Tropical Health Matters

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.

Solomon Afolabi has delved into the challenges for public health in 21^st Century Africa in the posting below. He is currently an Advisor to the Upper Nile Institute (UNI) of South Sudan, Kiryandongo, Uganda and an Alumnus of the Johns Hopkins Bloomberg School of Public Health and its African Public Health Network.

As we move further into the 21st century, the challenges facing public health in Africa are becoming increasingly complex and difficult to address. Despite numerous advancements in medical technology, many African nations continue to struggle with a wide range of health issues, which have been their most pressing challenges. These issues span a wide spectrum, from infectious diseases like cholera, malaria, Ebola, HIV, and more recently, coronavirus, to an escalating burden of chronic diseases. However, these health concerns are not isolated; they intersect with broader socio-economic factors such as poverty, armed conflicts, and government mismanagement. WHO in April 2023 stated that, “for all the hard-won gains that have been made over the past 75 years, more than 100 health emergencies still occur in the African Region annually, including outbreaks of cholera, yellow fever, meningitis, measles, and Ebola. These emergencies still pose a significant threat to the health, well-being, and development of African countries”

Photo: Cholera active case finding team, Kalikiliki settlement in Lusaka, Zambia (October, 2023)

The battle against infectious diseases in Africa is still ongoing. While a significant number of these diseases have been largely eradicated in other parts of the world, they continue to pose a serious threat to the health and well-being of millions of people across the continent. As earlier stated, these diseases including tuberculosis  are still major public health concerns in many African nations, and efforts to address these issues are often complicated by factors such as poverty, lack of access to healthcare, limited resources and governments not making meaningful investments.

Another major challenge facing public health in Africa is the rising incidence of non-communicable diseases (NCDs), which includes conditions such as cancer, diabetes, and cardiovascular disease, often associated with lifestyle factors such as diet, exercise, and smoking. Contrary to the traditional thought of NCDs as diseases of affluence, they are becoming increasingly prevalent in many African countries. This is partly due to changing lifestyles and the adoption of more westernized diets, as well as limited access to preventative healthcare services.

A third major challenge facing public health in Africa is the impact of environmental factors on health. Poor air quality, contaminated water, and inadequate sanitation are all major factors contributing to a range of health problems across the continent. In many cases, these environmental factors are linked to poverty and lack of access to basic resources such as clean water and sanitation facilities. Climate change is also expected to have a significant impact on public health in Africa in the coming decades, with rising temperatures and changing weather patterns likely to exacerbate existing health challenges.

Photo: Climate change projected to cause global food shortages, WHO-AFRO

Furthermore, there is the challenge of ensuring that healthcare services are accessible and affordable to all. Many African nations continue to struggle with limited resources and infrastructure when it comes to healthcare and ensuring that all individuals have access to basic healthcare services remains a significant challenge. This is compounded by factors such as corruption, political instability, and conflict, which can disrupt healthcare services and limit access to care. Despite these challenges, there are also reasons for optimism when it comes to public health in Africa. Advances in medical technology and healthcare delivery are helping to address many of these issues, and there is growing awareness of the importance of preventative healthcare measures such as vaccination and early detection. Additionally, there are many dedicated healthcare professionals and organizations working tirelessly to improve vaccine production and health outcomes across the continent.

In conclusion, the challenges facing public health in 21st century Africa are many and varied. From the ongoing battle against infectious diseases to the rising incidence of non-communicable diseases and the impact of environmental factors on health, there are many complex issues that need to be addressed. However, with continued investment and dedication, there is reason to believe that progress can be made in improving health outcomes for all Africans.

Affordable pharmaceuticals play a major role in the control of infectious and tropical diseases. Dr Naveen Anaswara and Dr Ashok Kumar Kanaparthi explore the importance of quality generic medicines in India in a post on the class blog for the course Social and Behavioral Foundations of PHC. See their thoughts below.

Even though National Medical Commission(NMC) emphasizes the importance of prescribing generic drugs in India, it is not being implemented in the ground level. Many stake holders including Indian Medical Association(IMA) are skeptical regarding the quality of generic drugs compared to branded drugs. India is one country with highest out of pocket expenditure especially for drug purchases.Usage of generic drugs can reduce the out of pocket expenditure ensuring equity.

The Hatch-Waxman Act, also known as the Drug Price Competition and Patent Term Restoration Act, was passed on September 24, 1984, during the 98th United States Congress. It created the current system of government regulation for generic drugs in the country and encouraged the pharmaceutical industry to produce generic drugs.Many countries follow the generic drugs prescription.The generic drugs should be with the same efficacy and quality as the branded drugs.

