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Africa: Dramatic Anti-Malaria Results
AfricaFocus Bulletin
Feb 5, 2008 (080205)
(Reposted from sources cited below)
Editor's Note
New anti-malaria interventions, when applied together, can have
dramatic results, according to a new World Health Organization
study. The study reported declines in cases in children under five
of 60% in Ethiopia, 64% in Rwanda, 29% in Zambia, and 13% in Ghana,
between the period 2000-2005 and the year 2007. The greater impact
in Ethiopia and Rwanda was clearly associated with massive
campaigns of free distribution of long-lasting insecticidal-treated
bednets.
This AfricaFocus Bulletin contains excerpts from the study, which
was released on January 31. For additional news and background on
malaria, see http://www.who.int/malaria and
http://allafrica.com/malaria Previous AfricaFocus Bulletins on
health issues are available at http://www.africafocus.org/healthexp.php
Another AfricaFocus Bulletin sent out today contains an update on
President Bush's budget proposals and rival Congressional proposals
to increase the budget allocation for global health. While
President Bush highlighted renewal of spending on HIV/AIDS in his
State of the Union Message, activists and congressional advocates
say that his budget proposal "flat-lines" funding at current levels
and does not respond adequately to the needs.
New on http://www.noeasyvictories.org
5 full-length transcripts of interviews for book:
Mary Jane Patterson - http://www.noeasyvictories.org/interviews/int05_patterson.php
Ben Magubane - http://www.noeasyvictories.org/interviews/int06_magubane.php
Robert Van Lierop - http://www.noeasyvictories.org/interviews/int07_vanlierop.php
Geri Augusto - http://www.noeasyvictories.org/interviews/int10_augusto.php
Dumisani Kumalo - http://www.noeasyvictories.org/interviews/int14_kumalo.php
++++++++++++++++++++++end editor's note+++++++++++++++++++++++
Impact of long-lasting insecticidal-treated nets (LLINs) and
artemisinin-based combination therapies (ACTs) measured using
surveillance data, in four African countries
Preliminary report based on four country visits
31 January 2008
Submitted by: World Health Organization, Global Malaria Program
Surveillance, Monitoring, and Evaluation Unit
[Excerpts. For full report, including tables and figures, and
other related information on malaria visit
http://www.who.int/malaria]
Abstract
Background and methods:
In collaboration with The Global Fund, the World Health
Organization evaluated the impact of recent investments in
malaria control by conducting field evaluations in four countries
(Zambia, Ethiopia, Ghana, and Rwanda) in November- December 2007.
The main interventions were nationwide distribution of
long-lasting insecticidal nets (LLINs) and
artemisinin-combination therapy (ACTs) medicines.
The principal method was review of clinical data at rural
hospitals and health centers geographically distributed in each
of four countries. In Zambia, we reviewed data at the national
level for all hospitals and clinics. The main impact indicator
was percentage change in the number of in-patient malaria cases
and deaths in children <5 years old prior to and after nationwide
implementation of LLINs and ACTs. The weighted average percentage
decline of in- patients in children <5 years old in in-patient
facilities visited in Ethiopia was 60% for cases and 51% for
deaths, and, in Rwanda, was 64% for cases and 66% for deaths.
Zambia national data showed decline of 29% in cases and 33% in
deaths in children <5 years old. In general, non-malaria cases
and deaths remained stable or increased, except in Ghana. The
median decline of in-patient malaria in Ghana was 13% for cases
and 34% for deaths, but non-malaria cases and deaths declined
more than those from malaria (40% and 42%).
Conclusion.
We found strong initial evidence that the combination of LLINs
delivered during mass distributions to all children <5 years or
all households and nationwide distribution of ACTs in the public
sector was associated with widespread decline of >50% in
in-patient malaria and deaths throughout Rwanda and Ethiopia. The
main difference between Ethiopia and Rwanda with dramatic impact,
compared with Zambia and Ghana with more limited impact, was
sufficient quantities of LLINs delivered in mass distributions in
2005 or 2006.
About This Report
This preliminary report is due on 31 January 2008 to the Global
Fund from WHO about visits to four African countries.[Ethiopia,
Rwanda, Zambia, and Ghana] ... For this preliminary report, we
concentrated on in-patient ("hospitalized") malaria cases and
deaths in children <5 years, the age group with the highest
mortality rate due to malaria. As we extend our analysis, we will
add more information on older age groups, out-patient cases,
laboratory data, measures of dispersion, and other more in-depth
analyses.
