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Monthly Archive for "November 2009"

HIV Bill Brieger | 30 Nov 2009

World AIDS Day 2009 and Malaria

wad_logo.jpgThe UN Secretary General’s statement for the 2009 World AIDS Day reflects a theme common to the UN’s emphasis for malaria elimination – universal coverage. According to the Secretary General. “On World AIDS Day this year, our challenge is clear: we must continue doing what works, but we must also do more, on an urgent basis, to uphold our commitment to reach universal access to HIV prevention, treatment, care and support by 2010.”

091125_unhomephoto250x173.jpgUniversal coverage is reflected in this year’s theme, “Right to Health.” The right to health also means that those who live with HIV/AIDS in much of the tropical world also need access to health services that prevent and treat malaria because co-infection with the two diseases presents a greater threat to health and survival.

The research world has been grappling with the challenges of HIV and malaria co-infection as was in evidence during numerous presentations at the recently concluded MIM 5th Pan-African Malaria Conference in Nairobi.  A few of the many abstracts are excerpted below.

In Cameroon HIV/Malaria co-infection was more associated with … lower CD4+ counts, high parasitaemia, high fever frequency, longer illness duration and low Hb concentration (Theresa Nkuo-Akenji, et al.,, MIM 2009 Abstract 388).

At Tororo District Hospital, Uganda a cross-sectional study of HIV-infected women taking TS prophylaxis and HIV-uninfected women taking IPT–SP (1:3 ratio) found that microscopic infection was associated with Low Birth Weight for all women, but
Submicroscopic (PCR) infection was associated with LBW only among HIV-uninfected women (Patrick M. Newman et al.,, MIM 2009 Abstract 424).

For HIV-infected children in Kampala, Uganda, both AS/AQ and AL were highly efficacious. Compared to AL, AS/AQ was associated with a higher risk of neutropenia, anorexia, malaise and abdominal pain. In HIV-infected Ugandan children AL was safer and better tolerated than AS/AQ (Fredrick Kateera et al.,, MIM 2009 Abstract 594).

malaria-and-hiv-at-mim-2009-sm.jpgFinally, Peter Ouma et al. (, MIM 2009, Nairobi, Abstract 131) studied Peripheral Malaria Parasitaemia in Pregnant Women, Kenya. Their findings are seen in the graph to the right. Both cotrimoxizole and SP offered some protective effect for both HIV+ and HIV- women.

Please read the MIM abstracts for more current research on HIV and Malaria, and remember that universal coverage is a basic right, one that should help us re-visit commitments that were once made to ‘Health for All.’

Migration &Resistance &Treatment Bill Brieger | 29 Nov 2009

Getting tough on monotherapy artemisinin drugs

In Guyana Stabroek News reports that, “Minister of Health Dr Leslie Ramsammy has thrown down the gauntlet to pharmacies to desist from selling the single dose artemisinin malaria drug by the end of this year or he would instruct officers from the Food & Drugs Department to size the drug from their shelves.” Guyana has been promoting ACTs since 2004.

In Guyana, the coastal areas are considered to be malaria free while the interior areas are considered to be high-risk malaria areas. Guyana therefore, may not me among the most endemic countries for malaria, but all endemic countries need to take the disease seriously, like Guyana’s Minister of Health, in order for global elimination to succeed.

Guyana has seen success in promoting malaria control. In endemic areas bednet use by children under 5 years of age increased from 7% to 70% between 2000 and 2006, according to the Multiple Indicator Cluster Survey.

Guyana’s Round 7 Global Fund proposal also aims to decrease malaria incidence by 70%. Included in the strategies are diagnosis and treatment with the intention that all health facilities (including the private sector) would be appropriately trained and equipped with microscopes and have adequate amounts of drugs and rapid tests. This is why the need for appropriate treatment with ACTs, not monotherapy drugs is being stressed.

As we have mentioned before, Guyana’s malaria control efforts are complicated by migrant miner populations in the endemic areas. It is such populations that may help drive the demand for cheaper, though inappropriate malaria medicines like artemisinin monotherapies.

An interesting irony is that WHO lists Guyana among the 16 countries that have never registered artemisinin monotherapy drugs. This implies that the availability of such medicines in Guyana is truly against the law and also shows how slippery the pharmaceutical import business can be.

WHO as of 16 November 2009, lists 33 endemic countries as not taking adequate steps to stop the sales of monotherapy artemisinin drugs.  Another 29 have “taken regulatory measures to withdraw the marketing authorization of oral artemisinin-based monotherapies after implementing ACT policy.” The approach of these 29 does not mean the immediate withdrawal of monotherapies, as some like Nigeria are simply letting the current registration of these drugs run out – meaning they may be on the market for another 2-3 years.

