Posts or Comments 20 July 2024

Monthly Archive for "February 2011"

Community &Partnership Bill Brieger | 25 Feb 2011

Promoting world peace – controlling malaria

the United States Peace Corps is celebrating its 50th anniversary this year.  Volunteers have been working in malaria endemic countries since the beginning of the program. Here we will share a few recent Peace Corps malaria activities. We encourage current and former volunteers to share with us their experiences and lessons learned in controlling malaria.

peacecorps_gov.jpgIn Zambia the Peace Corps has partnered with a local NGO called Youth Activists Organization to bring advocacy messages and educational materials to the community level. Peace Corps Senegal reports that …

Peace Corps Volunteers in all regions of Senegal are leading efforts to prevent malaria, the leading cause of child mortality in Senegal. Volunteers are providing malaria prevention education and have led insecticide treated mosquito bed nets distribution campaigns that have become a model for the rest of Senegal. These efforts are leading to the first large scale universal bed net coverage in the history of Senegal, aiming to significantly reduce malaria caused disease and deaths.

Individual volunteers have written about their experiences, as seen in the following account from Senegal

I worked with three phenomenal community health workers to organize and distribute nets to every family. In the weeks leading up to the distribution, we surveyed all of the families, counting their sleeping areas and numbers of nets in good repair. Working over three days, we traveled house-to-house distributing nets. The chief of Goudel Comi was overcome with gratitude. 

Peace Corps volunteers have even been the subjects in malaria research. One study examined self-reported adverse events associated with long term antimalarial chemoprophylaxis in over 1700 Peace Corps Volunteers. Another study monitored mefloquine resistance in Peace Corps Volunteers.

The Peace Corps even enters into classrooms in U.S. schools from grades K-12 to offer curricular ideas and share experiences from the field. Students can simulate the role of a Peace Corps Volunteer working to prevent the spread of the disease.

The success of malaria control ultimately rests in and with the community. Peace Corps Volunteers are strategically placed to help make sure this happens.

Social Factors &Treatment Bill Brieger | 23 Feb 2011

Ask and ye shall receive – though not always a valid answer

child-interview-2-sm.jpgObinna Onwujekwe and colleagues have documented a major problems with health seeking behavior surveys – people do not always give valid responses. This is not to say that people lie, but the interview situation can be a complex social interaction in which things are not always as they seem. In Onwujekwe’s study while respondents indicated that their preferred source of care for malaria illness were public and private clinics, their main actual source of care for recent malaria episodes were the patent medicine dealers.

Perceptions of what are ideal and expected behaviors often differ from what people actually do. For example with guinea worm 75% of residents in rural southwestern Nigeria said that clinics offered the best treatment for the disease. Examination of clinic records during the same time found that only about 3% of actual sufferers attended a clinic.

When asked why, villagers complained that guinea worm could not be cured with western medicine and that treatment which included bandaging the open ulcer agnered the worm and made the disease worse. In fact a fair number of people who were treated at clinic actually attended for another reason, and the health worker just happened to notice the guinea worm ulcer.

Another issue is gender. in Onwujekwe’s survey a majority of the respondents were female. Women in health surveys have been found to give ‘don’t know’ responses more often than men. The interview is a formal social situation with a visitor to the home. Sometimes women may not feel comfortable giving opinions on behalf of their households.

The key lesson from these experiences is that while we urgently need data on whether people are actually gaining universal access to malaria treatment services, we need to take caution in how we approach interviewees and how they believe they should answer us. Interview techniques that set people at ease and find several different ays to ask the same question about treatment choices can help improve data collection. Only with valid responses, will we learn if our services are reaching people and where improvements are needed.

Drug Quality &Treatment Bill Brieger | 22 Feb 2011

Tea Time – Artemisia annua in a bag

malaria-tea-sm.jpgRecently in a small provisions shop in Abuja I bought a box of ‘Anti Malarial Tea’ bags. The 20 bags/sachets weighed 2 grams each. The instructions were to use “3 times daily, one bag each time.” The only ingredient listed was “Herba artemisiae annuae.”

