Tropical Health Matters

Ghana, like other countries in the region, is reported to be revising its national malaria strategy. Most countries developed a new strategy document around 2001, at the beginning of the Roll Back Malaria Partnership, that reflected the goals of achieving 60% coverage of the core interventions (ITNs, IPT and appropriate and timely case management).  This level was supposed to have been achieved by 2005, and then new targets of 80% coverage took effect for the 5-year period starting 2006.  Many changes occurred between 2001 and 2006 including the availability of artemisinin-based combination therapy (ACT), long-lasting insecticide treated nets (LLINs), and the re-emergence of indoor residual spraying (IRS).

Some shifts in policy have occurred, and it is natural for a new strategy to be developed to account for these. The Global Fund for Fighting AIDS, TB and Malaria (GFATM) noted that Ghana switched to ACTs, and now the country needs to embody this in their malaria strategy. Ghana was given permission to use artesunate-amodiaquine as its ACT rather than the pre-qualified drug artemether-lumefantrine.  Drug quality issues resulted in serious side effects that eroded the public trust. The Food and Drugs Board took action, and as the GFATM noted, the PR worked hard “to overcome the bad publicity around the launch of ACTs.” Therefore the new malaria strategy needs a strong health education component to overcome and remaining public skepticism about the intentions and quality of the national malaria control effort.

Another challenge of the new malaria strategy will be to prevent the diversion of nets into the private sector. This problem likely arose in part due to the fact that cost was a major issue that prohibited net ownership before the start of the GFATM grant.

Ghana is also considering IRS, which is possible now that Ghana has been designated a PMI country. The challenge with IRS is determining the appropriate insecticide because of varying resistance of vectors in different regions of the country.

Overall the biggest challenge in revising the malaria strategy is determining Ghana’s own national malaria control needs and then coordinating the input of donors to meet those needs rather than developing a strategy based solely on what the donors expect.

The Associated Press reports “a 40 percent increase, to $4.5 billion, for fighting AIDS, malaria and tuberculosis overseas” from the new US Congress.  This was especially amazing given both the stiff competition among various programs, as well as what the AP observed to be strong efforts to control spending on special projects known as earmarks.

A special thanks is due to the many agencies and NGOs who joined hands for advocacy to promote a malaria free future. their letter to Congress made a difference. There are strong indications that this spending bill will be signed by the President, enabling the President’s Malaria Initiative to actually take off with its own funding.

The current Newsletter of the Tropical Disease Research (TDR) Program highlights the role home management of fever/malaria can have in reducing the deaths of over one million children annually. TDR notes the value of having child doses prepackaged in order to enhance provision of the correct amount of medicine to children.  The Newsletter quotes Professor Umberto D’Alessandro from the Prince Leopold Institute of Tropical Medicine in Antwerp, Belgium, who said, “There are no data available on the effects of ACT when it is given by mothers to their children without proper diagnosis. It should reduce mortality, but we simply don’t know if it does.”  This has led TDR to support Studies using ACTs in home management settings in Benin, Burkina Faso, Cameroon, Ethiopia, Malawi, Nigeria, Uganda and the United Republic of Tanzania.

Some encouraging preliminary results were published last year from independent work in Ghana. An article by Gyapong et al. reported that, “Adherence of agents and caregivers to the treatment (with Coartem) was 308/334 (92.5%). Delay in seeking care was reduced from 3 to 2 days. No serious adverse drug reactions were reported. Community members were enthusiastic about the performance of the agents.”

Turning research into practice, and thereby making ACTs available in the home, will require several steps.  There are at least two effective strategies for getting malaria medicines for prompt care of children into the home.  One is training and supplying community volunteers, while the second is selling antimalarials in licensed shops, often at subsidized prices. For these strategies to save children’s lives, policy decisions are needed concerning whether ACTs will remain prescription drugs or whether they can be sold in the licensed medicine shops which are near the home.

An article by Mokuolu et al. in the January 2007 issue of the American Journal of Tropical Medicine and Hygiene, reports on changes in malaria drug sales before and after the issuance of the new national antimalarials drug policy. Data come from doctors’ prescriptions at University of Ilorin Teaching Hospital pharmacy in Kwara State.  The Federal Ministry of Health, with support from WHO conducted two rounds of malaria drug efficacy trials, and based on these a new policy promoting Artemisinin-based Combination Therapy (ACT) was drafted in 2004. The policy was not officially inaugurated until May of 2005.  Data from Ilorin examine both 2004 and 2005.

The hospital pharmacy operates a revolving fund with prices pegged just above cost. Sales of drugs containing artemisinin increased by 300% in just one year.  Also, as a percentage of total malaria drug doses sold, medicines containing artemisinin rose from 18% in 2004 to 49% in 2005.  The proportion of sales of chloroquine, the former first line drug, dropped from 73% to 27% in the same period.  These changes occurred in spite of the fact that the cost of a course of chloroquine tablets was about 12 US cents compared to between US $2.30 and $7.20 for a tablets containing artemisinin.  It appears that prescribers are adopting the new policy, and consumers are paying the price.

Three issues of concern arise from the findings.  In 2005, over two-thirds of the drugs containing artemisinin were not ACTs, but artemisinin monotherapy formulations (see photo above). WHO has demanded that sales on monotherapy drugs be halted in order to prevent the spread to resistance to artemisinin. The current approach of the Nigerian Agency for Food and Drug Administration (NAFDAC) has taken the approach of not intending to renew the license of monotherapy drugs when these expire, but not in pulling the drugs off the shelves.  A second concern is the fact that a small (~7%) but notable portion of drugs were sold in syrup form which is not only more expensive but also less stable. Child dose packets of ACT tablets are available (see photo below). Finally sulphadoxine-pyramethamine (SP) continues to be a large portion of total sales (23% in 2005) in spite of the fact that SP, according to national policy, should be reserved for Intermittent Preventive Treatment in pregnancy and not used for curative purposes.

