Climate &Ecosystems &Elimination &Environment &Equity &Gender &Genetics &Monitoring &Mosquitoes &Research &Surveillance Bill Brieger | 25 Apr 2024
Drought, Malaria, and Climate Equity
The 2024 World Malaria Day Theme of “Gender, Health Equity, and Human Rights” cannot be divorced from the inequities of climate change wherein the countries that contribute the least to the problem suffer the most, including the deleterious effects of changing malaria geographics. The current severe drought in Zambia, Zimbabwe, and Malawi is a case in point.
As a recent headline in VOA news states, “UN officials in Zambia to assess worst drought in 20 years.” The government has declared a drought officially where it “has affected a total of 8 provinces across the country with highest impacts in Southern, Central, Eastern, North-western, Western, and Lusaka Provinces.”
Drought should not be confused with a “normal” dry season. What we are seeing in Southern Africa now is an extended dry period in what should have been the rainy season. A study in Mali suggests that adult malaria-carrying mosquitoes “have endured the dry season by aestivating—the hot-weather equivalent of hibernating.” Unfortunately, an extended dry period of a drought may be more difficult to endure for the adults, but possibly the eggs are more resistant. Additional studies paint a more complicated picture.
Weather cycles intensify with climate change. El Niño, which can lead to droughts also produces warming in higher elevations so there tends to be an increase in malaria transmission in areas in the highlands.
Research in Zambia published just two years ago reported increasing trends of malaria in areas covering over 47% of all health facilities, while a declining trend was seen in areas covering 27% of health facilities. The decreasing trend was noticeable in the south, where malaria risk is lowest, and current drought conditions higher. The authors stress the need for continued geographic surveillance and implementation of control strategies geared to the conditions in each area.
A systematic review of the effects of climate change identified “vector borne disease (including malaria, dengue and West Nile Virus)” as a major concern as well as “nutrition-related effects (including general malnutrition and mortality, micronutrient malnutrition, and anti-nutrient consumption),” which compromises the ability of children to fight disease. The review found different impacts of drought ranging from increase mortality a year after a drought, to the disappearance of some vector species. The lesson is that each country needs to monitor their situation carefully. For Zambia, UNICEF reports that, “significant number are children, at risk of food insecurity, acute malnutrition, and disease.”
Research on drought effects on malaria arose from a study that examined the effects of drought on malaria infection (genetic) complexity and transmission in lizards (Plasmodium mexicanum and Sceloporus occidentalis). The authors noted that, “relationship between rainfall and parasite prevalence is somewhat more ambiguous.” Thus, the authors recommended that more information is needed about human malaria parasites and drought since “drought may cause shifts in human disease outcomes independent of any changes to prevalence.”
The United Nations challenges us by observing that, “Due to the complex relationship between malaria and climate change, gaps in knowledge still exist in the mechanisms of the linkage.” Changes in temperature, rainfall, and humidity need to be monitored for effects on vectors, parasites, and human movement. The current situation requires a more nuanced and complex approach to interventions if malaria elimination can be achieved while also preventing gender discrimination, promoting health equity and preserving human rights.
Equity &Gender &Health Systems &Migration &Nomadic People &poverty Bill Brieger | 05 Mar 2021
Nomads in Mali Face Barriers to Health Care
We are sharing the abstract of a just published article by Moussa Sangare and colleagues entitled, “Factors hindering health care delivery in nomadic communities: a cross-sectional study in Timbuktu, Mali,” that appears in BMC Public Health. As COVID-19 has been disrupting health services generally, we need greater awareness of the serious barriers faced by more vulnerable populations even in better times.
Background: In Mali, nomadic populations are spread over one third of the territory. Their lifestyle, characterized by constant mobility, excludes them from, or at best places them at the edge of, health delivery services. This study aimed to describe nomadic populations’ characteristics, determine their perception on the current health services, and identify issues associated with community-based health interventions.
