Posts or Comments 15 July 2024

Monthly Archive for "February 2009"

Malaria in Pregnancy Bill Brieger | 28 Feb 2009

Implementing MIP interventions in Ghana

anc-health-educ.JPGThe US President’s Malaria Initiative (USAID) in Ghana is supporting malaria in pregnancy programming capacity building with the Ghana Health Services through two of its partners, ACCESS and Quality Health Partners.  We made site visits to four health facilities to get an idea of what is happening on the ground before reviewing both pre-service and in-service curricula for training midwives on malaria in pregnancy (MIP) control.

This was by no means a scientific sample, but we did visit antenatal clinics at an urban polyclinic, a district hospital, a sub-district health center and a regional hospital. Of the three main components of malaria in pregnancy control, intermittent preventive treatment (IPTp) was uniformly well implemented. Case management of malaria illness for pregnant women also appeared to be well organized. ITN stocks were available at only one facility, and sold for about ¢2.5 (about $2 US).

While there were good stocks of sulphadoxine-pyrimethamine (SP) for IPTp, in most cases women had to buy sachets of ‘pure’ water in order to take the SP as directly observed treatment.  ANC clinic registers and women’s ANC booklets were set up for IPTp recording, but coverage appears low.  Ghana requires 3 doses of IPTp. At the district hospital less than half of those registering for ANC got the first dose, and only 23% got three, and in the rural sub-district, only 17% got IPTp3. Unfortunately SP was still being sold as treatment in nearby pharmacy shops.

Case management was the responsibility of a clinician, not the midwives.  The midwives must refer women suspected of having malaria. In two clinics referral was made easier by having a rotating doctor posted in the ANC daily. Diagnosis was based on laboratory testing – blood films in the three larger facilities and RDTs at the rural clinic.  Unfortunately the latter had been without RDTs for some months.  Clinic pharmacies were well stocked with ACTs and quinine.

ITNs were not directly available in any ANC visited. Even at the hospital where they were seen, a woman had to buy it at the children’s outpatient department.  Staff at the remaining clinics said they had some stock in the past.  There was no place to record ITN provision in the woman’s ANC booklet. One district malaria focal person had erroneously advised the midwives to give bednets after delivery as in incentive, thus leaving the woman exposed to malaria during pregnancy. ITNs were on sale at nearby pharmacies for between ¢8 and ¢12. A voucher scheme that provided a ¢4 discount was no longer operating.

Ghana has most of the elements for good MIP control within its grasp.  Better coordination, improved coverage and access to ITNs must be achieved.

Coordination &Funding &Monitoring Bill Brieger | 22 Feb 2009

Counting down to World Malaria Day 2009

rbm-sm.gifWith about 2 months and 3 days to go until World Malaria Day 2009 partners are encouraged by RBM to start preparing to tell their own stories “to show the international community how far it has come – and how far it needs to go to reach its global malaria response.” Our target now for 2010 is 100% – universal coverage – with hopes of bringing malaria deaths near zero by 2015.

Its good to set targets and timetables – just as long as these are realistic – and do not ultimately discourage people. Guinea worm was supposed to have been eradicated in 1995, but remains in Sudan, Nigeria, Ghana, Burkina Faso, Niger, Togo and Ivory Coast according to a BBC report in December.  Donor fatigue sets in.  And in these days of economic downturn, even if donors are not tired, their purses are not as deep.  Counting funds and resources also needs to be part of the RBM countdown.

Nigeria is a high burden country and a good place to keep watch on progress toward targets. The National Malaria Control Program and colleagues has been good at publishing progress.

buttonwhite_fr.gifIn both cases there were regional disparities – children in the south were more likely to sleep under a net than those in the north. This was not for lack of trying, since the recent article also documents net distribution in the study areas over a 12-month period.  It will be interesting how and if RBM partners will rally to help Nigeria double its net coverage rates in the next two years.

The Nigeria studies reported on number of children who slept under nets the night before the study, which is one of the key indicators of Roll Back Malaria success.  Counting alone will not be helpful in documenting progress towards universal coverage and eventual elimination unless all partners use standard measures. RBM’s Monitoring and Evaluation Reference Group has provided guidelines and toolkits, which all partners should read and use when reporting on their own progress.

