Malaria Matters

BBC is featuring community medicine distributors in Uganda as part of its series on ‘Survival TV’. While the video starts with how things were in a Ugandan community with a funeral of a child who died from malaria, the work of two community medicine distributors in combating malaria with readily available packs of Coartem® (arthmether-lumafantrin) and long lasting insecticide treated nets (LLINs) ultimately provides a positive outcome for Ugandan children.

Home management of malaria (HMM) is not new to Uganda. Kolaczinski and colleagues reported, “In 2002, home-based management of fever (HBMF) was introduced in Uganda, to improve access to prompt, effective antimalarial treatment of all fevers in children under 5 years. Implementation is through community drug distributors (CDDs) who distribute pre-packaged chloroquine plus sulfadoxine-pyrimethamine (HOMAPAK®) free of charge to caretakers of febrile children.” Caregivers for children were impressed by the safety of the blister packs, and having been guided be the CDDs 95% of them had administered the correct dose of medicine to their children.

The medicines have changed to arthmether-lumafantrin now, but a recent 3-country assessment “provides encouraging data on parasitological outcomes of children treated with ACT in the context of HMM and adds to the evidence base for HMM as a public health strategy as well as for scaling up implementation of HMM with ACTs.” On average correct adherence was 94% across Uganda, Ghana and Nigeria.

The benefits HMM are not just to the individual child and family, but also to the health system. Sievers and colleagues found in Rwanda that “both admissions for malaria and laboratory markers of clinical disease among children may be rapidly reduced following community-based malaria control efforts.” They also cautioned that as malaria cases and hospital admissions became less frequent, “More accurate diagnosis and management of febrile illnesses is critically needed both now and as fever aetiologies change with further reductions in malaria.”

Another effect of properly organized HMM is reflected in the title of a new article appearing in Malaria Journal: “Implementation of home-based management of malaria in children reduces the work load for peripheral health facilities in a rural district of Burkina Faso.” Not only were fewer children with malaria seen at health facilities in the intervention communities, but in fact more children in those communities were actually treated for malaria in those communities.  HMM clearly improved access to correct malaria treatment.

This access issue was demonstrated in a study by the Tropical Disease Research (TDR)project of UNDP, World Bank, WHO and UNICEF. In districts using CDDs for HMM more children were reached. In fact excepting Cameroon where there were policy and logistical challenges to community drug distribution, reaching the RBM targets was seen as feasible through HMM compared to where malaria treatment was made available only through the normal health care system.

The TDR project built on the successful experience spanning over a decade of ivermectin distribution to control onchocerciasis. When community directed distribution started, health workers worried that communities were not capable to taking charge on medicines. Later they learned that not only could communities deliver ivermectin safely and accurately, but that they could maintain good annual treatment coverage. Finally the health workers learned that community directed distribution helped the health system reach ‘people beyond the end of the road’ who otherwise would not have benefitted from services.

HMM empowers the community and enhances the ability of the health system to reach those in need. HMM should be a central strategy in any malaria control program.

The past few weeks have seen economic changes last experienced during the Great Depression of 80 years past.  David Rothkopf observed in the Washington Post that the shock may be greater than that experienced post-9/11. “That’s because while 9/11 changed the way we view the world, the current financial crisis has changed the way the world views us. And it will also change, in some very fundamental ways, the way the world works.” The economic crisis will cost the US government more than the wars in Iraq and Afghanistan and for investors and the public, the Wall Street plunge of Monday cost more that the $700 billion financial package that just passed the US Congress.

According to the New York Times, “The (financial) crisis has become the biggest financial challenge for European policymakers since the introduction of the euro as a Continent-wide currency in 1999.” On Saturday, “the leaders of France, Germany, Britain and Italy pledged to prevent a bankruptcy on this side of the Atlantic.”

Under the circumstances one might wonder if the US and other G8 countries can maintain their commitment to fighting disease in the world. This may or may not have been responsible for comments reported Friday on GhanaWeb:  “The US Ambassador to Ghana Mr Donald Gene Teitelbaum on Friday assured Ghanaians that the fight against malaria remained a priority on President George Bush’s agenda. He said it was the President’s wish that there will be a time when the two countries will meet and celebrate the wiping away of malaria from Ghana and Africa as whole.”

These economic threats come at a time when the Global Fund is aiming for a larger grant porfolio, the World Bank is substantially ‘boosting’ its support, and new funding mechanisms like the Affordable Medicine Facility - malaria (AMFm) may be coming on line. Malaria advocates need to monitor the situation closely, especially if progress highlighted in the recently released World Malaria Report of 2008 is to be sustained.