Methods: To develop a better health policy and strategic approaches adapted to nomadic populations, we conducted a cross-sectional study in the region of Timbuktu to describe the difficulties in accessing health services. The study consisted in administering questionnaires to community members in the communes of Ber and Gossi, in the Timbuktu region, to understand their perceptions of health services delivery in their settings.
Results: We interviewed 520 individuals, all members of the nomadic communities of the two study communes. Their median age was 38?years old with extremes ranging from 18 to 86?years old. Their main activities were livestock breeding (27%), housekeeping (26.4%), local trading (11%), farming (6%) and artisans (5.5%). The average distance to the local health center was 40.94?km and 23.19?km respectively in Gossi and Ber. In terms of barriers to access to health care, participants complained mainly about the transportation options (79.4%), the quality of provided services (39.2%) and the high cost of available health services (35.7%). Additionally, more than a quarter of our participants stated that they would not allow themselves to be examined by a health care worker of the opposite gender.
Conclusion: This study shows that nomadic populations do not have access to community-based health interventions. A number of factors were revealed to be important barriers per these communities’ perception including the quality of services, poverty, lifestyle, gender and current health policy strategies in the region. To be successful, future interventions should take these factors into account by adapting policies and methods.
Case Management &Children &CHW &Communication &COVID-19 &Education &Gender &ITNs &Politics Bill Brieger | 13 Sep 2020
Malaria News Today 2020-09-12/13 Weekend
Recent news over this weekend included efforts at school and peer education on bednets in Ethiopia, gender inequality effects of COVID-19 and pandemics, a reduction in severe malaria in Rwanda and increased use of home based case management, and the altering of scientific reports by political appointees. Links in these summaries take one to the full story.
Effectiveness of peer-learning assisted primary school students educating the rural community on insecticide-treated nets utilization in Jimma-zone Ethiopia
Abstract: Making insecticide-treated nets (ITNs) utilization a social norm would support the global goal of malaria eradication and Ethiopian national aim of its elimination by 2030. Jimma zone is one of the endemic settings in Ethiopia. This study aimed to report effects of malaria education, delivered by students, on community behaviours; particularly ITNs. The intervention engaged students from primary schools in participatory peer education within small groups, followed by exposing parents with malaria messages aimed at influencing perceptions and practices.
Over the intervention periods, the findings showed significant improvement in exposure to and content intensity of malaria messages delivered by students. Socio-demography, access, exposures to messages, and parental perception that students were good reminders predicted ITN utilization over the intervention periods with some changing patterns. Exposing the community to malaria education through students effectively supports behaviour change, particularly ITN usage, to be more positive towards desired malaria control practices. A school-based strategy is recommended to the national effort to combat malaria.
Melinda Gates calls on Leaders to Ensure that Women, Girls are Not Left Behind in the Global Response to COVID-19
Melinda Gates has launched a paper exploring how the COVID-19 pandemic has exploited pre-existing inequalities and drastically impacted women’s lives and livelihoods. In the paper, titled “The Pandemic’s Toll on Women and Girls,” Melinda makes the case that to recover fully from this pandemic, leaders must respond to the ways that it is affecting men and women differently. She puts forward a set of specific, practical policy recommendations that governments should consider in their pandemic response—to improve health systems for women and girls, design more inclusive economic policies, gather better data, and prioritize women’s leadership.Writing in the paper, Melinda describes how previous disease outbreaks, including AIDS and Ebola, tend to exploit existing forces of inequality, particularly around gender, systemic racism, and poverty.
Melinda concludes, “This is how we can emerge from the pandemic in all of its dimensions: by recognizing that women are not just victims of a broken world; they can be architects of a better one.
Severe malaria drops by 38% in Rwanda
In its annual Malaria and Neglected Tropical Diseases Report, the Ministry of Health says that the national malaria incidence reduced from 401 cases per 1,000-person in 2017-2018 fiscal year to 200 cases per 1,000-person in 2019-2020. According to the report, 4,358 cases of severe malaria (representing a 38 per cent reduction) were reported at the health facility level compared to 7,054 in 2018-2019. The decrease in malaria deaths is attributed to home based management interventions, the free treatment of malaria for Ubudehe Categories I and II and the quality of care at health facility level.
