Posts or Comments 18 July 2024

Monthly Archive for "March 2012"

Epidemiology &Mortality Bill Brieger | 29 Mar 2012

Malaria and Older Adults

Recent research has stressed the increase risk of death from malaria that elderly tourists face. Mortality from P. falciparum malaria increased steadily with increasing age with case fatality rate peaking in the group aged over 65 years. The authors explain that, “These data are supported by previous reports of increased case fatality and higher levels of parasitaemia in elderly people,” but the three studies cited focus only on travelers and tourists back in the UK, not adults and elderly people living in endemic regions.

This leads on to wonder about the risks malaria poses to elderly people in endemic countries, especially as populations throughout the world are aging.

While the recent controversial study that suggests that malaria deaths in adults have been underestimated world-wide, it does not specifically address the suspected prevalence of malaria morbidity and mortality in older adults. Specifically the authors “estimated more deaths in individuals aged 5 years or older than has been estimated in previous studies: 435 000 (307 000-658 000) deaths in Africa and 89 000 (33 000-177 000) deaths outside of Africa in 2010.”

Concerning the “outside Africa” component mentioned above, a study of adult and child malaria mortality (both falciparum and vivax) in India published in 2010 did report a higher malaria mortality risk in persons over 60 years of age.

More documentation on malaria morbidity and mortality in persons over 60 years in age in endemic countries is needed. Although portions of this segment of the population may no longer be in their productive years, they do consume health care resources, and as grandparents play important roles in child care.

scan_io-012-sm.jpgIn addition there is need to ascertain reasons for any differing patterns that may be detected. The study on tourists did not think that co-morbidity in elderly patients was responsible but instead implied that older people on holidays may forget to take their prophylaxis.

What differences in health behavior might be found in elderly populations in malaria endemic countries – maybe greater reliance on less efficacious indigenous concoctions? Are there differences in terms of perceptions of severity and seriousness of illness? Are there differences in care access?

The respect and quality of care we give the elderly says a lot about the societies in which we live.

Funding &Partnership Bill Brieger | 20 Mar 2012

A World Bank for the 21st Century (and malaria elimination?)

By the end of this week someone will be nominated to replace Robert Zoellick as President of the World Bank.  Traditionally this nomination has been made by the United States, and it appears that this tradition is likely to be maintained.  The question is whether the traditional nominee – a white, older male of US citizenship – will be able to lead the World Bank in the Twenty-first Century.

The Washington Post today features two articles on this critical rite of passage. Howard Schneider raises, “The question now is whether the bank’s new leader, who could be named in the coming days, can enhance the institution’s role at a time when developing countries are emerging as the engines of world economic growth.” The mixed roles of the Bank – lender, donor, provider of technical assistance – and the emergence of other major and upcoming economic strong houses leads Amar Bhattacharya of the G-24 Secretariat to ask whether there is a clear goal for the institution at this point in time. His answer is ‘No.’

In contrast Michael Gerson sees a positive future because Zoellick’s leadership, he believes, leaves the “rarest of legacies: a multilateral institution with its reputation enhanced. Zoellick acted decisively to help stabilize the finances of struggling nations during the worst of the financial crisis, as well as to provide relief to countries hit hard by a worldwide spike food prices. He has increased transparency at the bank while successfully raising funds to recapitalize it.”

Gerson stresses the Bank’s need to listen to countries that receive its loans or grants since he sees no ‘silver bullet’ emanating from external development or aid experts. He traces as an example the evolution in country needs and requests from Rwanda which asked for emergency food aid in 2007, but a few years later sought investments to increase agricultural productivity and “Now is asking for help building storage facilities, so expanding crop yields are not wasted.”

Schneider does stress that the technical knowledge provided by the Bank is of equal importance as the financial resources it can mobilize. Who then is in the best position to marshal needed technical inputs while at the same time maintaining a humble leadership style that emphasizes that we need to learn from the low and middle income countries themselves?

