Tropical Health Matters

A year ago The Economist remarked that there was “More Money than Sense” do deal with the world’s public health problems. But then below the headline we see that, “The money is there. So why is it not being spent? That is the big puzzle about the rich world’s efforts to improve health in poor countries.” This ties in with a current study by Robert Snow and colleagues that concludes not enough is being spent on malaria to reach the Millennium Development Goals in 2015.

Snow is quoted in The Guardian as saying, “What we have done in this paper is try to estimate how much money is awarded to countries according to how many people live at risk. What we can say at this stage is there isn’t enough for a minimum package of interventions … They are often getting much less than a dollar per person at risk and we know that you need at a bare minimum $4.”

After costing the basic package of malaria interventions at 80% coverage, the authors concluded that, “Using the range of predicted annual needs we estimate that there remains a 50%–450% shortfall of funding to achieve the scaling up of malaria control required worldwide.”

Although this publication would not have benefited from knowledge of the recent G8 Summit, the lack of news-breaking financial commitments for health at Hokkaido is unlikely to influence their conclusions.

Scientific American shows that reputationa are on the line. “The stakes are exceedingly high. Not just millions of lives but also the very capacity of the world to take on big and crucial goals is at stake. In the case of malaria, we can restore health and unleash massive economic gain, but only if countless agencies, dozens of countries and hundreds of millions of individuals can effectively take a shared action.”

We can also throw inequities into the mix. The Guardian explains that, “funding was not spread evenly, with some countries receiving far less per person at risk of the disease than others.” Mathanga and Bowie show that inequitable distribution of malaria interventions also occur at the country level. In Malawi, “Overall ITN coverage increased from 5% in 2000 to 35% in 2004. However, there was a disproportionate concentration of ITNs amongst the least poor compared to the poorest group… The present distribution strategies for ITNs are not addressing the needs of the vulnerable groups, especially the poor. Increasing access to ITNs by the poor will require innovative distribution models which deliberately target the poorest of the poor.”

Finally, Scientific American points out that the problem is more than cash: “Still, the timing will be very tight and will require an unprecedented degree of coordination among financing, training, monitoring and logistics. Each sub-Saharan country will need to adopt, vet, fund and monitor a scaled-up antimalaria plan very quickly. The major global manufacturers of commodities such as bed nets, antimalaria drugs and diagnostics will have to raise production to hundreds of millions of units. Tens or hundreds of thousands of community health workers will need weeks of training.” The list goes on, but do the donations and contributions?

The Clinton Foundation is tackling a challenge that faces the world market for artemisinin-based combination therapy (ACT) medicines – the supply, demand and ultimately the price of the basic ingredient. The move by malaria control partners to get countries to switch to ACTS and save lives amid the failing efficacy of chloroquine and sulfadozine-pyrimethamine was relative swift and did not account for the normal market forces involved in introducing new pharmaceutical products, especially when these are provided free or at cost to the end user.

In addressing Kenya’s rapid policy change to ACTs, Zurovac and colleagues concluded that, “Changes in clinical practices at the point of care might take longer than anticipated. Delivery of successful interventions and their scaling up to increase coverage are important during this process; however, this should be accompanied by rigorous research evaluations, corrective actions on existing interventions and testing cost-effectiveness of novel interventions capable of improving and maintaining health worker performance and health systems to deliver artemisinin-based combination therapy in Africa.” They also said that policy makers should be “carefully prepared for a myriad of financial, political and legislative issues that might limit the rapid translation of drug policy change into action.”

According to news reports, “In 2002, Clinton established an HIV/AIDS initiative that sought to negotiate lower prices for anti-retroviral treatments, and he since has expanded his focus to include malaria treatments such as artemisinin-based combination therapies, or ACTs. One of the factors making the price of artemisinin so volatile – fluctuating from $155 to $1,100 per kilogram in recent years – has been a wildly erratic cycle of shortage and excess of the extract.”

Earlier this year, one of the major producers of ACTs, Novartis, announced, “a 20% average reduction in the price of Coartem^® tablets (artemether/lumefantrine 20 mg/120 mg), the state-of-the-art artemisinin-based combination treatment (ACT) for malaria. Starting this Friday, which is World Malaria Day, this price reduction will increase access to Coartem for millions of malaria patients, especially children in low income regions of Africa.”