There has also been a steady increase of proportion of children under 5 and above plus adults who are seeking care from 13 per cent to 58 per cent in 2015-2016 and 2019-2020 respectively. “This indicates that interventions such home based treatment of children and adults that contributed to early diagnosis and treatment have been successful in decreasing the number of severe cases and consequently the number of malaria deaths,” the report indicates.
Political appointees sought to alter CDC scientific reports so they don’t contradict or undermine the president
Caputo (a US presidential appointee) and his communications staff have worked to delay CDC reports that contradict President Donald Trump’s rhetoric. One publication was held back for about a month, according to Politico, for recommending against the use of hydroxychloroquine, a malaria drug touted by the White House as a potential cure for COVID-19.
The reports, written by career scientists, are known as the Morbidity and Mortality Weekly Reports, and according to Politico, are used to “inform doctors, researchers, and the general public about how Covid-19 is spreading and who is at risk.” Jennifer Kates, of the Kaiser Family Foundation’s global health work, who has relied on past reports, told Political they are “the go-to place for the public health community to get information that’s scientifically vetted.” Alexander (a presidential appointee), in this missive, said any future reports related to the coronavirus “must be read by someone outside of CDC like myself.”
Borders &Diagnosis &Elimination &Environment &Gender &Health Education &Health Workers &Indoor Residual Spraying &IRS &ITNs &Mosquitoes &Plasmodium/Parasite &Vector Control Bill Brieger | 07 Jul 2019
The Weekly Tropical Health News 2019-07-06: Eliminating Malaria in Low Transmission Settings
This week started with articles that drew attention to the challenges of malaria in low transmission areas and with low density infections. Malaria Journal has provided several insightful articles toward this end.
Being an island has certainly helped Zanzibar make progress toward malaria elimination as witness the fact that malaria prevalence has remained below 1% for the past decade. Not only does Zanzibar still face threats of infection from the mainland, it may also experience an upsurge locally if residual transmission and the role of human behavior and community actions are not well understood. April Monroe et al. conducted in-depth interviews with community members and local leaders across six sites on Unguja, Zanzibar as well as semi-structured community observations of night-time activities and special events to learn more.
While there was high reported ITN use, there were also times when people were exposed t mosquitoes while being outdoors during biting times. This could be around the house, or at special night events like such as weddings, funerals, and religious ceremonies. Men spent more time outdoors than women. Clearly appropriate interventions and needed and should be promoted in culturally appropriate ways in order to further reduce and eventually eliminate transmission.
Angela Early and colleagues presented findings on a diagnostic process of deep sequencing for understanding the dynamics and complexity of Plasmodium infections, but stress that knowing the lower limit of detection is challenging. They present “a new amplicon analysis tool, the Parallel Amplicon Sequencing Error Correction (PASEC) pipeline, is used to evaluate the performance of amplicon sequencing on low-density Plasmodium DNA samples.”
The authors learned that, “four state-of-the-art tools resolved known haplotype mixtures with similar sensitivity and precision.” They also cautioned that, “Samples with very low parasitemia and very low read count have higher false positive rates and call for read count thresholds that are higher than current default recommendations.” Better understanding of the genetic mix of plasmodium infections as countries move toward low transmission and elimination is crucial for selecting appropriate interventions and evaluating their outcomes.
Hannah Edwards and co-researchers examined conditions for malaria transmission along the Thailand-Myanmar border in areas approaching malaria elimination. While prevalence may be less than 1%, residual transmission still occurs. Transmission occurs not only around residences but in the forests where people work. The researchers therefore looked at the behavior of both humans and insects. Overall, they found that, “Community members frequently stayed overnight at subsistence farm huts or in the forest. Entomological collections showed higher biting rates of primary vectors in forested farm hut sites and in a more forested village setting compared to a village with clustered housing and better infrastructure.”
