Tropical Health Matters

We encourage the malaria community to learn lessons from other disease elimination and eradication programs. Guinea worm appears to be on its last ‘legs’, and we need to consider how it dropped from over 3 million global cases annually in the 1980s to around 3,000 now.

Nicholas Kristof of the New York Times has encouraged people to take heart in efforts to eliminate the disease from Sudan, one of the apparent four remaining strongholds of the disease. He has written a ‘good news column’ from Sudan and stresses that, “This district (where he is visiting) is, in fact, one of the last places on earth with Guinea worms. If all goes well, Guinea worms will be eradicated worldwide in the next couple of years — only the second disease ever to be eliminated, after smallpox.”

The additional ‘couple years’ should be seen in the context of initial efforts that set the target date for global eradication at 1995.  No one says eradication – the total elimination of a disease from the world – is an easy task, but preventing people from drinking guinea worm infested pond water is a little easier than preventing malaria.  If guinea worm eradication is overdue, what can we say about hopes expressed in recent years to eradicate malaria?

Yes, we too like to look for good news. Donald Hopkins of the Carter Center (see photo) told the New York Times recently that, “After 20 years, the Carter Center is ready to declare a major victory in its war on guinea worm: Nigeria, once the worst-afflicted country in the world, appears to be free of the worms. It will take two more years for the World Health Organization to make it official, but not a single worm has been found in Nigeria for 12 consecutive months.”

Why more years? Certifying that a disease is no longer in a country requires continued surveillance after the last known case. Specifically, those countries that had active transmission when the eradication efforts started around 1986 “need to continue surveillance for three years after reporting zero cases and should then be visited by an International Certification Team (ICT) to ascertain that the country is disease-free. The country report and ICT report are presented to the Commission.”

Tayeh and Cairncross drawing lessons from the guinea worm eradication certification process for other diseases explain that, “It is important to reduce the cost of certification and at the same time to ensure that interruption of the disease transmission has really taken place. It is also important not to overload a country’s health system with work when the disease is no longer a public health problem and interest in it has waned.”

IRIN reports that, “Some 80 percent of cases worldwide are in Southern Sudan, a region left in ruins by a 22-year long civil war,” where a settlement was reached only in 2005.  This is another lesson for malaria elimination since the disease actually thrives in war torn areas with diminished amenities, housing and health care.

Kristof ends his column thus: “My favorite moment came when we were bouncing along with Anyak (a local child) toward the Carter Center compound. I asked him what he wants to be when he grows up, and he answered with the most prestigious and altruistic position he could imagine: ‘I’d like to be a Guinea worm volunteer.'”

Hopefully guinea worm will truly be eradicated before Anyak grows up. Maybe he can then focus his career goals on malaria instead. We will need such people of dedication to maintain the long years of surveillance needed to certify the end of malaria when it comes.

Jhpiego, through USAID Kenya’s AIDS, Population and Health, Integrated Assistance (APHIA II) Program in Eastern Province, supported observance of World Malaria Day 2010. The Provincial Malaria Control Coordinator has written to share their experiences and express they appreciation as seen below. (Photo: drying nets in Isiolo District

From: Alfred Maina
Sent: 27 April 2010 16:01
To: Kennedy Manyonyi, Deputy Project Director, APHIA II Eastern
Subject: World Malaria Day Eastern Province

Hi Dr Manyonyi,

Hope this finds you well. I wish to confirm to you that we had a successful world malaria day launch at Kibugua, Meru south district yesterday. We had a good attendance that I would estimate to about 700.We feel the involvement of the Kathatwa community unit attached to the dispensary did a lot in mobilization of the community. The Mugirirwa community unit as well as the Magnet theatre group were also involved in the event which resonated well with the local community and this is the way to go if we are to collaborate with the community in improving their health.

The Provincial health team was led by the Provincial Director of Public Health who was accompanied by the Provincial Public Health Officer, the Provincial Health Education Officer,Provincial Clinical officer and the Provincial Records and Information Officer. The Meru South DHMT was fully represented and other government departments such as Water, Children’s Office, Education, County Council and Registration. The Meru South D.C. was the guest of honour.