Unless all endemic countries take action like that proposed in Guyana, we may not be proceeding along the pathway to elimination, but down the road to drug resistance.

Advocacy &Monitoring Bill Brieger | 26 Nov 2009

Malaria Advocacy – how do we measure success?

shm-abola5.jpgThe Malaria Advocacy Innovation Grants have recently issued a report on their activities. The grants were expected to support “ideas and partnerships that reached new audiences in creative ways and tackled difficult issues such as equity, transparency and accountability.” The 3-year program reached 16 African countries and did involve audiences ranging from the expected civil society groups to government leaders, business people and researchers.

The challenge with advocacy efforts is what do we measure as success? By way of results or indicators, the Malaria Advocacy Innovation Grants “aimed to boost advocacy efforts to improve Africa-to-Africa accountability for response to malaria suffering on the continent as well inspire African civil society organizations and media to become “leaders” in the fight against malaria.”

Examples of success reported by these “mobilizing for malaria” projects include:

  • Nigeria: the partner substantially boosted the capacity of local civil society by organising a five-day malaria advocacy training session. 35 people representing 28 CSOs were trained
  • Tanzania: 37 MPs were trained in a workshop, and became instrumental in forming a first-of-its kind coalition of Tanzania Parliamentarians Against Malaria (TAPAMA)
  • Ghana: a magazine Eyes on Malaria was created, connecting malaria research findings and policy with day to day issues
  • Mozambique: a project focused on mobilizing and engaging government representatives and businesses resulted in several enterprises starting to plan malaria control interventions as part of their social responsibility programmes

According to WOLA, Bread for the World and CEDPA, “Aspects (of advocacy) to be evaluated include the execution of strategies, the impact of the initiative in solving (or not solving) the specific problem, its contribution to the empowerment of the group and of civil society, and consequences for democracy.”

The Malaria Advocacy Innovation Grants have just concluded, and hopefully we can expect more in terms of evaluation from the project. In the meantime we have some key outputs documented. Ultimately we would like to learn how these advocacy efforts impacted on malaria programming and whether the CSOs who were trained become sustainable themselves and continue to contribute in a meaningful way to fighting malaria in their countries and regions.

Eradication &Surveillance Bill Brieger | 23 Nov 2009

Lessons from guinea worm eradication

When the international effort to eradicate guinea worm started in 1987 the focus was on only 20 currently endemic countries.  Tayeh and Cairncross report the status of these countries at the end of 2008

  • 6 have interrupted transmission and been certified as free of guinea worm
  • 8 have interrupted transmission and certification is under way
  • 6 are still reporting cases, of which three are a major focus

boy-extraction2-sm.jpgGuinea worm is a highly focal disease that does not move too easily. The differences in transmission and the sheer number of endemic countries sets malaria off clearly from guinea worm. But are there lessons to learn?

Of concern here is the process of certification that transmission has stopped.  Looking at malaria’s pathway to elimination, we realize that most countries are in the scale-up phase of control and have a long way to go to sustain control and enter pre-elimination, let alone elimination and then prevention of re-introduction.  At some point in the elimination phase, which could be 20 years from now, countries will need to be certified free of malaria.

Tayeh and Cairncross address the realities that larger scale eradication programs like polio take a regional approach to certification, as a country-by-country approach would be too costly.  They also discuss the dangers of re-introducing a disease to places that are free of transmission, which corresponds well with the final phase of the malaria elimination pathway.

Another issue is the challenge of identifying cases when transmission becomes very low. The system of rewards to citizens may not be most appropriate for malaria, but the ability to keep people engaged in eradication efforts when they don’t see a reason will be difficult.

What our colleagues don’t mention is the challenge of false positives. We found that local beliefs in guinea worm endemic areas can lead to high false positive rates on surveys – that swelling on his leg, that ache in her stomach, those rashes on his body.  Local beliefs about malaria presentation abound, too.  It is good, therefore, to start considering what surveillance and certification of malaria elimination will look like now, so a good system is in place when the time comes. In fact we may get good opportunities to practice in places like Zanzibar.

Corruption Bill Brieger | 17 Nov 2009

“extortion, theft of public funds or other corrupt conduct …”

… can buy a $35 million estate in Malibu, California, a fleet of luxury cars, speedboats and a private jet, according to the New York Times. What does it buy for the poor, malaria stricken people of Equatorial Guinea?

