Posts or Comments 18 July 2024

Monthly Archive for "February 2007"

Mortality &Policy Bill Brieger | 25 Feb 2007

Malaria and the Demographic Transition in Africa

Recently we commented on an article in the Bulletin of WHO concerning fertility and equity.  Now a manuscript by Conley, McCord and Sachs look specifically at the relationship between malaria and excess fertility (see attached map on total fertility rates in 2003 from WHO).  They note that, “Much of Africa has not yet gone through a ‘demographic transition’ to reduced mortality and fertility rates.” They found that, “child mortality (proxied by infant mortality) is by far the most important factor among those explaining aggregate total fertility rates, followed by farm productivity. Female literacy (or schooling) and aggregate income do not seem to matter as much, comparatively.”


Maternal malaria is also implicated when they note that, “There is some evidence that malaria may reduce lactation period, which might increase fertility through decreased child spacing. Likewise, malaria in pregnancy is also associated with low birthweight and increased neonatal and infant mortality—which is in line with our models.”

They conclude that, “This is where the theory of the demographic transition started: save the children and families will choose to have fewer children.”  They do explain that the transition time between reduced infant and child mortality and reduced fertility may take a generation or two.  The lesson here is that increased fertility may in fact be an inequity caused by child deaths, especially from malaria, and that family planning alone will not address this imbalance.

Malaria is holding back the demographic transition and economic development in Africa.  An investment in treating and preventing malaria in women and children will have long term benefits.  International donor programs like GFATM, World Bank Booster and PMI can help start the process of reducing mother and child mortality, but the effect on fertility and economic development will require a long term commitment by governments in endemic countries. There is no room for complaints about the cost of ACTs and LLINs!

Malaria in Pregnancy &Treatment Bill Brieger | 25 Feb 2007

Treating Malaria in Pregnancy: Searching for an Answer

The present WHO malaria treatment guidelines state that, “The antimalarials considered safe in the first trimester of pregnancy are quinine, chloroquine, proguanil, pyrimethamine and sulfadoxine–pyrimethamine. Of these, quinine remains the most effective and can be used in all trimesters of pregnancy including the first trimester.”  The guidelines go on to say that, “There is increasing experience with artemisinin derivatives in the second and third trimesters (over 1000 documented pregnancies). There have been no adverse effects on the mother or fetus.”  Where problems arise is choosing a safe partner drug for ACTs, as WHO has come out against monotherapy artemisinin treatment. The unfortunate balance is between known safe drugs, for which resistance has grown, or drugs that have not been sufficiently tested.  WHO concludes that, “Despite these many uncertainties, effective treatment must not be delayed in pregnant women.”

dscn9999a.JPGThe thorny issue of treating malaria in pregnancy has been addressed in recent journal articles.  In The Lancet Nosten et al. Emphasize the importance of prompt and appropriate treatment because of the severe impact malaria has on the mother, the fetus and eventually the newborn. Dellicour et al. in Malaria Journal conclude that with the ‘limited data available’ artemisinins are unlikely to cause fetal loss or abnormality when used late in pregnancy.

Ward et al. in The Lancet believe that adequate ‘information is not available’ on toxicological liabilities of artemisinins on the mother and fetus.  At the same time Valley et al. in Malaria Journal provide a whole table of potential drugs that can be used in pregnancy for IPTp and discuss the safety of these.

All authors agree that there are inadequate studies of large enough size to come to definitive solutions, and all are concerned about the ethnics of testing drugs during pregnancy.  Is the answer to this dilemma treatment with pharmacovigilance, which would be challenging in resource poor endemic areas? Is the solution clinical trials?  Pharmacovigilance faces another challenge. When health workers are told on one hand not to give artemisinins to pregnant women and on the other to report any adverse reactions to artemisinins the result is no data due to fear of repercussions if supervisors found that artemisinins were given to a pregnant woman

Can infected women wait? The reality is that in most endemic countries national malaria case management policy simply states that health workers should prescribe the currently accepted national malaria treatment for pregnant women, though they do address the need for such drugs as quinine during the first trimester.

Health workers in the field need answers and guidance, and international bodies like WHO need to step forward quickly with a more definitive course of action to find those answers.

