Category Archives: Research

Zero Malaria Starts after Lockdown?

The novel 2019 coronavirus, also known as COVID-19 and SARS-COV2, is casting a heavy shadow over the 2020 World Malaria Day. People are trying to remain upbeat declaring the tagline “zero malaria starts with me,” but nothing can hide the fear that the current pandemic will both disrupt the current delivery of essential malaria preventive and treatment services, but will have longer term impacts on malaria funding and our capacity to learn new ways to reach malaria elimination goals. As we can see in the graphic to the right, accessible, lifesaving, community-based services may be especially hard hit.

Another ironic image is the indoor residual spray (IRS) team member with a face mask needed for protection from the insecticides being sprayed. When will such teams be able to go back into homes? When can household members actually pack out their belongings so that spraying can commence? When will such masks not be needed for intensive care COVID-19 case management instead?

WHO is urging “countries to move quickly to save lives from malaria in sub-Saharan Africa” because “New analysis supports the WHO call to minimize disruptions to malaria prevention and treatment services during the COVID-19 pandemic.” This will be difficult in high burden countries like Nigeria that are already on lockdown with over 1,000 coronavirus cases detected already. Modeling by WHO and partners has projected, “Severe disruptions to insecticide-treated net campaigns and in access to antimalarial medicines could lead to a doubling in the number of malaria deaths in sub-Saharan Africa this year compared to 2018.”

The Global Malaria Program offers guidance for tailoring malaria interventions to the present circumstances. Great concern is drawn from previous epidemic situations when observing that, “it is essential that other killer diseases, such as malaria, are not ignored. We know from the recent Ebola outbreak in west Africa that a sudden increased demand on fragile health services can lead to substantial increases in morbidity and mortality from other diseases, including malaria. The COVID-19 pandemic could be devastating on its own – but this devastation will be substantially amplified if the response undermines the provision of life-saving services for other diseases.”

Specifically, GMP recommends that national malaria programs should ensure the following:

  • a focal point for malaria is a member of the National COVID-19 Incident Management Team.
  • continued engagement with all relevant national COVID-19 stakeholders and partners.
  • continued access to and use of recommended insecticide-treated mosquito nets (ITNs)
  • continuation of planned targeted indoor residual spraying (IRS)
  • early care-seeking for fever and suspected malaria by the general population to prevent a spike in severe malaria
  • access to case management services in health facilities and communities with diagnostic confirmation through rapid diagnostic tests [RDTs]
  • treatment of confirmed malaria cases with approved protocols
  • continued delivery of planned preventive services normally provided to specific target populations (SMC, IPTi, IPTp)
  • the safety of all malaria personnel and their clients in the process of carrying out the above interventions

In editorial in the American Journal of Tropical Medicine and Hygiene by Yanow and Good address the damaging longer term impact of the present shutdown. “The impacts of research shutdowns will be felt long after the pandemic. Many scientists study diseases that do not share the same obvious urgency as COVID-19 and yet take a shocking toll on human life. For example, malaria infects more than 200 million people and takes the lives of nearly half a million people, mostly young children, each year.1 During laboratory closures and without clinical studies, there will be no progress toward treating and preventing malaria: no progress toward new drugs, vaccines, or diagnostics.”

The case for continuing malaria services to save hundreds of thousands of lives is not difficult to make. The actual implementation during lockdowns and quarantines is a management challenge. The importance of malaria testing to provide patients with appropriate care for the right disease is crucial. The question is whether in resource strapped endemic countries these decisions and management arrangements can be made in a timely fashion and for the long term whether the next generation of research can proceed with much needed new medicines and technologies.

COVID19 Challenges for African Researchers

Not surprisingly COVID-19 related travel restrictions and bans now occur throughout the world, and for African researchers, this means inability to travel for research related collaborations, planning meetings and conferences. Thus, it becomes necessary to ask, “What can we do here at home,” especially considering increasing restrictions on local movement and gatherings.

In the very short time since COVID-19 was finally and officially recognized in China, many research articles have been published. Although these obviously focus on China, they raise possible research questions that need to be addressed in Africa, especially those countries still at the early stages of the epidemic.