“… despite a federal law and a presidential proclamation that prohibit corrupt foreign officials and their families from receiving American visas,” The Times reports that the owner of this California wealth, Teodoro Nguema Obiang, the Forest and Agriculture Minister of Equatorial Guinea and the son of its president, is allowed to enter the US freely.

In the malaria world, Equatorial Guinea has been recently help up as an example of progress along the pathway to malaria elimination. On the third day of the recently concluded MIM 5th Pan-African Malaria Conference Equatorial Guinea, or more specifically its better endowed island half, Bioku featured as a case study in the plenary session.  According to TropIKA’s daily conference summary

Bioko, off the coast of Equatorial Guinea, was the next case example, another “island laboratory” with important lessons for the mainland. Dr Immo Kleinschmidt discussed the first 5-year phase of the island’s malaria control project. There has been huge success in some places, he said, but others continue to struggle, and though Bioko is on the road to elimination, “it’s not going to be easy.”

Several other presentations featured the Bioku experience.These come on the heels of recently published articles in the American Journal of Tropical Medicine and Hygiene detailing results that “provide encouragement that the additional resources for combining IRS and LLIN are justified,” and that “Effective malaria control measures can dramatically increase child survival and play a key role in achieving millennium development goals.”

An accompanying editorial in AJTMH makes more clear than the articles that possible funding for the interventions studied may have come from Marathon Oil’s 2003 infusion of US$ 15.8 million to reduce malaria transmission on Bioko Island and possibly more recent Global Fund support to sustain intervention.

While government is said to be a partner in such enterprises, it would appear from the New York Times article that corrupt government officials alone could have eliminated malaria long ago on both Bioku and the mainland with money to spare for other African countries that lack the ability to siphon off oil profits for personal use.

The AJTMH editorial asks, as it must, whether the reported gains can be sustained.  Global Funds may or may not continue, but the writer hopes that corporate responsibility and its philanthropy will continue to maintain the scale-up of malaria interventions.  If those two sources fail, maybe the Minister of Forestry and Agriculture can sell his Malibu estate for the benefit of his country people.

Equity Bill Brieger | 16 Nov 2009

Ethnic Minorities and Universal Coverage

dscn6801-sm.JPGIf we are to achieve universal coverage – a crucial step along the pathway to malaria elimination – we must be sure that all at risk populations are reached.

IRIN news gives us reasons to pause.  Reporting on Vietnam, IRIN found that, “Maternal mortality rates vary widely across the country. In Cao Bang province, with a 98 percent ethnic minority population, there are 411 maternal deaths for every 100,000 live births, according to UNICEF. In Binh Duong province, near Ho Chi Minh City, the rate is less than one-tenth of that.”

In remote mountainous areas IRIN notes that, “Minorities such as the H’Mong mostly still give birth at home, and are far less likely to access healthcare, especially antenatal care, health specialists say.” An important part of antenatal care is prevention and treatment of malaria.  Besides geographical access, minorities also have financial access problems since they are often poorer than the general population.

Minority access affects many countries and health problems. We found that in southwestern Nigeria, migrant Fulani populations were less likely to get childhood immunizations than their sedentary counterparts. The Fulani there depend more on private health providers to avoid perceived discrimination at local government health services. The settlements of these cattle herding peoples were often overlooked during guinea worm surveillance activities.

Specific to malaria, Dysoley and colleagues found that ethnic minorities working in the forests of Cambodia, while more susceptible to malaria, have been neglected in the past. Ahmed found in Balgladesh differential health and health-seeking behaviors among ethnic groups for illnesses including malaria where Bangalis were more likely to seek qualified allopaths as providers than did ethnic minorities.

Timely and equitable access to effective malaria interventions for all peoples in endemic areas is the only way that malaria can be eliminated.

Burden &Malaria in Pregnancy Bill Brieger | 11 Nov 2009

Burden of Malaria in Pregnancy

The Malaria in Pregnancy Consortium (MIPc) highlighted its ongoing research activities at the recently held 5th Pan-African Malaria Conference in Nairobi.  While results on issues like new malaria treatment and preventive regimens are still in the works, the MIPc did report on preliminary efforts to measure the burden of malaria in pregnancy.

Although international agencies like WHO have given estimates of malaria in pregnancy (MIP) risk, one has not always been sure of how these figures were derived. The MIPc has begun to gather and reanalyze current data to get a better picture of the situation in 2007 since we expect that there will definitely be changes as progress is made toward malaria elimination.

