implications for the development of a new form of bivalent vaccine against both HIV-1 and malaria.”

On the programming side, Lugada et al. examined how “Integrated disease prevention in low resource settings can increase coverage, equity and efficiency in controlling high burden infectious diseases,” in rural Kenya, and reported on a campaign that provided, “HIV counseling and testing, 60 male condoms, an insecticide-treated bednet, a household water filter for women or an individual filter for men, and for those testing positive, a 3-month supply of cotrimoxazole and referral for follow-up care and treatment.” (PLoS One. 2010 Aug 26;5(8):e12435)

Reid reported on how injections for suspected malaria cases in drug shops and stores Tanzania and other rural African settings sets the stage for HIV and other infections. The need to prevent such practices can help both diseases. (Rural Remote Health. 2010 Jul-Sep;10(3):1463)

Noting that, “Co-infection of human immunodeficiency virus (HIV) with malaria is one of the pandemic problems in Africa and parts of Asia,” Oguariri and co-investigators examined, “the impact of pyrimethamine (PYR) and two other clinical anti-malarial drugs (chloroquine [CQ] or artemisinin [ART]) on HIV-1 replication.” They showed that, “10 μM CQ and ART inhibited HIV-1 replication,” while “10 μM PYR enhanced HIV-1 replication.” This is important news for malaria case management in areas with high HIV prevalence. (Virus Res. 2010 Nov;153(2):269-76)

While these studies individually may not be earth-shaking, they do point to the continued need for partnership between Malaria and HIV control programs – common interests do exist together with the common desire to save lives.

Widespread efforts to scale up insecticide treated net ownership to meet 2010 Universal Coverage targets are underway in most endemic countries of Africa.  The majority have been using their Global Fund grants to make this leap, supplemented by contributions of other partners.

What happens when a country does not have Global Fund resources at this time? Current efforts in Sierra Leone to reach its nearly 6 million citizens provide a lesson on how to cope.

The AFP has reported on a “20-million-dollar campaign to distribute mosquito nets has been funded by the World Bank, the British Department for International Development (DFID), the Federation of the International Red Cross, the United Methodist Church and other health partners.” These partners are “attempting to get insecticide-treated mosquito nets into each household in the country and to ensure their proper use,” using a house-to-house campaign, which is challenged by poor road conditions.

VOA quotes Lianne Kuppens of Unicef in Sierra Leone who said, “”We have roughly 6 million people and we have 3.2 million bed nets already in the country as we speak. So it’s the first time ever that we are going for universal coverage of bed nets.”

Kuppens also noted that ITN use by children below 5 years of age was below 25%, a problem exacerbated by net mis-use – “nets often find their way into the marketplace or are used as fishing nets or shower scrubs. Vegetable growers use mosquito nets to protect cabbages and carrots from harmful bugs.”

VOA also reports that the campaign has a strong “hang up” component that is using “Street theatre, community radio and religious leaders (to) help convince people that hanging their nets over their beds is better in the long run than selling them or catching fish with them.”

But back to the Global Fund …

Sierra Leone’s experience with the Global Fund (GF) may certainly be influenced by its status as a post-conflict country.  The Principal Recipient of the current Round 7 Grant, the Ministry of Health, has, according to GF progress reports, experienced some management challenges.

The Round 7 grant has been running for 2 years and just recently received a “conditional Go” for Phase 2 funding.  ITNs were a small piece of this grant that aimed more at improving malaria treatment.  By 30th April 2010 the grant had distributed only 277,093 of a targeted 312,498 nets for young children and pregnant women.

While the GF does not attempt to strengthen health systems directly, it certainly makes it possible for countries to use grants for their own health system strengthening efforts. More countries should take advantage of this potential. In the meantime, partners should continue to pull together as is the case in Sierra Leone to ensure Universal Coverage.

Two news stories today remind us that low and middle income countries (LIMCs) not only continue to suffer from infectious diseases like malaria, but that they are also burdened with chronic health problems arising from ‘western lifestyle’ behaviors like smoking and over-eating.

The New York Times describes efforts of cigarette companies, not only to promote use of tobacco products, but also to intimidate through lawsuits LMICs who try to control tobacco advertising and sales. Specifically …

Companies like Philip Morris International and British American Tobacco are contesting limits on ads in Britain, bigger health warnings in South America and higher cigarette taxes in the Philippines and Mexico. They are also spending billions on lobbying and marketing campaigns in Africa and Asia, and in one case provided undisclosed financing for TV commercials in Australia.