Background
Conversations, field trips, and research reports indicated impact
from long-lasting insecticidal nets [LLINs] and artemisinin-based
combination therapies provided by national governments and
international partners, but systemic documentation was lacking.
Surveys alone were not providing sufficient and timely impact
data for advocacy or to optimally inform management decisions at
district, national, and international levels. Therefore, the
Global Fund and WHO used routine surveillance data to measure
impact in several African countries. Because most countries did
not have strong surveillance and logistic information systems in
place, it was necessary to make field visits to districts,
hospitals, and health centers to assess surveillance and logistic
data. Five countries were chosen to be visited by WHO malaria
personnel--Zambia, Ghana, Ethiopia, Rwanda, and Tanzania. This
preliminary report covers four countries that had visits during
November and December 2007.
Methods
Countries were chosen based on their early (2003-2006)
introduction of LLINs and ACTs and qualitative assessment by
Global Fund and WHO staff about reasonable nationwide
distribution. The visits took place during November-December 2007
and lasted two weeks. A written protocol was followed by all
teams for selection of districts and health facilities, and data
collection. Both Ministry of Health and WHO personnel were
involved in data abstraction. In Ethiopia and Rwanda, we
attempted to mostly select districts with stable malaria as well
as widespread geographical representation. In Zambia and Ghana,
all districts have stable malaria. In each selected district, we
planned for interviewers to visit one hospital and one
out-patient health facility. Interviewers abstracted data either
from health-facility copies of national surveillance forms, other
health information forms, or from patient registers. Data was
collected from the district health team about the starting date
of distribution of insecticide-treated nets (ITNs), LLINs, and
ACTs in the district; and the quantity that was received by
month. At least two persons visited each district for at least
two days. We attempted to abstract monthly data starting in 2000.
In in-patient facilities, we collected data on in-patient malaria
and all-cause cases and deaths for two age groups- -<5 years and
H5 years. In out-patient facilities, we collected data on
out-patient malaria and all-cause cases for two age groups (<5
years and H5 years) and malaria laboratory testing data where
available (number of suspected malaria cases, number tested,
number laboratory positive). Additional health information data
was collected at the national and district level about
surveillance and malaria interventions.
Selection of districts.
We planned to visit 4 districts in each country and to examine
national surveillance data if that was available. In Ghana, 4
districts in different parts of the country were selected based
on the knowledge of reasonable malaria program operations by the
national malaria program. Previous knowledge of impact measures
was not used to make selections. In Zambia, we examined quarterly
national health management information system (HMIS) data from
2000 to the second quarter of 2007. More than 900 health
facilities report in-patient data and approximately 1300 health
facilities report out-patient data. In addition, 4 districts were
selected for visits that had high percentage decline in inpatient
malaria cases in children <5 years old based on HMIS
data. HMIS data by health facility was available, including third
quarter 2007, for two of the districts visited. In Ethiopia,
Ministry of Health officials wanted to expand the number of
districts (weredas) from four to eight and the health facilities
to 13 to cover four major Regions--Ormoya, SNNP, Amhara and
Tigray (these regions have areas with moderate and unstable
malaria). Two districts (one health centre and one hospital) were
selected from each Region. Selection of the districts was mainly
based on knowledge of malaria burden and epidemiological risk
factors (such as altitude, water bodies, etc). In Rwanda, despite
the original plan to cover 4 districts, the scope of the
evaluation was extended (at the request of the national malaria
programme) to include all five provinces. We selected two
districts randomly per province; hence covering 10 of 33
districts. We selected one hospital and one health center per
district, covering 9 out of the 39 hospitals and 10 out of the
439 health centers. All heath centers had in-patient data and all
outpatient departments had data on malaria laboratory testing.
One health facility was excluded from analysis because of
incomplete data.
Number of health facilities included in the analysis.
In-patient data came from approximately 900 facilities in Zambia,
4 facilities in Ghana, 7 facilities in Ethiopia (6 hospitals and
1 health centre), and 19 facilities in Rwanda (9 hospitals, 10
health centres). Out- patient data came from approximately 1300
facilities in Zambia, 13 facilities in Ethiopia (6 hospitals, 7
health centres), and 19 facilities in Rwanda (9 hospitals, 10
health centres).
Pre-intervention and post-intervention time periods.