Unlike in US , India lack stringent quality checking mechanisms.India has struggled with the problem of illegal narcotics for a considerable amount of time. The Central Drug Standard Control Organization (CDSCO) found that approximately 4.5% of generic medications sold on the domestic market in 2018 were below par. In the meantime, the country’s dearth of high-quality testing facilities is the root of the problem.

When the Department of Pharmaceuticals introduced the Jan Aushadhi Scheme (JAS) (Public Medicine Scheme) in 2008, the Government of India (GOI) appeared to be taking a strong stand against the private pharmaceutical industry’s outrageous drug prices by providing generic medications at reasonable costs.But due to lack of enough publicity, poor supply chain and lack of prescriptions from doctors this scheme could not flourish.

India have to take the campaign for generic drugs prescription. At the same time Ministry of India should ensure the standard quality of all generic drugs.

Our Stance: Support for Generic Drug Promotion

1. Public Awareness Campaigns: Initiating comprehensive public awareness campaigns can empower patients and families with information about the benefits of generic drugs.
2. Incentives for Healthcare Providers: Offering incentives to physicians, pharmacists, and hospitals for prescribing and dispensing generic drugs can drive adoption.
3. Enforcement of Policy: Stronger enforcement measures by government health authorities are essential both for prescriptions and quality assurance.

Embracing generic drugs in India is not merely a policy suggestion but a pathway to equitable and affordable healthcare. By working collaboratively with stakeholders, advocating for informed choices, and implementing concrete strategies, we can make quality healthcare accessible to all.

Tom Kehinde has posted an important perspective on local and community action in HIV control on the blog for the course Social and Behavioral Foundations of Primary Health Care. See the key issues from that posting below.

Nigeria grapples with one of the highest burdens of HIV/AIDS globally, with an estimated 1.9 million people living with the virus. Despite significant international assistance, the country heavily relies on external financing to combat the epidemic. This dependency on foreign aid is unsustainable in the long term and undermines Nigeria’s ability to address the epidemic effectively, perpetuating health disparities and social inequalities. Marginalized populations, such as women, youth, face heightened vulnerability to HIV infection due to limited access to prevention, treatment, and care services. To confront this pressing issue, empowering local HIV control organizations through increased domestic funding not only enhances their capacity to deliver targeted interventions but also fosters community ownership and sustainability.

(Photo source: The guardian)

Highlighting the position of stakeholders on this issue, firstly, WHO plays a pivotal role in providing technical guidance and support to countries like Nigeria in combating HIV/AIDS. Collaborating with WHO to develop evidence-based guidelines and technical assistance programs could bolster Nigeria’s efforts towards mobilizing domestic resources for HIV financing. National Agency for the Control of AIDS (NACA): the leading agency responsible for HIV/AIDS control in Nigeria, NACA advocates for increased domestic financing and empowerment of local HIV control organizations. Partnering with NACA to strengthen advocacy efforts and capacity-building initiatives could drive policy change. Despite the importance of mobilizing domestic resources for HIV financing, several challenges persist. These include inadequate funding allocations in national budgets, limited institutional capacity for effective resource mobilization and management. Developing a strategic plan such prioritizing advocacy for increased domestic funding for HIV/AIDS programs, enhance coordination among stakeholders, strengthen institutional capacity for resource mobilization and management, and promote community engagement and ownership of HIV/AIDS interventions. To conclude, mobilizing domestic resources for HIV financing is vital for Nigeria’s epidemic control. WHO must provide tailored guidelines, technical support, and advocate for local engagement. NACA should prioritize policy advocacy such as lobbying for increased budget allocations, strengthen collaboration as establishing joint task forces with other government agencies and NGOs, facilitating resource-sharing and coordinated efforts, and enhance community involvement. These concerted efforts will empower local organizations, bolster health systems, and mitigate the HIV burden, fostering sustainable development.