Of course Novartis, like other producers must not only rely on supplies of this natural product which is subject to the normal risks of agricultural production, but also to the fact that countries who need ACTs do not always order their supplies in a timely and coordinated manner. This is despite the fact that Novartis has had an edge on other ACT manufacturers by being the first WHO prequalified drug, guaranteeing its priority purchase through Global Fund grants.

The AP story goes on to explain that, “Clinton said he has negotiated with six suppliers involved in producing ACTs that have agreed to certain price ceilings that the foundation says will help keep prices constant and not so dependent on the fluctuating cycles.The agreements are with two suppliers at three levels of the supply chain — raw material, processing and final formulation — and the foundation hopes to add more suppliers.”

Previously we have addressed the potential for synthetic artemisinin production as well as the need for continued research into new and alternative malaria drugs. Stabilizing the price of the raw product will certainly have short term benefits. The long term requires increasing the scope of our malaria treatment arsenal.

Emmanuel Fiagbey, VOICES representative in Ghana, reports on community events that promote malaria control in Ghana.

Community events popularly referred to as community education durbars have become a powerful strategy for promoting adoption of appropriate strategies for fighting malaria in Ghana. District Malaria Advocacy Teams developed with the help of the Ghana Voices for Malaria-free Future project are the driving force behind the use of this strategy. In the Keta District of the Volta Region and the Asuogyaman District of the Eastern Region health workers now work with community health promoters and community leaders to organize these malaria education events. During these events community members are empowered with information to adopt the right approaches in preventing and treating malaria. These include:

• Early reporting of fever conditions at the nearest health facility
• Acceptance and use of the new antimalaria medication – Artesunate Amodiaquine combination for the treatment of malaria
• Quick transfer of referred cases of severe malaria to the nearest hospitals
• Attendance of antenatal clinic by pregnant women and their accessing and completing IPT

Acceptance and Use of Insecticide Treated Nets

Prevention by always sleeping in ITNs is highly promoted through the community events where community health workers demonstrate the process of hanging the nets. They also
encourage satisfied users to present testimonies of how ITN use has contributed to reduction in malaria incidences in their households to other community members.

Improving IPT through Community Mothers Support Groups

In the Asuogyaman District, the District Malaria Advocacy Team is supporting the development of Mothers Support Groups to encourage pregnant women access and complete IPT in order to protect their unborn babies and themselves.

The Mothers Support Group program goes beyond IPT promotion only and provides opportunities to mothers with babies to share ideas on managing other childhood illnesses apart from malaria. Improving the health of children under five and their mothers through better nutrition and feeding practices is also promoted through this program which is facilitated by the Community Health Nurses.

Anecdotally these community programs are yielding great benefits to the mothers in maintaining the health of their children and themselves. “The group is a wonderful source of support. For the past one year none of my group members reported of malaria in their families” said a Community Health Nurse, Apegusu, Asuogyaman District.

This update has been prepared by Emmanuel Fiagbey of the Ghana VOICES office.

Under the sponsorship of the Ghana Voices for Malaria-free Future a group of journalists have come together to form a network to promote advocacy for Malaria control. Members of the network, the Ghana Media Malaria Advocacy Network (GMMAN) come from various print and electronic media houses including the Graphic Communications Group, Ghanaian Times, Weekly Spectator, Chronicle, and the Enquirer, Adom FM, Peace FM, Volta Star Radio, Jubilee FM, Kesben FM, Eastern FM, Radio Gold, and Radio Upper West, TV3, TV Africa Ltd, Metro TV and Ghana Television (GTV).

The Objectives of the Network are to:

• disseminate timely and appropriate information on malaria control efforts with the view to promoting the use of ITNs, motivating health professionals to administer approved medications for the management of malaria, and effectively informing the Ghanaian population of the need to uphold and practice effective prevention measures;
• monitor and accurately report on ongoing malaria control interventions within the context of educating the people of Ghana to maintain clear focus on making their communities malaria-free; and
• contribute to building and strengthening the capacity of all journalists in Ghana to report positively on malaria.

“It is our hope that our efforts as media practitioners would help promote the course of malaria in the eyes of government, the donor community, the private sector and civil society in generating more resources and support for achieving a malaria –free Ghana. There are national, district and community voices against malaria but we want to assure the malaria program community that we of the media can be louder and highly positive voices against malaria,” Says Ms. Rosemary Ardayfio, Leader of GMMAN.

