Posts or Comments 18 July 2024

Monthly Archive for "May 2013"

Severe Malaria Bill Brieger | 31 May 2013

Disabilities – the role of malaria

sotwc-2013-unicef_reports_reportcover_ena.jpgUNICEF’s 2013 State of the World’s Children focuses on “Children with Disabilities.”  Some attention is paid to the role of communicable or infectious disease in the cause of disabilities and the need for children with disabilities to benefit from disease control services, just like any other child.

Of particular focus in the realm of infectious disease is recognition that, “… immunization is an important means of pre-empting diseases that lead to disabilities.” The Report goes on to explain for example, that, “More children than ever before are being reached. One consequence has been that the incidence of polio – which can lead to permanent muscle paralysis – fell from more than 350,000 cases in 1988 to 221 cases in 2012.”

Malaria as an infectious disease continues to exert a disabling effect on children in endemic countries. The Report does present a case study of children who spent several years in a residential home for children with mental disabilities in the Republic of Moldova, but it is also important to recognize that malaria and other infectious diseases can lead to such problems.

In reporting on neurological disease in Sub-Saharan Africa, Donald Silberberg and Elly Katabira explained that, “In addition to the hundreds of thousands of children who die each year from cerebral malaria, many more survive (often repeated attacks) and develop sequelae that have yet to be quantified. These include cognitive disorders and epilepsy.”

Likewise Ngoungou and colleagues after studying children with cerebral malaria in Mali found persistent neurological sequelae including, “ headaches, mental retardation, speech delay, bucco-facial dyspraxia, diplegia and frontal syndrome (one case each), dystonia (two cases), epilepsy (five cases) and behavior and attention disorders (15 cases).”

Immunization is of course a major tool in preventing disability, but we also need to examine the role other disease control efforts can play on preventing disability. Also as mentioned in the case of immunization above, we also need to ensure that all children with any kind of disability in a malaria endemic area promptly receive all necessary treatment and preventive interventions.

Elimination &Eradication Bill Brieger | 27 May 2013

certifying elimination of guinea worm – lessons for malaria

The efforts to eliminate guinea worm from Nigeria are coming to a close 28 years after the challenge was taken up at national conference in 1985. At the time there were over 650,000 cases in the country. In just eight years between 1988 and 1995 Nigeria saw a precipitous decline in cases down to 16,374 as seen in the attached map from the Carter Center.

nigeria-erad-chart-line-2009-zero-sm.jpg1995 had been posited as the first target date for global guinea worm eradication (see countdown calendar page below), and while efforts came close to eliminating it in Nigeria, the process dragged on for 14 more years until we reached zero annual reported cases. Now there are only a few countries left. The last verifiable case in Nigeria was November 2008. What is the process of ensuring that guinea worm has been eliminated from Nigeria?

A major step over the past few years has been to maintain surveillance since guinea work thrives from neglect.  As Steve Dada from This Day reported, “WHO officials say finding and containing the last remaining cases of the disease is the most difficult stage of the eradication process, because cases usually occur in remote, hard-to-reach areas.” The communities were involved, as evidenced from a radio announcement heard in Jos, Plateau State last Saturday in which people were encouraged to keep looking for the disease.Surveillance efforts have even made use of events like national immunization days to seek out information on possible cases.

As reported recently in the Vanguard, “The Federal government is offering a cash reward of N25,000 (~$160) for every report of authentic new guineaworm cases in any part of the country. In 2011, a N10,000 reward was offered for a similar report.” So far no authentic case has been found, but indigenous beliefs about the disease has meant many false positives over the years, accounting for the many rumors reported by the Vanguard. These efforts are part of the program to prepare Nigeria for a visiting team from the World health Organization in June 2013 to certify elimination.

dscn0361-a.jpgIn preparation for eventual certification of all countries, WHO established in 1995 “an independent International Commission for the Certification of Dracunculiasis Eradication in 1995. The Commission comprises 12 public health experts from all six WHO regions.”  WHO explains that, “A country reporting zero cases over a period of 12 consecutive months is believed to have interrupted transmission of dracunculiasis and is classified as being in the pre-certification stage … After at least three years of pre-certification and consistent reporting of zero indigenous cases, a country becomes eligible for certification.”