When “Counting Malaria Out” on 25 April 2009, RBM encourages partners to, “Make 2009 the start of the countdown. Make the lives of every man, woman and child count as the international community intensifies its battle against malaria.” This will definitely require a well funded and coordinated effort.

Environment &Epidemiology Bill Brieger | 19 Feb 2009

Micro-Geography and Malaria

dscn1030sm.JPGWe know at the global level that malaria currently clusters in countries that are relatively closer to the equator rather than in temperate or colder regions.  A study out of Papua New Guinea (PNG) emphasizes the need to learn about local variations in malaria distribution as an aid to proper planning and intervention.

Meyers and colleagues found that, “malarial infection is significantly and independently associated with lower elevation and greater distance from administrative centre in a rural area in PNG.” They considered that higher elevations would be hillier with less opportunity for water collection, and locations on the outskirts of villagers may be closer to swampy or agricultural lands where mosquito breeding would be greater.

Local geography also plays a role in the distribution of urban malaria. A recent study in Ouagadougou, Burkina Faso found that malaria was “focused in areas which are irregularly or sparsely built-up or near the hydrographic network” such as urban gardens as well as in poorer neighborhoods. The solutions to urban areas are multi-sectoral according to Donnelly et al. : “Urban malaria is uniquely amenable to prevention and control as the existing health, urban planning, agricultural and governance structures present opportunities for collaborative approaches that can include both the community and the substantial private sector.”

The East African Highlands are another example of geographical variations of malaria distribution in a country.  These are areas where malaria is seasonal.  Recent investigation has shown how climate change may actually be changing the seasonal distribution of rain, vector and thus malaria. Deforestation can also create geographical variations in malaria distribution.

Natural and man-made variations in geography within countries and even communities have important implications for the planning, targeting and timing of malaria control activities.  Clinics in certain areas may need more stocks of ACTs. Supplies of drugs, nets and spray should be timed in advance of known seasonal onset of malaria in other areas.  As elimination comes closer to reality this micro-planning for micro-geographical areas will be the only way to keep the disease under control. It will also require a multi-sector approach.

Drug Quality &Resistance Bill Brieger | 14 Feb 2009

ACT Treatment Failure – reality today … or tomorrow

The ‘F’ word has appeared in peer reviewed malaria literature. “Failure of artesunate-mefloquine combination therapy for uncomplicated Plasmodium falciparum malaria in southern Cambodia,” reads the title of a new article in Malaria Journal. The authors concluded that, “It is unclear whether the treatment failures are due solely to mefloquine resistance or to artesunate resistance as well. The findings of delayed clearance times and elevated artesunate IC50 suggest that artesunate resistance may be emerging on a background of mefloquine resistance.”

In narrowing down an explanation for treatment failure, the authors considered the following:

  • Adulterated and counterfeit drugs are on the market, but it was unlikely that these entered into their study
  • Mefloquine dosage ideally varies by weight, and some could have been underdosed, but again analysis shows this was not a factor

The authors also surmised that if resistance to mefloquine is at play, this may expose the patient to only a three-day dose of the artesunate, which then would effectively make artesunate a monotherapy and open to provoking resistance at that dose.

Lim and colleagues consider how resistance to artemisinin drugs could develop in artemether-lumefantrine (AL). coartem-sm.JPG Challenges to absorption of lumefantrine exist and may be related to diet. Here again, the artemisin drug would effectively become 3-day dose of monotherapy, if the partner in the combination was compromised.

Fortunately Premji et al. reported in Africa that “food consumption is adequate post-weaning (and) it appears that only a very small amount of dietary fat is necessary to ensure optimal efficacy with AL and that the fat content of standard meals or breast milk in sub-Saharan Africa is adequate.”

Could home management be a tipping point for ACT resistance.  Data from Ajayi et al. “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.” A strong health education component to home management is still necessary.

After modeling the scenarios for ACT resistance, Pongtavornpinyo and co-researchers offer a prescription for action.  They conclude that, “The spread of drug resistance could be slowed down by controlling presumptive drug use and avoiding the use of combination therapies containing drugs with mismatched half-lives, together with reducing malaria transmission through vector control measures.”

Pongtavornpinyo also noted that resistance is more likely to develop in low transmission areas such as found in studies from Southeast Asia mentioned above. Even in high transmission areas, “high ACT coverage alone cannot reduce malaria transmission unless it is used together with vector-control measures.”