Since the inauguration of the GMMAN, the print media have become very buoyant with news reports and feature stories on various issues related to the fight against malaria in Ghana. Between April and May 2008 alone over 25 publications on malaria have appeared in the Daily Graphic, the Ghanaian Times and the Chronicle alone while community radio stations all over the country have been very active in organizing radio talk shows to educate the population on key malaria issues such as the use of ITNs and the efficacy and safety of the new malaria drug Artesunate and Amodiaquine Combination and IPT for pregnant women using Sulphadoxine Pyrimethamine.

The television stations have not been left out. Ghana Television, TV Africa, TV3 Ltd. and Metro TV have all increased program coverage on malaria. Thus the fight against malaria now receives great visibility in the eyes of the public and hopefully, these efforts by the media advocates will contribute to greater knowledge of prevention and treatment of malaria among the people of Ghana.

Examples of some of the malaria articles featured recently in the Ghana Chronicle are listed below.

• Eradicating Malaria And the Search for New Tools, 3 July 2008
• Malaria Constitutes 40 Percent, 30 June 2008
• Northern Health Services Declare War On Mosquitoes, 2 May 2008
• Intensify Fight Against Malaria, Ammren Tells African Leaders, 1 May 2008
• Alarming Rate of Malaria Cases in Asutifi District, 29 April 2008
• World Malaria Day – The Experts View Point, 25 April 2008

Hopefully other countries will take this experience as a cue to organize their own malaria media advocacy efforts.

The field of malaria research is dynamic. We are always learning new aspects about the disease and its interaction with the biological, social and economic environments.  News stories today highlight two such interactions that have implications for public health beyond malaria control.

Reuters reports on Canadian researchers whose “surprising findings suggest that treating malaria with the cheap, widely used drug chloroquine — a close cousin of fluoroquinolones — may boost the risk of resistance to these antibiotics,” in South America. This resistance has even been found in remote villages where people have never even taken the antibiotics, fluoroquinolones.

As Davidson and colleagues note in PLoS One, It is not only a matter of chloroquine, but the some of replacement first line treatments, artimisinin-based combination therapies (ACTs) that contain a related drug like amodiaquine. We may be preventing death from malaria while boosting the chances of people not being able to control other diseases with cheap, available antibiotics.

Another interesting dynamic reported by the BBC is that, “A gene which apparently evolved to protect people from malaria increases their vulnerability to HIV infection by 40%.”The story points out an irony: “People of African descent have a variation of the “DARC” (Duffy antigen receptor for chemokines) gene which may interfere with their ability to fight HIV in its early stages. The Cell Host and Microbe study says the gene accounts for millions of extra HIV cases in sub-Saharan Africa.However, people with the gene appear to live longer with HIV than other.”

The scientific article on this dynamic, appearing in Cell Host and Microbe, and observed that, “The sum of the in vitro and genetic epidemiologic findings demonstrates that HIV might exploit DARC to its advantage: binding of HIV to DARC, a molecule that is expressed on one of the most abundant cell types (RBCs), might afford a unique biological niche that favors viral survival and persistence.”

The Weijing He and colleagues point out the need for further understanding of the dynamic among malaria, immune defenses, HIV and genetics: “Of broad interest, our studies underscore that DARC impacts on chemokines, malaria, and HIV, a ménage à trois. However, given the importance of the chemokine system in host defense, immune responses, and inflammation, it will be important to determine the contribution of DARC to the pathogenesis of other infectious disease and inflammatory disease states.” Ultimately we cannot address the problem of malaria without looking at the broader dynamics of infectious diseases and genetics in a given setting.

Update provided by VOICES country representative for Ghana, Emmanuel Fiagbey.

The recent challenge thrown by Bill and Melinda Gates to the malaria community to work towards eradicating malaria has moved malaria advocates and program managers in Ghana to start examining the status of the country’s fight against malaria along the continuum of Control, Elimination and Eradication strategies.

