Malaria Matters: Issue 10, February 2002

This issue of Malaria Matters - Featuring Netting News was funded by: Siamdutch Mosquito Netting Co., Ltd. They can be reached at: 15 Sukhumvit Soi 33, Bangkok 10110 Thailand, phone: +66-2-258-5621, fax: +66-2-259-5084, info@siamdutch.com, www.siamdutch.com.

VitANet: The integration of vitamin A and ITN interventions

By Peter R. Berti, PhD, PATH Canada and Mark W. Young, MD, CIDA

As readers of this newsletter will know, malaria infection places a tremendous burden on the health of individuals living in malarious areas. Globally, there are approximately 1.5-2.7 million malaria deaths each year, most of which are in children under five years and pregnant women. In sub-Saharan Africa (SSA), it is estimated that 1 million deaths and over 200 million episodes of clinical disease occur each year. In many of these malarious areas, the population's health is further compromised by vitamin A deficiency (VAD). Approximately half a million children become blind each year due to VAD, two-thirds of these die within months of going blind. Further, over 200 million children are more vulnerable to infectious disease, including malaria, because of inadequate vitamin A intake. Most countries in SSA have greater than 10% prevalence of VAD among young children with some greater than 20%. The prevalence of VAD globally is decreasing, however it remains an enormous problem in SSA.

We now have available various technologies for reducing the impact of both malaria and VAD. For malaria the correct and consistent use of insecticide treated bednets (ITNs) in malarious areas can reduce the frequency and severity of clinical episodes of malaria in Africa by 20-63% (median = 45%) and the incidence of mortality by up to 60%. A similar reduction in young child mortality can be achieved through the elimination of VAD. A common strategy for eliminating VAD is the distribution of vitamin A capsules (VACs). In recognition of the health impact of VAD, in many countries, including most countries of sub-Saharan Africa, ministries of health have incorporated distribution of vitamin A capsules (VAC) into their national health plans.

The question now is not the effectiveness of ITNs or VACs but how to maximise the health benefits by delivering them effectively and efficiently. The challenge for programmers is to increase ITN usage and VAC coverage in a sustained, cost-effective manner. One solution may be through the integration of these two programs. The commonalties in the epidemiology of malaria and vitamin A deficiency are outlined in Table 1. In addition to these, a biological synergy has been observed between vitamin A deficiency and malaria: In Papua New Guinea, supplementation with Vitamin A in children under five years resulted in a 30% reduction in Plasmodium falciparum clinical episodes and a 36% reduction in parasite density. (Shankar 1999, in the Lancet).

The delivery mechanisms of the two strategies, as summarized in Table 2, may be complementary, as the scheduling of net retreatment with pyrethroid, and VAC distribution take place approximately every six months. The recommended twice-yearly VAC supplementation protocol [WHO, 1997] is the norm for most country-level programs. On the other hand, large-scale net retreatment campaigns are rare. By integrating the two programmes it may be possible to increase the coverage of both at a cost less than the combined cost of running the two programmes separately. PATH Canada is currently seeking funding to do this operational research.

(This article is based on a longer report, produced with the support of the Micronutrient Initiative in Ottawa.)

Table 1 - Similarities in Epidemiology between vitamin A deficiency and malaria

Risk Factor	VAD	Malaria
Age	Pre-school children School-age children Adolescents	Pre-school children (endemic areas); School children and adults (epidemic areas)
Physiologic Status	Pregnancy Lactation	Pregnancy
Diet	Diet low in vitamin A, or carotenoids and fats	Diet low in vitamin A and zinc
Immune status	Underlying infection	Underlying infection
Cultural factors	Dietary related, feeding patterns	Sleeping arrangements, Health seeking behaviour
Seasonality	All year but with peak period pre-harvest (food shortage)	All year but with peak period during/after rains
Socio-Economic Status	"Disease of Poverty" related to lack of available income for purchase of food	"Disease of  Poverty" related to lack of financial resources for purchase of prevention and treatment
Location	Poor growing areas, landless (urban, peri-urban)	Low-lying, wet areas, anywhere with mosquitoes
Knowledge	Lack of awareness of VAD (causes, prevention, effects)	Lack of awareness of malaria (causes, prevention, effects)

 