Unfortunately at present unavailability of ACTs may be a bigger problem in these high transmission areas, such as the frequent stock-outs in Uganda reported by Start News. This is despite several years of Global Fund support for malaria control in Uganda. Purchasing the new ACTs in commercial pharmacies is too expensive for most, and so people resort to buying the older and cheaper drugs for which there is resistance.

Either way – whether resistance to artemisinin develops tomorrow or people are forced to take cheaper but less effective drugs today – the patient suffers.

Drug Quality Bill Brieger | 12 Feb 2009

Can we guarantee malaria drug safety?

Since November 2008, Nigeria has experienced another round of child deaths due to fake and adulterated drugs for children. Four months later after 84 deaths “Nigerian drug regulators have announced they have arrested 12 people in connection with the poisoning of 111 babies with a tainted medicine” according to the BBC.

BBC explained the problem with the commercial teething mixture: “The paracetamol-based syrup, used for treating sore gums, was found to have been contaminated with diethylene glycol, used as an engine coolant. It caused the babies’ kidneys to fail.”

The Blog “Nigeria Health Watch” pointed out back on December 12th that, “We had the “normal” responses from the concerned parties in our beloved country as we have come to expect…. “  In short, there was lack of preventive detection for the tainted mixture, but a lot of vocal indignation by authorities in the press after children started to die.

abasept03-007b.jpgWhile there have not been reports of deaths from malaria drugs, Onwujekwe and colleagues report on a disturbing situation with quality of drugs in southeastern Nigeria. After collecting and testing products from 225 public and private providers (including medicine shops) in six sites, both rural and urban, they found first and foremost that only around 10% stocked the nationally recommended first line malaria treatment, artemisinin-based combination therapy (ACTs).

Fortunately none of the medicines had passed their expiry dates. Chloroquine (CQ) and sulphadoxine-pyrimethamine (SP) were still being stocked and dispensed although the former has been found to have seriously reduced efficacy and the latter is supposed to be reserved for intermittent preventive treatment (IPT) in antenatal clinics. Around 40% of CQ and SP failed quality testing. The monotherapy artemisinin drugs and the ACTs performed better with only one failure.

While these poor quality malaria drugs will not kill children directly as in the case of the adulterated teething mixture, they contribute to child mortality.  If children can’t get the recommended medicines for malaria and those they get have little or no active ingredient, they may still be receiving a death sentence.

National malaria control efforts involving the Global Fund and DfID are recognizing and responding to the need to involve all sectors in providing appropriate malaria medicines to Nigerian children.  While the drugs provided through such programs are likely of high quality, these donors would also help the country by providing technical assistance and capacity in pharmaceutical surveillance and vigilance so that the total malaria drug supply is safe.

Epidemiology Bill Brieger | 08 Feb 2009

Darwin at 200, as malaria evolves

Charles Darwin’s 200th birthday is this Thursday, 12 February 2009, and Darwin published his masterwork, On the Origin of Species, 150 years ago and died in 1882. This was just two years after Alphonse Laveran identified the parasite that caused malaria.  Since then it has been possible to learn how the wheels of evolution roll along for humans, mosquitoes and the plasmodia species that cause malaria. These lessons aid in the continuing battle to save human life.

Within humans, evolution of “the protective effects of sickle cell trait (HbAS) against severe malaria and the resulting survival advantage are well known.” Malaria Journal reports that “protection against mild malaria episodes” among those with the trait may also result in improved child nutrition and reduced stunting. A reduced survival rate of SS fetal genotype may be associated with placental malaria. The LA Times also describes the human side of the malaria evolution triangle:

Among the genes whose purpose is understood, the biggest category is devoted to fighting infectious diseases. For instance, the researchers found more than a dozen new genetic variants involved in fighting malaria to be spreading rapidly among Africans.  Scientists had previously identified several mutations that offered protection against the disease. Most were shared by people of African descent, because the scourge is most widespread on that continent. But malaria afflicts people throughout the tropics and subtropics, and additional mutations to combat the disease arose in Thailand and New Guinea, Hawks said. One of the newly discovered mutations helps defend against a form of the disease in which malaria parasites congregate in blood cells in the placenta, causing a high rate of miscarriage.