Obviously, studies on the clinical management are needed, and one group of Chinese researchers are examining “biological products have broadly applied in the prevention and treatment of severe epidemic diseases, they are promising in blocking novel coronavirus infection,” especially based on reports from previous coronavirus experiences like SARS and MERS.[1] Other studies have examined the role of managing blood glucose levels[2], anticoagulant treatment[3] and the potential of antiviral treatment,[4] among others. What aspects of clinical management will become important to African patients’ survival?

In the process of requesting adequate diagnostic, monitoring and treatment supplies and equipment generally for the country, the tertiary and research hospitals need to ensure they have made requests for the equipment and supplies that are needed not just to provide life-saving treatment, but also to test appropriate approaches in the local setting. Each setting is different and must be studied because already there are anecdotal reports of younger age groups being affected by severe disease in the USA compared to earlier reports from China.

Taking a lesson from the Ebola epidemic in West Africa, there is need to study how COVID-19 will affect the delivery of health care, especially malaria services. Patrick Walker and colleagues[5] modeled the effects of health systems disruption on malaria including challenges in receiving based treatment when clinics were overwhelmed, seen as possible sources of disease and finally shut down as health workers themselves died. Outreach services like insecticide-treated net distribution were also stopped, and the efforts of community health workers were curtailed. To what extent is that happening with COVID-19?

Until there are proven drugs and vaccines, it is extremely important to learn about local epidemiology[6] in order to develop appropriate strategies to prevent the spread of COVID-19. This effort should involve researchers from many disciplines such as public health specialists, anthropologists, sociologists, educationists, and psychologists.

While the medical research mentioned above is carried out in hospitals and clinics, people conducting social and epidemiological studies ideally should be in the community where we can observe people washing their hands or not, gathering in groups or not, and finding out why they do these things. We need formative research to help develop health education, and at the same time ensure social and educational scientists can gather information to evaluate whether the health education as appropriate and worked.

Likewise, research is needed on health systems[7] and must involve political scientists, economists, public administrators, and of course public health specialists, also. A great danger exists for people who cannot keep a social distance from themselves such as those incarcerated in prison and living in camps for refugees and internally displaced people,[8] a common problem throughout the continent. They too need to get into the organizations and systems that provide care and learn what the policy makers and decision makers are thinking.

As Bronwyn Bruton has observed,[9] “Some 40 percent of Africans live in water-stressed environments in which obtaining access to clean water—let alone soap—is an insurmountable daily hurdle, and for those populations, even simple measures to prevent the spread of the virus, such as frequent handwashing, will be out of reach.” In addition he asks difficult questions about what happens to children who are home and cannot go to school, the vast numbers of people in the informal economy who cannot rely on a salary, if they stay home, and the many people in conflict zones. These are questions that urgently need to be studied in Africa.

Answers to our COVID-19 research questions are needed urgently, probably much sooner than funding can be found to support such research.  The question for our African research colleagues is what can be done now with resources at hand in an environment where movement is restricted? We will definitely need speedy responses from our Institutional Ethics Review Boards and be creative in our use of research methods.

Roxana Elliott[10] reports that data collection in the diverse African region “is difficult, especially when measuring statistics such as mobile penetration, which require face-to-face data collection in order to include those who cannot be reached via mobile. Language barriers, lack of infrastructure, and the sheer number of people throughout Sub-Saharan Africa make collecting face-to-face data nearly impossible due to cost and time constraints, especially in rural areas.” She, therefore, suggests that mobile-based surveying methodologies can alleviate these issues. She also recommends a country-by-country approach, and hence we see that in 2017 an estimate of 32% of the population had a smartphone 48% a basic phone, and 20% no phone.

How can social and health researchers design studies using this mobile resource to answer vital COVID-19 questions in the nearest future? If our students are now at home, can they, for example, be contacted to observe, at a safe distance, the human health related actions in their communities? Can they interview family members to learn why people practice prevention or not? Can they relate family experiences seeking health services for suspected respiratory illness?  Can they report on the water supply situation in the rural and urban areas where they are staying?

There are the questions which African colleagues can debate at a proper social distance (via phone, zoom, Skype, WhatsApp, and others), and come up with creative ways to find answers to prevent a worsening epidemic in Africa.