The Ghana Voices for Malaria-Free Future project provided the forum. It brought together 45 malaria advocates including the leadership of the National Malaria Control Program (NMCP), the Ghana Media Malaria Advocacy Network, District Directors of Health, Malaria Scientists and Researchers, Disease Control Officers of the Ghana Health Service, NGOs and National Voices against Malaria. University of Ghana Professor Issabella Quakyi, NMCP Manager Dr. Constance Bart-Plange, and RBM Coordinating Committee Chairman Prof. David Ofori Adjei were the discussants

The forum concluded that:

• The complex life cycle of the plasmodium species makes the disease very difficult to beat.
• Significant challenges remain including drug resistance, insecticide resistance, and continuing environmental degradation. leading to increasing transmission and finally absence of an effective vaccine.
• Ghana is steadily progressing through the Control phase with the hope of reaching the Elimination phase in the next few years.

Tasks for Achieving Eradication

• Sustaining the gains so far made
• Enforcement of malaria policies and recommended practices Intensified attitudinal change among health workers, the private sector, community members and all other stakeholders
• Better monitoring of ITN utilization
• Enhanced public/private sector collaboration on drug policy implementation.
• Improved diagnosis of the disease using appropriate tools
• Adoption of integrated approaches to malaria
• Generation of local resources to support malaria control efforts
• Strengthened of NGO participation in malaria control programs

According to Prof. David Ofori Adjei, “The renewed global call for malaria eradication demands greater political will and involvement of all stakeholders. Malaria eradication is possible when we protect ourselves from getting the parasite and adopt new tools for effective management of the disease.”

The process that ensures people in malaria endemic countries get appropriate and timely life saving treatment starts far away from the individual sufferers. Researchers determine safe and efficacious medicines, international agencies issue guidance, national governments develop treatment policies, guidelines and standards, pharmaceutical companies scale up production, funds to purchase drugs are mobilized, orders for medicines are placed and shipped … and after all these steps treatment has still not reached those in need.

Once the medicines are in the country (either produced there or imported) the supply/distribution chain continues through both public and private warehouses and medical stores. In the public sector the debate over who delivers or collects the medicines start – do states, regions, and districts collect from the national stores or are the medical stores responsible for shipping supplies out to the regions and districts. The debate begins again at the district level when individual facilities contemplate how to get their own supplies.

Assuming the appropriate medicines reach the shelves of the frontline clinic or medicine shop, the next step is for clients to obtain these for themselves and their children.  Eligibilty questions come up – are free medicines only for children or everyone.  Finally the medicines reach the home.  Success of malaria control ultimately rests on the last step, taking the full, correct dose of the medicines.  So what do we know about adherence to malaria drug regimes?

In Senegal Souares and colleagues looked at adherence to a regimen of SP-amodiaquine, in use then, as a proxy for adherence to ACTs at the point when this would be introduced, since both had a 3-day regimen. They found that, “35.3% of children did not comply with the recommended doses and 62.3% did not exactly adhere to the drug schedule. Despite the good efficacy of the drugs, adherence to the therapeutic scheme was poor.” Even though efficacy was good, they foresaw a time when poor adherence could lead to drug resistance and recommended training of health workers to improve patient-provider communication about adherence.

We cannot wait for haphazard adherence to lead to ACT failure. ACT performance standards are needed and should be part of the roll out of any government or donor funded malaria treatment program.  Importantly, training on these standards must reach the private and informal sector, too.

The Journal of Tropical Pediatrics reported on a study in Burkina Faso, which showed that afebrile children infected with Plasmodium falciparum, still suffer the consequences of malaria. A graph summarizing the findings by Ouedraogo and colleagues shows moderate to severe anemia also occurs in infected children that do not show obvious signs of the disease.

Even though the children in this Burkina Faso study were only 6-23 months old, the findings reinforce our recent discussion about malaria in school children, who suffer problems of anemia, lethargy and poor attention in school when infected even if they do not show other signs of malaria.

It was not mentioned whether the children in Burkina Faso had access to ITNs. Burkina Faso itself has received little attention from the international malaria partners. Its 2-year Global Fund grant has finished, although the country was awarded a Round 7 grant. By the end of the first grant only 29% of households had an ITN/LLIN.

Much valuable malaria research has been conducted in Burkina Faso. The present study emphasizes that the international community should not forget the needs of Burkinabe for quality malaria programming.

China has been a major source of life-saving artemisinin-based malaria medicines for Africa. Unfortunately China is also a source of life-taking military support in Africa.