Sudan’s Mental Health Crisis: Community-Led Peer Mental Health Counseling

Omnia Hassan has posted about a unique program of peer-led mental health counseling. Read her thoughts below and check them in the class blog of Social and Behavioral Foundations of Primary Health Care. As Sudan faces persistent war and conflict, the focus must turn to Sudanese internally displaced persons (IDPs) who are unable to escape the country, facing increasing incidence rates of several serious mental health burdens. Graphs Source: Mental health consequences among Sudanese due to the armed conflicts and civil unrest of 2023: a cross-sectional study In Sudan, there are only two psychiatric hospitals and seventeen outpatient mental health facilities for a population of over 40 million. To support the IDPs with improved access to mental health care, the development of a community-led mental health counseling program may be beneficial where community members are educated on how to counsel their peers through mental health burdens. This initiative aims to reduce the effects of mental health illnesses, create a space to speak about difficult experiences, provide accessible mental health resources, and empower Sudanese individuals, restoring their autonomy. A successful example of this program in Uganda with Rwandan and Somali refugees with PTSD where the evidence demonstrated that 65% of participants no longer fulfilled the criteria for PTSD. Universities in Sudan, such as Ahfad University of Women, have committed themselves to the education and training of community members to equip them with the knowledge and skills to provide mental health counseling for their peers. The Sudan Ministry of Health (MoH) has lent staff and workers to increase the numbers of those being trained to become lay counselors. Funding is a particular point of discussion, and the United States has frequently sent funds to Sudan for humanitarian assistance. The U.S. Department of State funded a grant for the Ahfad University of Women before as part of the University’s Trauma Training Treatment Center. Photo Source: Reuters The UN Refugee Agency acknowledges the displacement issues brought upon the Sudanese population during the war. They have explicitly commented on the displacement of Darfuris in the western region of Sudan, sharing the interventions they have implemented to mitigate mental health issues, such as promoting social cohesion. With over 10 million people uprooted and 9 million people internally displaced, Sudan’s war fuels the largest displacement crisis in the world. The mental health of these individuals needs to be addressed as they endure the most grueling event of their lives.

 

Sue Lee has posted about the progress being made with Seasonal Malaria Chemoprevention in Mali on the class blog site for Social and Behavioral Foundations for Primary Health Care. Learn more about the issue below.

As highlighted by the U.S. President’s Malaria Initiative, Mali’s Kita district is grappling with a significant health challenge — malaria. Seasonal Malaria Chemoprevention (SMC) has emerged as a potent strategy to combat this, yet hurdles such as inadequate healthcare infrastructure, logistical issues, and insufficient community education hamper effective delivery. We advocate for policy enhancements and increased funding to improve the healthcare delivery system for SMC in Kita, Mali.

The Ministry of Public Health and Hygiene plays a crucial role. By highlighting SMC’s successes in similar settings and urging the integration of these strategies into national policies, supported by evidence, we can persuade the MoH to prioritize improved healthcare delivery mechanisms for SMC, ultimately enhancing child health in Kita.

Collaborating with the Malaria Consortium offers technical expertise and resources, which could amplify our efforts, ensuring the program’s best practices and enhancing our advocacy and fundraising capabilities.

Community Health Workers (CHWs) face challenges due to inadequate resources and training, particularly concerning SMC. Enhanced education and financial support for CHWs can bridge the gap between communities and healthcare services, allowing higher community engagement and effective delivery of health interventions.

Engaging local community leaders, such as village heads, through informational sessions and providing them with educational materials can foster community support and amplify SMC acceptance.

Caregivers of children under five are central to the success of the SMC program; Engaging caregivers through targeted awareness campaigns and providing clear, simple information about SMC’s benefits can foster trust and increase program uptake.

Lastly, the Global Fund’s role is also crucial. By crafting detailed proposals that resonate with their strategic objectives, we can secure the necessary funds and support to expand our SMC initiatives effectively.

The fight against malaria in Kita requires collective action to overcome logistical and educational barriers, ensuring all children under five are not just survivors but thrivers in the face of malaria. By uniting stakeholders, from government officials to local communities, we can transform the landscape of malaria prevention in Mali, ensuring a healthier future for the most vulnerable. Join us in this critical mission to combat malaria and safeguard our children’s futures

Almost 40 years ago efforts got underway to eradicate another human infectious disease from the face of the earth. Smallpox eradication. Defined as the total elimination of the disease from every country, had been successful, facilitated by the basic technology of an effective vaccine. There were difficult times with the organization and management aspects of smallpox eradication, but the organizers of the campaign were able and willing to adapt their strategies as they learned more about the epidemiological, social, and cultural aspects of the disease.

Praise has been given to guinea worm efforts because of the start contrast between 3.5 million cases in the mid-1980s to only 13 so far verified in 2024. Interestingly, progress has been inching, as one author put it, toward zero for at least 10 years, long after the earlier target date of 1995. Clearly a disease that was theoretically “simple” to eliminate through the provision of clear, safe water supplies, was not so simple after all.