Catholic Relief Services describes the life of Rasmané, a day laborer in Burkina Faso, who works at “a plastic chair factory, where he makes about $37 a month. This won’t go far for Rasmané, his four kids, his mother and wife. That’s why they eat baobab leaves and cheap millet (see photo by Lane Hartill/CRS). A sack of rice that would last a few weeks costs about $55.”  According to CRS, “Some 75 percent of people living in or near Burkina’s major cities don’t have enough food to eat.”

Staple food prices have more than doubled. “Rasmané says he has never seen food prices jump like this. A portion of corn last year was 50 cents. Now, it’s $1.15. A portion of millet was 55 cents. Now it’s $1.25. For someone who doesn’t know from one day to the next if he will work, these price swings sting.” CRS notes the contrast: “Residents of Burkina Faso spend about 76 percent of their monthly income on food. Americans, on the other hand, spend only about 10 percent of their income on food a year, according to the USDA.”

The question arises, what if one of those 4 children get malaria?  Kouéta and colleagues found in Burkina that poor nutritional status was one of the key factors associated with increased risk of death in children with malaria.

Burkina had a short-lived Global Fund Malaria Grant in Round 2 and recently started on its Round 7 grant in June 2008. The first objective of the new grant is to “ensure proper treatment of simple malaria cases diagnosed in health facilities.” Public, private and community health workers are to be trained in proper case management. The GFATM expressed concern in the first progress report that there be proper coordination between principle and sub-recipients for full implementation. The need to closely monitor ACT estimations and actual consumption was stressed.

A reading of the Round 7 proposal implies that ACTs may be subject to the overall national strategy of cost recovery.  One wonders if people like Rasmané can really pay for proper malaria treatment for their children?

Malaria “vectorial capacity was estimated to be 77.7% higher in the deforested site than in the forested site” in western Kenya according to a new study by Afrane and colleagues. Deforestation created micro-climates and micro-habitats. They concluded that “deforestation in the western Kenyan highlands could potentially increase malaria risk,” and unfortunately, “In African highlands where temperature is an important driving factor for malaria and the human population generally has little functional immunity.”

Generally, “Kenya’s forests are rapidly declining due to pressure from increased population and other land uses,” as explained by the World Rainforest Movement (WFM). The process has been long standing from including early establishment of large agricultural plantations in the last Century to continued agricultural expansion based on population growth and logging. WFM advocates for community involvement in forest conservation.

Kenya is making progress on reducing malaria deaths through successful LLIN and treatment efforts, but this may be offset if communities do not see the connection between malaria and their environment.  Intersectoral collaboration in malaria control is crucial so that gains in malaria intervention coverage are not counteracted through expanding endemic areas.

The Roll Back Malaria Partnership has launched the Global Malaria Action Plan around the world with the “collective input of 30 endemic countries and regions, 65 international institutions and 250 experts from a wide range of fields.” The goals of the plan follow:

• Achieve universal coverage, as recently called for by the UN Secretary-General, for all populations at risk with locally appropriate interventions for prevention and case management by 2010 and sustain universal coverage until local field research suggests that coverage can gradually be targeted to high risk areas and seasons only, without risk of a generalized resurgence;
• Reduce global malaria cases from 2000 levels by 50% in 2010 and by 75% in 2015;
• Reduce global malaria deaths from 2000 levels by 50% in 2010 and to near zero preventable deaths in 2015;
• Eliminate malaria in 8-10 countries by 2015 and afterwards in all countries in the pre-elimination phase today; and
• In the long term, eradicate malaria world-wide by reducing the global incidence to zero through progressive elimination in countries.

At the same time the international community gathered at the United Nations Headquarters in the context of meeting the Millennium Development Goals to pledge support that would make this plan a reality.  According to the BBC, “World leaders and philanthropists have pledged nearly $3bn (£1.6bn) to fight malaria at a summit in New York. The meeting, at the UN, is looking at ways of meeting the Millennium Development Goals - targets on reducing global poverty by the year 2015. Donors hope the money will be enough to eradicate malaria by that time.”

Eradication by 2015 may be a bit of a stretch because according to the Guardian, “A key part of the strategy is the introduction of a vaccine against the deadly disease, which is now just entering the final stage of trials. Although the vaccine is expected to be only partially effective, it will still save thousands of lives.” Working out the logistics of delivering the new vaccine will take time, but that is not reason to dispair.