“The BBC has found the first evidence that China is currently helping Sudan’s government militarily in Darfur. The Panorama TV programme tracked down Chinese army lorries in the Sudanese province that came from a batch exported from China to Sudan in 2005. The BBC was also told that China was training fighter pilots who fly Chinese A5 Fantan fighter jets in Darfur.”

“The BBC has established that Chinese Fantan fighter jets were flying on missions out of Nyala airport in south Darfur in February …When the plane unleashed two bombs Kaltam’s five-year-old daughter, Nura, was dismembered from the chest up. Her eight-year-old son, Adam, was killed instantly, as was her 20-year-old daughter, Amna.”

UN Peace Keepers find it almost impossible to do their Job. According to the New York Times, “The fact that the peacekeepers find it hard to protect themselves, much less the people of Darfur, came into sharp relief last Tuesday when well-armed militiamen ambushed a U.N. patrol, killing seven and wounding 22. U.N. officials, as well as diplomats assigned to the Security Council, worry that the attack may signal worse to come from the Sudanese government.

The UN Security Council seems divided over recent International Criminal Court indictment of Sudan’s leaders over Darfur. The New York Times observed that, “‘The Security Council has been too shy in responding to Sudan’s refusal to comply with regards to Darfur,’ said Bruno Stagno Ugarte, Costa Rica’s foreign minister,” but others are less certain. “Five Council members, including China, Indonesia and Libya, questioned Costa Rica’s position, suggesting that the body was too one-sided in condemning the government and not the rebels.” It will be interesting to see how the Security Council reacts to the BBC’s news.

As the Olympics approach, world leaders caution against any mention of China’s international endeavors so as not to ‘offend the Chinese people’. One would think that supporting death in Sudan by the Chinese government would also be an offense against the Chinese people. Conflicts like that in Darfur promote the spread of malaria. Peace efforts that save lives and prevent malaria are long overdue.

Providing malaria treatment once a term to Kenyan pupils offers important benefits according to this headline: “Malaria prevention in schools reduces anaemia and improves educational potential in Kenyan school children.” In fact lower rates of anemia and improved classroom attention were achieved. Children do not have to be observably sick from malaria to be affected by the disease – the prevalence of P. falciparum was around 40% in these children at baseline.

The study which is fully described in The Lancet, was “A stratified, cluster-randomised, double-blind, placebo-controlled trial of IPT in 30 primary schools in western Kenya. Schools were randomly assigned to treatment (sulfadoxine-pyrimethamine [SP] in combination with amodiaquine or dual placebo) by use of a computer-generated list. Children aged 5–18 years received three treatments at 4-month intervals (IPT n=3535, placebo n=3223). The primary endpoint was the prevalence of anaemia, defined as a haemoglobin concentration below 110 g/L. This outcome was assessed through cross-sectional surveys 12 months post-intervention.”

Here is an example where Millennium Development Goals for health and education goals can be achieved through a common intervention.

Of course the benefits of a school-based health program are based on the levels of school attendance, and as reported, “School-age children represent 26% of Africa’s population where 94% of children go to school.”  It should be stressed that this figure is for primary school students.

Interestingly the average age of the study pupils was almost 14 years, likely reflecting late start for education possibly due to family financial problems. The implication for community level malaria control is that there may be a large number of 5-8 year old children who are not yet in school, but are hopefully protected by ITNs at home.

While WHO’s Global Malaria Program (GMP) acknowledges the existence of a now quite extensive body of research on intermittent preventive treatment for infants, it has yet to endorse the practice. The fact that the current study on school children was “funded by the Gates Malaria Partnership which is supported by a grant from the Bill & Melinda Gates Foundation (with) additional funding … provided by the Norwegian Education Trust Fund and multi-donor Education Development Programme Fund of the World Bank; DBL Centre for Health Research and Development; and the Wellcome Trust,” is unlikely to sway opinion at GMP, which has been critical of Gates’ involvement in malaria control and research.

While some may question the use of SP as part of the IPT regimen for these children, the overall concept of IPT for primary school pupils is valuable. One cannot assume that because they don’t look sick that these children are in fact healthy and are not part of the malaria transmission process – it would be a mistake to neglect school children. Partners need to work together to increase available interventions that can reach this group so that endemic countries will ultimately benefit not only from their improved educational attainments, but also from their enhanced economic potential as adults.