Environment &Treatment Bill Brieger | 24 Feb 2007

Indigenous Knowledge and Malaria

The World Bank has been operating a program and website that focuses on indigenous knowledge of communities and cultures where health and development projects take place. While this website explores obvious issues such as indigenous medicine and farming practices, it also looks at how local knowledge and practices can contribute to improving program management and evaluation.

Nearly 100 issues of IK Notes have been published since 1998.  For example, IK Notes #51 reminds us that quinine was derived from the chincona tree, and now artesunate drugs come from the Chinese herb, Artemisia annua.  This issue goes further to how the Tanga AIDS Working Group is enlisting the ready availability, knowledge and skills of indigenous healers to enhance home based care.

The economics of indigenous healing are examined in IK Notes #32. This issue notes that because of the local perception that malaria is relatively easy to diagnose, community members seek the most readily available and least expensive forms of treatment, often leading to the choice of indigenous medicine instead of going to hospital.


IK Notes #52 addresses the relation between indigenous perceptions of disease/illness and the knowledge of local plants for treatment.  A study in Ethiopia found that where there were no local equivalents of the term ‘malaria’, specific plants for treatment could not be isolated.

Mali is the focus of IK Notes #47 where a local plant has multiple uses. “Traditionally, rural women used Jatropha curcas for medicine (seeds as a laxative, latex to stop bleeding and against infections, leaves against malaria) and for soap production.”

neem-igboora.JPGIndigenous knowledge has been documented in the preventive realm. In IK Notes #73 focus groups in Malawi found that, “Malaria stands out as the single largest health problem in all of the study communities. A local wild shrub cited as an effective mosquito repellent, is used to varying extents among the study communities.”

Explore the IK website and think about how you can ensure that indigenous knowledge in other malaria endemic areas can be documented and put into use to save lives.

Partnership Bill Brieger | 22 Feb 2007

Role of NGOs in Malaria Control

Civil Society Organizations (CSOs) such as non-governmental organizations (NGOs) and faith based organizations (FBOs) have traditionally played important roles in charitable and social welfare work both in their home countries and abroad.  For example, the African Program for Onchocerciasis Control (APOC) makes a point of pairing NGOs with government entities in order to enhance technical capacity and financial accountability in implementing river blindness control efforts.  The Global Fund to Fight AIDS, TB and Malaria (GFATM) encourages local CSO representation on national Central Coordinating Mechanisms to ensure that consumers have a voice in the planning and execution of grants.  The US President’s HIV/AIDS effort (PEPFAR) makes a point of involving CSOs, especially FBOs from both donor and recipient countries in program efforts.  A recent summit in Washington explored the ways civil society can contribute to malaria control efforts.

Two important questions need to be addressed concerning the criteria for NGO involvement in malaria control. First is the extent of expertise they bring to the situation – both technical expertise as well as cultural expertise. Secondly, one needs to address economies of scale – do NGOs have the capacity to reach large program coverage goals in an efficient manner?  Obviously the answer is that some do and some don’t.  Good intentions will not achieve RBM coverage goals of 80% (ITNs, IPTp and case management) by 2010.

I have asked colleagues for their experiences. Their views from around Africa on involving NGOs in health programming are summarized as follows:

  • Selection of NGO partners based on their faith-based status, as opposed to their performance, capacity, and ability to deliver quality services and technical assistance, is costly and delays results.
  • New NGO partners often require significant investments in building their capacity before they can be expected to deliver results.
  • Choice of such partners in Washington, Geneva or London makes it extremely difficult to engage local/national partners in any kind of dialogue or joint planning.
  • A double standard is often applied in terms of demanding results from FBOs versus other development agencies.
  • Experienced health-oriented FBOs do exist in the field and have worked for years without a political agenda, making them more acceptable in the countries where they are based than those imposed from the outside.
  • Involvement of CSOs and FBOs does work if they are strengthened under the wing of an experienced international development agency.

Faith in this case therefore should not be “faith that donors will fund our organization”, but “faith that our organization can deliver the services that will save the lives of mothers and children.”