According to the Washington Post, the current suspected nominees have ranged from Hillary Rodham Clinton and Sen. John Kerry to Susan Rice and Lawrence H. Summers, though for various reasons these have said they are not interested or are unlikely choices.

wb-booster-countries.jpgJeffrey Sachs has let it be known that he is interested in the job, though Schneider notes, “But he says the administration has not approached him.” Sachs is certainly familiar with the needs of low and middle income countries, but would he or the other US candidates take a learning, rather than a prescriptive approach to working with these countries?

Another name breaks the US white male mold – Nigeria’s Finance Minister and Coordinating Minister for the Economy, Dr. Ngozi Okonjo Iweala. CP-Africa recently reported that, “Dr. Okonjo Iweala reportedly recently told the BBC that it is time to open it up to competition and that top jobs at international institutions should be filled on merit.”  They also though that such an appointee would only be successful with support from China.

What is at stake for the malaria community? Currently the World Bank has commitments for malaria control in 21 African countries up to US$ 762.8 million.  This has been used to finance over 73.8 million treated mosquito nets and 25.3 million doses of effective malaria medication over the past five years, a major dent in the overall efforts to scale up malaria control.  Given the current questionable status of Global Fund support, efforts by all other partners including the World Bank are crucial.  Hopefully the new leadership at the Bank will sustain this in line with the commitments of each national malaria control program.

Communication Bill Brieger | 15 Mar 2012

Malaria Misinformation

Many malaria partner organizations depend on the media to disseminate malaria information and generate support for their programs. And yet, unless the malaria organization itself issues carefully crafted press releases, interaction with the media can be challenging.

dscn0974-news-sm.jpgThis week has seen two examples of the media getting it wrong on malaria-related stories. The first came from the Yemen Post from where reports of an impending malaria and polio vaccination campaign emerged. This was later clarified to be measles and polio, but not before many people wondered ongoing research on malaria vaccines had become operationalized so quickly.

A newspaper in Nairobi issued the second questionable story.  Supposedly a study had been issued that showed less than half the people in Nyanza were using their insecticide treated nets properly.  The Nairobi Star  said that people were not using nets because of taboos or were using them to protect their gardens. It is not that net misuse does not happen, but the scale that was reported, 51%, was startling.

In short order it was revealed that no such study had been done, but that the press had relied on anecdotal reports from a community group.  In fact health researchers familiar with the area, on reading the story raised another important issue – because there are no proper plans for disposal of old nets, it is possible some people were re-purposing those, not the new nets.

Mosquito misinformation is quite common. The press in Ghana often reports on the activities of sanitation companies and local government councils who are engaging in environmental management of vector breeding and claims this is malaria control. Their efforts to clear garbage and dirty gutters are commendable, but this work is aimed at other mosquitoes, not anopheles who tend to breed in clear, sunlit collections of water.

Malaria endemic countries often have many national and local newspapers, but this does not mean that they have adequate strength in professionally trained science and health journalists, who can spot the problems noted above, or at least be curious enough to check the facts.

Most times these stories go unread by the malaria community, but occasionally they can cause confusion and embarrassment when they misrepresent program activities. Monitoring the press after such stories are published is not the answer. Working with the press to help them understand malaria technical issues and activities is recommended.

ITNs Bill Brieger | 08 Mar 2012

Nigeria continues its net campaign efforts

An update by Ogu Omede, National Malaria Control Program, Nigeria

progress-in-llin-distribution-in-nigeria.jpgNigeria has targeted 64 million LLINs to be distributed. 45 million have already been distributed (71% of target). 28 states out of 37 completed with 9 left.

States lead the actual campaign implementation in collaboration with NMCP using the principle of the ‘three ones’: one plan, one implementation process, one monitoring mechanism.  The State Support Team (SST) is an implementation arm of NMCP that providea Technical Assistance for the LLIN campaign. This consists of 4 teams of 7 persons each; 3 workstream advisors and 2 overall coordinators. Distribution efforts are funded by DFID, USAID and World Bank.

Several challenges exist. There was inability to access operational funds from World Bank due to audit since September 2011.  There are inadequate stocks of LLINs in Millennium Development Goal States. Degradation of some storage areas has occurred.

campaign-status.jpgSome states want to distribute this slow moving inventory without adherence to National Guidelines because of delays. Support operations face SST attrition, partner fatigue, and increased operational costs. There is even loss of nets that have been in storage for over a year.