A Lancet article reported in the BBC documents how adult obesity in Brazil, Mexico and South Africa are above the average for Organization for Economic Co-operation and Development (OECD) countries. Recommendations to reverse these trends include “media campaigns promoting healthier lifestyles, taxes and subsidies to improve diets, tighter government regulation of food labeling and restrictions on food advertising.”

We have here an intersection among the public, the private and the personal. Although individuals can make personal choices and public health organizations can provide health education, the private sector can use their disproportionately enormous financial resources to advertise unhealthy behaviors and threaten in court those who oppose their efforts against health. Statements by agencies like the World Health Organization (WHO) may have a relatively smaller effect here.

The balance seems completely different when it comes to malaria. All partners appear to promoting the same healthy agenda – use of Long Lasting Insecticide-treated Nets and prompt treatment with appropriate antimalarial drugs to name a two key behaviors. The role of WHO is stronger in determining what are appropriate malaria commodities including its pre-qualification of medicines and the WHOPES evaluation scheme for reviewing insecticides.

These WHO processes influence the bulk of purchases for major international donors and national malaria control programs. This is not to say that “unqualified”, substandard or counterfeit malaria drugs don’t make it into the markets of developing countries, but the legal framework is more likely to work against such unhealthy schemes.

Hopefully the malaria partnership that promotes healthy behaviors will continue, resulting in reduced mortality among vulnerable groups such as young children.  It would be a shame for these efforts to reduce infant and child mortality were overshadowed by forces that threaten the lifespan in later years from obesity and tobacco induced cancers and coronary problems.

AIDSPAN has produced another valuable issue of the Global Fund Observer (GFO) that reports and analyzes the challenges of implementing Global Fund grants. Three of the main articles address serious gaps in various areas of programming.

The first gap is one of funding. As we discussed recently, even with an overall increase in pledges to the GFATM, the amounts are inadequate to achieve goals. The inability to raise funds at all level shows serious weaknesses in commitment and planning. AIDSPAN notes consequences of this such that for example …

In fact, though, this week’s pledges provide only $2.9 billion for Rounds 10, 11 and 12. The current estimate of the cost of Phase 1 of Round 10 is $2.0 billion. So the prospects for adequately funding Rounds 11 and 12, and Phase 2 of Round 10, are currently bleak, unless funds significantly in excess of this week’s pledges end up being raised.

The second gap is in oversight of procurement and supply management (PSM). “Deficiencies in the oversight of procurement and supply management (PSM) arrangements may be exposing Global Fund grants to unnecessary and unacceptable risks. This is one of the conclusions of an audit report released by the Fund’s Office of the Inspector General (OIG) in April 2010.”
Some of the main PSM deficiencies as summarized by GFO are –

• weak forecasting of requirements for drugs and health product
• weak technical specifications for procurement
• absence of, or weak, procurement policies and procedures
• poor inventory management
• poor storage and transportation facilities at national and sub-national level
• weak procurement planning resulting in frequent emergency procurements and
• inadequate management information systems

The third major gap reported in the GFO is lack of civil society participation in County Coordinating Mechanisms (CCMs) for global fund grants. The article highlights the Civil Society Action Team’s recent report. This report documented the fact that while persons affected by the three diseases in theory have representation on CCMs, they often do not take part in the real decision making.

In particular, “civil society representatives often lack the capacity and expertise to fully engage in CCM processes and to properly represent their constituents.” Lack of participation threatens the relevance and acceptability of programs.
These gaps focus on weaknesses basic health systems management processes and competencies. It is not enough to point out these gaps. Serious efforts are needed to strengthen health systems. Unless these three gaps are closed, partner interest in pursuing the noble goals of disease control and elimination will be threatened.

As the G8 Summit convenes in Canada this weekend, there comes a time for reflection and accountability. In fact accountability is the theme for a publication – “The Muskoka Accountability Report takes stock of recent G-8 commitments related to development, assesses the results of G-8 actions and identifies lessons for future reporting.” The report explains that …

In 2005, at the Gleneagles Summit and the United Nations Millennium +5 Summit,G8 countries and the world’s major aid donors made commitments to increase Official Development Assistance (ODA). Based on these specific commitments, the Organization for Economic Co-operation and Development (OECD) estimated that ODA from all OECD-Development Assistance Committee (DAC) bilateral donors would increase by around $50 billion a year by 2010, compared to 2004.