Indications for the use of this dried herb product were as follows: “The Product can be used to eliminate plasmodium agamous body. It can also be used to control symptom and kill plasmodium. It has similar effect on resist virulent chloroquine malarias.”

The manufacturing date was blank, but the espiry date was listed as ‘2014.’ Storage was recommended as “Store in shade, light-avoided and airproofed.” In fact the tea bags were sealed in a silver colored bag.

This product was obviously not moving fast, and there was little likelihood that it was competing with orthodox antimalarial drugs. Still one might be concerned about monotherapy and drug resistance.

A recent article in the journal Molecules did address the potency of artemisia annua in different forms of extraction. The researchers found that …

the ancient Chinese methods that involved either soaking, (followed by wringing) or pounding, (followed by squeezing) the fresh herb are more effective in producing artemisinin-rich extracts than the usual current method of preparing herbal teas from the dried herb. The concentrations of artemisinin in the extracts was up to 20-fold higher than that in a herbal tea prepared from the dried herb, but the amount of total artemisinin extracted by the Chinese methods was much less than that removed in the herbal tea. While both extracts exhibited potent in vitro activities against Plasmodium falciparum, only the pounded juice contained sufficient artemisinin to suppress parasitaemia in P. berghei infected mice.

Here again one wonders if using the dried herb as tea would contribute to parasite resistance.  Another group of researchers tested the tea on malaria in mice and found that, “The tea does not decrease the parasitaemia fast enough.”

Herbal medicines form the base for many remedies throughout the world. Although a website for the actual company named on the box, Xiamen Jianxi Health Product Co., Ltd., was not found, another site listed 70 different teas including –

  • Eye Bright Tea
  • Kidney & Liver Mind/Care/Flush Tea
  • Anti-Hypertensive Tea
  • Anti Malarial Tea
  • Refreshment & Heat Clearing Tea
  • Cough Sputum Removing Tea
  • Stomach & Heart Burn Relieving Tea

In our quest for universal access to and appropriate use of ACTs, we forget that people still have many treatment alternatives.  Until we can make quality ACTs cheaply and easily available in endemic countries, people who suspect they have malaria will make all efforts – whether teas, antibiotics, analgesics, inefficacious malaria drugs and the like – to address their problems.

Advocacy &Migration &Surveillance Bill Brieger | 21 Feb 2011

Football: Malaria Awareness or Malaria Vector

With the 2010 World Cup taking place in Africa, a great opportunity became available to highlight health and development issues on the continent. One of those issues was malaria and the message was carried by a consortium of groups who formed United Against Malaria.

largefootballcharles-sm.jpgUAM has continued its efforts to advocate for malaria elimination beyond the World Cup. Late last year five CECAFA national teams joined UAM during the CECAFA Tusker Cup in Dar es Salaam, Tanzania, from late November into December. The Ghana Football Association, as one example, featured its players in television documentaries about the devastating effects of the disease.

The very nature of competition among football clubs and associations requires travel within a country and among countries.  A news story out of Jamaica (which was declared malaria-free in 1966) yesterday highlights that football can also ‘transmit’ malaria between countries …

The Jamaican Ministry of Health has reported the confirmation of three cases of malaria among players of the Haitian under-17 football team who are in Jamaica to play in the CONCACAFUnder-17 championship in Montego Bay. The Haitian players are being treated. According to the Jamaica Observer, The Ministry of Health has recommended that in the circumstances they do not participate in the tournament and therefore return to Haiti. These arrangements are presently being made. The Ministry of Health has implemented mosquito control measures and a surveillance system to try to quickly identify any new cases.

Malaria truly has no borders, as stressed on World Malaria Day in 2008. Living on an island does not protect when both people and mosquitoes can travel.  Places like Jamaica and Mauritius need to be constantly vigilant – it is not just the high burden countries that need to worry about whether we can reach malaria elimination.

