Tropical Health Matters

Because Akwa Ibom State is one of the seven States involved in the World Bank Malaria Booster Program in Nigeria, the Bank became aware of Jhpiego’s ExxonMobil Foundation supported work in Community Directed Interventions (CDI) to improve coverage of malaria services in seven local government areas in the State.

CDI was pioneered by the African Program for Onchocerciasis Control with Ivermectin and in the past 15 years has reached over 100,000 villages in Africa. CDI places responsibility for distribution of basic health commodities in the hands of community members who made decisions on distribution mechanism and timing and selection of volunteer community directed distributors (CDDs). The value of CDI beyond onchocerciasis control was proven through a 3-year, 7-country study sponsored by the Tropical Disease Research Program of UNDP/World Bank/UNICEF/WHO.

The World Bank included CDI as a key strategy for the additional funding provided to its seven Nigerian states.  To enable these states to deliver malaria services through CDI, the Bank encouraged the National Malaria Control Program (NMCP), one of the managers of the Booster Funds, to contract Jhpiego to provide CDI training for teams from the seven Booster states.

Two 5-day CDI took place between 22 November and 3 December 2010.  Participants included staff from each States’ Malaria Control Programs and Ministries of Health along with representatives of NGOs and consultants contracted by the states to help them implement CDI.  The Workshop was delivered in 11 main sessions as follows:

1. Overview and Objectives for Workshop on Implementing Community Directed Interventions
2. The Value of Community Involvement
3. Community Structure Networks & Organization
4. The CDI Process; Roles of Partners & Focal Persons
5. Applying CDI to Home Management of Malaria; Sample CDD Lesson on CCM/HMM
6. Applying CDI to LLINs and Vector Management
7. Applying CDI to Controlling Malaria in Pregnancy
8. Record Keeping and Reporting (M&E)
9. Supply Chain Management for CDI
10. Applying CDI to Deliver Malaria Plus Packages
11. Follow-up Activity Planning

Trainers included Bill Brieger, Jhpiego Senior Malaria Specialist; Dipo Otolorin, Jhpiego Nigeria Country Director; Bright Orji, Jhpiego Program Officer for Akwa Ibom State; Gbenga Ishola, Jhpiego M&E Officer, Nigeria; Oyedunni Arologun, Department of Health Promotion and Education, University of Ibadan; and Godwin Ntadom, National Malaria Control Program.

A total of 42 participants attended from Akwa Ibom, Anambra, Bauchi, Gombe, Jigawa, Kano, and Rivers states and 8 from the NMCP. They took part in role plays, crafting educational songs, producing sample CDD lessons and developing follow-up action plans. The NMCP will now follow-up with these states to ensure that CDI training is rolled out to the local governments, the primary health care facilities (PHCs) and ultimately the small villages, settlements, clans and hamlets in the catchment areas of PHCs. In this way prompt and appropriate malaria treatment can reach people within 24 hours and all recipients of recently distributed insecticide treated nets will hang and use them to prevent the disease.

During a recent malaria diagnostics assessment to Burkina Faso, we found health workers who were concerned that malaria rapid diagnostic tests showed fewer positive results in the dry season even though they often suspected that their patients had malaria. The big challenge for health workers is accepting the fact that even when they use clinical algorithms, not all febrile illnesses that they suspect to be malaria are actually malaria.

The dry season in the African Sahel is the period for epidemics of meningitis. Seasonal epidemics of meningitis kill thousands in Africa every year.

According to CDC “Meningitis infection is characterized by a sudden onset of fever, headache, and stiff neck.” These are similar to early malaria symptoms, but in addition CDC says that people with meningitis may experience nausea, vomiting, photophobia (sensitivity to light), altered mental status.

BBC reports that, “For the people in Niger, Mali and Burkina Faso, a new meningitis vaccine offers hope of an escape from one of the world’s deadliest, most disabling and infectious diseases. So there is little wonder that the queues were enormous when a pilot project for the MenAfriVac vaccine got underway in the three West African countries in recent weeks.”

This vaccine was developed specially for Africa and costs around 50 US cents per dose and should be effective for 10-15 years. Meningitis A is “caused by the bacterium Neisseria meningitidis group A, which mostly attacks infants, children, and young adults. It accounts for ninety per cent of all meningitis epidemics in Africa. The outbreaks strike during the dry season. In 1997, in the worst epidemic on record, 25,000 people died,” as reported by the BBC.

As with other public health interventions, scaling up of this new vaccine will be on overcoming dependent on logistical challenges, in this case the need for sustained funding. As noted, the effort will being in only 3 countries, but “450 million people … are at risk of this disease … in the very well known African meningitis belt.”