We estimated the percentage change in malaria cases and deaths by
comparing the average annual number of cases and deaths before
large-scale distribution of LLINs and ACTs (usually 2000-2005)
with the number of cases and deaths in the latest
post-introduction period (2007). We used the same period of
analysis (for example, January to October or January to November)
for both baseline and post-intervention (2007) periods. The
baseline period (2001-2005) was constant in Rwanda. In Ethiopia,
we used different baseline periods depending on the availability
of data. For in-patient data in Ethiopia, data was missing for
2001 for 3 of 7 in-patient facilities, for 2002-2003 for 2 of 7
in-patient facilities, and for 2003 for 1 or 2 of 7 in-patient
facilities. Instead of imputing data, we reduced the baseline
period to include years in which data was available for 6 or 7 of
7 in- patient facilities.
...
Results
Impact--Ethiopia and Rwanda. Percentage decline of in-patient
malaria cases and deaths in children <5 years old in 2007
compared to 2005 was 64% for cases and 66% for deaths in Rwanda,
and 60% for cases and 51% for deaths in Ethiopia. Figure 1 and 2
show trends of in-patient malaria and non-malaria cases in
children <5 years by year for Ethiopia and Rwanda. In-patient
malaria cases in children decline markedly while nonmalaria cases
remain stable (Ethiopia) or decline only slightly (Rwanda). ...
Impact--Zambia. From national data, percentage decline was 31%
for in-patient malaria cases and 37% for in-patient deaths of all
ages, and was 29% for cases and 33% for deaths in children <5
years. Non-malaria in-patient cases and deaths remained stable,
but out-patient cases increased 48%. The median percentage
decline from HMIS data for the 4 districts that were visited was
73% for in-patient malaria cases in children <5 years old and was
76% for in-patient malaria deaths in children <5 years old. In
two districts that we visited that had mass distribution of LLINs
in 2005 or 2006, percentage decline was 71% in cases and 33% in
deaths of in-patients <5 years old in Kalomo district, and was
53% in cases and 85% in deaths in Kaoma district.
Impact--Ghana. The median percentage decline was 13% for
in-patient malaria cases and 34% for in-patient malaria deaths in
children <5 years old. However, non-malaria cases declined even
more--40% for non-malaria in-patient cases and 42% for
non-malaria in-patient deaths in children <5 years old.
Interventions.
Table 3 shows available national-level information
about LLIN and ACT distributions by country. Ethiopia Ministry of
Health (MOH) conducted two mass distributions of LLINs--one in
2006 and one in 2005--both targeting one LLIN per 2 persons. ACTs
were first distributed in the public sector in 2005. Rwanda MOH
introduced LLINs and ACTs nationwide within a 2-month period
(September-October 2006). The MOH conducted mass LLIN
distribution to children <5 years in September 2006 during the
measles campaign. ACTs were introduced quickly in October 2006 to
public-sector health facilities. No nationwide mass distribution
was conducted in Zambia in 2005-2006 (nationwide mass
distribution was mostly completed in 2007). A nationwide mass
distribution of LLINs to children <24 months was conducted in
November 2006 in Ghana. There was stock-out of LLINs for routine
distribution at antenatal care clinics in Ghana in the districts
that we visited for nearly all of 2007. LLIN use. Survey data
indicated use of insecticide-treated nets in children <5 years
old of 23% in Zambia in 2006, 55% in Ghana in 2007, and 60% in
Rwanda in 2007.
...
Discussion
This report documents for the first time marked, geographically
widespread impact in medium- and large-sized countries using
large- scale distribution of LLINs and ACTs. Our investigation
showed that declines of malaria cases and deaths were dramatic in
Rwanda and Ethiopia (>50%) and occurred within 12-24 months of
nationwide 11 distribution of LLINs and ACTs. In fact, declines
in in-patient cases and out-patient laboratory-confirmed cases
occurred within 60 days of nationwide distribution in Rwanda
(Figure 4). In both Rwanda and Ethiopia, similar declines (>50%)
occurred for impact measures that required malaria laboratory
testing--out-patient laboratory-confirmed cases and malaria slide
positivity rate. In Rwanda, all 19 health facilities performed
malaria smears on all suspected malaria cases. The decline in
in-patient and out-patient laboratory-confirmed malaria cases
occurred in the face of increases in out-patient and inpatient
non-malaria cases in most countries during 2001 to 2004- 2005 due
to introduction of health insurance schemes, resolving civil
conflict, and improvement of health services.
In Rwanda, there was a difference in percentage declines of inpatient
cases and deaths, and out-patient laboratory-confirmed
malaria cases in the 10 health centres compared to 9 hospitals.
We are investigating this difference with further analyses.