References

[1] Yan CX, Li J, Shen X, Luo L, Li Y, Li MY. [Biological Product Development Strategies for Prevention and Treatment of Coronavirus Disease 2019. Article in Chinese] Sichuan Da Xue Xue Bao Yi Xue Ban. 2020 Mar;51(2):139-145. doi: 10.12182/20200360506. (English abstract in PubMed).

[2] Ma WX, Ran XW. [The Management of Blood Glucose Should be Emphasized in the Treatment of COVID-19. Article in Chinese]. Sichuan Da Xue Xue Bao Yi Xue Ban. 2020 Mar;51(2):146-150. doi: 10.12182/20200360606.

[3] Tang N, Bai H, Chen X, Gong J, Li D, Sun Z.Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy. J Thromb Haemost. 2020 Mar 27. doi: 10.1111/jth.14817. [Epub ahead of print]

[4] Wu J, Li W, Shi X, Chen Z, Jiang B, Liu J, Wang D, Liu C, Meng Y, Cui L, Yu J, Cao H, Li L. Early antiviral treatment contributes to alleviate the severity and improve the prognosis of patients with novel coronavirus disease (COVID-19).J Intern Med. 2020 Mar 27. doi: 10.1111/joim.13063. [Epub ahead of print]

[5] Patrick G T Walker, Michael T White, Jamie T Griffin, Alison Reynolds, Neil M Ferguson, Azra C Ghani. Malaria morbidity and mortality in Ebola-affected countries caused by decreased health-care capacity, and the potential effect of mitigation strategies: a modelling analysis. www.thelancet.com/infection Published online April 24, 2015 http://dx.doi.org/10.1016/S1473-3099(15)70124-6

[6] Luan RS, Wang X, Sun X, Chen XS, Zhou T, Liu QH, Lü X, Wu XP, Gu DQ, Tang MS, Cui HJ, Shan XF, Ouyang J, Zhang B, Zhang W, Sichuan University Covid-ERG.[Epidemiology, Treatment, and Epidemic Prevention and Control of the Coronavirus Disease 2019: a Review. Article in Chinese]. Sichuan Da Xue Xue Bao Yi Xue Ban. 2020 Mar;51(2):131-138. doi: 10.12182/20200360505.

[7] Philip Obaji, Kim Hjelmgaard and Chris Erasmus Coronavirus infections in Africa are rapidly rising. Its weak health systems may buckle. USA Today. Updated 27 March 2020, Accessed 29 March 2020. https://www.usatoday.com/story/news/world/2020/03/27/coronavirus-africa-preparedness-rising-covid-19-infections/5076620002/

[8] Nick Turse. In West African Coronavirus Hotspot, War Has Left 700,000 Homeless and Exposed. The Intercept. March 26 2020, 5:33 p.m. https://theintercept.com/2020/03/26/burkina-faso-africa-coronavirus/

[9] Bronwyn Bruton. What does the coronavirus mean for Africa?. Atlantic Council. Tue, Mar 24, 2020. https://atlanticcouncil.org/blogs/africasource/what-does-the-coronavirus-mean-for-africa/

[10] Roxana Elliott. Mobile Phone Penetration Throughout Sub-Saharan Africa. GeoPoll (In Market Research, Tech & Innovation). Posted July 8, 2019 https://www.geopoll.com/blog/mobile-phone-penetration-africa/

Multilateral Initiative for Malaria: Posters Range from Prevention to Cost to E-Learning and Beyond

A major feature of all conferences are the poster sessions. These are often overlooked due to timing and placement. Fortunately at the recent 7th Multilateral Initiative for Malaria Conference in Dakar, tea breaks and lunch were made available in the poster tent ensuring more people came to view. Even so some people may have missed the valuable knowledge shared through this medium. We tweeted many of the posters during the event, but below are six posters in more detail.

These range from evaluating a malaria surveillance system to financing systems to sustain malaria drug supplies, including through community pharmacies. The potential of E-Learning for malaria capacity building was explored, and the process pf establishing a national malaria operations research agenda was presented. Several posters examined the seasonal malaria chemoprevention (SMC) program in the Sahel of West Africa including one from Mali as seen below.

