Malaria Matters

We can include malaria among the various environmental problems created when humans destroy forests. Yesterday’s Guardian International looked at the problem in the Peruvian Amazon and reported that, “Climate change and deforestation are behind the return of malaria in the Peruvian Amazon. Off-season rain is altering the pattern of mosquito development, leaving puddles containing the lethal larvae in areas where malaria had been nonexistent.” Unfortunately, this forces “the mosquito to move to new areas and spreading the disease to places where people are not aware of the disease, where villagers lack the means to get hold of mosquito nets and preventive medicines, and where health authorities have no presence.”

Similarly, Afrane et al., reported that, “Significant increases in net reproductive rate and intrinsic growth rate for mosquitoes in the deforested area suggest that deforestation enhances mosquito reproductive fitness, increasing mosquito population growth potential in the western Kenya highlands.”

Yasuoka and Levins have reviewed “60 examples of changes in anopheline ecology and malaria incidence as a consequence of deforestation and agricultural development.” They found that, “sun preference was significantly associated with an increase in (anopheline) density,” although they did insert the caveat that the changes are complex and not necessarily linked directly with increased malaria incidence. They conclude that, “Because deforestation is a process that cannot be readily controlled for a variety of political and economic reasons, investigations and assessments of possible impacts of future deforestation will be crucial to minimize the ecological degradation caused by human activities and to prevent epidemics of malaria and other vector-borne diseases.

Another challenge of deforestation to malaria control is loss of plants that could provide new treatments for malaria and other diseases. Kayode demonstrates in Ekiti State, Nigeria how botanicals used by local populations for treating malaria are becoming rarer. The problem arises because of a land tenure system that pushes the boundaries of farms into the forests.

As if there were not already enough competition for scarce malaria control funding, such changes in climate and mosquito breeding can make the problem worse. In looking at the economic burden of malaria we talked about the need to integrate malaria control and development planning. Now we can see that environmental management must also be a strong part of that picture.

A new study published in Tropical Medicine and International Health (TMIH) shows that the burden of malaria falls disproportionately on poorer households. Somi et al. report that, “Poorer households bear a greater economic burden from malaria relative to their consumption than better-off households. Households are particularly vulnerable to malaria in the rainy season, when malaria prevalence is highest but liquidity is lower. Alternative strategies to assist households to cope with seasonal liquidity issues, including insurance, should be investigated. The seasonal variation in the economic burden of malaria has implications for the design and interpretation of studies.” The attached graph shows these findings for the rainy season.

In the same issue of TMIH, Deressa et al. look at the experience of rural families in an area of epidemic malaria and conclude that, “Malaria poses a significant economic burden on rural households and individuals both through out-of-pocket payment and person-days lost.” They suggest that, “The promotion and implementation of insecticide-treated nets would alleviate the economic consequences of the disease.”

Malaria Journal reported last year that, “The impacts of malaria on household economic status unfold slowly over time. Coping strategies adopted can have negative implications, influencing household ability to withstand malaria and other contingencies in future,” in a review article by Chuma et al. These negative coping strategies include borrowing money and selling assets, often because poor people have delayed seeking treatment they know they cannot afford.

As mentioned above, providing ITNs to the poor is a step in the right direction. Other pro-poor interventions that cut mortality and improve equitable access to services include “Strict monitoring of patients, removal of prescription charges for families, and small financial incentives for the staff cut hospital mortality for malaria” and “Implementation of home based practices using prepackaged antimalarial drugs.”

Ultimately, as Chuma et al., suggest, “To protect the poor and vulnerable, malaria control policies need to be integrated into development and poverty reduction programmes.” In short - the Millennium Development Goals see malaria control as part of development, not a vertical disease program. Donors and health planners need to take note.

VOICES is hosting a 5-day “International Conference of Malaria Advocates” in Bamako, the capital of Mali. The overall objectives of the meeting include:

• Strengthen coordination among malaria advocates particularly information-sharing, planning, and priority setting
• Highlight achievements and challenges in achieving SUFI and malaria advocacy
• Advocate to President Amadou Toumani Toure for more visible political support for malaria control.