The launching and fundraising was noted in Uganda, one of the countries that could benefit. Uganda’s New Vision reported that, “Health state minister Dr. Emmanuel Otaala yesterday said the malaria toll in Uganda stands at 320 people a day translating into 115,840 victims a year. He said the Global Malaria Action Plan involved a combination of prevention measures which include use of insecticide-treated mosquito nets, indoor residual spraying, use of anti-malarial treatments and killing of mosquito larvae.” The New Vision accounted that the nearly $3 billion of pledges came from a wide variety of sources ranging from the Gates Foundation and the World Bank to DfID, the Global Business Coalition on HIV/AIDS, TB, and Malaria, the United Nations Foundation, Malaria No More and even the Sesame Workshop.

AFP quoted Bill Gates: “”We need innovation, new drugs, and the most dramatic thing we need is vaccine.” Gates noted that malaria control programs “are achieving impressive new gains,” and that scientific innovation “could soon give us powerful new vaccines and drugs. “If we build on this momentum, we can save million of lives and chart a long-term course for eradication of this disease.”  In The Gates Foundation’s home town, the Seattle Times called the event at the United Nations, “a malaria Woodstock.”

Afrol News reported that these “Funding commitments will support rapid implementation of Global Malaria Action Plan.” This will only be possible if there is a strong health systems strengthing component, since as we have noted before, existing achievements are in many places still below the Abuja targets set for 2005. Rapid movement without attention to the systems that can sustain elimination interventions will never lead to eradication.

The buzz about the 2008 World Malaria Report (WMR) has been largely centered around the recalculation and subsequent reduction of annual morbidity estimates. Some good news identified 10 countries including some in the Mediterranean and Middle Eastern area that are close to elimination.

At the same time concerns about coverage have surfaced. Leadership News of Abuja explained that, “The report, however, noted that much more work remained to be done. ‘In Africa , only 125 million people were protected by bed nets in 2007, while 650 million are at risk.’”  One of the challenges with the figures is that the 2008 WMR draws primarily on 2006 data.

That being the case, it is only fair to judge progress toward the Abuja goals and indicators in the WMR based on the 2005 target of 60% coverage.  MICS or DHS data from 2006 were available in the WMR Annex concerning whether children under five years of age slept under an insecticide treated net for 17 African countries.

The attached chart gives a sobering perspective on the Abuja targets.  In 2006 reports none of the 17 countries had achieved the desired 60% of these children having slept under an ITN the night before the survey.  The figures ranged from a low of 6% in Cote d’Ivoire to 49% in the Gambia.  Half of these countries achieved 20% or less.

Great strides continue to be made in distribution and use of ITNs and other malaria interventions, but clearly the Abuja targets served more as an inspiration than a realistic goal.  The Global Fund in June of this year reported a doubling in the numbers of ITNs distributed. The United Nations has called for universal coverage.  The pressure mounts.  Will donors and endemic-country governments be up to the task of reaching 80% coverage by 2010 - which is a quadrupling of the 2006 figures in Africa?

The Nigerian Tribune announced today that, “Dr. Saraki [Kwara State Governor] will today flag off the ‘Malaria-free Kwara State’ as pregnant women and children below five years are expected to receive free malaria treatment throughout the state.” In addition, “The government had released N200 million for the procurement of insecticide-treated mosquito-nets which were expected to be distributed free to the people of the state.”

Service costs are definitely a barrier for women who need protection against malaria during pregnancy.  While the Tribune’s story does not mention other costs associated with antenatal care (ANC) where malaria services are provided to pregnant women, experiences in other states show that while long lasting insecticide-treated nets and intermittent preventive treatment are provided free to pregnant women, they must pay registration and other fees for the complete package of ANC services.  In Akwa Ibom State these fees vary from one local government to another, but basic registration can cost between US $2-5 and routine medicines like folic acid and iron can add another 50 cents - $1 each month.

What happens in Akwa Ibom and possibly elsewhere is that if women are not able to pay for the registration fees, they are not given the free services.  In the local governments where Jhpiego has a malaria in pregnancy control project, efforts have been taken to convince ANC clinic staff to provide the free services even if a woman cannot pay other fees, but some staff are reluctant because they fear entering a woman’s name for the free services unless they can also record fees collected from the same person.

In other places, like Mali, IPTp and LLINs are free, but malaria treatment for adults (including pregnant women) has costs. In many places there are time and transportation costs for pregnant women who attend ANC.  Proposals to keep ANC visits (and thus their costs) to a rational minimum through WHO’s Focused Antenatal Care (FANC) approach are often not understood or valued by health workers who believe the old schedule of an ever increasing series of monthly, then fortnightly and then weekly ANC visits is desirable even when statistical reality shows that few women attend ANC two or more times.