Please contact the authors for additional information and updates. Readers who presented a poster at MIM are welcome to share their findings with us.

 

MIM – Fostering the next generation of malaria researchers in Africa – gaps and emerging opportunities

Dr Olumide Ogundahunsi of the of the Unicef-UNDP-World Bank-WHO Tropical Disease Research Program (best known as TDR) helped organize a symposium on the history and future goals of the Multilateral Initiative for Malaria (MIM) at the current MIM Conference. He describes the symposium, efforts to launch a MIM Society, and related issues below.

Dakar is hosting the 7th Multilateral Initiative for Malaria (MIM) Pan Africa Malaria Conference 21 years after the first such gathering of malaria researchers in the city in 1997. At that time Northern research and development organizations including NIH/Fogarty, WHO/TDR, Wellcome Trust, SIDA and others sought to take measure of the malaria research experience and needs of African scientists and scientific institutions. It was challenging at that time to find strong and representative core of malaria researchers across the continent. Arising from that first conference was the development of MIM and a plan for building the capacity of African researchers through a series of malaria research grants that included both postgraduate training as well as support for applying the acquired skills in undertaking malaria research.

Dr John Reeder, Director of TDR and Prof Fred Binka

Between 1997 and 2007 MIM supported Fifty six (56) research capacity strengthening (RCS) grants through the Special programme for research and training in Tropical diseases (TDR) for an aggregate amount of $12.9 million from 1997 to 2007.  The grants responded to basic gaps in capacity, research tools/commodities/supplies and communication. The latter reflected a major need for researchers to connect with the global malaria research community to learn and share.

These grants under the aegis of the MIM/TDR task force on Malaria RCS addressed the following broad research themes: Pathogenesis and Immunology of Malaria, malaria vector control (including insecticide resistance), Chemotherapy and antimalarial drug resistance, research and development of new tools from natural products, and research to facilitate malaria control interventions. At the Symposium Representatives of the 56 MIM grantees from West, Central, East and Southern Africa shared experiences during and after completion of their MIM grant. These included –

  • Professor Francine Ntoumi, Malaria immunology and pathogenesis research capacity in Central Africa, University Marien Ngouabi, Brazzaville, Republic of Congo
  • Professor Lizette Koekemoer, Malaria vector research capacity in Africa, University of the Witwatersrand, Johannesburg, South Africa
  • Professor Abdoulaye Djimde, Malaria treatment and antimalarial drug resistance in West Africa., Univerity of Bamako, Bamako, Mali
  • Professor Wilfred Mbacham, Malaria treatment and antimalarial drug resistance in Central Africa, Univeristy of Younde 1, Younde, Cameroon
  • Professor Kwadwo Koram, Malaria epidemiology research capacity for elimination and control in Africa, Noguchi Memorial Institute for Medical Research and University of Ghana,  Accra, Ghana

These speakers demonstrate MIM’s and their own specific achievements in following areas:

  • -Capacity built with infrastructure, technology transfer, skill acquisition and graduate students and postdocs trained (including their current status/subsequent contribution to malaria research and (or) control)
  • -Resources/other grants leveraged
  • -Collaborations established and sustained
  • -Contributions to national and regional malaria research capacity, control and elimination.

MIM ‘alumni’ speaking at the Symposium

Since that time those receiving the MIM RCS were able to benefit from further TDR and other malaria research grants and in the process have themselves helped develop new generations of malaria scientists in the universities and institutes where they work. MIM has continued to address the original research gaps. The holding of six subsequent Pan-African conferences.  Grants were also provided for establishing satellite communications systems at three institutions where grantees were based.

Participants in this process who attended the current conference (MIM2018) were able to help achieve on of the objectives of the symposium that is “highlighting the importance of continuous investment in training and monitoring of young African scientists.” The symposium also articulated the unmet and emerging gaps in research capacity of particular relevance to malaria control and elimination.

Visiting the TDR booth to discuss MIM experiences and research opportunities

MIM started and continues as a partnership among Northern and African research organizations with a rotating secretariat. For the past 10 years the MIM secretariat has been based in Africa, and most recently in Cameroon in the Biotechnology Centre of the University of Yaoundé.