The Muskoka Report notes that ODA increased from $80 billion to $120 billion, with $24 billion coming from G8 countries. But it also explains that this $10 billion shortfall is actually $18 billion in 2004 dollar value. The report notes the following health accomplishments:

• G8 contributions account for $12.2 billion or 78 percent of the total contributions to the Global Fund
• G8 is on track to provide over 100 million insecticide-treated nets
  by 2010
• For the period 2005 to 2009 G8 funding to the Global Polio Eradication Initiative was $1.68 billion

Although the dollar amounts seem large, the Washington Post reports from Toronto that, “Canada announced on Friday a multibillion-dollar initiative to combat infant mortality and improve maternal health globally, but the aid package was far smaller than expected, undercut by a new drive toward austerity that reduced the contributions of wealthy nations.”

An expected package of $10 billion from the G8 may turn out to be only $7.3 billion. “… the plan highlighted how world economic dynamics have made a sudden lurch toward less government spending.”

Oxfam has called the contribution gap between 2005 promised and 2010 realities a ‘bounced check‘ that undermines the G8’s credibility. Maybe this is an accounting trick, suggests Oxfam:

Oxfam also decried the G8’s attempt in their own accountability report to minimize their breach of faith by using 2009 dollars instead of 2004 dollars for the calculation and deducting for lower growth, thus showing only a $10 billion shortfall.

Oxfam calls on the G8 to show the “political will and leadership that at least equals that we saw at Gleneagles.” This involves not only acknowledging that the gap is nearly double the apparent dollar value, but also taking steps to close it.

Save the Children recommends that the Muskoka Summit recommit to funding, but that these “Governments need to do better at the September U.N. Summit on the Millennium Development Goals .” The President of Save the Children observed that while the G8 and upcoming G20 leaders are worried about economic stability …

… both the leaders and the public should understand that global economic growth can never be balanced if the world doesn’t address the tragic circumstances surrounding birth and early life in much of the developing world. Without decisive action, the social costs of global economic downturns will only hit harder and last longer.

The BBC reports today that, “World leaders are due to focus on the nuclear disputes with Iran and North Korea on the second day of the G8 summit in Canada.” Maybe they will eventually come to the realization that global poverty is also a problem for all. As BBC notes, “Mr Obama has called for the group to pull together to promote economic growth, saying that world economies are ‘inextricably linked’.”

The nomadic Maasai people of East Africa are certainly not immune to malaria. Research by Bussmann and colleagues shows a wealth of ethnomedical responses to the problem and points out that, “The Maasai pastoralists of Kenya and Tanzania use a large part of the plants in their environment for many uses in daily life.” Specifically, they reported that …

“Although malaria treatment is often available at health centers, the traditional use of herbs for the treatment of ‘malaria and fever’ is still common. The cures mostly involve the ingestion of purgative plant extracts, obtained by boiling plant material. In the Sekenani valley the most important species used to treat malaria were Achyranthes aspera, Warburgia salutaris, Combretum molle, Olea europaea, Sporobolus stapfianus, Teclea nobilis, Toddalia asiatica and Cissus quinquangularis.”

Likewise Koch and co-researchers learned from three Maasai healers the names of 21 indigenous herbs used to treat malaria. “Of the species tested, over half were antiplasmodial, and all but one displayed selectivity for the malaria parasite Plasmodium falciparum.”

A new NGO, Maasailand Health Project (MLHP) based in Washington State, USA, is trying to bring current anti-malaria technologies to a Maasai community in Tanzania. The project focuses on six boma or villages in an approximately 200 square mile area in which nearly 500 people live. MLHP’s “first shipment of 100 nets, 50 blood test kits, 30 treatments of medication, and training,” took place last month.

The group has been in touch with USAID and the Tanzanian Ministry of Health, so hopefully this effort can be integrated with the overall national malaria control program and thus be sustained. Integration of programming for nomadic people is crucial since none of the currently operating Global Fund malaria grants in either Tanzania or Kenya explicitly mention outreach to the Maasai.  The US President’s Malaria Initiative Malaria Operations Plans for both countries are also silent on the needs of the pastoralists.

Unfortunately Kenya’s unsuccessful Global Fund Round 9 malaria proposal intended to involve the Maasai Pastoralist Development Foundation. “This organization has an extensive community network which will be mobilized as part of BCC-Community Outreach. Its capacity will be built through the dual track PR as part of Community Systems Strengthening.”

National and cross-border malaria control efforts need to plan for and finance efforts to protect nomadic, migratory and minority populations from malaria. Without attention to the needs of these populations, malaria cannot be eliminated.

