Organizations Against Malaria

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QUESTION

What is a good organization that helps stop malaria?

ANSWER

There are many organizations that work very hard to control malaria. The most well known are those that design policies and implement projects to control malaria on the ground, in places where the disease is most deadly. These include multilateral international organizations such as UNICEF and the World Health Organization (as well as its regional counterparts, such as the Pan-American Health Organization, PAHO), country-led aid organizations such as DIfD in the UK and USAID in the US (the President’s Malaria Initiative, PMI, is largely implemented via USAID) as well as non-governmental organizations which seek to improve the lives of people in developing countries, such as Save the Children, Malaria No More and many other such groups.

Some of these groups have also joined forces to create multi-faceted organizations and programmes dedicated to controlling malaria, such as the Roll Back Malaria consortium and the Global Fund to fight AIDS, TB and Malaria, which provides millions of dollars of funding to projects throughout the world.

Secondly, there is also an aspect to malaria control which is not so easily seen on the ground, and that is the vast numbers of researchers who are dedicated to finding new drugs to treat malaria, new methods for control and new insecticides to prevent transmission from mosquitoes, among many other examples. These researchers are found in universities and research institutes all over the world, including many in sub-Saharan Africa, India and other places where the burden of malaria is very high.

On our website, you can find some personal accounts of scientists, working for the global pharmaceutical company AstraZeneca, who are doing drug discovery research in Bangalore, India. There are also blog posts from scientists at Princeton looking at transmission of malaria between monkeys and humans in south-east Asia, and information about cutting edge research at the Global Health Group at the University of California, San Francisco, whose members conduct work on a variety of aspects of malaria biology and control initiatives.

The “E” word and the “V” word: Two Holy Grails of Malaria Control

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The Roll Back Malaria Partnership talks confidently of elimination—many others question if this is possible without new interventions. The recent publication of the first Phase 3 clinical trial for a malaria vaccine shows promise, but is it actually good enough?

REVIEW OF:

  • Roll Back Malaria Partnership, “Eliminating Malaria: Learning from the Past, Looking Ahead”, Progress & Impact Series, vol 8, October 17th, 2011
  • RTS,S Clinical Trials Partnership, “First Results of Phase 3 Trial of RTS,S/AS01 Malaria Vaccine in African Children”, New England Journal of Medicine, October 18th, 2011

This past week has been a busy one in the world of malaria research and control. On Monday, the Roll Back Malaria Partnership (a joint enterprise between the World Health Organisation, UNICEF, UNDP and the World Bank) released the 8th volume in its Progress & Impact Series, entitled, “Eliminating Malaria: Learning from the Past, Looking Ahead”. The report summarizes RBM’s malaria eradication and elimination efforts to date, and outlines action plans and on-going progress in all malaria-endemic countries around the world. The overall tone of the document is highly positive, emphasizing the various success stories of countries achieving or nearing elimination of malaria in different parts of the world.

This is nowhere more obvious than in Chapter V’s regional summary of the WHO African Region, where no mention is made of the countries that are struggling the most with malaria control, but instead the focus is entirely on congratulating the 4 countries that have already achieved elimination, and praising those 12 countries with existing or imminent plans to move towards elimination. The document as a whole is a comprehensive overview of the status of malaria control, although somewhat light on epidemiological specifics. I was also dismayed to see at least two large photographs of fingerprick blood samples being taken without protective gloves being worn, against all standard diagnostic protocol!

But that’s an aside. In their conclusion, the authors primarily support “existing interventions”, and caution against waiting for “better options” to become available, given the measurable successes already being achieved in many settings using already-available control strategies such as bednet distribution, improved access to diagnosis and treatment and vector control.