 

Hopefully the authors will continue to monitor malaria drug prescribing and branch out into the state and local governments as well as into the private sector to learn more about response to the new national ACT policy. Learning about compliance with the new policy in the private sector is crucial, because this is where the bulk of malaria drugs are sold and where the bulk of controversy about drug quality exists. (Note that pictures of malaria medicines herein do NOT constitute an endorsement.)

Most people anticipated President Bush’s State of the Union Speech for clues about the direction of war or domestic policy. Obviously we at Voices for a Malaria Free Future were anticipating news on the fate of the President’s Malaria Initiative, which is threatened by lack of adequate funds if the fiscal year 2006 budget levels remain in place. In fact, the President said to the assembled Houses of Congress, “I ask you to provide $1.2 billion over five years so we can combat malaria in 15 African countries.”  Hopefully Congress knows the importance of this initiative and the lives at stake, because the address was not a very strong sales pitch.

An interesting feature in the New York Times today is a comparison of the frequency of key words used in this President’s past State of the Union addresses.  Malaria was mentioned once last night, twice last year and not at all in previous years. More commonly mentioned words in last night’s address were Iraq (34), insurance (14), oil (9) and economy (8).  Africa, where the most deaths from malaria occur, was mentioned three times, and AIDS, the focus of another major Presidential initiative was voiced only once this year, but four times in 2006.

Political commentators muse that malaria control may be one of the key points in Presiden Bush’s legacy.  This will only happen if there is greater leadership and advocacy for malaria programs, and if a true bipartisan spirit prevails, putting the long term interests of children, pregnant women and workers in malaria-endemic countries ahead of short term political gains.  Malaria needs to be mentioned more than once for this interest to develop.

Canadian Press has reported that, “A Canadian program that’s saved thousands of Africans from deadly malaria has been scaled back while federal officials decide whether to renew funding.”  These funds had been used by the Canadian Red Cross and UNICEF to run bed net distribution program in several countries.Of even greater concern is the willingness and ability of malaria endemic countries to show a commitment for tackling the disease.  News from the World Social Forum in Nairobi is that, “African governments’ failure to deliver on a 2001 vow to spend 15 per cent of budgets on health has cost the continent 40 million lives, activists including Nobel winners Desmond Tutu and Wangari Maathai said yesterday.”  The gathering further noted that, “Malaria kills more than one million Africans a year, nearly 90 percent of the global total.”

Most donor supported malaria programs are time-limited. Global Fund grants, for example are for only five years, and the President’s Initiative is currently slated only until around 2010.  This is not to say that other funds will not become available, but the inability of endemic countries to step up to the plate and commit more funds for health and malaria threatens their ability to sustain malaria control.

Another perspective is offered by the group WEMOS who report that, “Public expenditure, however, is restricted by IMF macroeconomic policies and conditions. … Budget ceilings imposed by the IMF are ineffective and have negative effects on the health sector. Although exemptions can be made (and sometimes are) if extra money becomes available for the health sector, these increases do not come anywhere near the expenditure needed to achieve the health-related MDGs.” A 4-country study found recent health expenditures as a portion of the national budget ranging between 8.6% and 12.0% as seen in the figure below.

Clearly the problem of adequate funding for malaria is multifaceted. Multi-national organizations, bilateral donors and endemic country governments need to work together to ensure that the future is malaria-free.

While there is much concern now for securing adequate funding levels for US efforts to fight malaria, it is important to look toward future commitments, since malaria is not a disease that will be easily defeated. A quick search has found that several potential candidates for the US Presidency in 2008 have thought about the problem of malaria. Mention of any particular candidate herein does not constitute an endorsement, nor is the selection meant to be representative. The hope is that malaria control advocates can build on potential interest by candidates to heighten action throughout the country to make a malaria free future.

A recent report noted that, Senator “Brownback is laying the foundation for a broadened platform, working to draw attention to problems in Africa, including the violence in Sudan’s Darfur region, human sex trafficking and efforts to fight AIDS and malaria.”

After a visit to malaria-endemic Kenya, “Illinois Senator Barack Obama says Americans should be aware of and support African efforts to control infection disease. “What we want to make sure of is that we’re dealing with these issues [in Africa] before they get out of hand, and then start getting exported to the United States.”

Former Secretary of Health and Human Services, Tommy Thompson, shepherded the current administration’s HIV, TB and Malaria efforts and served as chairman of the Global Fund board. His continued commitment to controlling malaria would be extremely likely.

Senator Hillary Clinton stated that, “We have to have greater cooperation, creating new international alliances, treaties and conventions to deal with the challenges and dangers that confront the entire world, whether it be a potential pandemic such as bird flu, the continuing spread of diseases like HIV-AIDS, malaria and tuberculosis, or so many of the others that we read about on a daily basis.”

Senator John McCain honored Mrs. Laura Bush with these words, “Mrs. Bush has become the face of America’s commitment to the developing world, highlighting our country’s efforts to end pandemic diseases like malaria and HIV/AIDS.”

Former Senator John Edwards spoke in London saying, “Along with other countries and the UN, we should be leading the effort to do simple things like buy mosquito nets to protect children from Malaria.”

Bringing an end to the destruction caused by malaria is hopefully something that all candidates can agree upon.