Preventing meningitis in Africa will not only save lives directly, but should reduce the chances that a febrile child is misdiagnosed as having malaria and allowed to die from another disease.

Widespread efforts to scale up insecticide treated net ownership to meet 2010 Universal Coverage targets are underway in most endemic countries of Africa.  The majority have been using their Global Fund grants to make this leap, supplemented by contributions of other partners.

What happens when a country does not have Global Fund resources at this time? Current efforts in Sierra Leone to reach its nearly 6 million citizens provide a lesson on how to cope.

The AFP has reported on a “20-million-dollar campaign to distribute mosquito nets has been funded by the World Bank, the British Department for International Development (DFID), the Federation of the International Red Cross, the United Methodist Church and other health partners.” These partners are “attempting to get insecticide-treated mosquito nets into each household in the country and to ensure their proper use,” using a house-to-house campaign, which is challenged by poor road conditions.

VOA quotes Lianne Kuppens of Unicef in Sierra Leone who said, “”We have roughly 6 million people and we have 3.2 million bed nets already in the country as we speak. So it’s the first time ever that we are going for universal coverage of bed nets.”

Kuppens also noted that ITN use by children below 5 years of age was below 25%, a problem exacerbated by net mis-use – “nets often find their way into the marketplace or are used as fishing nets or shower scrubs. Vegetable growers use mosquito nets to protect cabbages and carrots from harmful bugs.”

VOA also reports that the campaign has a strong “hang up” component that is using “Street theatre, community radio and religious leaders (to) help convince people that hanging their nets over their beds is better in the long run than selling them or catching fish with them.”

But back to the Global Fund …

Sierra Leone’s experience with the Global Fund (GF) may certainly be influenced by its status as a post-conflict country.  The Principal Recipient of the current Round 7 Grant, the Ministry of Health, has, according to GF progress reports, experienced some management challenges.

The Round 7 grant has been running for 2 years and just recently received a “conditional Go” for Phase 2 funding.  ITNs were a small piece of this grant that aimed more at improving malaria treatment.  By 30th April 2010 the grant had distributed only 277,093 of a targeted 312,498 nets for young children and pregnant women.

While the GF does not attempt to strengthen health systems directly, it certainly makes it possible for countries to use grants for their own health system strengthening efforts. More countries should take advantage of this potential. In the meantime, partners should continue to pull together as is the case in Sierra Leone to ensure Universal Coverage.

2010 is winding up as a year of natural disasters.  The scope of some, like the floods in Pakistan, lead people to ponder the effects of global warming. When the disasters are located in malaria endemic areas, malaria itself may be a second disaster in the making.

There was much talk about the potential epidemics of malaria after the Haiti earthquake – people living unprotected in tent cities as water pooled around these as the rainy season approached and eventually Hurricane Tomas provided a knock-out punch.  CDC documented that malaria transmission was clearly going on in the early post-quake days, but, few reports were coming out during the rainy periods.

Some preventive malaria measures for Haiti, like introduction of larvivorous fish, were reported, but the headlines have been grabbed over the past couple months by a more visibly deadly disease – cholera. Some of the same problems of displacement, poor environmental conditions, including the poor housing situation, have put Haitians at risk for both cholera and malaria, and the end is not in sight.

Floods this year in the African Sahel and Pakistan have also displaced populations and created greater breeding opportunities for mosquitoes thereby, increasing the number of cases among people already adversely affected by the floods. These situations demonstrate the challenges of weak heath systems that find it hard to respond to malaria made weaker or even destroyed by natural disasters. For example IRIN reported that even prior to the floods Pakistan’s national malaria strategy implementation was lagging.

WHO makes it clear that not all disasters that lead to malaria outbreaks are ‘natural’…

Malaria epidemics kill more than 100 000 people of all ages every year and up to 30% of malaria deaths in Africa occur in the wake of war, local violence or other emergencies.

An effective emergency response, according to WHO, involves some of the key elements needed to deliver malaria services during normal times: 1) coordination among partners, 2) accurate and timely assessment, 3) planning, 4) implementation and 5) monitoring and evaluation. The difference in an emergency is the timescale. The health systems concerns here are that if these steps have not been taken in ‘normal’ times, the impact of malaria in an emergency will be harder on the population.

Efforts to strengthen health systems therefore, should have a beneficial impact in the event of emergencies – if trained staff are in deployed, procurement and supply chains deliver commodities and feedback mechanisms are in place to enhance future planning, people may have a better chance of surviving from malaria during the next disaster

This month marks the 4th year for Malaria Matters and our 500th posting. Two of our first postings we examined what happens to chloroquine when it is no longer used as a first line drug,and how malaria proposals fare at the Global Fund.