What does all this mean for malaria? First, even though we are talking about a process in Nigeria that spanned nearly three decades, this is relatively short.  The characteristics of guinea worm disease (and even small pox, its predecessor in eradication) make it relatively easy to spot. Few people could confuse a worm emerging from one’s body, as seen in the photo from the Carter Center, with another disease. One does not need a microscope either.

foot-close-up2-sm.jpgWe have been reminded recently that malaria parasites can even ‘hide’ at submicroscopic levels without causing any symptoms. Even with malaria symptoms there is easy confusion by the public with other diseases. We are certainly nowhere near the point of offering $100 rewards for detection of malaria cases.

There are a number of other key differences such as a ‘vector’ that stays in the pond for guinea worm, while malaria carrying mosquitoes can fly a few miles.  The key lesson therefore, is the need to adapt elimination efforts and timelines to the realities of each disease.  So while we will not be giving financial rewards for case detection just yet, we should continue to give recognition to Malaria Champions like President Joyce Banda of Malawi.

Another lesson is the fact that WHO established its guinea worm elimination certification process long before all countries were close to reaching goals.  This can help malaria program planners envision the surveillance processes they will need to out in place to eliminate the disease, especially since it will likely be, like guinea worm, hiding in the more remote and poor areas of a country.

Finally we must congratulate Nigeria in its guinea worm elimination success and hope this provides motivation for malaria elimination, too.

Drug Quality &Treatment Bill Brieger | 24 May 2013

AMFm – more than empty boxes?

dscn2941-sm.jpgThe Affordable Medicines Facility malaria (AMFm) was aimed at ensuring high quality low cost medicines reached the public and saved lives.  Nigeria was one of the biggest challenges for AMFm with having the highest burden of disease of any single country.  Unfortunately the vastness of the problem seemed to work against the effort.

Instead of concentrating the resources on a few pilot states of local government areas, as often happens, the project was spread thinly across the nation. There was no way that enough medicine would be provided to treat the large number of cases seen annually in the country. In the states only selected medicine shops received training and supplies. Out-of-stock syndrome was common.

dscn2801-sm.jpgOne can find the AMFm logo on empty boxes of medicine as seen in the attached photos from medicine shops.  The shop keepers do find the boxes useful for storing other things, and then resort to selling chloroquine to their customers. When will we learn how to conduct pilot programs so that thy actually produce meaningful results and guide future policy decisions?

The AMFm Evaluation Phase 1 Report acknowledges the following among the many factors hindering the AMFm implementation in Nigeria:

  • Delayed approval of ACT orders to FLBs
  • Inadequate supply of ACTs
  • Unstable supply of ACTs
  • High transport costs to rural areas
  • Inadequate ACT supply pipelines
  • Inadequate distribution of ACTs to rural areas
  • Re-indication of chloroquine
  • Interrupted ACT supplies nationally
  • Availability of chloroquine in market

These were certainly issues that could have been addressed with focus on a smaller and more clearly defined pilot area.

Health Education Bill Brieger | 08 May 2013

Targeting Children as the Primary Audience for Public Health and Malaria Programs

Our second Guest Posting by Erica Kuhlik examines important questions on the relationship between communicable and non-communicable diseases.

blog-posting2-kuhlik-pic1.jpgTargeting children of primary school age with health education and behavior change interventions is essential in developing countries.  Due to the success of illness prevention programs targeting children under the age of five in developing countries, more children survive longer than ever before.[1]  This is an incredible achievement for public health, but also means there are more older children at risk of illness and death from diseases like malaria.

For instance, one study in Kenya found that despite living through the most vulnerable first five years, children of primary school age still suffered an average of 25 episodes of illness over the 30-week study period.[2]  Our photo shows an application of this idea where members of the malaria club prepare to present their skit about malaria at Jolly Mercy Primary School in Wakiso District.

The result of chronic illness on children is tragic.  Repeated bouts of malaria can cause anemia, increased susceptibility to other diseases, and long-term neurological problems.[3]  Chronic illness also causes children to miss school and reduces their capacity to succeed.[2] The extent of serious illness among children in developing countries makes them prime targets of health interventions.

Such interventions are met with success because children of primary school age are at a stage in their lives when they are both impressionable and beginning to develop new habits.[4]  Children are open to learning healthy habits and behaviors that will help prevent the diseases to which they are vulnerable, like malaria. Additionally, the aforementioned study showed that in 19% of the illness episodes, children were self-treating using herbal remedies and Western medicines.2

blog-posting2-kuhlik-pic2.jpgThese results show that children have the capacity to take responsibility for their health and also suggest that health education programs can target children with information on disease prevention and treatment.  Children can share what they learn as seen in our photo where a student at Nakatunya Primary School in Soroti District displays her malaria message.