Going forward the MIM is evolving into the MIM Society, a broad-based society which will focus among others on organizing regular MIM conferences, promoting research capacity strengthening and foster and unite the different initiative on the continent and worldwide. The MIM society will also invigorate the young African scientist to emerge as outstanding researchers and leaders with ground breaking innovation in science and its applications to development.

The MIM Society will be a global non-profit organization whose mission is to unite all human resources, young and experienced, working on malaria (from researchers over implementers, teachers, producers, funders, policy makers) to strengthen and sustain the capacity of malaria affected countries and to be an umbrella organization for all malaria related initiatives. The MIM Society through its members will guarantee capacity building goals for malaria researchers set by MIM 20 years ago will be carried forward for another 20 years and more.

Urine Rapid Diagnostic Test for Malaria: Results Published

Results of testing the innovative Urine Rapid Diagnostic Test for Malaria developed by Fyodor Biotech have been published in the Journal of Clinical Microbiology. Authors from multiple collaborating institutions include Wellington A. Oyibo, Nnenna Ezeigwe, Godwin Ntadom, Oladipo O. Oladosu, Kaitlin Rainwater, Wendy O’Meara, Evaezi Okpokoro, and William Brieger. The abstract appears below.

fydor_0 Background: The need to expand malaria diagnosis alongside policy requirements for mandatory testing before treatment motivates exploration of non-invasive rapid diagnostic tests (RDTs). We report the outcome of the first cross-sectional, single-blind clinical performance evaluation of a Urine Malaria Test (UMT) for Plasmodium falciparum (Pf) malaria diagnosis in febrile patients.

Methods: Matched urine and fingerprick blood from participants ?2 years with fever (axillary temperature ?37.5°C) or history of fever in the preceding 48 hours were tested with UMT and microscopy (as gold standard). BinaxNOW® (Pf/Pan) blood RDT was done to assess relative performance. Urinalysis and Rheumatoid Factor (RF) tests were conducted to evaluate possible interference. Diagnostic performance characteristics were computed at 95% CI.

UNT is winner of innovations prize

UMT is winner of innovations prize

Results: Of 1,800 participants screened, 1,691 were enrolled; 566 (34%) were febrile, 1,125 (66%) afebrile; test positivity among enrolled participants: 341 (20%) by microscopy, 419 (25%) UMT, 676 (40%) BinaxNow Pf and 368 (22%) BinaxNow Pan. UMT sensitivity among febrile patients (for whom the test is indicated) was 85% and specificity 84%. Among febrile children ?5 years, UMT sensitivity was 93%, specificity 83%. Area under receiver-operator characteristic curve (AUC) of UMT (0.84) was not significantly different from Binax Pf (0.86) or Binax Pan (0.87), indicating that the tests do not differ in overall performance. Gender, seasons, and RF did not impact UMT performance. Leukocytes, hematuria and urobilinogen concentration in urine were associated with lower UMT specificity.

Conclusion: UMT performance was comparable to BinaxNOW Pf/Pan tests, and is a promising tool to expand malaria testing in public and private healthcare settings where there are challenges to blood-based malaria diagnosis testing.

Malaria Plus Brexit – let’s hope no Malexit

brexit and africaNo one knows for certain the full implications of Britain’s narrow vote to leave the European Union (EU). Since Britain has been a major player in malaria research and development aid, questions naturally arise of whether the British exit (Brexit) from the EU will affect development aid and global research generally and malaria aid and research specifically.

Earlier this week the Brookings Institution examined the ways that a Brexit could affect Africa. Here are some of the possibilities adapted to malaria –

  • Volatility in the global economic market will affect not only the British economy but also those of malaria endemic countries, possibly reducing the reducing available funds for national contributions to malaria control at home, a major goal for sustaining malaria control and elimination
  • Britain specifically may not be able to sustain its financial contributions to malaria aid through the Global Fund, bilateral malaria programs and of course it would no longer contribute to the European Development Fund which currently stands at nearly 15% of its total.
  • The British economy which like all modern nations depends on trade would be affected by the need to renegotiate hundreds of trade agreements around the world. Less trade likely means less income and less development aid.