Issues like drug resistance by malaria parasites provide focus to the discussion on continuing evolution of the malaria parasites.  Durand and colleagues explain that, “Drug development programs exhibit a high attrition rate and parasite resistance to hemotherapeutic drugs exacerbates the problem. Strategies that limit the development of resistance and minimize host side-effects are therefore of major importance.” They report on efforts to use an understanding of evolution to design better malaria drugs.

The mosquitoes themselves evolve to adapt to changing environments, human behavior and pesticides. Muller and co-researchers encourage continued study on how “Insects exposed to pesticides undergo strong natural selection and have developed various adaptive mechanisms to survive.”

Resistance to pyrethroid insecticides in the malaria vector Anopheles gambiae is receiving increasing attention because it threatens the sustainability of malaria vector control programs in sub-Saharan Africa. An understanding of the molecular mechanisms conferring pyrethroid resistance gives insight into the processes of evolution of adaptive traits and facilitates the development of simple monitoring tools and novel strategies to restore the efficacy of insecticides.

With continued changes in human behavior such as in agriculture and urbanization, as well as human impact on the environment, malaria will continue to evolve. Darwin has given a guide to understanding the complex evolution of malaria. Two hundred years on, we must continue to fund research that advances this understanding and uses it to keep ahead of the disease.

Funding &Research Bill Brieger | 07 Feb 2009

Does malaria research get too much money?

Of course the answer to this rhetorical question is a resounding “NO”, but the issues of both equitable and adequate funding for disease research and control efforts continues to be debated. From the following press release one might get a different impression:

The first survey of global public and private investment into R&D (Research and Development) for new products for neglected diseases has found that funding was over US$ 2.5 billion in 2007. The lion’s share of funding – almost 80% – went towards HIV/AIDS, TB, and malaria. Many significant diseases responsible for killing millions of people in developing countries – including pneumonia and diarrhoeal diseases – remain underfunded and collectively received less than 6% of total funding. These are the results of the G-FINDER ‘Global Funding of Innovation for Neglected Disease’ survey, released and published in London today by The George Institute for International Health.

Malaria, according to the report, received 18% of R&D funding.  Just as a reality check, Unicef’s State of the World’s Children in 2008 indicated that globally malaria accounts for directly 8% of under-five age child mortality.  Neonatal and infant deaths attributable to malaria in pregnancy are not differentiated. The impact of malaria is much higher in endemic countries than global estimates imply.

No one is arguing that the solution is a redistribution of the existing pie so that there is more money to search for better treatment for pneumonia, for example. We need a larger pie, which could be a major challenge in these tough economic times.  In fact the impact of the economic downturn on water, sanitation, nutrition and housing, to name a few areas, themselves may have a bigger impact on disease control that R&D dollars.

Recent events such as those at Davos and TED show that some corporations and foundations are trying to keep up their support for disease control and research. More partners need to join the effort.

ITNs Bill Brieger | 02 Feb 2009

Are there enough nets in the house?

Review of surveys from 15 countries shows that, “Within ITN-owning households, many children and pregnant women are still not using them. Between-country analysis with linear regression showed child ITN use increases as intra-household access to ITNs increases,” according to Eisele and colleagues. They note further that –

Results from within-country logistic regression analyses were consistent with between-country analysis showing intra-household access to ITNs is the strongest and most consistent determinant of use among children. The gaps in ITN use and possession will likely persist in the absence of achieving a ratio of no more than two people per ITN.

bednet-drawing-on-clinic.JPGThe Roll Back Malaria Partnership asserts that, “To achieve universal coverage, countries must go beyond the procurement and financing of interventions to ensure that the products can reach every person at risk.” Calls for universal coverage have been simplified to two nets per household.

Many households in Africa contain between 5-6 people. Are two nets enough to ensure vulnerable groups are covered? If one generously estimates the population of pregnant women and children under fiver years of age to be 25%, then yes, two nets may suffice. But what really happens in terms of intrahousehold allocation of valuable resources?

Again Eisele et al. suggest that, “Countries should aim to achieve greater than one ITN per household to ensure adequate intra-household access for children and pregnant women.” They realized that having a net does not guarantee its use, but the more nets there are in a household, the greater likelihood that vulnerable groups have a chance at being protected. Specifically they recommend that –

Once intra-household access to ITNs is attained, the remaining gap between ITN use among children and pregnant women within households possessing them may be minimized further with behavior change communication campaigns.

BCC alone will not solve the problem – communities must be actively involved in their own net distribution and use promotion programs.