The main highlights of the day included:-

1. A road show/procession that started at Chuka district hospital,throughout the town streets onto the Chuka Runyenjes road, through the market centres in Magumoni and finally into the venue.
2. Involvement of Kathatwa and Mugirirwa community units through:
• Demonstration of IRS using sprayers owned by the Kathatwa unit
• Demonstration of proper use of ITNs
• Demonstration of net re-treatment by the CHWs
• Presentatin of a skit by Mugirirwa CU on malaria control interventions
• Presentation of a play by the magnet theatre group.
3. About 600 nets were distributed to the vulnerable members of the community including pregnant mothers,children under 5 and a few elderly individuals.
4. Speeches by the following people:- DPHO, APHIA 2 representative from Meru south, PSI representative, Provincial Malaria Coordinator and PDPHS.

The main speech was given by the D.C who implored the community to partner with all stakeholders in malaria control interventions in the district.

All in all the activity was a huge success and on behalf of the PHMT, I wish to register our appreciation for the financial support and the great collaboration we had in this event. We look forward to even greater partnership towards improving the health of the communities in this province.

Regards,
Dr Karagu Maina, Provincial Malaria Control Coordinator, Eastern Province

Eliminating malaria, let along eradicating it, does not come cheap. In places like Zanzibar that have seen “prevalence rate come down from 35 percent before 2008 to below 1 percent,” there is worry that success may actually discourage continued support.

Zanzibar is right to worry. As its malaria control program staff observed, “Malaria prevalence was reduced to 1-2 percent in the 1970s, and then people relaxed.” Sri Lanka had similar experiences:

History shows that malaria control efforts must be sustained to be effective. Sri Lanka is an example of a country where malaria roared back after nearly being eliminated in 1963. But those eradication efforts were not sustained and by 1990 there were a quarter of a million cases. Fortunately malaria control was stepped up again and levels have dropped once more to just 673 cases reported in 2008.

Zanzibar’s worries are real. Even though progress is happening, IRIN noted that the malaria program says it has reached only 60% of households with indoor residual spray and 40% of pregnant women with intermittent preventive treatment. Achieving and maintaining targets of 95% and 80% respectively will take continued financial commitments. As a spokesperson net manufacturer Vestergaard Frandsen said, “We can’t afford to let funding backslide and threaten this progress.”

In addition to maintaining interventions, Zanzibar is in a position to show the additional costs of monitoring and documenting elimination. This includes establishing and maintaining its Malaria Early Epidemic Detection System. Again, the Zanzibar malaria control program warns that, “Each district also needs its own surveillance and response team and there is a need for more trained personnel. To set up this system you also need a lot of money.”

Dr. Steven Phillips, medical director of global issues and projects for ExxonMobil is optimistic about the major increases in malaria funding globally, but also is cautious…

You can imagine with the economic headwinds, with the global downturn and also with a lot of competing priorities that donor governments have, the real question is will this level of finance be sustained? And if it’s not sustained what’s going to happen to the progress?

The Global Fund also offers a word of caution: “Despite remarkable progress in the past few years, any reduction in the flow of funding to fight the disease could put recent achievements at risk.” They estimate that $20 billion raised between 2011-13 would meet “72 percent of global need in 2015 for insecticide-treated nets for malaria, but they also are considering less ambitious scenarios like $13 and $17 billion.

In fact, lack of major donor support for low transmission areas like Botswana in Southern Africa points to the need to orient donors to the financial challenges of working toward and achieving malaria elimination. Establishing more focused and intense intervention in some of Botswana’s northern districts as well as epidemic outbreak detection in the eastern areas is not cheap.

WHO pointed out that, “The Government of Botswana is the major financier for malaria control, accounting for more than 90% of total expenditure.” There are unmet financial needs in the areas of surveillance, vector control and human resources. Is this the fate of Zanzibar as the islands become low prevalence areas like Botswana?

Fortunately Zanzibar has a 10 million Euro Global Fund Grant that will last through 2014 as well as PMI support, but not every low transmission area is as fortunate.

There are great expectations for achieving universal coverage of malaria interventions by 31 December 2010. Success at that point in time will be meaningless unless interventions are sustained and new interventions appropriate to achieving elimination some years hence are funded.

Some people love their spouse, some people love their new car, and apparently some people love DDT.

Love is not a particularly rational emotion, even more so when it comes to inanimate objects like cars and pesticides. Those who love DDT have now even equated stopping its use with population control in Africa.  One wonders where these same people stood when real ‘population control’ or genocide was happening in Rwanda and Darfur (to name a few of the more obvious human atrocities). Somehow one doubts banning of DDT can be equated with Darfur.