In Ethiopia, indoor residual spraying (IRS) has been a wellestablished
vector control intervention for a long period. It is
applied in a focalized manner by targeting villages at risk for
malaria epidemics. All districts that we visited had been
applying IRS in a limited way while deploying LLINs to all
populations. We were not able to evaluate contribution of IRS to
the decline.
The nationwide decline in in-patient malaria cases and deaths in
children in Zambia by approximately one-third is a significant
achievement. However, the nationwide decline in Zambia appears to
have been lower than in Rwanda and Ethiopia. The key difference
between Zambia compared to Rwanda and Ethiopia appears to have
been insufficient LLINs to distribute nationwide in 2005 or 2006
in Zambia. In addition, our visits to districts and health
facilities showed frequent stock-outs of ACTs occurred at health
facility level in Zambia during the 2006-2007 malaria seasons.
However, in contrast to the moderate impact nationally, decline
of in-patient malaria cases in children in two districts with
mass distribution of LLINs in 2005 or 2006 that we visited in
Zambia was similar to the decline in Ethiopia and Rwanda.
The lack of definite impact associated with LLINs and ACTs in
Ghana is unexplained. The decline was 13% for in-patient malaria
cases and 34% for deaths in children <5 years but the declines in
non-malaria cases (40% and 42%, respectively) was greater. This
is consistent with general improvement in general health
services, but it is difficult to confidently ascribe the moderate
declines in malaria cases and deaths to the malaria
interventions. The short period of data available (2005-2007) at
the hospital level limited our analysis. Both malaria and
non-malaria out-patient malaria cases were rising in 2005-2007,
probably due to effects of health insurance in 2006 and 2007.
However, it was clear that the decline in Ghana did not approach
that of Rwanda, Ethiopia, or two districts in Zambia with mass
LLIN distribution.
Several factors may be involved in the limited impact. First,
there was insufficient funding to conduct nationwide distribution
of LLINs to all children <5 years or to all households. Instead,
LLINs were distributed to all children <24 months in November
2006 with the limited LLINs that were available. Environmental
conditions, increased rainfall, fees for public-sector ACTs,
limited data to measure pre-intervention baseline, and higher
malaria transmission, alone or in combination, could be
responsible for the unexpected finding.
...
Our investigation revealed that surveillance is a powerful tool
for quickly and continuously monitoring interventions with high
impact at the health facility, district, and national level. In
addition, the "slide positivity rate" (percentage positive out of
total patients with laboratory test results) was shown to be an
excellent indicator in both Ethiopia and Rwanda. The slide
positivity rate declined progressively from 30-60% to near 10%
and below in most health facilities in Ethiopia and Rwanda.
Surveillance data was not being used as a management tool in most
countries and districts that we visited, which is not unexpected
since the Roll Back Malaria partnership and The Global Fund have
not fully supported use of surveillance data to monitor impact,
either locally or at national level, in high-burden African
countries. Management information systems monitoring stock-outs
at the health facility and district level were also not in place.
Going forward, we believe that decentralized monitoring of
surveillance and logistics data, and information systems to
support analysis and use of data will be key to achieving maximal
program performance and effectiveness. ...
Although great progress has been made, much more needs to be
done in the four countries to reach malaria mortality reduction
levels of >75% in all districts. Many households still do not
have 2 LLINs per one person and many children are not
consistently sleeping under LLINs each night. The percentage of
children that receive an ACT within 24 hours of onset of fever is
not optimal.
In summary, this initial data indicates that widespread
distribution of sufficient (at least to all children <5 years)
LLINs and ACTs in the public sector resulted in widespread
dramatic reductions in the burden of severe malaria morbidity and
mortality. More limited impact in Zambia (nationwide) and Ghana
was associated with lack of nationwide distribution of sufficient
LLINs. Surveillance data revealed a potential issue with impact
in Ghana. International partners should urgently collaborate with
national governments to ensure that all households have at least
one LLIN per two persons, and that surveillance and logistics
monitoring systems are in place in all high-burden countries to
highlight management issues and enable action to resolve them.
The magnitude of decline (>50%) found in Rwanda and Ethiopia is
similar to that needed to reach Abuja mortality reduction targets
for 2010 (>50%). It appears that dramatic reduction in malaria
mortality can be achieved quickly and may enable many African
countries to make rapid progress towards the child survival
Millennium Development Goal.
AfricaFocus Bulletin is an independent electronic publication
providing reposted commentary and analysis on African issues,
with a particular focus on U.S. and international policies.
AfricaFocus Bulletin is edited by William Minter.
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