Chloroquine was valued because it was inexpensive and therefore justifiably used for presumptive treatment. Resistance showed not only that the presumptive treatment approach was likely flawed, but that single drug or mono-therapy treatments were not appropriate. Research today continues to document the spread of chloroquine resistance for example, in vivax and falciparum malaria in Indonesia.

What our 2006 posting addresses was the fact that chloroquine resistance did reduce after the drug is withdrawn as the front line treatment in Malawi. These findings were backed up by a study from Kenya published last year. The Kenya researchers reported “a reduction in resistance to CQ following official withdrawal in 1999 was found, but unlike Malawi, the decline of resistance to CQ in Kilifi was much slower,”ultimately taking twice as long as it did in Malawi – assuming use remains at a low level.

The practical research question moving into the future toward malaria elimination is whether an inexpensive drug like chloroquine can ever again find a place in the pharmacological arsenal against malaria. The experiences of both increasing and reducing drug efficacy also stress the importance of maintaining strong pharmaco-vigilence as part of any national malaria control effort.

Concerning the Global Fund we expressed disappointment in 2006 that malaria grants performed so poorly in Round 6 allocations in terms of relative proportion of total grants as well as proportion of submitted grants approved. Since that time the Roll Back Malaria Harmonization Working Group has mobilized human resources to strengthen the grant writing process. Since that time malaria grants have been gaining a greater share of total resources and have had better success in being approved.

According to AIDSPAN, this year’s Round 10 allocations may be a mixed bag for malaria. While 79% of submitted malaria proposals were recommended for approval (better than the 50% overall approval rate), only a small number of proposals were submitted (24) and ultimately approved (19) of the 89 from all sources.

This low ‘turnout’ may reflect the economic constraints at the Global Fund where there had even been some doubt earlier that a Round 10 would be issued, but it reflects poorly on the need to scale up and sustain malaria interventions into 2015 and beyond. This also does not reflect changes in Global Fund approaches such as the rolling continuation credit and the potential move toward funding based on national strategy, all of which are changes at the GFATM since 2006.

Overall once can see that in four short years the funding and technical landscape surrounding the control and elimination of malaria are changing quickly. We are closer now to a vaccine, WHO has updated its malaria treatment guidelines, long awaited rapid diagnostics tests are rolling out in larger quantities, and countries, such as those in southern Africa, that need to develop pre-elimination strategies are being identified. We intend that Malaria Matters will help you keep up with these vital changes.

In SciDec.net we read that, “Cuba has announced plans to build biolarvicide factories in Brazil and several African countries in a bid to tackle malaria and dengue fever.” The move is based on apparent successes of efforts such as those in Angola where the Director-general of Labiofam says that, “Angola, for instance, has reduced malaria incidence by 50 per cent, and some areas have seen a 70 per cent fall,” with similar results in Accra, Ghana.

WHO says that larviciding is “indicated only for vectors which tend to breed in permanent or semi-permanent water bodies that can be identified and treated, and where the density of the human population to be protected is sufficiently high to justify the treatment with relatively short cycles of all breeding places.” What actual documented evidence is there from Angola and elsewhere in Africa about the use and effectiveness of larviciding?

An article on the history of malaria control in Liberia reviews early efforts to use synthetic insecticides for indoor residual spraying and larviciding.  Unfortunately, “These projects encountered a spate of difficulties that foreshadowed the general retreat from malaria eradication efforts across tropical Africa by the mid-1960s.” What has changed now that we are in the days of rolling back malaria?

A newly published article on mosquito larval source management in areas experiencing flooding in The Gambia concluded that …

The intervention was associated with a reduction in habitats with late stage anopheline larvae and an 88% reduction in larval densities. The effect of the intervention on mosquito densities was not pronounced and was confounded by the distance of villages to the major breeding sites and year. There was no reduction in clinical malaria or anemia. Ground applications of non-residual larvicides with simple equipment are not effective in riverine areas with extensive flooding, where many habitats are poorly demarcated, highly mobile, and inaccessible on foot.

A key approach to the use of larvicides may be integrated vector management, where there is not reliance on one control measure alone. In the Kenyan highlands researchers found that, “Vector control with microbial larvicides enhanced the malaria control achieved with ITNs alone. Anti-larval measures are a promising complement to ITN distribution in the economically important highland areas and similar transmission settings in Africa.”

Larviciding was found to have a positive effect in reducing childhood malaria in Tanzania where “larviciding reduced malaria prevalence and complemented existing protection provided by insecticide-treated nets. Larviciding may represent a useful option for integrated vector management in Africa, particularly in its rapidly growing urban centres.”

