Posts or Comments 18 July 2024

Monthly Archive for "October 2008"

Health Systems &Procurement Supply Management &Treatment Bill Brieger | 25 Oct 2008

When does treatment become control?

The introduction of Artesunate-Amodiaquine in M’lomp village, Senegal has been monitored over time by Sarrassat and colleagues.Their efforts were motivated by experiences in Thailand, South Africa and Zanzibar, where a decrease in malaria morbidity was observed following the introduction of artemisinin-based combination therapy (ACT).

mali-as-aq.JPGDecreased incidence has been postulated as an effect of artemisinin-based medicines’ ability to kill gametocytes and reduce transmission (Drakeley et al.; Nosten et al.; Carrara et al.; Barnes et al.; Battarai et al.).

Sarrassat’s team also observed a decrease in the incidence rate and repetitiveness between 2001 and 2002. They were worried that lower rainfall might also have contributed to the findings, especially since treatment coverage was less than ideal.

Ultimately Sarrassat et al. concluded that, “In sub-Saharan countries, in order to optimize the impact on malaria morbidity, ACT deployment must be supported, on the one hand, by a strengthening of public health system to ensure a high ACT coverage and, on the other hand, by others measures, such vector control measures.”

A home management strategy has been one recommendation to improve the ability of health systems to increase ACT coverage. Generally though timely procurement and supply procedures are required to make ACTs available for the whole population at risk. In order to do this, health systems need strengthing as Sarrassat suggests.

Health Systems &IPTi Bill Brieger | 22 Oct 2008

IPTi and EPI – healthy links

Recently we highlighted some lessons that malaria control efforts could learn from immunization program management, and observed that this was important because malaria control interventions such as ITN distribution have often been linked with immunization campaigns.  Another link is use of the Expanded Program for Immunization (EPI) services as a delivery mechanism for intermittent preventive treatment for infants (IPTi).

Pool and colleagues have reported on the acceptability of EPI as a channel for IPTi delivery in Tanzania. The researchers concluded that, “In this setting, IPTi delivered together with EPI was generally acceptable. Acceptability was related to prior routinization of EPI [emphasis added] and resonance with traditional practices. Non-adherence was due largely to practical, social and  structural factors, many of which could easily be overcome.”

eritrea-polio-immu.jpgFor example, mothers would have preferred drops instead of tablets for their infants. As with vaccines, mothers knowledge about the whole process was vague and generally consisted of an understanding that the process promoted health rather than controlled specific diseases. Structural factors related to poverty. Despite potential limitations, EPI appears to be a good platform for IPTi delivery.

A review of the Demographic and Health Survey for Tanzania shows that the country has maintained a full immunization coverage rate of around 70% over the past 4 surveys (12 years), but that in the most recent survey (2004) at least 90% of infants had at last one EPI contact. This again speaks well for incorporating IPTi into an existing system that reaches most infants.

The DHS does show some other factors in EPI coverage that would also affect IPTi and reinforces structural factors as a concern. There was lower rural than urban immunization coverage.  More educated and wealthier parents were more likely to get their infants immunized that less educated and poorer ones. DPT3 coverage in 2004 was only 75% for those in the lowest wealth quintile compared to 96% among those in the highest quintile.

These wealth/access disparities are no reason to dissociate IPTi from EPI, but they do emphasize the need for overall health reform so that disease prevention interventions equitably reach all children and families.

Health Rights &Performance Bill Brieger | 20 Oct 2008

Equity for Minority Groups

The group Drive Against Malaria has focused on “malaria prevention for the Bantu and ignored Pygmy population in this difficult to reach area by distributing LLITNs and ACTs and providing diagnostical support,” in Cameroon.

It is not clear whether the Pygmy areas of Cameroon were intentionally left out of national malaria control plans, but the Global Fund Round 3 Malaria grant for Cameroon specified tha “Premises will be identified in the Far North, North, West, South West, North West, Adamaoua and Centre provinces, and provided with net treatment equipment and skilled staff to ensure training and quality control of the community treatment units.” Not mentioned were Littoral, South and East Provinces where pygmy populations are more common.