Taken together, children represent a population that can be highly vulnerable to disease, in need of health interventions, and in an impressionable stage of their lives, thus allowing for the opportunity to introduce healthy habits and behaviors to reduce their burden of disease.


All pictures were taken by the author with permission from August to October 2012.

  • [1] Bundy, D., Shaeffer, S., Jukes, M., Beegle, K., Gillespie, A., Drake, L., Lee, S. F., Hoffman, A., Jones, J., Mitchell, A., Barcelona, D., Camara, B., Golmar, C., Savioli, L., Sembene, M., Takeuchi, T., & Write, C. (2006). School-Based Health and Nutrition Programs. In D. Jamison, J. Breman, A. Measham, G. Alleyne, M. Claeson, D. Evans, P. Jha, A. Mills, & P. Musgrove (Eds.), Disease Control Priorities in Developing Countries (pp. 1091-1108). New York City: Oxford University Press.
  • [2] Geissler, P. W., Nokes, K., Prince, R. J., Achieng’ Odhiambo, R., Aagaard-Hansen, J., & Ouma, J. H. (2000). Children and medicines: self-treatment of common illness among Luo schoolchildren in western Kenya. Social Science & Medicine 50, 1771-1783.
  • [3] Malaria Consortium
  • [4] Harre, N., & Coveney, A. (2000). School-based scalds prevention: reaching children and their families. Health Education Research, 15(2), 191-202.
  • For more information see: Kolucki, B., & Lemish, D. (2011). Communicating with Children: Principles and Practices to Nurture, Inspire, Excite, Educate and Heal. UNICEF.

Health Education Bill Brieger | 07 May 2013

Uganda: The Stop Malaria Project’s School Health Program

Our Guest Posting by Erica Kuhlik describes a project in which she was involved for the MSPH degree requirements at the Johns Hopkins Bloomberg School of Public Health. STOP Malaria is a USAID funded project managed by JHU’s Center for Communications Programs.

Schools have been found to to be an ideal place for young people to learn about malaria. The Stop Malaria Project (SMP) in Uganda has been using an exciting approach to combat the high prevalence of malaria in rural communities: a school health program that teaches children about malaria and empowers them to act as agents of change in their communities. Previous study in Kenya has shown that school children can learn about malaria and other common diseases and have an influence on their peers and families.

blog-posting1-kuhlik-pic1.jpgThe program uses active and participatory learning techniques to teach children about malaria transmission, infection, diagnosis, treatment, and prevention. Participatory learning methods show children how certain behaviors can reduce malaria and also allow children to practice the behaviors, thereby improving their self-efficacy to perform them.  A “Talking Compound” as seen in the photo is one way to help students learn. In these ways, participatory learning empowers children to adopt the promoted behaviors.

The students are also encouraged to share the malaria messages with their peers and families, effectively acting as change agents in their communities.  By empowering children to act as agents of change, school health programs can reach secondary audiences in the community at little or no cost.   Taken together, the use of active learning methods to teach and encourage children to be agents of change is known as the child-to-child approach.

blog-posting1-kuhlik-pic2.jpgDespite its recent launch, the Stop Malaria Project’s malaria education program already has significant reach.  In its fourth year alone, SMP reached over 350,000 students across Uganda through thousands of health education sessions using the child-to-child approach (The Uganda Stop Malaria Project Annual Performance Report: 2012 Year 4. Kampala, Uganda).

Discussions with these children have shown them to be highly knowledgeable of SMP’s malaria messages about prevention, diagnosis, and treatment and can demonstrate correct insecticide-treated net use as seen here.  Their teachers have used participatory learning techniques by integrating the malaria information into songs, poetry, drama plays, drawings, and posters.  Some children have even reported behavior change in their households as a result of sharing the malaria messages with their parents.

blog-posting1-kuhlik-pic3.jpgThe experience of the Stop Malaria Project demonstrates that school health programs using the child-to-child approach can be implemented in developing countries.  As we can see, the children have developed their own malaria messages. These programs offer the opportunity to reach vulnerable children and their families with valuable health information to improve the local health conditions.

[All pictures were taken by the author with permission from August to October 2012.]