Treatment Bill Brieger | 14 Feb 2007

Considering the Complexities of Coartem Use

Two current articles in Tropical Medicine and International Health show that the use of artemether-lumefantine as the only pre-qualified, life saving artemisinin-based combination therapy (ACT), faces serious challenges.  Ashley et al. report that attempts to improve adherence by reducing the somewhat complicated 3-day, 6-dose regimen of coartem to once a day treatment were less effective. The problem was inadequate absorption of lumefantrine.  They concluded that the present regimen be maintained and that the diet includes fat to enhance absorption.  In a related article, some of same authors found that the small amount of fat in soya milk was needed to enhance lumefantrine bioavailability and absorption.

In light of the fact that the more complicated 6-dose regimen is required, another article by Conteh et al. stresses the importance of good communication between providers of malaria medicines and consumers to improve adherence.  Poor communication often meant that caregivers delayed in giving the crucial first dose to their children.

 Mamiro et al. report that poor and rural African children often suffer stunting and malnutrition.  A key need is for greater energy density in their diets, including fats/oils.  They also found that malaria was associated with such stunting.  If higher consumption of dietary oils is needed to make artemether-lumefantrine more effective, communication between providers and their clients will also need to include dietary counseling relevant to the low income status of most of the children at risk.

Funding Bill Brieger | 13 Feb 2007

Nigeria Donates to Fight Malaria

The Global Fund to Fight AIDS, TB and Malaria (GFATM) not only gives money to disease control programs in developing and middle income countries, it also receives financial support from these same countries.  To date, US $9,757,422,805 has been pledged to the Global Fund, of which US $6,736,768,490 has been paid.  Approximately 4% of the payments have come from foundations and other philanthropic sources. The Global Fund therefore, relies on governments for the bulk of its resources.

Nigeria announced a US $10 million pledge to the Global Fund. This comes on top of an existing pledge of US $30 million ($9 million of which has been paid).  Other African countries that have actually paid into the Fund include Burkina Faso, Kenya, South Africa, Uganda, Zambia and Zimbabwe, for a grand total African contribution received of nearly US $17 million. Another four African countries have made pledges.

The saying that ‘it is not the amount of the gift, but the thought that counts,’ certainly applies here. The fact that some endemic countries are willing to make a contribution to the global disease fight shows a level of commitment that all should emulate.

Malaria in Pregnancy &Mortality Bill Brieger | 12 Feb 2007

Measuring Malaria as a Cause of Maternal Mortality

Advocacy for strengthening malaria in pregnancy control programs is founded on the assumption that malaria is an important cause of both maternal morbidity and mortality as well as child/birth outcomes. UNICEF has recently undertaken work in India to pinpoint more accurately the various causes of maternal deaths. According to The Hindu Newspaper, “The Maternal and Perinatal Death Inquiry (MAPEDI) or the social audit — also known as verbal autopsy.” The survey in West Bengal found that, “Of the 106 maternal mortalities reported … Fifty one per cent deaths were due to direct obstetric causes like bleeding, infection, eclampsia, and obstructed labour, 27 per cent due to indirect causes like anaemia, malaria, hepatitis, tuberculosis and cardiac, while 22 per cent died due to other causes.”

Measurement of exact cause of death in rural and poor communities can be difficult. Sometimes the association between maternal mortality and malaria is circumstantial. Romagosa et al. found in Mozambique that maternal mortality followed the same seasonal pattern as malaria illness. They reported that malaria accounted for 23% of maternal deaths.

A new study published by Fortrell et al., has shown the challenges of obtaining reliable and valid data on maternal deaths that might be malaria. These challenges included among others 1) a general underestimation of malaria in pregnancy, 2) difficulty in distinguishing clinically among febrile illnesses, and 3) HIV and malaria co-infection. Different models and approaches, including verbal autopsy, to analyzing death data in Burkina Faso yielded widely varying estimates of the cause specific mortality fraction for malaria from 10% to nearly 25%.

These efforts show that malaria is certainly a factor in maternal mortality. Continued research support is needed, as explained in the UNICEF study for, ” providing an understanding of the contributing factors that can be used by decision-makers and stakeholders to address obstacles to quality obstetric care and to identify ways to prevent avoidable deaths.”