According to Panapress as reported in Afrique en ligne, “Malaria represents 33 per cent of the complaints in the health centres in Mali and children below five account for 34.4 per cent of the cases.” The conference will build on such important malaria statistics to hone the advocacy skills of participants.

Mali is an appropriate host country for this effort as it is a recipient of malaria support from both the Global Fund to Fight AIDS, TB (GFATM) and Malaria and the US President’s Malaria Initiative (PMI). PMI selected its focal countries based on existence of other donor support in order to provide synergies that will hasten malaria control. Advocacy in Mali should help forward this agenda.

Early assessment of the malaria grant by GFATM found that, “The overall program performance in meeting the overall expectations was inadequate. Results on the impact indicators have also not been reported on. However … the program has demonstrated potential for improvements.” (See “MAL-102-G01-M-00-GSC.pdf” at GFATM Mali Website.) There was also need for better program monitoring on the ground. Advocacy can help turn the potentials into realities.

MSF and Save the Children are not waiting for more children to fall ill and die from malaria. They are using community volunteers to get treatment out to the villages. According to the UN IRIN, “The results from both the MSF project and a similar one being run by Save the Children are due to be presented to the government later this year, but the staff of both projects told IRIN that provisionally they have recorded at least a 50 percent improvement in the number of children being treated.” These successful efforts are another boon to the advocacy process. International donors and NGOs should use the example of Mali to pull together for advocacy efforts in all malaria endemic countries.

In August Dodoo et al., reported in The Lancet about community backlash to a deworming program in Ghana. What may have been a few side effects, other diseases or preexisting conditions led to rumors that propelled citizens into ‘mass hysteria and civil unrest,’ and ultimately threatened confidence in the public health system (www.thelancet.com, vol. 370, August 11, 2007, pp. 445-6).

This is not Ghana’s first major public relations disaster with medicines. In 2004 Ghana adopted artesunate-amodiaquine as its first line antimalarial drug, which appeared fortuitous since the drug could be manufactured locally. When the amodiaquine component was wrongly formulated in some products and reactions occurred, the public almost rejected the need for ACTs to treat malaria. fortunately pharmacovigilence capacity did exist at the University of Ghana.

Other incidents in vary from ‘exaggerated’ response to side effects as has occurred in the ivermectin distribution programs for controlling onchocerciasis (Semiyaga et al.) to real life threatening reactions during a Pfizer drug trial debacle in Nigeria. Regardless of the ‘real’ pharmacological outcome of public health drug research and distribution programs, community perceptions, responses and rumors must also be monitored and addressed.

Thus, in addition to pharmacological aspects of pharmacovigilence, we also need a social, emotional and cultural barometer in communities where programs are based. According to Dodoo et al., this social vigilance requires, “excellent communication, and crisis management planning to accompany public-health programmes that involve mass administration of a drug.”

Social vigilance can perform two functions. First it can respond quickly to real threats to health and life, whether from drug reactions or use of drugs that are no longer effective. Secondly it can dispel rumors where these threaten the life saving ability of truly safe community drug distribution programs.

The US Embassy in Tanzania has announced a donation of about 50 insecticide-treated nets to HIV/AIDS orphans. While this is a relatively small effort, it sets a good example for possible synergies between HIV and Malaria programming and funding.

The attached map from WHO shows the geographical overlap of the two diseases. According to WHO’s Global Malaria Program, “The resulting co-infection and interaction between the two diseases have major public health implications.

• HIV-infected people must be considered particularly vulnerable to malaria;
• Antenatal care needs to address both diseases and their interactions;
• Where both diseases occur, more attention must be given to specific diagnosis for febrile patients.”

It is important therefore that ITNs are not only given to orphans, but all HIV infected people, particularly pregnant women. Malaria enhances transmission of HIV to the child, and therefore ITNs are an important component of PMTCT. Therefore, all donor programs that have both malaria and HIV components need to plan together to serve those in need and not think only in vertical control paradigms.

PS - Thanks for your support and interest. This is our 100th malaria blog.