Despite his recent health and family challenges President Jimmy Carter has never waivered from his support to eradicate guinea worm as reported by CNN.  The Carter Center’s 2023 report showed a remarkable reduction in Guinea worm cases, bringing the ancient parasitic disease closer to being eradicated.  Alix Boisson-Walsh provides details in a Lancet Infectious article entitled “Diseases Guinea worm disease inched closer to eradication in 2023.”  The Carter Center shared these highlights for 2023:

• Eradication of Guinea worm disease remains in sight with only 13 provisional human cases reported worldwide in 2023.
• The Carter Center announced Thursday. The number matches the lowest annual total of human cases ever reported, following 13 cases in 2022 and 15 in 2021.
• When The Carter Center assumed leadership of the global Guinea Worm Eradication Program in 1986, an estimated 3.5 million human cases occurred annually in 21 countries in Africa and Asia.

• The grisly parasitic disease has been reduced by 99.99% since eradication efforts began and is poised to become the second human disease and the first parasitic disease eradicated in history.
• Reports of animal infections slightly increased due to expanded surveillance in Angola and Cameroon.

• All figures for humans and animals are provisional until officially confirmed, typically in March. Guinea worm is poised to become the second human disease in history to be eradicated, following smallpox, as well as the first parasitic disease and the first without a medicine or vaccine. Community-based and innovative behavioral change and local mobilization are the key drivers of success.

Building on seven World Health Assembly resolutions and hosted by The Carter Center, Reaching the Last Mile, the UAE, and the WHO, representatives of impacted countries (Angola, Chad, Ethiopia, Mali, South Sudan, Sudan, Democratic Republic of the Congo, and Cameroon) and organizations renewed their commitment to eradicating the debilitating disease by 2030 by signing the Abu Dhabi Declaration on the Eradication of Guinea Worm Disease, in 2022 and pledged to commit resources, energy, and policy initiatives to eradicate Guinea worm disease.

Four decades of disease eradication work may seem like a long time, but like smallpox, guinea worm has been around for millennia. CDC notes that, “In 1959, the World Health Organization (WHO) started a plan to rid the world of smallpox,” and “the 33^rd World Health Assembly declared the world free of this disease on May 8, 1980.”

Malaria eradication efforts started, stalled and resumed beginning with the National Malaria Eradication Program in the USA on July 1, 1947. Subsequently, “the World Health Organization (WHO) submitted at the World Health Assembly in 1955 an ambitious proposal for the eradication of malaria worldwide.” We are still aiming for 2030 and beyond to rid the world of malaria country-by-country.

In 1998 Walter R. Dowdle outlined three indicators that were considered to be of primary importance in eradicating a disease. These included “an effective intervention is available to interrupt transmission of the agent, practical diagnostic tools with sufficient sensitivity and specificity are available to detect levels of infection that can lead to transmission, and humans are essential for the life-cycle of the agent, which has no other vertebrate reservoir and does not amplify in the environment.” In 2000, Aylward and colleagues also posed three criteria including “(1) biological and technical feasibility, (2) costs and benefits, and (3) societal and political considerations.”  Andrews and Langmuir post the awkward reality that “If … the decline in new cases is halted by circumstances which slow it down to a fluctuating equilibrium at some point approaching but not quite reaching zero, the disease may be declared administratively to be under control, though it is certainly not eliminated.”

The persistence of low-level human transmission of guinea worm may appear encouraging when compared to he initial estimate of 3.5 million infections, but we hope that the political and social commitment will persist so that the dwindling cases will eventually reach zero. Additional effort is needed now that one of Dowdle’s criteria has been breached, another vertebrate reservoir (domestic dogs, cats and others who share unsafe water sources with humans). The costs and benefits can be questioned as eradication is drawn out over time. Guinea worm has always epitomized the concept of NTDs wherein not just the disease but the people who suffer from it are neglected. Eradication will only come when that neglect stops.

Mike Toso, Senior Program Officer at the Johns Hopkins Center for Communication Programs shares an update on visualizing malaria behaviors and determinants of malaria behaviors.

Breakthrough ACTION and the U.S. President’s Malaria Initiative are excited to announce the launch of the Malaria Behavior Survey (MBS) Dashboard, a new resource available on the MBS website.

The MBS Dashboard presents cross-sectional data collected from individuals and households in sub-Saharan African countries. This interactive dashboard allows users to explore MBS data on a single easy-to-explore platform. Currently, the dashboard includes data from six countries, and Breakthrough ACTION plans to add others as data points become available.

The dashboard shows a selection of the most important data points from the full MBS. It can be easily accessed on one’s smartphone if users are out in the field or at an informal meeting.