The two promising articles from Kenya and Tanzania would be strengthened if large scale operations like those described for Angola were better documented and published because as was seen in Liberia many years ago it was the basic operational issues that limited program effectiveness.

Devine and Killeen report in discuss some of the practical issues of larviciding in Malaria Journal and note that, “The effective operational implementation of these campaigns is difficult, time consuming, and expensive,” in part because of “The myriad and cryptic nature of aquatic habitats and the difficulty in identifying and targeting the most productive of these (which) makes maximizing that impact very challenging.”

Devine and Killeen recommend a “new auto-dissemination methodology” based on a “detailed characterization of oviposition behaviour and of the effective transfer distances between feeding, resting and aquatic resources.” Again, these are good ideas, but what of evaluation of current large scale approaches underway? In addition, as RTI suggests programs must establish “baseline information on the acute, intermediate, and chronic effects of chemicals used in malaria vector control on workers and the general population.”

The basic question remains – what can we learn about the right conditions for larvicide use as a major tool in integrated vector management for malaria? All partners in rolling back malaria have a responsibility for helping this learning process by documenting and publishing their experiences. Maybe the proceedings of the recent Labiofam Conference in Havana will be published soon.

Two news stories today remind us that low and middle income countries (LIMCs) not only continue to suffer from infectious diseases like malaria, but that they are also burdened with chronic health problems arising from ‘western lifestyle’ behaviors like smoking and over-eating.

The New York Times describes efforts of cigarette companies, not only to promote use of tobacco products, but also to intimidate through lawsuits LMICs who try to control tobacco advertising and sales. Specifically …

Companies like Philip Morris International and British American Tobacco are contesting limits on ads in Britain, bigger health warnings in South America and higher cigarette taxes in the Philippines and Mexico. They are also spending billions on lobbying and marketing campaigns in Africa and Asia, and in one case provided undisclosed financing for TV commercials in Australia.

A Lancet article reported in the BBC documents how adult obesity in Brazil, Mexico and South Africa are above the average for Organization for Economic Co-operation and Development (OECD) countries. Recommendations to reverse these trends include “media campaigns promoting healthier lifestyles, taxes and subsidies to improve diets, tighter government regulation of food labeling and restrictions on food advertising.”

We have here an intersection among the public, the private and the personal. Although individuals can make personal choices and public health organizations can provide health education, the private sector can use their disproportionately enormous financial resources to advertise unhealthy behaviors and threaten in court those who oppose their efforts against health. Statements by agencies like the World Health Organization (WHO) may have a relatively smaller effect here.

The balance seems completely different when it comes to malaria. All partners appear to promoting the same healthy agenda – use of Long Lasting Insecticide-treated Nets and prompt treatment with appropriate antimalarial drugs to name a two key behaviors. The role of WHO is stronger in determining what are appropriate malaria commodities including its pre-qualification of medicines and the WHOPES evaluation scheme for reviewing insecticides.

These WHO processes influence the bulk of purchases for major international donors and national malaria control programs. This is not to say that “unqualified”, substandard or counterfeit malaria drugs don’t make it into the markets of developing countries, but the legal framework is more likely to work against such unhealthy schemes.

Hopefully the malaria partnership that promotes healthy behaviors will continue, resulting in reduced mortality among vulnerable groups such as young children.  It would be a shame for these efforts to reduce infant and child mortality were overshadowed by forces that threaten the lifespan in later years from obesity and tobacco induced cancers and coronary problems.

November 11th is Veteran’s Day in the United States. Over the years soldiers have been vulnerable to malaria. During the U.S. Civil War 150 years ago over 14,000 Union troops are estimated to have died from malaria. While death estimates were not available for the Confederates, it was thought that over 40,000 malaria cases occurred in an 18-month period in the middle of the war.

Today places like Afghanistan and the Horn of Africa pose a malaria threat to troops, so there is malaria prophylaxis for soldiers. Sometimes the prevention itself poses problems. “The Army has dropped Lariam — the drug linked to side effects including suicidal tendencies, anxiety, aggression and paranoia,” and now prefers doxycycline for people who may react to mefloquine.

The military takes malaria seriously now. The Walter Reed Army Institute of Research (WRAIR) puts a priority on malaria research since, “Malaria remains highly relevant to the military because of its prevalence, variety (there are four species that infect humans), debilitating nature, potential lethality, and tendency to become resistant to drugs. No organization in the world has WRAIR’s experience in the complete spectrum of malaria research.”

