topnaman | Malaria blog

This month’s issue of the Bulletin of the WHO brings a fantastic interview with Dr Newman, director of the organization’s malaria program. A very good line:

At the centre of everything you have national malaria control programmes, which are much more sophisticated than 20 years ago.

NGrams are a neat Google feature which let’s you see the percentage of books in a year which mention a term of interest. Results for malaria in all the English language works they have cataloged between 1800 and 2008:

Notice the major peaks corresponding to the ‘discovery’ period (1890-1920) and war/eradication era (1940-1960) for malaria followed by a steady decline with a small uptick in the last ten years.

Dr Jack Chow, a former WHO official with a colorful background including management consulting and investment banking, takes a bird’s eye view of the World Health Organization in Foreign Policy magazine. WHO cannot become complacent (see here) and needs to pursue serious reforms but my agreement with Dr Chow ends there.

First, the “product” of WHO is not expertise but the ability to operate as a neutral forum for cooperation between all countries. WHO is an intergovernmental agency. Period. This feature makes it unique among other health related organizations and provides unmatched credibility and mandate. In fact, it is this aspect which enables WHO to host the diverse and talented technical panels which produce the guidelines and standards that represent the agency’s expertise.

Second, strengthening country offices is an important goal but the most pressing, and admittedly difficult, reform WHO needs is in its financing structure. WHO budget comes from two sources: general UN contributions by member countries and donated funds (usually earmarked). The balance between the two sources has changed with the latter growing in proportion with time. Now, regular contributions compose only 20% of the total meaning that the vast majority of WHO budget, and consequently operations, is under donor control. Laurie Garret notes:

Yet, as Harvard University’s Christopher Murray points out, the WHO itself is dependent on donors, who give it much more for disease-specific programs than they do for its core budget. If the WHO stopped chasing such funds, Murray argues, it could go back to concentrating on its true mission of providing objective expert advice and strategic guidance.

Overall, the article belays impatience with an admirable spirit to just “get things done” but without much concern for process, sovereignty, and accountability. Dr Chow advocates for WHO to become the go-between for donors and to bypass governments to directly work with NGOs, bilateral programs, and the private-sector groups “on the ground”. Barring the question of whether this is even desirable (it undercuts state responsibility for health and represents mission creep), if WHO is underfunded, understaffed and already can’t keep up with government needs as the article notes – how will it handle those of additional players? I expected more.

For a work that carefully dissects WHO place today in the context of it’s long history see the five-part series from the unfortunately now defunct blog Effect Measure.

Probably the largest, longest running, drug efficacy monitoring effort in the malaria world yet little appreciated and recognized. I hope our analysis and publication of thirty years of data (sorry, not open access – email me for the PDF) helps amend that. And something I do not say often enough: I am so grateful for my colleagues and mentors in India, with whom I have learned, and continue to learn, the difficult task of improving public health.

Good sentences:

Malaria can not be won by fighting from the meeting room. It is won by fighting in the frontline where decision, appropriate for the situation, is implemented with decisiveness. The key to malaria elimination is the frontline worker and its supervisor… Seeing the result of his work will motivate the front line workers to perform better and lift up his spirit that he is contributing to the improvement of the world.

From Gil de la Cruz, a government medical officer in the Philippines, who shares his experiences directing local malaria elimination efforts.

The Affordable Medicines Facility for malaria (AMFm, previously introduced here) may go down as one of the largest failures in public health history. Subsidizing effective antimalarials (namely artemisinin-combination therapies) for sale through private vendors (largely the wide-spread pharmacy/drug kiosk) is an untested idea for increasing access – yet is backed by more than $225 million in funding at a time when the successful Global Fund is struggling to finance existing commitments.

First, are decreased private sector costs even passed on to buyers? It’s hard to say in any systematic way, especially past the small trial projects. Daily Nation media from Kenya reports that the first batches to hit drug stands all over the country are going for 1.25  to 6 times the recommended price of Sh40 (US$0.50). Expect similar reports from other countries.

Second, even if the strategy works to lower drug costs in pharmacies – will it have much public health benefit? Access issues will likely persist in rural areas, where the treatments are most needed, as pharmacies are concentrated in urban areas anyways. Among those with access, the majority of people with fever will not actually have malaria and that proportion is declining as control efforts are strengthened. The resultant overuse of drugs will be enormous, other etiologies of fever may go untreated, and increased drug pressure could quicken the spread of resistance. Adherence to the full course of drugs, which are dispensed without much counseling, may be poor. Coupling a system of diagnosis with the subsidized drugs  seems near impossible, and not doing so is irresponsible.