In both 2014 and 2015 the United Kingdom contributed 8% of the total contributions received by the Global Fund to fight HIV, TB and Malaria. In addition “UK’s official development assistance (ODA) is expected to rise to £11.3bn when it hits the 0.7% target. With a population of about 63 million, the figure works out at roughly £137 per Brit.” In 2012 the malaria component was estimated at 2%.

Patrick Vallance and Tim Wells examine the importance of global collaboration on malaria research. This requires the free flow of researchers and their needed supplies across national borders, especially malaria research that has had to date a pan-European character. They describe the collaboration needed “between commercial and non-profit organizations, and between academic science and medicine. Without such partnerships, advances in fighting this deadly disease would not have been possible.”

Vallance and Wells give the example of “GSK’s research site in Tres Cantos, Spain. The lab operates with the support and advice of a broad range of actors, including GSK, the Wellcome Trust, the European Union, and MMV (Medicines for Malaria Venture), as well as various other product-development partnerships and academic centers.” Such efforts may be jeopardized when permits for malaria scientists to work in other countries are more difficult to obtain.

There may be other aid mechanisms too, the Commonwealth Secretariat being one. During World Malaria Day in 2012 the Commonwealth Secretariat pledged to assist in sustaining the gains made in tackling malaria.  We hope that Brexit will not become an exit for malaria commitments and saving lives.

“Nobel” drug discoveries rewarded, but delivery of malaria and filarial medicines to the community also matters

Herbs, soil and hard scientific work have yielded Nobel Prizes in Medicine/Physiology for three scientists whose results now save millions of lives from death and disability due to malaria, onchocerciasis (river blindness) and filariasis (elephantiasis), according to the New York Times. Two of the winners, “Dr. Campbell and Dr. Omura, developed Avermectin, the parent of Ivermectin, a medicine that has nearly eradicated river blindness and radically reduced the incidence of filariasis.” Dr Tu Youyou, “inspired by Chinese traditional medicine in discovering Artemisinin, a drug that is now part of standard anti-malarial regimens and that has reduced death rates from the disease.”

Community Case Management of Malaria in Rwanda using Rapid Diagnostic Tests and ACTs

Community Case Management of Malaria in Rwanda using Rapid Diagnostic Tests and ACTs

The development of these chemicals into human medicines was a long time coming, and in the case of artemisinin, over 2000 years. The Guardian quotes the Deputy Director of the Liverpool School of Tropical Medicine as saying that, “Artemisinin was discovered when fatalities from malaria were rocketing and the world was terrified we’d be looking at a post-chloroquine era. It has been a real game-changer.”

In fact artemisinin in combination with other medicines or artemisinin-based combination therapy (ACT) rescued many lives in the face of parasite resistance to earlier first line drugs like chloroquine and sulfadoxine-pyrimentamine (though artemisinin resistance is now growing). ACTs are also made freely available to populations in malaria endemic countries through such programs as the Global Fund to fight against AIDS, TB and Malaria (GFATM), the US President’s Malaria Initiative, the World Bank and others.

Avermectin began its medical role as a veterinary drug that killed parasites in livestock. Eventually research by Merck based on the similarities between animal and human filarial worms led to the testing and development of ivermectin to control onchocerciasis through annual doses that killed microfilariae.

Not only are both ACTs and ivermectin on WHO’s essential medicines list, but they form the basis of global efforts to eliminate disease. Once Merck determined that ivermectin was safe and effective in humans, it began donations of the drug to what has become the African Program for Onchocerciasis Control (APOC) and its counterpart that is working to eliminate the disease in the Americas. APOC and its national counterparts now reache people in over 200,000 endemic villages in 18 African countries with annual doses.

Community Directed Distribution of Ivermectin in Cameroon

Community Directed Distribution of Ivermectin in Cameroon

While we celebrate the recognition that the drugs and their discoverers are receiving, we should not lose sight of the fact that without good delivery mechanisms these life saving medicines would not reach the poor, neglected, often remote populations who need them.

Beginning in 1995, APOC and the Tropical Disease Research Program of WHO and partners pioneered what has now become known as Community Directed Interventions (CDI) where the thousands of communities “beyond the end of the road” and their selected volunteers organize the annual ivermectin distributions. This community directed approach works for community case management of malaria, too.