The collapse of health and other social infrastructure is a common outcome of conflicts such as civil wars. In such settings one does not talk about ‘health sector reform’ glibly, but must consider the whole issue of health sector rebuilding. Two post-conflict countries are currently included in the US President’s Malaria Initiative (PMI), Angola and Liberia. Both are also recipients of GFATM malaria grants. What do lessons about malaria control can we learn from administering these two programs?

The situation in Angola is summed up succinctly by the PMI country assessment. “Angola recently emerged from almost three decades of civil war that severely impacted its development, particularly the health sector. It is estimated that 80% of the health facilities were looted or destroyed during the war and that the existing health system covers only about 30% of the Angolan population, with even lower utilization rates.” The national surveillance system “has limited human and financial capacity and lacks nationwide coverage, standardized procedures for the collection and analysis of data, and an effective communication system to ensure timely reporting.”

In addition to limited laboratory facilities, the PMI assessment found procurement problems. “Given that many key agencies and systems are not yet in place or fully functional, the GFATM proposal proposes that procurement functions be carried out by WHO while providing for support not only for the program of activities under the NMCP but also for strengthening the system in general.” To address these challenges, PMI and GFATM recipients have been working on coordination efforts over the past two years, according to GFATM. In addition GFATM recommends moving away from an external Principal Recipient and that the “PR shall present a revised plan that reflects the gradual transfer of responsibilities to the NMCP staff. A plan with measurable targets for the capacity-building activities should be agreed upon.”

Recently the US President expressed concern to the Liberian President about the continued death of Liberian children from malaria and indicated that PMI would be setting up shop soon. The GFATM Grant Performance Report of August 2007 for Liberia observed that, “The internal audit section has however not been able to conduct these audits in Liberia due to staff shortage as well as the situation of insecurity prevailing in the country.” Human resources for health are scarce generally in much of sub-Saharan Africa, and are exacerbated in post-conflict settings. In Liberia, GFATM noted that, “There is no M&E expert dedicated to this project.” It was further observed that, “There are some tensions existent in regards to having a non-local entity (UNDP) as PR.”

The selection of a non-indigenous Principal Recipient is not uncommon, but in post-conflict settings, lack of strong civil society organizations and weak government bureaucracies may be a factor. The Report further states, “There are very few active donors in Liberia and most organizations are struggling for funds. There is as a result little organized effort for harmonization of programs and requirements.

As of the August 2007 Report, Liberia was behind target in terms of staff training and number of service points supported for malaria case management, though they appear to be on target for reaching pregnant women and distributing ITNs. ITN distribution may be done outside the formal health system, but case management requires a fairly well organized public and private sector, even when volunteer community-based workers are involved.

Some of the health systems and implementation problems mentioned above may not appear terribly different from those faced by other Sub-Saharan countries, and maybe it is a matter of scale. Key lessons appear to be a need for collaboration and coordination among the often few donors on the ground and efforts to build and re-build local capacity. Citizens of these countries have suffered enough and do not need ‘wars’ among donors and recipients and certainly must win the war against malaria.

Do people have a right to live without malaria? This appears to be a theme that will be addressed at the first Annual Lecture on Malaria and Human Rights sponsored by the European Alliance Against Malaria and the UK Coalition Against Malaria on 10^th December 2007. The key speaker will be Professor Paul Hunt, UN Special Rapporteur on the Right to Health.

The Special Rapporteur on the right to the highest attainable standard of health defined this human right as “an inclusive right not only extending to timely and appropriate health care, but also to the underlying determinants of health, such as access to safe and potable water and adequate sanitation, healthy occupational and environmental conditions, and access to health-related education and information, including on sexual and reproductive health.”

According to the report, Water and the Right to the Highest Attainable Standard of Health, by Hunt and Khosla, “The prevention, treatment and control of epidemic, endemic, occupational and other diseases is a central obligation of the right to health.” These issues also feature prominently in the UN Millennium Development Goals.