The challenge is not providing free malaria control services but in visualizing malaria control within integrated health care delivery - in this case antenatal care. Until efforts are made to strengthen systems and integrate services, malaria in pregnancy will remain a burden to women and newborns.

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Some recent Malaria in Pregnancy References:

• Technical Expert Group meeting on intermittent preventive treatment in pregnancy (IPTp) WHO HEADQUARTERS, GENEVA, 11–13 JULY 2007
• Duffy PE. Plasmodium in the placenta: parasites, parity, protection, prevention and possibly preeclampsia. Parasitology. 2007;134(Pt 13):1877-81
• Uneke CJ. CID 2008:47 (15 October) Effects of Placental Malaria on Perinatal Outcome; Malaria and HIV. Yale Journal of Biology and Medicine, 2007; 80: 95-103
• Schwarz et al. Placental Malaria Increases Malaria Risk in the First 30 Months of Life. Clinical Infectious Diseases 2008:47 (15 October)
• van Geertruyden et al., The Contribution Of Malaria In Pregnancy To Perinatal Mortality. Am. J. Trop. Med. Hyg., 71(Suppl 2), 2004, pp. 35–40.
• Brahmbhatt et al., Association of HIV and Malaria With Mother-to-Child Transmission, Birth Outcomes, and Child Mortality. J Acquir Immune Defic Syndr _ Volume 47, Number 4, 472-476.
• Hommerich  et al., Decline of placental malaria in southern Ghana after the implementation of intermittent preventive treatment in pregnancy Malaria Journal 2007, 6:144
• Ter Kuile, et al., Reduction Of Malaria During Pregnancy By Permethrin-Treated Bed Nets In An Area Of Intense Perennial Malaria Transmission In Western Kenya. Am. J. Trop. Med. Hyg., 68(Suppl 4), 2003, pp. 50–60.
• Sirima et al., Malaria Prevention During Pregnancy: Assessing The Disease Burden One Year After Implementing A Program Of Intermittent Preventive Treatment In Koupéla District, Burkina Faso. Am. J. Trop. Med. Hyg., 75(2), 2006, pp. 205–211.
• Falade ei al., Intermittent preventive treatment with sulphadoxine-pyrimethamine is effective in preventing maternal and placental malaria in Ibadan, south-western Nigeria. Malaria Journal. 2007, 6:88
• Brentlinger PE et al., Bull World Health Organ. 2007;85 (11): 873-9. LBW in women taking IPTp 3 times was 7% vs 12% in those taking none. (Mozambique)
• Anders et al. Timing of intermittent preventive treatment for malaria during pregnancy and the implications of current policy on early uptake in north-east Tanzania. Malaria Journal 2008, 7:79 : Exit interviews in Tanzania found that while mean gestational month of first ANC attendance was 4.5 months, first provision of IPTp on average was at 6 months. Ultimately half of women did not get any IPTp.
• Holtz et al., Use of antenatal care services and intermittent preventive treatment for malaria among pregnant women in Blantyre District, Malawi. Tropical Medicine and International Health volume 9 no 1 pp 77–82, January 2004
• Roman E, Rawlins B, Gomez P, Dineen R, Dickerson A, Brieger W. Malaria in Pregnancy: The Dynamic Relationship between Policy and Program Implementation. Harvard Health Policy Review 2008; 9(1): 198-209.

For years the standard figure of malaria morbidity has been half a billion cases a year. Now, “The World Health Organization halved its estimate of the number of people who get malaria each year, saying Thursday that better measurement techniques had cut the number from 500 million people to 247 million.”

Previous figures apparently were based on estimates that mapped where people were likely to be exposed to malaria, but data collection is deemed to be more accurate in 2006, the most recent information as presented in the new World Malaria Report 2008.  Even with reduced morbidity, “WHO left unchanged the figure of malaria deaths. An estimated 881,000 people were killed by malaria in 2006 — most of them were children under 5.” But even with better data, “Less than one-third of the agency’s 192 member countries have acceptable registration of malaria cases and deaths.”

Science Magazine cautioned that, “the report’s authors say that the drop isn’t a sign we’re winning the battle, just that the methodology of gathering data is better.” Health statistics are challenging. Science also noted that, “Determining the burden of malaria is notoriously hard because many patients don’t seek or receive medical attention, and even if they do their case may not be lab-confirmed or entered into government statistics. One result is that WHO’s numbers have huge error bars: For instance, the estimate for Kenya ranges from 5 million to 19 million cases.”

Robert Snow of the University of Oxford, U.K. and the Kenya Medical Research Institute in Nairobi was quoted by Science as sayingthat “WHO still relies too heavily on weak government data, resulting in too rosy a picture.” Fortunately donors are recognizing more and more the importance of strengthening malaria data and monitoring and evaluation (M&E) capacity in endemic countries.