PLoS One has just published a study from Burkina Faso entitled, “Beer Consumption Increases Human Attractiveness to Malaria Mosquitoes.” Beer and water consumers were compared and “Water consumption had no effect on human attractiveness to An. gambiae mosquitoes, but beer consumption increased volunteer attractiveness.”

Specifically, “Body odours of volunteers who consumed beer increased mosquito activation (proportion of mosquitoes engaging in take-off and up-wind flight) and orientation (proportion of mosquitoes flying towards volunteers’ odours).”  The authors therefore concluded that, “beer consumption is a risk factor for malaria and needs to be integrated into public health policies for the design of control measures.”

This is not the first study to look at what attracts mosquitoes to human beings. For example in 2003 Mukabana and colleagues found that “… mosquitoes preferred certain individuals despite being presented with emanations of three persons simultaneously.”

A year later BBC reported on another study the found that, “A key chemical found in
sweat is what draws the mosquito that spreads malaria in Africa to bite its human victims.” The researchers from Yale and Vanderbilt indicated that, “The chemical, or odorant, in sweat responsible for this attraction is called 4-methylphenol.”

Researchers from the University of Florida also explained that, “… the process of attraction begins long before the landing. Mosquitoes can smell their dinner from an impressive distance of up to 50 meters … This doesn’t bode well for people who emit large quantities of carbon dioxide.”

So back to beer drinking – the smells and chemical attractants emitted by the beer drinkers put them at risk. What can be done?  During these days of counting malaria out we need all the partners we can get.  We ask whether breweries are contributing their fair share to protecting their customers and the customers’ families from mosquitoes? Shouldn’t breweries contribute a certain portion of the price of each bottle to the national malaria control program or an appropriate NGO?

Breweries are known for having contests and give aways at local pubs in order to increase sales – instead of giving away caps and t-shirts with the beer logos, maybe they should now give out insecticide treated bednets with their logos.  The role for corporate responsibility by the breweries could not be more clear.

When the words ‘religion’ and ‘Nigeria’ appear in the same sentence the implications can be mixed. Religion certainly plays a big part in Nigerian society. “A survey of people’s religious beliefs carried out in 10 countries (in 2004) suggests that Nigeria is the most religious nation in the world,” according to the BBC. Over 90% of Nigerians said they attended a religious service regularly, more than any of the 10 countries surveyed.

The survey also found that, “More than 90% of those surveyed in Nigeria and Indonesia said they would give their lives for their beliefs.”  This presents the other side of religion in the country.  Over the years the BBC has reported that religion is one of the major flashpoints for conflict in Nigeria. Religion continues to challenge the social and cultural fabric of the country. The difficulty in distinguishing religious, economic and ethnic sources of conflict has seemingly made the challenges more intractable.

Along comes a ray of hope, spurred by of all things, a deadly disease like malaria. The Center for Interfaith Action (CIFA) described Faiths United for Health (FUH) and reports that …

The Sultan of Sokoto and the Archbishop of Abuja, along with other leaders of Nigeria’s Muslim and Christian faiths, today joined Nigerian government officials to launch an unprecedented effort to eliminate deaths from malaria throughout the country. By the end of 2010, the religious leaders plan to train 300,000 imams, priests, pastors, and ministers to carry the malaria prevention message to cities, towns, and rural villages through sermons and other cooperative efforts.

The Christian Post quotes U.N. Secretary-General’s Special Envoy for Malaria, Ray Chambers, who attended the launch of the Nigerian Inter-Faith Action Association’s campaign in Abuja as saying, “Working together, Nigeria’s faith leaders have the credibility, influence, and reach to carry the message that ‘bed nets save lives’ to their nation’s most distant villages.”

The implication is that the more than 60 million insecticide-treated bednets being distributed in 2009-10 will only be effective if they are accepted, hung up and slept under. With such a large portion of the population attending religious services, the potential for an interfaith push to actually use the nets should have a big impact on reducing the disease. As John Bridgeland has said, “Faith-based and other leaders in civil society throughout Africa are emerging from the grassroots to ensure that nets are used properly in homes and villagers know the warning signs of malaria so they get help in a timely fashion.”

While the FUH offers hope, two important issues remain to be addressed.  First, malaria cannot be controlled in isolation and simply through campaigns. Efforts require a strong primary health system to sustain malaria control. Unfortunately This Day highlights, “Part of the irony of our national development is that rather than situations improving, some key sectors tend to deteriorate. One such instance is in the health sector where the once robust primary health care system is almost completely extinct now.”