The standard figures have been an annual 50 million pregnant women at risk globally, with 25-30 million in Africa. This may have been nased on live births reported. Other unknowns, according to the MIPc is whether Plasmodium vivax was considered and whether distinctions were made between stable and unstable transmission areas.

Advances made with the Malaria Atlas Project have helped as have UNDP population data for women aged 15-49 years.  There was also the challenge of going beyond live births to counting all pregnancies, whether these terminated early or went to term. MIPc was able to determine that around 13% of pregnancies may end in miscarriage. This is important since malaria itself may lead to miscarriage – live births only would not pick this up.

mip-burden-calculations-by-mipc.jpgThe attached chart shows calculations presented by MIPc. They noted that the African P. falciparum numbers were not much different than have been estimated to date.  more work on these data is underway, but the information presented in Nairobi provides us with the beginnings of a baseline prior to achievement of universal malaria intervention coverage and entry into the malaria elimination phase of intervention.

Another interesting MIP presentation was given by Patrick Duffey during the final plenary session of the MIM conference.  He summarized research that has identified a genetically different form of P. falciparum that infects pregnant women, especially those pregnant for the first time. Some immunity is developed in later pregnancy. This research should contribute to vaccine development.

Dr Duffey also shared information that similar biomarkers for pre-eclampsia are found in women who are pregnant for the first time and have malaria.

The MIM conference has been an important venue for stressing the continued importance of addressing and preventing malaria in pregnancy as a central strategy in our efforts to eliminate malaria overall.

——- see for example …
Muehlenbachs A, Fried M, Lachowitzer J, Mutabingwa TK, Duffy PE. Natural selection of FLT1 alleles and their association with malaria resistance in utero. Proc Natl Acad Sci U S A. 2008 Sep 23;105(38):14488-91. Epub 2008 Sep 8.

Avril M, Kulasekara BR, Gose SO, Rowe C, Dahlbäck M, Duffy PE, Fried M, Salanti A, Misher L, Narum DL, Smith JD. Evidence for globally shared, cross-reacting polymorphic epitopes in the pregnancy-associated malaria vaccine candidate VAR2CSA. Infect Immun. 2008 Apr;76(4):1791-800. Epub 2008 Feb 4.

Kabyemela ER, Muehlenbachs A, Fried M, Kurtis JD, Mutabingwa TK, Duffy PE. Maternal peripheral blood level of IL-10 as a marker for inflammatory placental malaria. Malar J. 2008 Jan 29;7:26.

Integration &Treatment Bill Brieger | 09 Nov 2009

Integrated community case management (ICCM) – a way forward

ccm-in-onileekaa.jpgICCM was the theme of a symposium at the MIM 5th Pan-African Malaria Conference last week. The organizers defined ICCM as a ‘strategy that delivers to the most vulnerable groups anti-malarials, antibiotics and a combination of oral rehydration therapy and zinc at the community level by trained community health workers.’ during the course of discussion CHWs were defined as people not only from the community, but also working in the community.

A little leeway has been taken with the latter definition in an ICCM study from Ghana where RDTs, ACTs, Amoxicillin and Paracetamol were availble for use by Community Health Officers posted in village health services known as Community Health Planning (CHPs) compounds.  Having both the RDTs and alternative treatment for pneumonia in the case of negative tests resulted in less overall drug use in the 8 intervention CHPs compounds compared with the 8 controls. Integration can only happen when health workers have all the materials they need to do appropriate case management.

Documentation of ICCM policy and program implementation for 68 countries was reported to the symposium. Only 55% of countries had a CCM policy for malaria, 50% for diarrhea, 30% for pneumonia and none for neonatal infections. Some countries were implementing without policies. Less than half had integration of three diseases – malaria, diarrhea and poneumonia.

Even with policies, not all countries implement CCM on a national basis, though there were examples of implementation across many or just a few pilot districts.

Potential barriers to CCM policy and implementation were identified through interviews with Ministry of Health officials from the selected countries. Common concerns were the ability to guarantee quality of care, incentives, supplies, monitoring and evaluation, training and supervision.

Ethical concerns were raised as to whether CCM really provides quality care to the poor.  In contrast, presenters working in post-conflict areas found that these situations provided opportunities for creative thinking on how to reach disenfranchised communities.

The session did not have time to get into the role of the informal private sector – especially patent medicine vendors – in CCM.  Also the focus on individual CHWs tended to divert attention away from the word ‘community.’ It is hoped that CCM can take a leaf from the Community Directed Interventions process and focus on strengthening community leadership and systems to take charge of health matters, and not rely solely on an individual CHW who may be here today and gone tomorrow.