Long before DDT was banned, the malaria eradication efforts of the 1950s-60s were grinding to a halt in many African countries for the basic reasons that health systems could not support sustained efforts and donors were tiring of funding the project. There is also the not so simple matter of insects developing resistance when only one pesticide is being used.

One key lesson of the earlier eradication project was that relying on a single intervention technology was not enough to control, much less eradicate, a complicated disease like malaria.

Now that we have several proven tools (long lasting insecticide treated nets, artemisinin-based combination therapy, rapid diagnostic tests, intermittent preventive treatment AND indoor residual spray) in addition to new tools on the horizon (e.g. vaccines), we can apply those in combinations that best suit the epidemiological situation in each country and region of a country.

Yes, spraying was included above, and is an integral component of current malaria control and elimination efforts because it can now be targeted, as with the other interventions, in the most effective places such as areas that have more seasonal and unstable transmission and thus, where annual spraying can be effective. Yes, DDT is included in the WHO approved list of chemicals for indoor use, but for countries that want choice, there are a dozen alternatives.

Why annual spraying? DDT may be cheap, but the spraying operation is not. Nor is it convenient to the people whose homes are sprayed. Spraying more than once a year would be more time and cost consuming than present funding and community tolerance could support. Very high year-round malaria transmission settings are not so amenable to IRS as they would require more frequent spraying.  WHO recommends the following for appropriate IRS use in epidemiologically appropriate areas:

Achieving [the highest possible] level of coverage and timing spraying correctly – in a short period of time before the onset of the transmission season – are crucial to realize the full potential of IRS. IRS is indicated only in those settings where it can be implemented effectively, which calls for a high and sustained level of political commitment.

Approved use of any pesticide for public health comes with the following caution: “When implementing IRS, it is critical to ensure that adequate regulatory control is in place to prevent unauthorized and un-recommended use of public health pesticides in agriculture, and thus contamination of agricultural products. Pesticide contamination can have serious ramifications for trade and commerce for countries exporting agricultural products.”

Those who love DDT may not find these concerns expressed about the object of their affection very comforting. But then love is fickle. Maybe next year these same people will fall in love with BPA.

World Malaria Day comes close on the heels of Earth Day (today), though the latter has been celebrated for about 30 years longer.  Malaria Day, April 25th, is near the beginning of the rainy and malaria season in the northern hemisphere, and rains – not enough or too much – are a major environmental concern on Earth Day. In short malaria is vitally linked with the environment. Here is a sampling of how various web sites see the connection.

A striking poster entitled “Stop Global Warming” by Professor Yoon of Seoul, Korea teaches environmental art. The global warming poster is by one of his students depicts a child at risk of malaria composed of many tiny mosquitoes.

Paul Chesser reviews the interrelated issues of malaria control and environmental effects of pesticides, particularly DDT. The benefits accrued through focused use of the chemical in industrialized countries with strong health systems. Aside from environmental concerns, spraying as a control tool did not succeed in poor countries where health systems could not sustain the effort on a broad basis.

We wonder whether 50 years later health systems in endemic countries are stronger, not only to ensure adequate spray coverage in appropriate locations, but also prevent ‘leakage’ into other sectors and misuse.

Cheryl Saban is an optimist. she suggests donating to malaria control efforts is the perfect Earth Day gift. “Malaria is an illness that can easily be eradicated — we have the knowledge of what to do – education, mosquito nets and medication, and the network of distribution is being worked out too.” We definitely need donations, though eradication may not be just around the corner.

The Earth Day web page reports on the Democratic Republic of Congo‘s National Biodiversity Strategy and Action Plan. This includes – “project for the restoration and rehabilitation of the national parks, plans for the protection and rehabilitation of endangered species and ecosystems, development of the Zoological and Botanical Institute of Congo, program to fight the vectors of malaria, National Program for sustainable agriculture and the National Strategy on Biosafety.”

The New York Times has observed that at 40 year old, Earth Day has become ‘big big business. “While the momentum for the first Earth Day came from the grass roots, many corporations say that it is often the business community that now leads the way in environmental innovation — and they want to get their customers interested.”

The malaria control/elimination effort has certainly attracted major supporters from the corporate world and entertainment industry. It has also benefited from the Product Red efforts to turn commercial instincts toward funds for HIV, TB and malaria control, but Malaria Day has yet to become so commercialized.