The Global Fund offers M&E guidance and encourages countries to write into their proposals means for strengthening their health information systems. Countries do not always take full advantage of these health system strengthening components. Partners should therefore, continue to provide guidance and encouragement to countries to improve their M&S and health statistics so that the next World Malaria Report will truly reflect both reality and hopefully progress.

The New Vision online (Uganda) reports that “The Government is to provide Coartem, an anti-malaria drug, to private health units at a subsidised price, the Ministry of Health announced yesterday.”  These will be sold at ‘affordable prices‘ according to the ministry.

“Primary health care state minister Emmanuel Otaala said the ministry, in conjunction with donors, would provide the drugs at sh200 per dose for children and sh800 for adults.” Normally Coartem costs “between sh12,000 and sh18,000 in private clinics.” In approximate dollar terms this is a difference between a subsidized rate of US $0.12- 0.48 compared to $7.25 - 10.87.

For implementation the devil will be in the details in terms of procurement and supply chain management (PSM) (public vs private) as well as positioning of the subsidized drugs where existing products may offer the shop owners a greater profit margin.

Nigeria is reframing its Round 4 Global Fund Malaria Grant to include the private sector and provides some lessons about the challenges of dual districution channels for ACTs.  The August 2008 grant progress report outlines these issues.

“There was a delay in the approval of the PSM plan because the PR wished to repackage their ACTs in a manner that would differentiate them from those given out by YGC (Yakubu Gowon Center - PR Public Sector), the other malaria PR. That is because SFH (Society for Family Health - PR private sector) is distributing ACT through the private sector with cost recovery and YGC distributes through the public sector for free. As there were no compliant factories in Nigeria, SFH had to change suppliers to one that could package the drugs according to their needs. This delayed the approval of the PSM plan which was finally approved on March 8th 2008. Procurement is now underway andimplementation can begin fully in the next quarter.”

Private sector involvement is crucial for achieving coverage for a number of reasons, least of which are the fact that in Nigeria it was estimated that a monitory of people with malaria get their treatment in medicine shops. One could never achieve 80% prompt treatment with ACTs only in the public sector.  So while the effort is commendable, it is not something that can be embarked upon quickly.

Well thought out logistics and monitoring plans are needed to ensure the subsidized ACTs actually reach their intended population.

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Please note that the World Malaria Report 2008 is now available to download from WHO’s Global Malaria Program.

A variety of rapid diagnostic tests (RDTs) have been developed to detect malaria parasites in primary care settings.  RDTs are in part a response to the higher costs of artemisinin-based combination therapies (ATCs) and the need to reduce wholesale use of ACTs for any fever in hopes of preserving efficacy longer. Because of the great threat of malaria to children under five years of age, most endemic countries still permit presumptive treatment with ACTs for these children.  RDTs therefore, can be an important component of case management in adult populations.

Even though the cost of arthmether-lumefantrine (AL) have been brought down, and efforts are underway to achieve similar cost reductions for artesunate-amodiaquine products, there still exists justification for RDTs from the standpoint of preserving efficacy.  Charlotte Zikusooka and colleagues have documented that, “Compared to treating patients on the basis of clinical diagnosis, the use of RDTs in all clinically diagnosed malaria cases results in cost savings only when 29% and 52% or less of all suspected malaria cases test positive for malaria and are treated with AS+SP and AL, respectively.” The cost savings is obviously also dependent on the relative price of RDTs compared to adult dose costs of ACTs.

These researchers ultimately conclude that, “While the use of RDTs in all suspected cases has been shown to be cost-saving when parasite prevalence among clinically diagnosed malaria cases is low to moderate, findings show that targeting RDTs at the group older than six years and treating children less than six years on the basis of clinical diagnosis is even more cost-saving. In semi-immune populations, young children carry the highest risk of severe malaria and many healthcare providers would find it harder to deny antimalarials to those who test negative in this age group.”

The study benefits hinge on health worker judgement: “This result holds true only if health workers prescribe and or dispense antimalarials to only the patients that are found to be malaria test positive.”  Discussion with primary care clinic staff in Mozambique recently showed that this may be a major stumbling block.  Apparently they administer the RDTs, but do not trust the results, so send the client to the laboratory. Then regardless of the lab results, they tend to treat with antimalarial drugs, because ‘one never knows.’

While RDTs have an advantage among adult patients (assuming a country actually makes provision of ACTs for adults a priority), their implementation cannot be effective without proper training and follow-up supervision to reinforce correct use.