While mosquitoes preferred to bite inside huts, their threat was magnified by those who did not use long lasting insecticide-treated nets (LLINs). While out in the farms and forests, people tended to wake early and increase their likelihood of being bitten. The authors discuss the challenges of dual residences in terms of LLIN ownership and even concerning the potential access to indoor residual spraying. The definition for universal net coverage needs to expand from one net per two people to include adequate nets wherever people are located.
The Amazonian area of Brazil is another area working toward malaria elimination, in particular, Plasmodium vivax. Felipe Leão Gomes Murta et al. also looked at the human side of the equation and identified misperceptions by both community members and health workers that could inhibit elimination efforts. They found, “many myths regarding malaria transmission and treatment that may hinder the sensitization of the population of this region in relation to the use of current control tools and elimination strategies, such as mass drug administration (MDA),” and LLINs.
Problematic perceptions included mention by both groups that the use of insecticide-treated nets, may cause skin irritations and allergies. Both community members and health professionals said malaria is “an impossible disease to eliminate because it is intrinsically associated with forest landscapes.” They concluded that such perceptions can be a barrier to control and elimination.
Efforts to eliminate malaria from low transmission settings are an essential to the overall global goals. These four articles tell us that close attention to and better understanding of humans, parasites and mosquitoes is still needed to achieve these goals.
Gender &Leadership &Women Bill Brieger | 23 Mar 2018
Women Making Malaria History
March is Women’s History Month and thus a time to examine the role of women in bringing an end to malaria. For many years studies at the household level have told us that women often lack the financial independence or social support to make important decisions about malaria treatment and prevention for themselves and their children. Furthermore, as WHO notes, “Gender norms and values … influence the division of labour, leisure patterns, and sleeping arrangements may lead to different patterns of exposure to mosquitoes for men and women.” As part of the solution to these problems, it is important to look at women role models in the fight against the disease – at women making malaria history.
One of these role models is Tu Youyou who became one of three scientists to win the 2015 Nobel Prize for medicine. Her work of over 40 years was virtually unknown to the outside world until then, but her study of artemisinin medicinal compounds has saved the lives of millions.
Moving from the lab to the community one can find role models who have broken role stereotypes. A few years ago President’s Malaria Initiative-funded Africa Indoor Residual Spraying (AIRS) project drew out attention to Maimouna Sanogo as a woman making a difference. She helped protect people in her country from malaria through her work as a supervisor on AIRS indoor residual spraying project in Mali. The AIRS project reported that, “As a woman in a leadership role, Maimouna is a trailblazer. In Mali, only 37% of women participate in the labor force, while participation is nearly double among Malian men (70%).”
Women have played crucial leadership roles in national malaria programs. Dr TO Sofola as Director of Nigeria’s National Malaria Control Program (NMCP, now National Malaria Elimination Program) guided the transition of case management policy to the use of artemisinin-based combination therapy, oversaw planning for the first massive national LLIN campaign, guided development of the World Bank Booster Program support, helped strengthen Nigeria’s first Global Fund Malaria Grants, and brought state level malaria control programs into the national strategy process. Women have also led NMCPs in Malawi, Kenya and other countries.
Dr Rose Leke, Emeritus Professor of Immunology and Parasitology, Faculty of Medicine and Biomedical Sciences, University of Yaounde, Cameroon, was one of six people to be given the Kwame Nkrumah Scientific Award for Women in 2011. Dr Leke explained the challenges facing women, “Science is still a challenging field for women to enter, and even more so in which to progress. At the university, I have seen many promising young women finish their studies and start jobs as assistants only to either get stuck in that position indefinitely or eventually leave to take care of their families. There just wasn’t the mentorship or financial support for research needed for them to be able to progress. It was an issue I really took to heart.” Therefore, Dr Leke and colleagues started the HIGHER Women Consortium in Cameroon. We provided training and mentorship to young women researchers.
Women in academics, research, government and front line programs have and continue to make history in the efforts to eliminate malaria. As Dr Leke’s example shows, these women leaders can make sure no one stands in the way of ensuring that the next generation of women scientists, managers and field workers make malaria history.