It is not perhaps without a touch of irony then that on Tuesday, the first comprehensive analysis of an on-going Phase 3 clinical trial for one of the most promising malaria vaccine candidates was published, in the New England Journal of Medicine. The quest for a malaria vaccine has been protracted, expensive and, thus far, basically unsuccessful, yet to many, global elimination of malaria will not succeed without an intervention that gives lasting protection against re-infection, given the extraordinarily high rates of transmission of malaria in some parts of the world.

The paper reports a reduction of clinical malaria and severe malaria by 56% and 47% respectively, although protection seemed to decay over time; further evaluations will be analysed in 2012 and at the conclusion of the trial in 2014. The authors of the paper are careful to note that the trial was conducted in a cohort with generally good access to medical care, well-supplied health facilities and widespread usage of bednets and other control interventions. As such, mortality from malaria was low even in the control group, and so conclusions about the impact of the vaccine on malaria-related deaths may be difficult to draw.

Moreover, the paper did not directly analyse the relationship between the antibody titers (levels of immune protection to malaria in the blood) conferred by the vaccine and if the patient got malaria or not. In previous studies (for example, Bejon et al.’s 2008 paper also in the NEJM), this relationship was weak, suggesting that the vaccine itself was not contributing strongly to levels of protection against infection, and that other factors were at play. One suggestion is that the adjuvant, a non-specific immune-response enhancer included in the vaccine, may itself play a role, and given that the control groups received vaccines with a different adjuvant, this may partially account for the variations in malaria prevalence seen between the children studied. However, these early data still show potential at least for reducing clinical cases of malaria in a highly-endemic African setting.

It should be noted that these findings do not come entirely as a surprise; there were early signs of potential, at least partial, protection from this vaccine (the results of the Phase 2b trials were published in The Lancet back in 2004). Despite this, the word “vaccine” is mentioned but twice in the latest RBM report. I have a deep admiration for the RBM and all that the partnership has achieved thus far in the struggle to control malaria throughout the world. Without a doubt, the scale of the problem is immense, and they are right to emphasise the enormous achievements many countries have realized, and particularly in reducing malaria mortality in the last 10 years. Nor would I advocate for countries to latch onto the promise of a vaccine too quickly; clearly more research is needed to evaluate the long-term efficacy of the vaccine, as well as its impacts specifically on mortality as opposed to morbidity; hopefully we will have some of these answers in a year, at the conclusion of the Phase 3 trial.

However, in the meantime, there is clearly a huge opportunity for using these preliminary findings to determine what role there might be, if any, for the vaccine in its existing form as part of new and improved control strategies. For example, if the vaccine is not fully protective, might it, perhaps counter-intuitively, actually be more effective in areas which are already well on their way to successful control, by reducing transmission below that which is viable for the persistence of malaria? Or will its role in reducing incidence of severe disease be equally well utilized in extremely high prevalence and low health infrastructure areas, where access to diagnosis and treatment is the limiting step in effecting control? To its credit, RBM has acknowledged this since the publication of the vaccine trial results, with the following statement from the CDC: “These promising vaccine trial results add to the hope that adding an effective vaccine to current malaria interventions will move us closer to that goal.” Perhaps the “better option” wasn’t so long in coming after all.

 

Reports of community mobilisation on prevention and treatment of malaria

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QUESTION:

Do you have any reports on community mobilisation on malaria prevention?

ANSWER:

There are a lot of organisations that utilise community involvement and mobilisation in their strategies to prevent and control malaria. One example of such an organisation is UNICEF; they work closely with governments to develop initiatives that allow for scaling up of community and health facility integrated packages for the control of malaria. Such packages might include distribution of bednets alongside messages about education to prevent malaria, plus diagnosis and treatment of infections. More information can be found on the UNICEF website.

Malaria in Sub-Saharan Africa

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QUESTION:

I live in the USA and I would like to start a business to fight mosquitoes and malaria: Can you advise me how and where to start?

ANSWER:

I take it from the subject heading of the question that you would like to focus on sub-Saharan Africa—a crucial thing to note at this stage is that malaria is serious disease that affects millions of people throughout Africa (as well as across the rest of the world’s tropical and sub-tropical regions) and as such, I would encourage you to think about ways in which you can help people fight the burden of this illness.