Hopefully in the future, groups like APOC will receive Nobel Prize recognition for ensuring that those in need actually receive the medicines they require. In the meantime we encourage more countries to adopt the CDI approach to reduce malaria deaths and work toward the elimination of malaria, onchocerciasis and filariasis.

AHI: Achieving People Centered Health Systems in Five African Countries

The African Health Initiative (AHI) will be presenting a second panel During the upcoming Third Global Symposium on Health Systems Research in Cape Town (30 September-3 October), entitled “Achieving People Centered Health Systems in Five African Countries: Lessons from the African Health Initiative.”

AHI was established in 2008 by the Doris Duke Charitable Foundation and seeks to catalyze significant advances in strengthening health systems by supporting partnerships that will design, implement and evaluate large-scale models of care that link implementation research and workforce training directly to the delivery of integrated primary healthcare in sub-Saharan Africa.

globalsymposium_logosThe five AHI country projects (Ghana, Mozambique, Rwanda, Tanzania and Zambia) will be sharing their experiences during the panel presentation. We will be tweeting at each panel presentation, and you can follow at: #HSG2014 and “Health  Systems Global” and “Bill Brieger Malaria“.

Highlights of the second panel follow:

Community health workers in Tanzania

Community health workers in Tanzania

It is a common claim that randomized controlled trials (RCT) are the ‘gold standard’ for scientific inference, with rigor derived from the imposition of stable interventions and statistically robust controls, and power derived from operational units as study observations. In health systems research, however, the ‘gold standard’ is more appropriately based on the relevance of research to decision-making. As a consequence, impact research is appropriately combined with implementation research, and units of observation are based on the way that systems function and decisions are made.

Mixed method complexity trials are indicated, with units of observation that integrate research with management processes. Presentations by scientists who are engaged in complexity trials in Ghana, Mozambique, Rwanda, Tanzania, and Zambia will highlight statistical designs that violate conventional standards of RCT, but derive rigor from mixed method research, hierarchical observation and modeling, and plausibility trials.

“Proof of utility” is derived from the operational adaptation of project implementation to local realities, monitoring process and outputs, testing impact, and revising strategies over time as needed. A learning process approach produces evidence-generating localities where operations serve as realistic models for large scale change in national systems.

DSCN6602aVarious terms used in the scientific literature to characterize this theme, such as ‘open systems theory’, the strategic approach, or participatory planning, each embracing the perspective that people centered service systems are essential to health systems strengthening. Practical examples of how to achieve people centered programming, however, are rare.

This panel presents five case studies that have confronted the challenge of developing, testing, and sustaining people-centered health systems in resource constrained settings of sub-Saharan Africa. These are outlined below.

– The Ghana Essential Health Interventions Programme tests the child survival impact system strengthening interventions. When monitoring identified perinatal health problems, priority was shifted to improving newborn and emergency referral services. Combined with political advocacy, changes increased access, improved quality, and expanded the range of services.

DSCN6373– The Mozambique project improves service quality by giving facility, district and provincial managers skills for identifying and fixing systems problems. Initial skills-building through training in leadership and management had only transitory effects. An evidence-driven redesign improved facility and district level operations and improved accountability.

– In Rwanda health-center-focused quality improvement data identified strategies for compensating health centers for reaching specific operational goals. Initial results show that the scheme has enhanced performance and fostered cross-center learning.

– The Tanzania Connect Project tests the survival impact of deploying community health workers. Connect monitoring showed that unmet need for family planning was inadequately addressed. Connect was redesigned to include comprehensive doorstep family planning services.

Zambia’s Better Health Care Outcomes through Mentorship and Assessment project was developed from people centered lessons emerging from scaling up an HIV program. A 42 cluster stepped wedge tests the impact of improving outpatient care with training, structured forms, electronic data capture, and community engagement. In response to implementation challenges, volunteer density was increased and mortality and clinical data capture operations were reformed.

While the studies employ contrasting designs, the projects share an adaptive approach to implementation. A concluding session summarizes lessons learned and implications for health systems strengthening in Africa.

New operational research projects in malaria elimination

MESAKate Whitfield is sharing with us the following information about MESA‘s operational research …

New operational research projects in malaria elimination started in April 2014, after being selected for funding through MESA (the Malaria Eradication Scientific Alliance).