Hopefully Malaria Day will maintain its focus on practical ways to help solve a problem by all partners – corporate, NGO, government and average world citizens, but at the same time attract enough attention to fill the large funding gap that remains.

RBM’s second report in the Progress and Impact Series provides us with the following data:

• Annual donor support for malaria control has increased dramatically (approximately 10-fold) between 2004 and 2009, estimated to have reached nearly $1.8 million in 2009
• Global production of ITNs has increased 5-fold since 2004, rising from 30 million to 150 million in 2009
• Six of the eleven countries with data collected in 2008 or 2009 showed >50% household ownership of nets, although the highest was 62%
• Averaging across 26 African countries (with 71% of <5 year child population), use of ITNs by children rose from 2% in 2000 to 22% in 2008

What do these figures tell us? First, money and commodities do not translate easily into indicators of success. Even household possession of the commodities does not guarantee use. And the best net coverage results achieved in 2008 or 2009 barely reach the RBM target of 60% for 2005, let along the 80% goal for 2010.

Some malaria community members have become cynical. “‘These are meaningless input measures that tell us only (the UN) is effective at spending other people’s money,’ said Philip Stevens, a health-policy expert at the London think-tank International Policy Network.”

C.Health also reports that, “Richard Tren, director of Africa Fighting Malaria, an Africa and US-based advocacy group, said measuring malaria spending and the numbers of drugs bought did not always mean more Africans had access to them.”

Obviously inputs are needed, but UNICEF reports that “available funds are still far short of the estimated $6 billion needed worldwide for effective malaria control in 2010.”

Partners are anxiously considering that the ‘Decade to Roll Back Malaria‘ comes to a close on 31 December 2010 and hope for success, but so far only Eritrea, Ethiopia, Equatorial Guinea’s Bioko island, Gambia, Ghana, Zambia, the Tanzanian island of Zanzibar and Sao Tome and Principe have scaled up malaria interventions and have observed marked reduction (30-95 percent) in morbidity and mortality indicators.

What can we expect from high burden countries like Nigeria and DRC where over a third of Africa’s malaria occurs? Nigeria is in the midst of distributing over 60 million LLINs, although there is still a gap of 9 million. Preliminary reports shared at a recent debriefing session on malaria progress in Abuja estimated that up to 25% of LLINs were ‘lost’ during distribution in one state.

Clearly nets produced for and acquired by countries is not the ultimate indicator we need to determine a decade’s success. We should not feel guilty about ‘spending other people’s money’ to eliminate malaria, but we should be accountable.

Readers have expressed concern about our recent look at embezzlement of Global Fund Grants.  The Lancet has now published a study that addresses what one might call ‘legal’ diversion of government funds away from health programs.

Lu and colleagues have examined development assistance for health (DAH) across countries and learned how it affects domestic government health spending. Their analysis showed two key findings

• DAH to government had a negative and significant effect on domestic government spending on health such that for every US$1 of DAH to government, government health expenditures from domestic resources were reduced by $0·43 (p=0) to $1·14 (p=0)
• DAH to the non-governmental sector had a positive and signifi cant eff ect on domestic government health spending

In response Sridhar and Woods express “worry that others will draw two rather crude conclusions,” that health funding should not be routed through governments, but rather it should go to NGOs. In defense of this position they offer some realistic limitations – accurate calculation of government expenditures and donor tendency to skew assistance through disease-specific programs.

Ooms and colleagues offer another reason to take the findings of Lu et al. with caution. They see examples of both increases (Rwanda) and decreases (Ethiopia) in government response to increased DAH and encourage us to try to understand what governments may be facing and plausible reasons for their thinking such as …

• Governments compensate for exceptional international generosity to the health sector by reallocating government funding to other sectors
• Governments anticipate long-term unreliability of international health aid by stalling possible increases of recurrent health expenditure, or
• Governments smooth aid by spreading aid across several years

Robert Davis, who provides an invaluable listserve drawing our attention to publications of child survival and health shared these Lancet pieces as well as another interesting article from 2007 on the role of DAH in immunization program achievements. Arevshatian and co-researchers documented that, “Rates of immunization coverage are improving dramatically in the WHO African Region. The huge increases in spending on immunization and the related improvements in programme performance are linked predominantly to increases in donor funding.”