You also should understand that many of the people who are at greatest risk from contracting malaria also happen to live in extreme poverty; an inability to pay for diagnosis or treatment is one of the great problems affecting the sustainability of malaria control initiatives in developing countries. As such, if you plan to start a business aimed at fighting mosquitoes and malaria, you need to think carefully about the model for such an initiative; for example, do you intend to make a profit? Many organisations already work in sub-Saharan Africa as non-profit organisations (NPOs), which use fund-raising or the sale of bednets in order to provide free services elsewhere, and these types of organisations are generally better respected in terms of their motivation to eliminate the burden of malaria in impoverished communities. So, if this sounds like the type of work you would be interested in setting up, I would look at the various other organisations that are already working on the ground in sub-Saharan Africa (Malaria No More, the Malaria Consortium, and non-governmental organisation such as the World Health Organisation and UNICEF, to name a few) and see if you can find a niche where you think you can make a difference to people’s health. To gain experience, you might also consider seeing if any of these organisations accept volunteers or have job positions open, to see what working to fight malaria is really like in practice.

Treating Malaria by Health Extension Workers: A Case Study from Ethiopia

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For many years the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) have been promoting an Integrated Management of Childhood Illness (IMCI) training package to ensure that nurses and doctors are capable of treating sick children at health facilities.  Over the years, with the realization that many children did not have access to health facilities and therefore were not being ttreated, the two organizations published a Joint Statement on Managing Pneumonia in Community Settings (2004)[1].  This groundbreaking document calls on countries to bring treatment of childhood illness – pneumonia as well as malaria and diarrhea closer to communities that need it, by empowering trained community health workers to identify and manage these problems. Many countries have followed this advice with excellent results.  Here is a story from Ethiopia.

Aminata is a health extension worker (HEW) at the Tebisa health post, located in a rural, hilly area of East Amhara, some 400 kilometers away from Addis Ababa, the capital city of Ethiopia. Aminata received training on integrated community based management of common childhood illnesses (iCCM) in early 2011. After the training, she carried the essential materials and supplies with her back to the health post, and started treating children suffering from pneumonia, malaria, diarrhoea and/or severe acute malnutrition.  In the last two months, she has treated 35 children under five.

HEW Ethiopia
A Health Extension Worker (HEW) with Almaz and her family. Photo: Dr. L. Pearson

One of the children suffering from malaria is a five year old girl, Almaz (which means diamond in Amharic). She developed fever one night in April. Her mother took her to the health post and she was seen immediately. Aminata checked her temperature (39.0 OC), and respiratory rate (children sometimes have pneumonia and malaria at the same time) and pricked her finger to obtain a drop of blood to perform a Rapid Test for Malaria (RTM) to look for malaria parasites [Ed: Rapid Diagnostic Tests, or RDTs, are another, more general term for these tests].

Almaz did not have rapid breathing, an indication of pneumonia, but she did have falciparum malaria (the most severe and deadly of the types of malaria found in humans, and caused by the Plasmodium falciparum parasite).  She was given Coartem (Arthemeter-Lumefentrine) treatment by mouth for three days.  Aminata gave the first dose of medicine and gave the mother the rest of the tablets, explaining when to give them. Aminata made a point to discuss how important it is to feed a sick child so they do not lose weight, and to be alert to certain ‘danger signs’ in case the child is not getting better, in which case they should return immediately to the health post.

On the second day of treatment her mother brought her back to the health post for a follow up check.   Almaz’s mother expressed her gratitude. “If the HEWs are not providing treatment for sick children, I would have to carry Almaz to the health center some 4 hours away by foot. I would also have to pay for the treatment.  We were frustrated before iCCM started because we were not able to help children with malaria and pneumonia”.

malaria medicines at health post Ethiopia
Malaria medicine available, for free, at the Tebisa health post in Ethiopia. Photo: Dr L. Pearson

“The communities trust and support us even more now”, said Aminata. “Now the mothers are so happy, they even bring the children for immunization without us having to push them”.