NOTE: ICCM training materials and job aids are being consolidated by WHO/Unicef. The CORE Group also has a set of CCM training materials under development.

Communication &Research Bill Brieger | 06 Nov 2009

Mixed Media Channels – is more better?

Two presentations today at the MIM 5th Pan-African Malaria Conference shared experiences with the use of mixed media channels to promote socially marketed malaria interventions as well as vouchers. Both speakers, Christopher Mshana and Hadji Mponda, are associated with the Ifakara Health Institute in Tanzania.

narchoct03-012-sm.jpgIn both projects a mix of communication channels were employed such as road show/drama, poster, radio, newspaper, health worker talks, cinema, branded vehicle, and free cap/T-shirt.

The social marketing communication project found some important age and gender differences in perceived exposure with younger males more likely to have reporting greater contact with the interventions such as road shows, caps/T-shirts, the branded vehicle and cinemas.  It was surmised that women may not have the time to attend such events.Another challenge was that even among those who were exposed to the communication activities, olnly 60% mentioned a malaria prevention method like nets, and 19% recalled the need to get prompt treatment for children at the health center. Messages on caps/T-shirts seemed to be recalled better than those from other sources.

The project observed an increase in care seeking after the communication efforts, but their inquiry was not designed to directly attribute this to the media interventions. Overall only 35% of 3632 people interviewed reported contact with the program’s media efforts.

Costs of the communication efforts were not reported, but it certainly seems to have been an expensive way to learn which channels reach whom with what messages. One wonders if more targeted media and messages could have been developed through formative research prior to the intervention.

The project that examined mixed communication methods used in promoting the net vouchers interviewed 6260 households. They did look at people’s normal media use behaviors, and found that for media like radio, newspapers and posters there was increase perception of health messaging from these sources with increasing socio-economic status.  The did not observe gender differences.

Only 23% overall had seen messages on the Tanzania Voucher Scheme. The main media source for information was the radio (60% of those who had heard).

Communications is seen as a main component of malaria control interventions.  These two project reports show the need to design such interventions in a way that not only allows attribution to behavior change, but also compares the relative effectiveness and cost of different media channels in achieving desired program ends.

Treatment Bill Brieger | 06 Nov 2009

Can Research Address Bottlenecks in ACT Delivery?

The ACT Consortium is in the process of addressing four key issues in ACT delivery through research projects in 9 countries with around 21 partner institutions according to a symposium Thursday at the MIM 5th Pan-African Malaria Conference. The Consortium had a long gestation period with the idea being floated around 2001 and final funding securred in 2007.

many-artemisinin-based-drugs-are-available.jpgDuring that gestation period millions of doses of ACTs have been delivered, and is universal coverage is to be achieved in 2010, millions more doses will have to be provided next year and beyond. Research results from the consortium may not come online for a few more years, and we hope that the findings will be relevant for sustaining treatment during the crucial years between scale-up and pre-elimination.

The four key areas for research into how to improve access to appropriate, high quality medicines are as follows:

  1. Access – including equity issues
  2. Targeting – with a focus on improved diagnostics, cost-effectiveness and supply management
  3. Safety – drugs are licensed after trials on only 6,000 people, so surveillance for rare adverse events is needed as well as interactions with other medications (e.g. for HIV)
  4. Quality – addressing substandard, fake/counterfeit, and degraded (through transport, storage) medicines

Panelists shared their research plans which included, for example, the possible effects of RDT use on rational prescribing. There is also interest in finding out what prescribers do when RDT results are negative, which depends on having treatment for alternative causes of fever.

There is a strong social science component that will explore provider and user perceptions and the determinants of the decisions they make to prescribe medicines and use them.  In Ghana the studies will have important economic implications for their national health insurance scheme.

In Tanzania where ACT access among children was said to be only 14% at present, the research is addressing the private sector and may tie in with the greatly anticipated AMFm grant. Tanzania is trying to scale up efforts at improving the quality of private sector medicine shops through training and franchising in Accredited Drug Dispensing Outlets – the ADDO shops. A Herculean effort to bring 10,000 new shops on board will be aided by research in at least 3 provinces.

Answers to many ACT access questions are needed now. We happily await the results of the ACT Consortium’s efforts. In the meantime countries should also use the operation research funding available through their Global Fund and soon to be deployed AMFm grants to answer more immediate delivery and bottleneck questions. Basic procurement, supply and use monitoring will also go a long way to inform our efforts to guarantee appropriate universal coverage of ACTs.

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