Even if there was no intentional neglect of this minority population, the reality of grant implementation shows that ITN coverage is far behind expectations. Even though retreatment centers have been set up in 6 provinces and around 900 communities, only 65% of the targeted children has been reached and 45% of the current target nets has actually been retreated three years after the grant started.The Global Fund concludes –

At the end of the third year of implementation of program activities, performance remains somehow not fully satisfactory. Delays in procurement of bednets have impacted the achievement of related targets, while the reporting of pregnant women receiving IPT is not fully convincing as data is based on estimation.

The figure below is extracted from the GFATM progress reports.

The Round 5 Malaria Grant is approaching the end of Phase 1. Efforts to ensure access to ACTs is proving challenging. In the most recent progress report one can see that  only 17% of targeted health facilities reported no stock outs lasting > 1 week of malaria drugs. Likewise only 62% of targeted health facilities had ACTs. Also only 43% of children under five in targeted areas received correct malaria treatment.

The Global Fund had this to say about the Round 5 grant performance: “Six months after program started, results are disappointing with only very few activities having been implemented.”  Clearly when grants don’t perform, minorities have a lesser chance of being served, assuming their regions, districts and communities are even targeted.  Greater accountability is needed.

Funding Bill Brieger | 17 Oct 2008

The Global Fund – a long process

The process of securing financial support from the Global Fund to Fight AIDS, TD and Malaria is a relatively long process with key steps that must be taken along the way.  With Round 8 supported projects soon to be announced at the upcoming Global Fund Board in November, it is useful to look at what happened with some of the Round 7 grants approved a year ago.

The chart below looks at 16 malaria grants approved for the African Continent. These grants averages over $53 million each with an average of $23 million slated for the first two years (Phase 1). Readers can download this grant information for study and planning.

The challenge is that even when a grant is approved, it is not actually awarded until a start-up action plan and budget is submitted and approved. After approval comes the grant signing, and finally the grant start-up.  Six of these grants have not been signed, and four that have been signed appear not have officially started.

It can take many months to prepare a grant proposal with many partners providing help, with many having started preparations as early as March 2007.  These grant proposals for Round 7 were submitted in July 2007 and as noted, approved in November 2007.  The lesson here is that grant writers, partners and advocates cannot sit back and smile when they head that a grant has been awarded – the work must continue until a grant agreement is signed.

Of course, even after signing, there is no time to rest – the clock starts ticking on Phase 1 performance. Although Phase 1 lasts 2 years, the reality is that a proposal for Phase 2 must be prepared and submitted around 18 months from the start. Enough documentable performance progress must be seen in order to keep the grant running.

Some of these 16 countries, and others throughout the world, have gotten off to a fair start, but their work has just begun.

Coordination &Performance Bill Brieger | 16 Oct 2008

Performance of Immunization Programs – lessons for malaria control

Malaria control and immunization programs do work together in the form of national or local immunization campaigns where insecticide treated nets are also distributed.  There is an assumption that there will be a synergistic effect on coverage of combining these efforts, but an important question is whether the existing base platforms of immunization programs in countries can really deliver better vaccine coverage, let alone better ITN ownership and use.

Colleagues at the World Bank have conducted a qualitative inquiry into immunization program management to identify factors that might lead to success and thus, form the basis for more structured research.  The Expanded Program for Immunization has at least a 30-year history to draw on, and thereby, offers a good foundation for study.  The researchers chose the period 1997-2002 and looked at four sets of African countries: those with higher than average coverage that has increased over the 6-year period, those with high but decreasing coverage, those with low but increasing coverage and ones with both low and decreasing coverage.

immunization-function-sm.jpgIn-depth study was conducted in six countries that covered the four categories of countries.  The study focused on five core management functions: 1) demand, 2) financing, 3) governance/institutional framework and the supply function which was divided into 4) management and 5) service delivery strategy.  A summary score of indicators achieved under each function yielded a 4-point score which is seen in the attached chart.

The authors noted that, “What distinguished the two high performers from all other countries in our exercise was a robust implementation of their immunization programmes. Only (those two countries) combined reasonably good governance and a solid institutional framework with reasonably good management, service delivery, financing and demand.”

The researchers suggested that, “One way that multilateral and bilateral partners in immunization may help is by offering countries  performance-based incentives without earmarking their assistance for specific functions.”