Finally, let’s remember this is not about providing a quality medical service and does nothing to strengthen a country’s health system. The essential strategy of AFMm is to enable people to continue to “self-medicate but now with better drugs”. It is a desperation move, a stop gap at best.

Pro-market groups, such as the Clinton and Gates foundations, who pushed AFMm are showing no signs of stopping – they’ve learned one trick (and not even well) and want to try it out everywhere. In an Indian editorial, Clinton Foundation blindly promotes the idea in a country where it possibly makes the least sense (in India less than 2% of fevers are due to malaria in most areas and the government is making large investments in improving primary care). While the private sector has a role to play in improving malaria care, we should not invest money or energy in risky and unproven approaches towards this end.

PS: Medecins Sans Frontieres commentary about quality concerns with AFMm

It worked. Really well.

Vivax malaria can relapse from liver stages (hypnozoites) adding to patient burden and further transmission. In tropical settings, upwards of 50-80% of patients may relapse within 1-3 months of the primary infection. Treating the dormant liver stages, which are unaffected by standard therapies, requires 14 days of treatment with primaquine. Adherence to therapy is generally regarded as poor – patients already feel better from the main therapy, primaquine has a number of side effects, and daily dosing for two weeks is a long regimen. Explaining the rationale for the therapy is important to ensure adherence but many health workers have little training or time for counseling and, in my experience, often altogether skip it.

Directly observed therapy (DOT) is exactly what it sounds like. It can be resource intensive but is a proven strategy for ensuring complete and effective treatment (particularly in tuberculosis control efforts). The powerhouse Mahidol University tropical diseases group conducted a randomized study of DOT primaquine in Thailand and followed the patients closely over the next three months to look for new infections.

Among those receiving DOT with primaquine the incidence rate of vivax malaria during follow-up was 3.4 cases / 10,000 person-days while in the self-administered group the rate of vivax was 13.5 cases / 10,000 person-days. No serious adverse events were reported. A quick number needed to treat calculation (with some assumptions about risks) reveals that in this setting the use of DOT primaquine in just 11 cases prevented 1 additional case over three months. The authors note the (already impressive) effect of DOT on subsequent P. vivax appearance is likely an underestimate. The self-administered adherence is inflated compared to the real world. Patients are more compliant under trial conditions (they know they are being studied) and a study follow-up visit at day 7 serves as a convenient reminder halfway through the treatment.

Takeuchi et al. also examined risk factors for vivax malaria reappearance and unfortunately devoted the entire discussion to these findings. I think more conversation about the DOT strategy itself – around questions of when, where, and how to use it in program settings – is the true point of interest in this work.

WWARN (previously introduced here) has released their interactive data viewer. It is fantastic to see and use.

Viewing the tabulated data for any study (as opposed to just summary data) is a bit tricky: > click on the study icon on the map > look to the bottom left of the pop-up > click investigate study and a new pop-up will appear.

While there are few (clinical) studies in the database thus far, WWARN should be commended for the extent of raw data they make available for each, including:

• Location map
• Study profile
• Patient age range
• Recurrent parasitemias
• WHO treatment outcomes
• PCR-Adjusted cure-rate chart
• Unadjusted cure-rate chart
• Cure-rate table

ECOWAS (the Economic Community of West African States) inaugurates a task force towards this end. I’ll just raise my eyebrow at this one.

(Related, via the great TropIKA):

Professor Chris Whitty, Head of Research for the UK Department for International Development, considers that malaria elimination is “most popular where it’s least attainable” and “most realistic in the countries that can attain it themselves”.

Which is why those espousing rhetoric (albeit less now) are dangerous.

We’ve talked about the looming threat of artemisinin-resistant malaria and its spread before (here and here). Well the Gates Foundation funded containment project for the P. falciparum strains along the Thai-Cambodia border has a blog. And it looks terrific – from vivid photos, an interview with Dr Wichai Satimai (director of the Thai Bureau of Vector-Borne Diseases), and a close look at the neat Cambodian cooler boxes, the writers have been busy since starting in September. I will be following with great interest.