This is not Jamaica’s first brush with the risk of reintroduction of malaria. An upcoming Tropical Medicine and International Health article reported that in 2006 Jamaica successfully controlled an outbreak of Plasmodium falciparum with 406 confirmed cases. The outbreak highlighted the need for increased institutional capacity for surveillance, confirmation and treatment of malaria as well as effective prevention and control of outbreaks which can occur after elimination. Jamaica appears to have successfully eliminated malaria after its reintroduction.

The West Indian Medical Journal reminds us that, “All the essential malaria transmission conditions–vector, imported malaria organism and susceptible human host–now exist in most” Caribbean countries, this re-emphasizing the need for constant surveillance. The added saddness in the current story is that not only does Haiti continue to suffer from the devastation of last year’s earthquake, but itself has been the ‘victim’ of imported disease – cholera.

As long as people, including football teams and UN Peacekeepers, continue to move around the globe, the difficulty of eliminating diseases like malaria will remain. The lack of current cases of malaria in a country is not justification for complacency, especially if the environmental and vector conditions for transmission persist.

Mosquitoes &Surveillance Bill Brieger | 05 Feb 2011

The great outdoors … for mosquitoes

The press has had a field day over the publication of data in Science that identifies a new population subgroup of the African malaria vector Anopheles gambiae. The mosquito variant in adult form is hard to catch and in the laboratory, very susceptible to malaria infection.

The authors clearly point out that there is no evidence yet that the GOUNDRY mosquito, named after a village in Burkina Faso where the researchers worked, is highly attracted to humans. The press has rounded up experts like William Black, a medical entomologist at Colorado State University to speculate on the matter. Black was quoted in the LA Times thus …

“We’ve got egg on our face. We’ve been working with this mosquito for so long … and right under our noses, here’s this other form of mosquito,” he said — one that could force researchers “to start thinking about what’s going on outside of those huts.”

Again Science itself accurately headlines an editorial on the article by saying that these findings could have ‘unexpected’ results.

Because the new mosquitoes were found in the same larval pool collections and were genetically indistinguishable from indoor-resting adult mosquitoes, the options for control point to larviciding should ‘Goundry’ prove a threat to humans.  This is a challenging control measure as not all larval pools are easily visible and in fact may be multitudinous. Of course prompt and appropriate treatment and IPTp have to be part of the mix, despite health systems weaknesses in delivering medicines that may be more of a threat right now than the mosquitoes.

The key lesson is not that an immediate, previously unknown threat lurks outside our huts, but that nature and malaria can continue to surprise us.  We have surveillance in Southeast Asia for parasite resistance and the growing potential for human-primate malaria transmission, to name a few of the upcoming challenges to eliminating this ancient disease. Vigilence is the key.

Communication &Treatment Bill Brieger | 04 Feb 2011

Hawking Malaria

In wondering whether Nigeria’s health system is non-existent, Seyi Abimbola suggested that, “It is safe to assume that every country has a health system, no matter how dysfunctional.”  Seyi also addresses the potential role of patent medicine vendors whose neighborhood shops have become ‘trusted’ institutions.  But let’s take this one step further beyond the shop.

The other evening after food, I was sitting with friends out on an Abuja back street having drinks when a man came buy with a straw tray on his head selling medicines.  These ‘drug hawkers’ specialize in what the Yoruba term pa’se po, a combination of pills and capsules, often sold in a small clear nylon bag that taken at once should relieve one of a particular ailment. Some actually say this mix that literally ‘combines or brings together the work of all’ can be formulated to treat all kinds of diseases in one. Colorful mixes of analgesics, antibiotics and even valium have been common.

One person at a nearby table began to explain his aches and pains and was given a mix of pain killers and vitamins.  I called the guy over and asked what he had for malaria and was given the mix pictured here – sulphadoxine-pyrimethamine, paracetamol and big multi-vitamin caplet.  These two mixes cost only 100 Naira (about 67 US cents) each.  Like many, this man had mixtures for both chronic and infectious illnesses.

pasepo-2sm.jpgThis hawker was a bit more sophistocated than most in that he sold the medicines still in their blister pack, and the malaria medicine, though no longer approved as a treatment in Nigeria, at least was not expired.  Of course when he walks around the neighbourhoods during the day, the tray on his head is explosed to the sun!