They also found that, “Reasonably good performance on at least some functions (the high but decreased coverage examples) appeared to be more beneficial to coverage than deficient performance across all (the two low coverage countries); doing a few things well, however, did not appear to be sufficient to ensure a high level of sustained success.”

Since wide scale implementation of malaria control is still coming on board in most countries, there are few examples of widespread intervention where a similar study could be conducted right now. Even so a preliminary assessment of factors that affect such management functions in crucial so that both scale-up and sustainability can be promoted until such time that eradication is truly feasible.

Coordination &Integration Bill Brieger | 13 Oct 2008

Integration may address NTDs – example of lymphatic filariasis

lf4ib-sm.jpgLymphatic filariasis (also known as elephantiasis) is another mosquito borne disease that plagues much of the population in malaria endemic areas. In fact is is the same anophelene species of mosquitoes which carry malaria that also transmit lymphatic filariasis in much of Africa. With talk of integration of disease control programs, one wonders what are the potential synergies of combining efforts against malaria and lymphatic filariasis?

Both share the preventive measure of bed nets, which is a major strategy for malaria control, but the main approach to eliminating filariasis is Mass Drug Administration (MDA). Two drugs in combination, ivermectin (or diethylcarbamizine citrate) and albendazole, are given annually. These annual doses kill the microfilaria and have some effect on the adult worms. Success as measured by prevalence below 1% can b achieved after 6 rounds of MDA depending on 1) initial level of LF endemicity; 2) effectiveness of vector mosquitoes; 3) MDA drug regimen; 4) population compliance.

If the two diseases share geography and in some cases a vector, have there been any actual attempts at a joint effort? At least two countries have attempted such within the context of their global fund grants for malaria, Togo and Papua New Guinea (PNG). Togo’s Round 4 GFATM grant aimed at “demonstrating the synergy effect of MDA on the impact of malaria control activities” in co-endemic areas. This was based in part of research that showed a negative impact of helminths on malaria infection.

An innovation in the PNG GFATM proposal is “Training of field staff to disseminate information about malaria and HIV/AIDS (who) will also be used for annual mass drug administration for lymphatic filariasis elimination.”

An NGO example of integration has been piloted by the Carter Center. “In 2004, the Carter Center-assisted Lymphatic Filariasis Elimination Program received 57,000 bed nets from the Nigerian Ministry of Health in a combined effort to prevent the spread of lymphatic filariasis, being addressed by the Center, and malaria, a project of the health ministry. The nets are treated with the insecticide deltamethrin, which is safe for humans yet kills the mosquitoes that are the carriers of both diseases in rural Africa. The bed nets have been distributed in four local government areas of Plateau and Nasarawa states in Nigeria, which are endemic for both diseases.”

The Carter Center has been using the same community distribution system found effective for onchocerciasis control. “Community volunteers distributed 38,600 insecticide-treated bed nets, while simultaneously treating 150,800 persons with ivermectin/albendazole.” A 30-cluster survey found a 9-fold increase in bednet ownership compared to baseline. “This first linkage of insecticide-treated bed net distribution with mass drug administration resulted in substantial improvement in insecticide-treated bed net ownership and usage, without adversely affecting mass drug administration coverage. Such integration allowed two programs to share resources while realizing mutual benefit, and is one model for rapidly improving insecticide-treated bed net coverage objectives.”

Since the Global Fund programs have yet to focus on neglected tropical diseases, these examples of integration between malaria and lymphatic filariasis, may be the best way to ensure parasite-free populations in endemic areas.

Community &Treatment Bill Brieger | 09 Oct 2008

Home and community management of malaria – key to sustainable targets

community-med-distrib-uganda-sm.jpgBBC is featuring community medicine distributors in Uganda as part of its series on ‘Survival TV’. While the video starts with how things were in a Ugandan community with a funeral of a child who died from malaria, the work of two community medicine distributors in combating malaria with readily available packs of Coartem® (arthmether-lumafantrin) and long lasting insecticide treated nets (LLINs) ultimately provides a positive outcome for Ugandan children.