The way forward can be achieved by getting support outside the WEorld Bank for now for 1) Operational funds, 2) Gaps in SST facilitation costs and 3) Procurement of LLINs to meet the gaps in MDG States targets

The NMCP and its partners are increasing support for the promotion of the net use culture which means undertaking Behavior Change Communication beyond the campaign period.  We are also encouraging transparent states and local government areas counterpart funding.

Community &Malaria in Pregnancy Bill Brieger | 08 Mar 2012

We need to improve IPTp access through community effort

Guest Posting by Bright Orji, Jhpiego, Nigeria

Malaria control in pregnancy in endemic nations is an integral component of Ante-natal Clinic and made up of three essential components. These include the 1) use of long lasting insecticide treated nets (LLINs), 2) intermittent preventive treatment of malaria (IPTp) using sulfadoxine-pyrimethamine, and 3) effective case management.

In recent times, National Malaria Control Programs (NMCP), State Governments and the Development partners embarked on campaigns for nets distribution and use through various methods that include routine, stand alone and through integration with other interventions such as measles campaign most times with under-five children and pregnant women as key entry points. However, these efforts have improved net ownership and use. Ownership of at least one ITN among households in Nigeria increased from 2% in 2003 to 8% in 2008 and more recently to 42% in 2010; similarly  net use increased from 1.3% to 5% and 33.7% during the same period (NDHS 2003, 2008; MIS 2010).

cdd-service-community-iptp2-sm.jpgOther components of malaria in pregnancy control have not enjoyed similar large scale campaign as nets. In 2003 National survey, IPT with sulfadoxine-pyrimethamine use among pregnant women was found to be 1%, and then increased to 5% in 2008 and further to 13.2%  in 2010 (NDHS 2003, 2008; MIS 2010) compared to the global RBM target of 80% and PMI 85%. IPTp and insecticide treated bed nets (ITNs) is a recommendation of World Health Organization. IPTp was first piloted as a project in 2002/2003 in three Local Government Areas (Akinyele, Ibadan South East and Ibadan North) of Oyo State, Nigeria. The outcome of this project among others informed policy direction for Nigeria.

It is important to note that IPTp implementation in Nigeria and elsewhere is faced with multiple challenges. These include lack of trained personnel, SP stock-outs – even though the medicine is available in-country and cheap but due to logistical distribution problem they are not where and when needed;  while  poor ANC attendance however has been identified as one of the major key factor for the low uptake of IPTp.

In the last two decade, there has been effort to improve the health system through the active involvement of communities in the distribution of health commodities. The notable concept in this regard was the Community Directed Distribution (CDI) that was first introduced in 1985 by African Program on Onchocerciasis Control (APOC).  Recently there has been growing effort that keyed into the lessons learned from APOC projects to apply the concept of CDI to malaria control using nets and IPTp as key entry points.

These efforts were piloted in Uganda and Nigeria respectively. The Ugandan project  findings showed that more women accessed IPTp and adhered to 2 doses of SP in the intervention arm compared to the control. Furthermore, ANC attendance increased as well as access and benefits from essential care at health facilities. Similarly, another study  concluded that the involvement of community distributors offered an alternative option in the administration of IPTp given that the strategy does not reinvent the while rather it keys into the existing health system and community structures.

Whilst it may be said that the Ugandan project was under control measures, the Nigerian project  was more of field implementation program. In the Nigerian program in Akwa Ibom State, over 45,000 pregnant women received IPTp in five years with the effect of CDI more on pregnant women access to IPTp, adherence to at least two doses of SP, and ITNs use, relatively very cheap and without distraction to ANC attendance. In both projects, there was no record of adverse event since SP has a very high safety profile if administered properly and appropriately too.

As many African countries struggle with meeting the Millennium Development Goals as well as the global targets for IPTp, the call to explore community IPTp as another option to strengthen the health system to improve the uptake of IPTp is increasing given the growing research evidence. Change does not just come; it comes with conscientious planning, discipline and deliberate effort. Countries might not meet the MDG targets if they choose to continue to do things the same way it is being done over the years.