Nigeria has long fought a battle against illegal sales of medicines, which often include fake or expired drugs. For example in 2007 the Federal Government “called for sanctions to be to put in place against persons who engage in unauthorised distribution, sale and dispensing of medicine or controlled substances.” While this article bemoaned the fact that, “Nigeria is one of the few developing countries in the world where medicines of all categories are sold in open market stalls, roadside kiosks, peddled in buses and hawked in basket along the streets,” the press from other countries also carry such stories as seen below from The Gambia

“… it is still a common practice for some people who have taken the sales of these drugs as a livelihood. This is no doubt a dreadful act and should be discouraged. It is sad to not e that the people who are hawking these drugs don’t even know the essence of the drugs, their indication, dosage, side effects or even their contra-indications. They just carry them in a transparent plastic bag and move with them from place to place particularly around the ferry crossing terminals.”

Efforts to bring down the cost of appropriate and approved malaria medicines such as those by the Clinton Foundation and the Global Fund’s new Affordable Medicines Facility for malaria, may not compete with the convenience and price of the drug hawkers. More regulation in a non-existent system will not do the trick. Maybe a more clever market-oriented consumer education approach would help? Let’s hawk ideas not expired medicines.

Community &Malaria in Pregnancy Bill Brieger | 02 Feb 2011

One person can have an impact on malaria in pregnancy services

atiamkpat-community-2-nets-sm.jpgUduak, a community directed distributor (CDD) for Jhpiego’s malaria in pregnancy (MIP) prevention program in Akwa Ibom State, Nigeria, was involved with pregnant women long before the MIP program started in 2008. She normally works as a traditional birth attendant attached to one of the churches in Atiamkpat community in Onna Local Government Area (LGA).

So, when Jhpiego introduced the ExxonMobil Foundation funded program that required volunteers selected by the community members to deliver MIP services, Uduak volunteered along with 38 other women to serve the villages and kin groups in the catchment area of Atiamkpat Clinic. On their part, the community leaders were happy that she volunteered because, “Uduak has been resourceful in the past and always committed in whatever assignment given to her”

Jhpiego had formed a state training team, which trained LGA health team members who in turned trained staff at the front line health facilities to deliver malaria in pregnancy services and enable communities to provide community directed interventions. These health facility staff trained volunteers like Uduak.

During the training that followed, Uduak was elected by her colleagues to be the chairperson that coordinates the activities of these volunteers. Asked the colleagues why they selected Uduak as their leader, one of the CDDs responded that, “Uduak is responsible and one who respects other people’s opinion.” In addition to providing malaria prevention services such as insecticide treated nets (ITNs) and intermittent preventive treatment of malaria in pregnancy (IPTp) to pregnant women in her own local community, she supervises and coordinates the other women volunteers, ensuring that they do not run out of stock of anti-malarial drugs and update their community registers for accurate service provision.

Uduak also organized and mobilized the traditional birth attendants in her community to send their clients for antenatal care that is a platform for providing MIP prevention services. She accomplished this with the support of the nursing officer attached the Atiamkpat Clinic and the traditional ruler. Uduak also provides community counseling sessions on malaria to pregnant women in her community as well as health talk to women in her church.

One of the project beneficiaries who received nets from Uduak shared her profound gratitude to Uduak because according to her, “Without Uduak I would not have started using the net but her consistency and persistence in reminding me to use the net prompted and encouraged me to do so.”

Prior to the activities of Uduak and her colleagues, Atiamkpat health facility was not patronized by pregnant women. The community members complained that the staff were not usually on duty at the time pregnant women visited the facilities. Uduak and colleagues met with the health staff and got their commitment to be at the facilities. This coincided with Jhpiego’s training of health staff to improve the quality of ANC and malaria control services they provided.