Table 2 - Similarities in Programming between Vitamin A Supplementation and ITNs

	Vitamin A Supplementation	ITN Distribution & Retreatment
Periodicity	Every 6 months	Every 6 months
Target Group	Children under 5 Pregnant/Lactating Women	Children under 5 Pregnant Women
Promotion/IEC	Focus on “Positive Health" (VAD - causes, effects, prevention)	Focus on “Positive Health” (Malaria- causes, effects, prevention)
Distribution Channels	Health Centres Health Workers Community Volunteers (Commercial Outlets)	Commercial Outlets Health Centres Health Workers Community Volunteers
Monitoring & Evaluation	Coverage (% receiving VAC), vitamin A status Morbidity Mortality	Coverage (% sleeping under ITN) Morbidity, serum parasite levels Mortality

 

Entry Points for Community-based Malaria Control in Africa

By Graham Root, PhD, Southern Africa Malaria, Control Programme, WHO

Why community-based malaria control?

For malaria control to be successful, the active participation of communities is vital. Decisions on whether to seek treatment for malaria or purchase an insecticide-treated bednet are made within the household not the health facility. Likewise, poor access to health facilities means treatment is often first sought within communities.

At the same time, the active involvement of communities can add value to malaria control programmes. For example:

• Communities´ knowledge and resources in the form of money, labour and materials can complement the health services resources
• Communities make better use of health services if they are involved in decisions about their development
• The likelihood of success is increased if a programme addresses the community's perceptions of their health needs and is managed with their support
• Local people gain experience and knowledge that helps empower communities and reduce dependence on external support.

Communities can be involved in a number of areas of malaria control. These include:

• Malaria awareness and education
• Prevention of malaria (e.g. ITN manufacture, promotion and retreatment; residual house spraying; basic environmental management)
• Diagnosis and home treatment of malaria
• Community surveillance in order to detect malaria outbreaks.

How can communities be reached?

A big challenge in setting up community-based malaria control is determining the best way communities can be reached. In other words, what entry points can be used to introduce and maintain community-based malaria control. For a community-based malaria control programme to be successful it is important that the entry points used are sustainable. Hence, whenever possible, existing institutions, structures and mechanisms should be used.

A large number of potential entry points exist within rural communities. The figure below illustrates potential entry points that can be used for malaria control in communities and categorises them into four groups: Local Government, NGOs and Civil Society, the Private Sector, and Informal and Other Avenues.

Local Government as an Entry Point

Important Local Government entry points include health, education, agriculture and local councils. These have the advantage of being well-established and relatively permanent features of rural communities even if they are often under-resourced. Within the health sector, health centres, community nurses, environmental health officers and technicians, and community health workers (CHWs) can all serve as entry points into communities. CHWs often form a vital link between the community and the formal health service and, hence, are ideally placed to co-ordinate malaria control activities. However, the CHW system in many African countries has deteriorated in the last decade and CHWs are often demotivated due to lack of financial incentives and inadequate support from the health service. Consequently, alternative entry points are likely to be needed.

Schools are an effective entry point for malaria control. Within rural communities the school is frequently regarded as a community resource - community members may have assisted in building the school, use it for community meetings or attend adult literacy classes run at the school. Addressing malaria within school health programmes has been done in a number of African countries. Often it has been limited to malaria education. However, more recently countries are broadening school-based malaria activities. For example, Ghana is promoting 'malaria-safe' school environments by screening dormitories, and offering treatment of malaria in schools using a designated teacher who holds pre-packaged first-line antimalarials, and clinically diagnoses and treats students with malaria.

Agricultural extension activities can serve as useful entry points. In communities where agricultural extension officers are active, they can provide technical support for malaria control activities (e.g. environmental sanitation) as well as be involved in malaria education and selling of insecticide-treated bednets. Agricultural Produce Marketing Boards can be used as a point of sale (possibly through a credit scheme) for insecticide-treated materials.

In terms of coordinating community-based malaria control, whenever possible, existing local government structures should be utilised. At the community level this is likely to be in the form of a village development committee which may report to either a ward committee or the district council. Decentralisation of government activities is occurring in many countries. Hence, district level government is becoming an important player in malaria control programmes.

NGOs and Civil Society as Entry Points

Many NGOs have extensive experience of working at the community level either directly or indirectly through community-based organisations (CBOs). CBOs may include women's groups, church groups, clubs and co-operatives. There are many examples of local micro-finance and business groups becoming involved in bednet manufacturing and selling. In epidemic-prone countries in Southern Africa, Red Cross volunteers act as community surveillance officers to provide an early warning system for malaria outbreaks. However, an issue of concern is the sustainability of using NGOs as entry points as they may be unable to form viable supportive structures in the medium-to-long term. Hence, community-based malaria control programmes that utilise NGOs as entry points and rely on them for support should ensure that other supportive structures, for example through local government, are built up.