Are the MDGs a ‘Bill of Rights’ to overcome poverty? The nations who signed on in 2000 “committed themselves to making the right to development a reality for everyone and to freeing the entire human race from want. They acknowledged that progress is based on sustainable economic growth, which must focus on the poor, with human rights at the centre.” In fact Hunt and Khosla note that the MDGs “cannot be achieved without effective health systems that are accessible to all.

Paul Hunt outlines two broad approaches to promoting the ‘right to health’, the judicial and the policy. “The “policy” approach demands vigilant monitoring and accountability.” This is where research and advocacy is needed. Hunt notes that neglected diseases affect neglected communities, and a rights approach helps spotlight the neglect and form a basis for advocacy.

UNICEF reports on use of this approach in Mozambique. “Malaria represents a significant health problem in Mozambique. Since the late 1990s UNICEF-Mozambique has developed a new strategy to fight malaria through a methodology combining human rights-based approach to programming and community capacity development,” and has used this to guarantee among others the distribution of free ITNs in areas of need. A health rights based approach is therefore, a valuable tool in the fight against malaria.

The World Development Report 2008: Agriculture for Development. points out starkly that agriculture has been neglected. Evidence exists that rural poverty has actually increased in Sub-Saharan Africa and South Asia, two areas of high malaria endemicity. Therefore the World Bank calls for greater investment in agriculture in developing countries. According to

Jaques Diouf in the International Herald Tribune, rising agricultural commodity prices, climate related disasters, and population increase are among factors threatening food security in the developing world. “World Bank studies show that a 1 percent price rise for staple food products leads to a drop of around 0.5 percent in calorie intake for the world’s poorest.” At the same time Diouf sees opportunities for African agricultural development if past neglect cited in the World Development Report is addressed. One needs to throw malaria into this equation.

The World Development Report identifies several ways in which malaria affects agriculture and agriculture affects malaria. Production systems, particularly irrigation and micro dams facilitate mosquito breeding. Generally the siting of villages and farms near water sources increases the likelihood of malaria, and malaria in turn is a major drain on agricultural production. The neglect of agriculture and the farming population over the years has rendered them less able to purchase or access malaria prevention and treatment services.

On the other hand some practices like keeping livestock near the house may deflect mosquitoes from humans. Even better, the Report identified that improved income from agricultural investments actually makes it possible for people to buy ITNs and obtain treatment in a timely manner. The key lesson from the report is that rural development - both in terms of health and agriculture - must be planned together for optimal benefits.

At our panel on malaria in pregnancy during the Women Deliver conference, a participant asked about the importance of cerebral malaria (CM) in pregnancy. Below is a brief review of recent available literature, which does indeed highlight CM as an important danger to pregnant women in certain settings.

For the most part the literature mentions the problem of CM in the form of review without presenting original data. For example, malaria is cited as one of the most frequent parasitic diseases in pregnancy in tropical countries, with CM as an important complication. [1] Such reviews distinguish that CM is more common and dangerous in low or seasonal transmission areas where the population has not built some natural immunity. CM has a wide geographic scope according to Karnad and Guntupalli who said that, “Infections such as cerebral malaria and acute viral hepatitis with fulminant hepatic failure are common causes of coma and seizures during pregnancy in tropical regions of Asia, Africa, and Latin America. [2]

As noted by Duffy and Fried, “In low transmission areas, women of all parities are at risk for severe syndromes like cerebral malaria, and maternal and fetal mortality are high. In high transmission areas, where women are most susceptible during their first pregnancies, severe syndromes like cerebral malaria are uncommon.” [3] Likewise, “Acute and severe consequences of pregnancy-associated malaria (PAM), such as materno-fetal death or cerebral malaria, seem limited to unstable malaria areas.” [4]

An example of a specific study came from Ethiopia where Mengistu et al., observed that, “Out of 204 reproductive age women admitted with severe malaria 57.8% were pregnant. Signs of severity occurred more frequently in the pregnant women and rural dwellers. The several neurological manifestations were most common complications for more than 70.0% of the pregnant women and in 60.0% of the non-pregnant women, namely cerebral malaria, convulsions, altered mental state and prostration. The case fatality rate 33.1% among the pregnant women was found to he significantly higher than the non pregnant (p = 0.03, OR 2.2. 95% confidence interval 1.1-4.2).” [5] Much of malaria in Ethiopia is of the highland and seasonal variety.