Now the staff have started receiving antenatal care clients. This increased from just two pregnant women in the three months preceding the intervention to fifty pregnant women in the first three months of intervention. The clinic is now also taking delivery of babies. Because of the way Uduak has been able to organize her group of CDDs, the catchment area of Atiampat Clinic has achieved on average 43% better coverage of the required two doses IPTp relative to its population compared to the three other clinics/catchment areas in the LGA.

Uduak has been a source of encouragement to her follow volunteers, one of whom noted that, “We would have stopped this work since we are not paid, but Uduak as continued to encourage and motivate us.”

Uduak was once asked what motivates her to carry out this assignment in absence of any financial reward or personal gain. She responded that, “The life and survival of pregnant women is my concern and much more important than money.”

One of the women beneficiaries noted that, “Uduak is selfless and committed to helping people. Her life is a testimony and challenging to us.” Uduak on her own part has vowed to keep doing the CDD job even though she does not benefit financially, explaining that, “There is an inner joy in providing quality community service, and this motivates me.”

[This story was compiled with the help of Bright Orji of Jhpiego Nigeria and Eno Ndekhedehe of Community Partners for Development, Akwa Ibom State, respectively.]

Leadership Bill Brieger | 01 Feb 2011

ALMA – long time no see

Since African Leaders Malaria Alliance (ALMA) was formed nearly two years ago, we hear only occasionally about its efforts to rally political will.  The last major news came in August 2010 at the 15th African Union Summit when leaders pledged a commitment to malaria in the context of maternal and child health. ALMA still maintains a website and a blog with recent and occastional postings, but generally its activities have been somewhat off the radar of the major media outlets.

Now during the during the 16th African Union Summit in Addis Ababa ALMA has resurfaced in public view. The occasion was award of recognition to four heads of state for their support of malaria programs. Recipients of the 2011 ALMA Award for Excellence are the heads of state of Guinea, Kenya, Uganda and Tanzania.

Although currently comprised of only 35 heads of states, ALMA notes as progress that, “Of the 45 malaria-endemic countries in Africa, 62% have removed tariffs on anti-malarial medicines, 42% have removed tariffs on LLINs, and 31 countries have taken measures to curtail the use of oral artemisinin-based monotherapies,” as reported by the Malaria Policy Center.

In addressing the Group, the UN Secretary General praised them for working toward the goal of Universal Coverage, He explained that, “The African Leaders Malaria Alliance is breaking down barriers, forging partnerships and getting supplies to families in record time. This is remarkable progress. We need to encourage it and use the response to malaria as a model for battling other illnesses and social ills.”

This is a challenging time for leadership in the fight against malaria. Not all heads of state have been watching the store as it were, since several Global Fund grants have been suspended on their watch due to corruption, often by government agencies serving as grant recipients.  Uganda, one of the four awardees of this year’s ALMA Excellence Awards, has had its own brush with the Global Fund.

Kenya was one of the countries covered in a 2008 study by the Global Fund of conflict of interest within its Country Coordinating Mechanism. Kenya was also singled out in an Office of the Inspector General Report to the 21st GFATM Board Meeting as one of the countries that had implemented less than half of the recommendations arising from its audit.

The East African Magazine recently published an African Presidents’ Index that ranken leaders on such factors as press freedom, corruption, democracy and human development. The ALMA award recipients ranked as follows out of 52:

  • Guinea – 29th at 42% score and a grade of F 
  • Kenya – 16th at 53% and a grade of C
  • Uganda – 20th at 50% and a grade of D+
  • Tanzania – 10th at 60% and a grade of B-

Hopefully the recognition by ALMA for malaria achievements will have an overall positive effect on leadership and political will in all areas of governance and human development.  Progress on one issue (health) and one disease (malaria) alone can not have a long lasting effect on defeating poverty and enhancing dignity of life in Africa.