Additionally, the dashboard uses the collected data to make recommendations for program implementers to follow. These recommendations are generated dynamically, corresponding to the selected country’s data. National malaria programs and other partners working in malaria SBC can use MBS results to develop evidence-based malaria SBC programs and strategies.

The MBS is unique in that it gathers data on the behavioral factors that influence people’s use of malaria prevention and treatment interventions. Surveys in multiple countries often measure behaviors but do not assess the cognitive, emotional, or social factors associated with those behaviors. Such insights will help programs more fully address the needs of individuals and communities in combating malaria.

Link to blog post: https://ccp.jhu.edu/2023/04/24/malaria-dashboard-data-research/ “New Malaria Behavior Survey Dashboard “Like a Swiss Army Knife”

Link to Malaria Minute podcast: https://publichealth.jhu.edu/malaria-research-institute-1 (episode “How can Behavioral Science Improve Bed Net Use” 5/15/2023

 

 

 

 

 

A new study from Kenya addresses one of the major challenges to malaria elimination. The authors note changing vector behaviour towards early morning biting has been established. Children are observed to come to school early, as do mosquitoes that have “peak landing between 06:00 and 07:00.” They also found that mosquitoes continue their activity until 11:00. The An. funestus mosquitoes they collected “were either fed or gravid, potentially indicative of multiple bloodmeals within each gonotrophic cycle, and had a sporozoite rate of 2.05%.” this is of particular concern because school aged children are not always prioritized in various malaria control interventions.

In Cambodia researchers found that “20% of collected Anopheles were active during the day, with increased day biting during the dry season.” Ellie Sherrard-Smith and colleagues explain that bednets and indoor residual spray are intended to work best when people are indoors and sleeping. They caution that, “Mosquito bites taken outside of these times contribute to residual transmission which determines the maximum effectiveness of current malaria prevention.” Their review documented that on average 21% of mosquito bites in Africa take place outside bedtime.

A study in Tanzania by Nicodem J Govella et al. noted that the use of insecticide-treated nets for malaria control has been associated with shifts in mosquito vector feeding behaviour including earlier and outdoor biting on humans. They concluded that efforts highlighting the need for control methods that target early and outdoor biting mosquitoes are now required.

In short, various changing factors ranging from climate and mosquito genetics to even the existing interventions like bednets that we use to control the biting of malaria carrying mosquitoes, threaten our ability to eliminate malaria. New vector control measures are urgently needed as is expansion of other interventions like malaria vaccines.

Bill Brieger and Bright Orji conducted an examination of national surveys and program reviews to document achievement of antenatal care and IPTp targets in Nigerian preparation for a poster presentation at the 2023 American Society of Tropical Medicine and Hygiene annual meeting in Chicago.

In 2012, the World Health Organization updated the Intermittent Preventive Treatment of malaria during pregnancy (IPTp) coverage indicator to a minimum of three doses. In 2014, Nigeria set the national target of 100% of women attending ANC to receive IPTp.

This study reviewed national survey data for antenatal care (ANC) attendance and IPTp provision from the 2013 and 2018 Demographic Health Surveys (DHS) and the 2015 and 2021 Malaria Indicator Surveys (MIS). Extracted from the national malaria program reviews (MPR) of the National Malaria Strategic Plans (NMSP) of 2014 and 2019 were explanations of program implementation issues. ANC4 attendance and IPTp uptake (1st and 3rd doses) were compared using descriptive statistics.

The 2015 MIS did not document ANC 4th visit, so attendance in the remaining surveys was 51%, 57%, and 52% (X2=160.0, df2, p <0.0001). The slow increase of ANC attendance and drop in 2021 meant that opportunity to acquire three IPTp doses was not possible for most women. Over the four surveys, IPT1 increased from 23% to 47% to 64%, then dropped to 58%. IPTp3 rose from 6% to 19% then dropped to 16.6% before increasing to 31% (X2= 1755, df3, p<0.0001).

The MPR reports identified four factors inhibiting achievement of the ANC and IPTp targets including insecurity (terrorism, civil unrest), poor integration of malaria in pregnancy into reproductive and maternal health programs, inadequate procurement and stock-outs of SP, and logistical hurdles (lack of vehicles and fuel). By not meeting ANC4 and IPTp1 targets, limits were set for IPTp3 uptake.

As other researchers have suggested, NMSPs embody global targets and may not reflect local realities. Local governments, who deliver the bulk of ANC and IPTp services, must be part of the process of setting and planning how to achieve targets.