WRAIR’s “Work on a vaccine is also progressing. Advanced molecular, genetic, and biomedical technologies are now being employed to produce candidate malaria vaccines. Field trials of these candidate pharmaceuticals are an essential part of the program and are underway in Thailand and Kenya.”

The military of all nations are at risk when they serve in malaria endemic areas. For example, a Philippine soldier “succumbed to malaria on 23 October 2008 while serving as a military observer with the U.N. Mission in Sudan.”

Another concern of malaria in the military is the potential for soldiers who contract malaria for spreading it to other countries or bringing it home. It was reported that Soviet soldiers serving in Afghanistan some years ago brought the disease back to republics in the Caucasus and Central Asia. Though this particular spread could be controlled, not all situations may be so fortunate.

Today a variety of injury and mental health problems may overwhelm the effects of malaria on soldiers. Still, soldiers are at risk. For example in 2002, “38 cases of malaria were identifiedin a 725-man Ranger Task Force that deployed to eastern Afghanistan.” Also over a 6-year span the Defense Medical Surveillance System reported 423 cases of malaria including Plasmodium vivax, P. falciparum, P. ovale, and P. malaria. A big challenge is the inability of health systems in non-endemic countries to treat and save lives of soldiers who return home with the disease.

There are basically two lessons from this issue. First malaria control must recognize that soldiers who may not be immune when they enter a malaria endemic war zone are at risk of malaria death. Secondly, as a mobile population soldiers have the potential for reintroducing malaria to areas where it may have been eliminated. War kills people; malaria kills people – when soldiers are infected a double dose of death potentially occurs

The East African today noted that, “Every African business in malaria endemic areas knows all about high absenteeism during the malaria season.” This opinion article goes further to state that, “Health spending cripples African consumers and governments, the tax base struggles to expand and foreign investment is discouraged by high rates of illness among workers,” referring to HIV, TB and malaria.

The solution according to the East African is, “For the African private sector to maximise these returns, awareness must be raised of effective practices in engaging health, and the benefits of partnership towards this end … Using established multilaterals like the Global Fund is an effective way for the private sector to engage health goals while maintaining business focus.”

While these are good sentiments, in reality of private or non-governmental contributions to the Global Fund have been minimal. Currently private pledges to date account for 4.4% of the total pledges ($29,928,488,771) to the Global Fund and a slightly higher 5.0% of the total paid ($18,146,056,176). One donor, the Bill and Melinda Gates Foundation, provided around three-quarters of this support.

The next largest private sources are the Product Red Campaign, which has paid 17.4% of the total private contribution, UNITAID (4.3%) and the Chevron Corporation (3.3%). These Global Fund contributions do not measure the total private contribution of global disease control, which includes, according to the Global Fund …

• Marketing campaigns and financial contributions
• Pro bono services and core competency partnerships
• Support for advocacy and governance, globally and locally
• In-country co-investments and operational contributions

The private sector is an identified constituency of the Roll Back Malaria Partners Forum. According to RBM the contributions of the private sector are as follows:

• First, the private sector possesses a breadth of expertise and implementation skills – including delivering products and programmes in the developing world.
• Second, the private sector has a particularly important role to play in ensuring the supply and efficient distribution of drugs, diagnostics, LLIN’s and other interventions against malaria.
• Finally, the private sector can bring the “business mindset” to the RBM Partnership, with its emphasis on good management practices and tangible results.

Clearly such contributions are not limited to financial ones and address in kind provision of expertise.The list also does not clearly identify individual focused efforts such as the Obuasi IRS program of AngloGold Ashanti, ITN donations from the telecommunications company MTN, or support from corporations like ExxonMobil to bilateral programs like the US President’s Malaria Initiative.

But back to the East African … are these contributions commensurate with economic benefits that can accrue from the major internationally and bilaterally funded efforts to control malaria? The answer probably comes down to the country level.  Private sector partners need to participate actively in each national RBM partnership forum so that their presence, expertise and of course financial help, can be felt.

PS:

Two news stories in the Washington Post shed further light on the issue. The first shows the need for increased private giving because foreign aid may be in doubt … “even the administration’s ability to provide direct climate assistance to poor nations over the next two years is in doubt because a looming budget battle with Republicans could freeze U.S. foreign aid at this year’s levels, or even cut it.”

The second highlights private sector philanthropy in other countries. “As India’s wealth continues to expand, a growing number of millionaires here are finding ways to do more for the poor, especially as cash-strapped foreign donors, including the United States, curtail aid.” Major religions in India may play a role in encouraging charity. “Indian billionaires give more than billionaires in China but less than those in developed countries, including the United States.”