In addition a 10-year review of malaria in pregnancy cases in Karnataka, India, which had risen to an incidence1.3% in 1998, found that, “Complications noted in our study were haemolysis, renal failure, hepatopathy and cerebral malaria.” [6] In the Arusha highlands a study of maternal death documented, “cerebral malaria [as a cause] of indirect death, accounting for 20 cases, with most of them occurring during an epidemic season.” [7]

Although at present the biggest attention to malaria in pregnancy is focused on stable transmission areas of the African region, this brief review suggests that vigilance to protect pregnant women from CM in all malaria zones is required. Not only are preventive interventions needed early in antenatal care, but staff involved in emergency obstetric care need to be trained to manage CM.

References.

1. Bourée P, Bisaro F. Parasitic diseases and pregnancy [Article in French] Rev Prat. 2007; 57(2):137-47

2. Karnad DR, Guntupalli KK.Neurologic disorders in pregnancy. Crit Care Med. 2005 Oct;33(10 Suppl):S362-71.

3. Duffy PE, Fried M. Malaria in the pregnant woman. Curr Top Microbiol Immunol. 2005; 295:169-200.

4. Cot M, Deloron P.Malaria prevention strategies. Br Med Bull. 2003;67:137-48.

5. Mengistu G, Diro E, Kassu A. Outcomes of pregnancy in severe malaria with emphasis on neurological manifestations in Gondar Hospital northwest Ethiopia. Ethiop Med J. 2006; 44(4):321-30.

6. Sitalakshmi S, Srikrishna A, Devi S, Damodar P, Mathew T, Varghese J. Changing trends in malaria–a decade’s experience at a referral hospital. Indian J Pathol Microbiol. 2003 Jul;46(3):399-401.

7. Olsen BE, Hinderaker SG, Bergsjø P, Lie RT, Olsen OH, Gasheka P, Kvåle G.Causes and characteristics of maternal deaths in rural northern Tanzania. Acta Obstet Gynecol Scand. 2002; 81(12): 1101-9.

Bill and Melinda Gates held an important malaria summit this week, where Melinda Gates stressed , “A goal of anything short of eradication would be unethical and a bad business decision, despite unsuccessful efforts to stamp out the disease in the 1950s and 1960s.” She stressed that scientific advances since those early eradication days make it worthwhile to revisit the idea of eradication. Truly there are vaccines on the horizon, new malaria treatments, long lasting insecticide nets, a variety of insecticides for IRS and strategies like IPTp to prevent malaria in pregnancy that did not exist before.

Bill Gates also pointed to the relatively large infusion of funding into malaria control: “The new initiatives have committed 3.6 billion dollars to control malaria.” Though of course this is still below amounts needed for control, let along eradication. This raises the issue of national and health systems support, not only in terms of financially matching donor funds but also in guaranteeing a system that is capable of long term sustainability of gains and concerted prompt effort to really achieve eradication.

A veteran in the efforts to eradicate smallpox and guinea worm, Donald Hopkins of the Carter Center, did raise a note of caution. “We have a very complicated disease with a history of failure in eradication,” he said. Simply striving to control the disease is a difficult enough task, he pointed out.” Experience has shown that eradication needs to rally strong human, organizational, financial and technical resources in a relatively short period of time. The lack of the organizational resources was a stumbling block of first effort to eradicate malaria, and one needs to be sure that health systems are up to the task this time. GFATM and World Bank do give resources for health systems strengthening, but other malaria programs do not.

Donors and people lose interest if eradication is promised but not fulfilled. “Bill Gates also called on US politicians running in the 2008 presidential campaign to keep Bush’s 1.2 billion-dollar malaria initiative alive,” according to the Seattle Times, so the advocacy process for eradication has started. Let’s take this as a sign of hope, but remain realistic of the hard work needed by all partners to make eradication happen.