MESA grants awardedThe MESA operational research portfolio includes: proof-of-concept of novel vector control and diagnostic tools, use of mapping technologies for surveillance and tailored response, and mobile phone applications for hard to reach populations. Urban, rural and forest settings are addressed. The projects are summarised below

  • Mopping up and getting to zero: mapping residual malaria transmission for targeted response in urban Lusaka, Zambia.
  • Using voice]based technology to improve access to malaria care and treatment among high risk mobile population of forest goers in Cambodia.
  • Applying novel nucleic acid surveillance to malaria elimination in South Cotabato Province, Mindanao, The Philippines.
  • Efficacy and safety of high]dose ivermectin in reducing malaria transmission.

Akros landscapeinety-one proposals were submitted to the call and after a thorough review process with an independent Peer Review Panel, 4 were selected for funding. The Peer Review Panel was composed of 12 experts from all over the globe. You can find a schematic of the review process through this link.

MESA (the Malaria Eradication Scientific Alliance) follows-up on the mal ERA agenda and provides a dedicated platform for the community in order to accelerate the translation of the science of malaria eradication for impact.

Don’t Forget Malaria on World AIDS Day

logo-wad2World AIDS Day coming up on Sunday 1 December 2013 is not just a time to think about progress and challenges of one infectious disease, but the interaction between HIV and other infections, especially Malaria.  Adu-Gyasi and colleagues express the relationship well in their article on malaria among HIV patients in Ghana: “Malaria is associated with an increase in HIV viral load and a fall in CD4-cell count. Conversely, HIV infection disrupts the acquired immune responses to malaria and the efficacy of antimalarial drugs.” Recent research provides continued insight that we must look at the two diseases as a joint problem in malaria endemic regions.

Research was conducted on mice that were infected with P. chabaudi malaria. The mice showed increased gut and genital mucosal T cell immune activation and HIV co-receptor expression. The implication of the findings was that malaria infection might enhance the sexual acquisition of HIV in humans, and the authors recommended further research to learn more.

In another study researchers looked at Malaria and HIV co-infection and their effect on haemoglobin levels from three health-care institutions in Lagos, Nigeria. The data showed that the total number of malaria infected patients were significantly higher in HIV sero-positive patients 47.7% (31/65) when compared with their HIV sero-negative counterparts 25.8% (262/1015) P = 0.047.  Not only was there a higher prevalence of malaria in HIV infected patients but also patients co-infected with malaria and HIV were more likely to be anaemic.

DSCN4965smBoth HIV and malaria in pregnancy present serious problems. Another recent study looked at Cotrimoxazole (CTX) prophylaxis versus mefloquine (MQ) intermittent preventive treatment (IPT) to prevent malaria in HIV-infected pregnant women. The study concluded that, “CTX alone provided adequate protection against malaria in HIV-infected pregnant women, although MQ-IPTp showed higher efficacy against placental infection. Although more frequently associated with dizziness and vomiting, MQ-IPTp may be an effective alternative given concerns about parasite resistance to CTX.”

Concern about malaria and HIV in pregnancy also focuses on the child. Research examined malaria diagnosis in pregnancy in relation with early perinatal mother-to-child transmission (MTCT) of HIV.   The authors reported that “HIV MTCT risk increased by 29% (95% CI 4-58%) per MIP episode. Infants of women with at least two vs. no MIP diagnoses were 2.1 times more likely to be HIV infected by 6 weeks old (95% CI 1.31-3.45).”

Finally since concurrent experience of both malaria and HIV infections means taking multiple drugs, researchers have also looked at the potential challenges of drug interaction. “An extensive literature search produced eight articles detailing n = 44 individual pharmacokinetic interactions.”  While various HIV medications either increased or decreased the exposure to malaria drug components including lumefantrine and artemisinin, artemether-lumefantrine or artesunate combinations generally had little effect on the pharmacokinetics of HIV-antivirals (with two exceptions).

It is difficult to say which disease is closer to reaching elimination goals, but unless both are understood from their mutual impacts on transmission and treatment of the other, both will continue to elude control efforts.