Funding &ITNs Bill Brieger | 11 Feb 2007

Selling Nets: Lessons from Mozambique

mozambique.jpgAccording to the President’s Malaria Initiative (PMI), one in seven children under five years of age dies in Mozambique, and at least 20% of these deaths are caused by malaria. Brentlinger et al. report on a project that attempted to save these lives using ITNs in the central part of the country.  These nets were sold through local shops and community leaders, although the latter channel proved to be ineffective. By the end of the 2-year project ITN ownership was still low at 40% and even lower (20%) for a net treated within the past 6 months.  Ownership was positively associated with higher socio-economic class and urban residence.

PMI selected Mozambique for attention in mid-2006 and since then has contributed to a mass ITN re-treatment campaign, with a goal of re-treating approximately 500,000 nets, protecting up to 1 million people. Upcoming plans will use Long Lasting Insecticide-treated Nets (LLINs) distributed through Antenatal Clinics.  Hopefully lessons learned about the low coverage achieved from selling nets will inform future national and PMI efforts to ensure that nets reach the rural poor at little or no cost.

Mortality Bill Brieger | 11 Feb 2007

Fertility, Equity and Malaria

A recent issue of the Bulletin of the World Health Organization raises important issues about the relationship between fertility and equity. The authors note that while concepts of equity are embodied in the Millennium Development Goals (MDGs), the relation between fertility and equity has been difficult to conceptualize, hence their article. The question raised is whether there are aspects of fertility that have “moral implications and [are] considered unjust, an inequity,” leading the authors to explore whether unwanted fertility inequities exists among different strata of societies.

Does the link between poverty, disadvantage and inequity apply to fertility? The authors found that total fertility rate in 41 developing countries was higher for poorer people, but they ask whether this in itself constitutes inequity. What if the poor actually desire more children? People can control fertility and access to family planning has enabled poor people to reduce their fertility if they so desire.  Excess mortality is clearly inequitable and undesirable, but is extra fertility on the same plane?  Excess and unwanted fertility does carry serious health and life risks but these paint only part of the picture of fertility. While poorer people were found to have higher unwanted fertility, their desired fertility was still higher than those who were better off, so this still begs the question of whether higher fertility in itself is an inequity.

The authors conclude, among other issues that, “However, high fertility equity should not lead to benign neglect any more than equity in high mortality or very low bed net coverage to combat malaria should lead to complacency.” This leads to thoughts about how much excess infant and child mortality from malaria is affecting fertility preferences among poor people who are more vulnerable to malaria.  Will attainment of the MDG, “Halt and begin to reverse the incidence of malaria and other major diseases,” ultimately have positive effects on fertility inequities?

Just as higher fertility appears to be accepted among disadvantaged populations, excess child mortality expectations too, have a cultural component. The Yoruba concept of abiku, the child who is born to die and then return, embodies a cultural explanation for infant and child mortality.  If children actually survive because of improved access by the poor to malaria control interventions, abiku, excess child mortality and excess fertility may become history.

Funding &Partnership Bill Brieger | 11 Feb 2007

“AIDS FUND” – and where’s Malaria?

The headline in the Boston Globe was telling: “French doctor chosen to head AIDS fund.” Clearly there is value in having practical experience in one of the three disease control efforts supported by the GFATM, but the not so subtle message could be that HIV/AIDS projects will continue to receive the bulk of funding as in the past (see chart from GFATM).  The New York Times was more evenhanded in when saying “French Doctor to Lead Global Disease Fund.”


The Financial Times stated, “Observers said Mr. Kazatchkine, who replaces Sir Richard Feachem, the British executive director for the fund’s first five years who is retiring at the end of March, was a highly respected candidate whose challenges would include expanding his expertise of malaria and how to manage a large financial institution.”  This learning process also appears to include a strong recognition of the role health systems factors play in the success of any disease control effort. According to “Kazatchkine said that he hopes Global Fund grants will help to fight not only HIV/AIDS, TB and malaria but also to improve health care infrastructures in developing countries.”

We wish Mr. Kazatchkine well in his new endeavor and trust he will avail himself of the malaria knowledge and skills of the many partners in the Roll Back Malaria Partnership.

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