Home management of malaria (HMM) is not new to Uganda. Kolaczinski and colleagues reported, “In 2002, home-based management of fever (HBMF) was introduced in Uganda, to improve access to prompt, effective antimalarial treatment of all fevers in children under 5 years. Implementation is through community drug distributors (CDDs) who distribute pre-packaged chloroquine plus sulfadoxine-pyrimethamine (HOMAPAK®) free of charge to caretakers of febrile children.” Caregivers for children were impressed by the safety of the blister packs, and having been guided be the CDDs 95% of them had administered the correct dose of medicine to their children.

The medicines have changed to arthmether-lumafantrin now, but a recent 3-country assessment “provides encouraging data on parasitological outcomes of children treated with ACT in the context of HMM and adds to the evidence base for HMM as a public health strategy as well as for scaling up implementation of HMM with ACTs.” On average correct adherence was 94% across Uganda, Ghana and Nigeria.

The benefits HMM are not just to the individual child and family, but also to the health system. Sievers and colleagues found in Rwanda that “both admissions for malaria and laboratory markers of clinical disease among children may be rapidly reduced following community-based malaria control efforts.” They also cautioned that as malaria cases and hospital admissions became less frequent, “More accurate diagnosis and management of febrile illnesses is critically needed both now and as fever aetiologies change with further reductions in malaria.”

Another effect of properly organized HMM is reflected in the title of a new article appearing in Malaria Journal: “Implementation of home-based management of malaria in children reduces the work load for peripheral health facilities in a rural district of Burkina Faso.” Not only were fewer children with malaria seen at health facilities in the intervention communities, but in fact more children in those communities were actually treated for malaria in those communities.  HMM clearly improved access to correct malaria treatment.

cdi-study-malaria-sm.jpgThis access issue was demonstrated in a study by the Tropical Disease Research (TDR)project of UNDP, World Bank, WHO and UNICEF. In districts using CDDs for HMM more children were reached. In fact excepting Cameroon where there were policy and logistical challenges to community drug distribution, reaching the RBM targets was seen as feasible through HMM compared to where malaria treatment was made available only through the normal health care system.

The TDR project built on the successful experience spanning over a decade of ivermectin distribution to control onchocerciasis. When community directed distribution started, health workers worried that communities were not capable to taking charge on medicines. Later they learned that not only could communities deliver ivermectin safely and accurately, but that they could maintain good annual treatment coverage. Finally the health workers learned that community directed distribution helped the health system reach ‘people beyond the end of the road’ who otherwise would not have benefitted from services.

HMM empowers the community and enhances the ability of the health system to reach those in need. HMM should be a central strategy in any malaria control program.

Funding Bill Brieger | 05 Oct 2008

Reassurance on malaria commitment needed as economic woes grow

The past few weeks have seen economic changes last experienced during the Great Depression of 80 years past.  David Rothkopf observed in the Washington Post that the shock may be greater than that experienced post-9/11. “That’s because while 9/11 changed the way we view the world, the current financial crisis has changed the way the world views us. And it will also change, in some very fundamental ways, the way the world works.” The economic crisis will cost the US government more than the wars in Iraq and Afghanistan and for investors and the public, the Wall Street plunge of Monday cost more that the $700 billion financial package that just passed the US Congress.

According to the New York Times, “The (financial) crisis has become the biggest financial challenge for European policymakers since the introduction of the euro as a Continent-wide currency in 1999.” On Saturday, “the leaders of France, Germany, Britain and Italy pledged to prevent a bankruptcy on this side of the Atlantic.”

Under the circumstances one might wonder if the US and other G8 countries can maintain their commitment to fighting disease in the world. This may or may not have been responsible for comments reported Friday on GhanaWeb:  “The US Ambassador to Ghana Mr Donald Gene Teitelbaum on Friday assured Ghanaians that the fight against malaria remained a priority on President George Bush’s agenda. He said it was the President’s wish that there will be a time when the two countries will meet and celebrate the wiping away of malaria from Ghana and Africa as whole.

These economic threats come at a time when the Global Fund is aiming for a larger grant porfolio, the World Bank is substantially ‘boosting’ its support, and new funding mechanisms like the Affordable Medicine Facility – malaria (AMFm) may be coming on line. Malaria advocates need to monitor the situation closely, especially if progress highlighted in the recently released World Malaria Report of 2008 is to be sustained.