In some countries, religious organisations can provide invaluable entry points into rural communities for malaria control. For example, Mission stations are common in many East and Southern African countries and offer a number of advantages: they are frequently located in remote rural areas with poor government service provision; they have a long-term commitment to the communities they serve; they command respect within communities; and they provide multiple entry points into communities through Mission hospitals and clinics, Mission schools, and churches and church groups.

The Private Sector as an Entry Point

Within communities the main private sector entry point are stores and kiosks. These can be regarded as "comprehensive" entry points as virtually the whole community uses them to some degree. Hence, they are ideal places to display IEC materials as well as to market and sell malaria prevention and control products (e.g. insecticide treated materials (ITMs), net treatment kits, repellents, pre-packaged first-line antimalarials). However, private sector partnerships with manufacturers, wholesalers and distributors are needed to ensure malaria control products are distributed to small, often distant, rural stores with limited turnover. Storekeepers can also be trained to diagnose and treat malaria as has been done in several African countries including Kenya and Uganda.

When communities are nearby commercial farms, community members may find employment on the farms. Such farms usually have a store for employees and sometimes for neighbouring communities. Farm stores could be outlets for malaria control products. In Zimbabwe, insecticide and bednet companies have targeted the sugar estates for the sale and distribution of malaria control products; credit schemes offered by commercial farmers have also been successful in stimulating demand for ITMs among employees.

Informal and Other Avenues as Entry Points

Certain individuals within communities or who visit communities on a regular basis may be appropriate entry points, particularly for malaria awareness and demand-creation activities. Throughout Africa urban workers maintain close ties with their rural family members and often maintain a rural home. Such people can serve as a useful conduit for dissemination of malaria information and stimulating demand for malaria control products. Advertising on buses and at terminals can help influence behavioural change among return migrants and is being done in several African countries. Likewise, marketing of ITMs can be done in the workplace.

Traditional healers and traditional birth attendants are two other examples of groups who can serve as entry points into communities. Distant and/or unaffordable formal health services has meant in some countries rural communities are increasingly turning to traditional healers for treatment. In Zimbabwe, several districts are piloting giving traditional healers chloroquine to treat patients. In Zambia, correct treatment of malaria by traditional healers is being addressed in partnership with the traditional healers association. Traditional birth attendants are often involved in antenatal care and can play an important role in preventing malaria and anaemia in pregnancy.

The above are examples of some of the many entry points that may be used for community-based malaria control. It is important to emphasise that communities and potential entry points vary appreciably both between and within countries and that which ever entry points are chosen, consideration should be given to their sustainability.

Effective community-based malaria control should not be seen as an end in itself but rather as a path-finder for creating sustainable community-based health systems in Africa that address priority health needs.

Upcoming Meetings

November 18-22, 2002: The Multilateral Initiative on Malaria (MIM) 3rd Pan-African Conference on Malaria, Arusha, Tanzania

The conference will focus on scientific progress and potential in malaria research with the aim of promoting the exchange of scientific ideas within Africa. The Conference will have specific sessions to discuss mechanisms for linking scientific research and malaria control activities. More than twenty MIM-supported research projects across Africa will also be presented. The Conference will consist of plenary presentations by world-renowned experts, numerous symposia on a broad range of topics, and daily poster sessions.

For more information contact:

Dr. Martin Alilio
Email: aliliom@mail.nih.gov
Tel:+1-301-402-6680//Fax:+1-301-402-2056

Websites of Interest

Malaria Foundation International

Established in 1995 to provide an interactive, central location to access information about malaria. The information ranges from General (e.g., Learn About Malaria, Travel Advisories, Literature, etc.) to Scientific (MFI´s Communication Center, On-Line Journals, Databases, Networks, comprehensive Conference Calendar, numerous links to agencies and societies, etc.) to Newsworthy (updated information about global and local malaria initiatives, malaria in the news, announcements, etc.).

Malaria educational site from Royal Perth Hospital

This site in now available in French, English and Spanish. You will find sections on diagnosis, prophylaxis, treatment and history. It also contains an innovative interactive "Test & Teach" self-assessment module. A CD-ROM version of the site is available for free to institutions with limited or no internet access. For more information regarding the CD-ROM contact: Graham.Icke@health.wa.gov.au.

Net Mark

Net Mark has completed a series of practical studies designed to provide information for both the public and private sector involved in promoting ITMs.