In the next two years, about 20,000 HEWs will be trained and supported to provide iCCM in 10,000 rural villages. Hundreds and thousands of young children in Ethiopia will benefit from the iCCM programme jointly supported by the government of Ethiopia, Catalytic Initiative of Canada, UNICEF and other development partners. Program implementation will focus on remote and harder to reach villages and households, to ensure every child is covered, no matter where they are and who they are.

The iCCM is be an important opportunity to further improve quality of care provided at the health posts, and accelerate toward the achievement of Millennium Development Goal 4, to reduce deaths of children under 5 by two-thirds by 2015.

[1] Management of Pneumonia in Community Settings (PDF)

Malaria – Free Bednets?

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QUESTION:

Why do people have to pay for the bed nets?  I think that is mean to the people and they should get them for free.

ANSWER:

You have hit on a very important and on-going debate in the malaria control community. In many places around the world, organisations such as UNICEF have distributed free, insecticide-treated bednets, and especially to mothers—pregnant women and children under five are the groups most at risk from dying from malaria.

In 2010, UNICEF reported that together with its partners (WHO, the EU and the World Bank, to name a few) 5.5 million free bednets have been distributed in DR Congo alone. Similarly, in Mozambique, the Malaria Consortium has been working in a partnership with DFID and the public sector to distribute 400,000 bednets to pregnant women as part of an ante-natal service, again targeting some of the most at-risk people.

However, you are right to say that in some cases, people have to pay for bednets; in some of the poorest countries in the world, this can seem like an unjustifiable expense. However, there are some arguments in favor of having people buy their bednets.

For example, some people argue that a purely public donation initiative is unsustainable, and in order to have an on-going distribution campaign, the private sector has to be involved at some level, and this usually means charging a fee for each bednet. Moreover, forcing people to buy their own nets would free up donor funds for other purposes. Similarly, it is thought in some circles that having payment encourages suppliers to continue producing and selling nets. Finally, there are suggestions that purchasing a bednet increases their value to the recipient, who subsequently uses their net more frequently and more reliably in the manner in which it is intended (and not, for example, as a spare fishing net, as I’ve seen in parts of Uganda!).

I believe a study in Malawi showed that by asking people in urban areas, who have a bit more disposable income, to purchase full-price bednets, the program was able to generate sufficient funds to offer bednets at a highly subsidized cost in rural, poorer areas of the country; by asking people to purchase the nets, the program believed bednet usage among its recipients was higher overall, than if the nets had been given out for free.

I think the organization that tried this approach was called PSI (Population Services International)—they also offered nurses a small monetary incentive to sell bed nets (at the small sum of 50 cents each) to the rural women who attended pre-natal clinics, thus encouraging them to offer the nets widely to pregnant women.

As the final word, a study in Kenya recently showed that as costs for services such as bednets increased, demand for the service among the poorest sectors of the population declined sharply. Instead, it seemed most economical and efficient to target high-risk groups with free bednets, who are also incentivized to use the product properly and value the protection it confers, such as pregnant women in ante-natal settings, rather than doling them out to the community at large.

So we’re back to where I started with this response; the great job that many organizations out there are doing in distribution insecticide-treated bednets to the people who need it the most, and who can’t afford to buy them themselves, although it is worth bearing in mind that alternative models of bednet funding and distribution might prove equally beneficial and potentially more sustainable, at least in certain areas.

I’m also going to ask Hugo Gouvras to weigh in on this one—he works for Malaria No More, an organization that has recently launched an innovative mechanism for accelerating funding provision for bednet distribution to Africa. Hopefully he can update anything that I have said which is old news, and provide additional information!