Secondly, perceptions of malaria illness are culturally based. It is not clear how indigenous African beliefs and religion fit into FUH.

Nigerians, like most people around the world, do not abandon their cultural beliefs just because they practice a cosmopolitan faith. Without attention to the indigenous cultural core of a peoples (e.g. sacrifice of beans and palm wine to Ogun at left above), we may risk low acceptance of our ‘miraculous’ malaria interventions.

If you want to walk fast, walk alone
If you want to walk far, walk together  (Maasai Proverb)

Walking together in partnership was the theme of the launching, held last night, of Kenya’s second national malaria strategy covering the years 2009-2017.  Officials from the Ministry of Public Health and Sanitation acknowledged throughout the ceremony the value of  partnership with the donor, research and civil society communities.

The document had been one year in the making and is accompanied by the Kenya Malaria Monitoring and Evaluation Plan for the same years. Dr Elizabeth Juma, who heads the Division of Malarial Control explained that the two documents are based on an extensive Malaria Program Performance Review, so that it is not a theoretical exercise.

In his keynote address Dr. James Gesami, the Assistant Minister for Public Health and Sanitation, reported that Kenya has made substantial progress in reducing child mortality and hospital admissions for malaria by to date distributing 90 million nets, prescribing 41 million doses of ACTs and protecting 8 million people in targeted areas with IRS.

A new feature of the strategic plan is to make future targeting of these interventions more epidemiologically appropriate based on a new map of malaria prevalence across the country. Dr Gesami said we have fallen short in the past of adequate documentation. Therefore, M&E is intended an a strong companion to the Strategy so that intervention can be monitored and impact measured.

Partnership at all levels was seen as the way to achieve the goals of the new strategy – involvement is needed of the public health sector, the private health sector, civil society, research institutions, donors, the communities and other public and private sector agencies such as agriculture and education. An example of the latter is the malaria free schools initiative enshrined in the Strategy. In short, “Malaria control is not the preserve of the Health Ministries, but is the responsibility of all of us.”

Speakers acknowledged that there are areas where past performance could be better, such as providing Intermittent Preventive Treatment to pregnant woman. There was hope though that the Strategy will guarantee a uniformity of purpose among all partners to achieve targets and result in a malaria free Kenya by 2017.

Jen Orkis reports that public health leaders and football players came together in Kampala recently to launch United Against Malaria efforts will use the 2010 World Cup as a focal point for raising awareness and funds for the fight against malaria. Jen explains that, “By leveraging football/soccer, one of the most popular sports in the world, UAM aims to raise global awareness and renew worldwide commitment to ending malaria, as well as increase the use of prevention tools and malaria treatment in Africa.”

Gabrielle Fitzgerald of Gates also described the “kick-off of Uganda’s United Against Malaria campaign – a coalition of local business, football and non-governmental organizations who have come together to raise awareness about malaria” on One‘s Website. She quoted Edgar Watson, CEO Federation of Uganda Football Association, as saying …

–

Football is a game that is so dear to my heart. It therefore gives me so much joy to see that the United Against Malaria campaign is using the football platform to fight malaria. I pledge to hold the football torch, as we, the coaches and footballers in Uganda all rally behind United Against Malaria. I do this for the children and for the future.

The launching represented a waide partnership including both public and private sectors. For example, the Monitor reported on the involvement of a key mobile phone network: “MTN, the official sponsors of the 2010 World Cup recognise that kicking malaria out of Uganda is not a fight one organisation can win. They are partnering with the consortium to raise awareness and help fight kick out malaria by 2010.”

From the public side Dr. Steven Mallinga, Minister for Health, used the occasion to raise awareness and was reported in the Monitor as saying, “Malaria is the leading cause of absenteeism from work and school due to the several bouts a person may suffer. He advised people to seek treatment within 24 hours of on onset of symptoms. He also encouraged people to sleep in mosquito nets and pregnant women to take the recommended malaria dose.”

UAM is looking for action now as well as sustained effort into the future. “Footballers, non-governmental organizations, foundations, governments, corporations and people like you who have joined forces ahead of the 2010 World Cup in South Africa to unite in the fight against malaria. By acting now, we can achieve unprecedented increases in mosquito net coverage across Africa to save millions of lives by the next World Cup in 2014.”

What is encouraging from the above quote is that is shows UAM is not here just for show, capitalizing on one fleeting event in 2010, the year when RBM coverage targets should be achieved. They also recognize that sustained effort is needed – getting people to use their nets regularly – to turn the coverage targets into reduced morbidity and mortality in the long run.