Assuming that the global community shares goals of eliminating diseases like polio, onchocerciasis, and malaria, DAH is needed to address the scale of these endeavors. Governments of endemic countries, if left their own devices, may not have given the same elevated priorities to these diseases as do donors and experts elsewhere, but fortunately neither are they adverse to using assistance to help their people.

Considering the current economic climate where the Global Fund worries constantly about replenishment, countries are right to question whether DAH commitment is really there to back these grand schemes into the future. As we have asked recently, are malaria donors prepared for a second round of universal net coverage in the next three years given the likely durability problems of LLINs?

Here is the reality. In Nigerian states that had not benefited from the earlier rounds of Global Fund support one could rarely find ACTs in government clinics.  Local government budgets for essential drugs were meager, and decisions had to be made whether using a sizable chunk for these expensive drugs was advisable or even feasible. Now with greater expansion of coverage in Round 8 as well as pilot efforts for the Affordable Medicines Facility malaria (AMFm), it is finally looking like affordable ACTs may be accessible at the community level.

Right now our challenges or concerns are not to bemoan the shifting of local government funds away from malaria drugs (which they were not purchasing anyway). We need to build the capacity of all levels of the health system to manage the new resources in a way that lives are saved and the Millennium Development Goals of 2015 are achieved.

… unfortunately the nagging thought remains, will these financial commitments to DAH be sustained?

In Nigeria there is a saying – “government money for government people.” The average citizen does not expect government officials, elected, appointed or hired, to use public money for public good, just to enrich themselves. Hence, one hears much grumbling but very little in the way of protest or advocacy for greater accountability in public expenditure.

The situation appears to be the same in Uganda, but instead this time it is global money for government people and their friends. International inquiries and complaints aside, it appears to be business as usual with Global Fund grants in Kampala.

Malaria World has brought our attention back to the continuing saga of Global Fund mismanagement in Uganda. The story stretches back to 2005 when grants were suspended for improper use of funds for ‘consultants’ and ineffective drugs, according to the Daily Monitor. On Monday the Daily Monitor reported that …

From: Emily Johnston
Sent: Saturday, April 10, 2010 12:04 AM
To: Brieger, William
Subject: Malaria Matters was named a top 50 public health blog
Hello Dr. Brieger

I’m just writing this to let you know about a new featured post we just made over here at Health Sherpa entitled, “Top 50 Public Health Blogs.” I thought that both you and your readers at Malaria Matters might find it to be an interesting article.

Please do let me know if you have any feedback — http://mastersofpublichealth.org/top-50-public-health-blogs.html

Malaria Matters: Bill Brieger is currently a Professor in the Health Systems Program of the Department of International Health at Johns Hopkins University as well as the Senior Malaria Adviser for JHPIEGO.

Warm Regards,
Emily Johnston
Health Sherpa

Rwanda has been commended for progress made toward eliminating malaria. Just to the south, Burundi appears to be experiencing an upsurge of the disease. Can it be contained?

MSF reports that, “Burundi has been grappling with a serious increase of malaria patients since the start of the year. The MSF teams have been cooperating with Burundi authorities to fight the spread of the disease by treating patients and distributing mosquito nets to prevent new infections.”

Fortunately the Canadian Red Cross has been working in Burundi distributing bednets, but donor support for malaria control in Burundi has not kept up with that of Rwanda.
Rwanda with a population of 9.2 million, has benefited much more from international donor support. Rwanda is in its fifth year of funding from the US President’s Malaria Initiative  and has received Global Fund malaria grants three times of which $109.5 million has been disbursed and another $100 million is in the pipeline.
Burundi with a population of 7.8 million, has just begun to receive attention from USAID’s malaria efforts. Of a current $53 million Global Fund Malaria grant, Burundi has received $17 million. A new Round 9 grant for $60 million has yet to be signed.

Burundi’s Road Map to 2010 shows a gap of 2.5 million long lasting insecticide-treated nets, and nearly half a million doses of artemisinin-based combination therapy drugs. Rwanda has no gap in these commodities.

When moving toward malaria elimination, we need to plan on a regional basis, not just country by country. Neither infected mosquitoes more humans bearing malaria parasites respect borders. Countries may need to be their brother’s keeper in order to protect the gains they have made.

Fortunately the Southern African Development Community‘s malaria elimination strategy enshrines this philosophy of mutual help among neighbors.  Other regions should follow suit.