Health Systems &Private Sector Bill Brieger | 02 Feb 2009

Infrastructure, the market and health in Nigeria – any solution for malaria?

“Nigeria (is) one of the emerging countries that is being penciled down by leading global economists and market observers as the most dynamic market driven economies on the African continent,” according to Eze Nwagbaraji reporting in the Vanguard Newspaper.  Certainly much of health care in Nigeria is market based.

On the other hand, Salisu Suleiman in the Daily Trust stresses a government role. “… government uses resources at its disposal to provide a number of goods and services, particularly those that may not be efficiently provided and equitably distributed through the market system. They include public goods, and services like education, health, water and power supplies, postal service, police protection, defense etc.”

What really happens? Nwagbaraji describes Enyiogugu, a large city in Imo State, and in particular points out that, “The community health center is a parasite – ill equipped and almost non-functional.” No wonder people look to the private sector for health care. Nwagbaraji suggested infrastructure bonds as a source of financing as well as the possibility of the private sector undertaking the upgrades and managing the results.  This may be the way to go since the public sector appears incapable of maintaining infrastructure improvements in places like Enyiogugu to date.

In the short term, where do people get help? Recognizing that the private sector accounts for a very large proportion of malaria treatment, Nigeria’s Global Fund recipients reformulated its Phase Two plan for the Round 4 Malaria Grant to involve patent medicine vendors (PMDs) in selling subsidized anti-malarials.  Informally, the Principle Recipient thinks that approximately 20% of PMVs in the 18 target states are participating in the plan.

This PMV approach is a good start. Since we estimate that 50-80% of the people get their malaria treatment from PMVs, this effort may serve as a pilot scheme. Is wider application possible?

Recently the Future Health Systems Consortium held a conference on the role of innovators and entrepreneurs in improving the performance of private providers of healthcare in Abuja, Nigeria. Actual social entrepreneurs presented innovations ranging from training PMVs to appropriate technology for district hospitals, health maintenance organizations for the poor and community involvement to improve health service quality in both public and private sectors.

These innovations must not only be encouraged but taken to scale if the market can truly help Nigerian in need of health care, including malaria treatment.

Funding &Health Systems Bill Brieger | 01 Feb 2009

Global Fund Gap – implications for high burden countries

We have commented on the consternation expressed over the shortfall of money to fund the current crop (Round 8 ) of Global Fund applications. It is useful to bring this problem to life looking at an actual grant proposal that is held in limbo.  Unfortunately Nigeria is one example – unfortunately because Nigeria probably has the highest burden of malaria.

Specifically the GFATM notes Nigeria’s Round 8 Application stands in limbo because certain …

Round 8 proposals … have been approved by the Board in principle and will be presented to the Board for funding approval, according to the comprehensive funding policy and as / when funding becomes available. The Global Fund Secretariat will be working with countries to find efficiencies in all Round 8 proposals to bring the total approved (Phase 1) funding for Round 8 at or below US$ 2.75 billion and to reduce the amount of Phase 2 funding (to be addressed during the Phase 2 renewal process).

The actual funding requested in Nigeria’s Round 8 proposal was nearly $600 million, of which $334 million was for phase 1. These figures look large in relation to the $74 million allocated for the Round 4 Malaria grant (which had been combined with Round 2), but when one considers the population of 140 million people combines to only about $4 per person, which is small considering the cost of nets, ACTs, logistics, health systems strengthening and the like.

One needs to remember that Nigeria has over 800 ‘health systems’ if one counts the 774 Local Government Areas (LGAs)  (districts), 36 states (plus one Federal Capital Territory) and federal system of tertiary level facilities. The NGO and private sectors may even represent their own systems in the eyes of some.  Constitutionally each level has its distinct health responsibilities, and LGAs are where primary health care and most of malaria services are delivered through government and a variety of formal and informal private channels.

It is these front line LGA ‘systems’ that need the most strengthening. While people may question the way LGAs spend their fundes, most of which come from federal subventions (read oil money), the reality is that the bulk of their expenses are recurrent ones, especially personnel.  Infusions of support from the Global Fund, World Bank, DfID, USAID and others will only create a critical mass of malaria control action if these LGAs are strengthened and then correctly manage malaria commodities and resources.

Delayed funding for high burden countries like Nigeria not only delays critical systems building but also delays saving of lives.  2010 is so close and yet so far away.