Global efforts focusing on eliminating malaria are counterproductive to the fight against the disease in Africa, experts have warned. They emphasise the importance of maintaining, and building on, control strategies rather than aiming for a target that may not be met. Buoyed by a reduction in malaria mortality in Africa, health leaders in 2007 switched their primary goal from control to elimination. But researchers from the Kenya Medical Research Institute-Wellcome Trust Research Programme in Nairobi now say that the emphasis on elimination or eradication in strategic plans for the next 10 to 20 years in Africa is 'at best irrelevant and at worst counterproductive', raising expectations that cannot be met. Increased use of insecticide-treated bed nets, improved rapid diagnostic tests and the replacement of failing drugs with artemisinin-based combination therapy are among the interventions that have helped to reduce malaria transmission and incidence substantially across the continent. On the coast of Kenya, for example, the incidence of severe malaria has fallen by more than 90% in the last five years. However, the researchers warn that positive results are not universal throughout Africa. A substantial funding gap remains to meet the estimated US$4 per head needed to treat malaria, which currently stands at less than US$1 per head.
Equitable health services
In this study, an initial assessment of hospital management systems demonstrated weak functioning in several management areas. In response, the authors developed a novel Master of Hospital Administration (MHA) programme, a collaborative effort of the Ethiopian Ministry of Health (MoH), the Clinton HIV/AIDS Initiative, Jimma University and Yale University. The MHA is a two-year executive style educational programme to develop a new cadre of hospital leaders, consisting of 5% classroom learning and 85% executive practice. It has been implemented with 55 hospital leaders in the position of chief executive officer within the MoH, with courses taught in collaboration by faculty of the North and the South universities. The programme has enrolled two cohorts of hospital leaders and is working in more than half of the government hospitals in Ethiopia. Lessons learned include the need to: balance education in applied technical skills with more abstract thinking and problem solving; recognise the interplay between management education and policy reform; remain flexible as policy changes have direct impact on the project; be realistic about resource constraints in low-income settings, particularly information technology limitations; and manage the transfer of knowledge for long-term sustainability. The authors hope that this programme will set a precedent for other sub-Saharan countries wishing to improve their health sector management.
According to this study, clinically protective malaria vaccines consistently fail to protect adults and children in endemic settings, and at best only partially protect infants. It identified and evaluated 1,916 immunisation studies between 1965 and 2010, and excluded partially or nonprotective results to find 177 completely protective immunisation experiments. Detailed re-examination revealed an unexpectedly mundane basis for selective vaccine failure: live malaria parasites in the skin inhibit vaccine function. It show how published molecular and cellular data support a testable, novel model where parasite-host interactions in the skin induce malaria-specific regulatory T cells, and subvert early antigen-specific immunity to parasite-specific immunotolerance. This ensures infection and tolerance to re-infection. The paper concludes that skinstage-initiated immunosuppression, unassociated with bloodstage parasites, systematically blocks vaccine function in the field. The model it uses exposes novel molecular and procedural strategies to significantly and quickly increase protective efficacy in both pipeline and currently ineffective malaria vaccines, and forces fundamental reassessment of central precepts determining vaccine development. This has major implications for accelerated local eliminations of malaria, and significantly increases potential for eradication.
Reproductive health problems among teenagers are the focus of a new European Union-funded project, which will investigate the effectiveness of existing programmes and identifying the structural drivers that restrict access to adolescent reproductive health (ARH) services in Niger and Tanzania. The INTHEC ('Health, education and community integration: evidence based strategies to increase equity, integration and effectiveness of reproductive health services for poor communities in sub-Saharan Africa') project has received EUR 2.75 million in funding under the European Union's Seventh Framework Programme. The project, launched in March 2010 and scheduled to end in February 2014, will also address the cultural barriers that currently limit access to or curb the effectiveness of ARH services in the two countries. Led by the Liverpool School of Tropical Medicine in the United Kingdom, the INTHEC consortium consists of experts from the fields of reproductive health research and interventional implementation, as well as leaders in governance and policymaking in Belgium, Niger and Tanzania. The government ministries responsible for ARH in Tanzania and Niger are partners in the programme, meaning that the outcome of the research will be genuinely owned by the key policymakers, helping ensure the impact of this research beyond the life of the project.
Primary health care in rural South Africa is predominantly provided by remote clinics and health centres. In 1994, health centres were upgraded and new health centres developed to serve as a health care filter between community clinics and district hospitals. This study set out to describe the spectrum of clinical problems encountered at a new health centre in an area of high economic deprivation and compare this with an adjacent community clinic and district hospital. The International Classification of Primary Care-2 (ICPC-2) was used to code data collected over a 13-week period from patients presenting at a community clinic, health centre and district hospital. Altogether, 4,383 patient encounters were recorded across all three sites in 2001. Most contacts at the clinic (97%) and the health centre (80%) were with a nurse. Females over 15 years of age comprised over half of all contacts at health facilities (53%). The most common diagnosis category was respiratory (23%). Cough was the most common symptom. Thirty per cent of children up to 5 years of age were seen for immunisations. Most childhood immunisations (79%) were carried out at the health centre. The study concluded that, of all the health care facilities surveyed, the health centre had the highest throughput of patients, indicating that the health centre is an efficient filter between the community and hospital. In this light, the ICPC-2 system can be successfully used to monitor encounters at similar African health care facilities.
This study aimed to describe the burden of malaria in Gauteng Province, and to identify potential risk factors for severe disease. It conducted a prospective survey of malaria cases diagnosed in hospitals throughout Gauteng from December 2005 to end November 2006. It identified 1,701 malaria cases, of which 1,548 (91%) were seen at public sector hospitals and 153 (9%) at private hospitals, while 1,149 (68%) patients were male. Most (84%) infections were acquired in Mozambique. While most patients appropriately received quinine, only 9% of severe malaria cases received the recommended loading dose. The incidence of malaria in Gauteng was higher than previously reported, emphasising the need to prevent malaria in travellers by correct use of non-drug measures and, when indicated, malaria chemoprophylaxis. Disease severity was increased by delays between onset and treatment and lack of partial immunity. The study recommends that providers should consult the latest guidelines for treatment of malaria in South Africa, particularly about treatment of severe malaria. A change in drug policy to artemisinin combination therapy for imported uncomplicated malaria in non-malaria risk provinces should be strongly considered.
Oral polio vaccine (OPV) is recommended to be given at birth together with BCG vaccine. This study investigated the effect of OPV given simultaneously with BCG at birth on the immune response to BCG vaccine. It compared the in vitro and the in vivo response to PPD in the infants who received OPV and BCG with that of infants who received BCG only. The study is the first to address the consequences for the immune response to BCG of simultaneous administration with OPV. The authors expressed concern that the results indicate that the common practice in low-income countries of administering OPV together with BCG at birth may down-regulate the response to BCG vaccine.
This study sought to describe the magnitude and variation of the epilepsy treatment gap worldwide. A systematic review of the peer-reviewed literature published from 1 January 1987 to 1 September 2007 in all languages was conducted, using PubMed and EMBASE. The purpose was to identify population-based studies of epilepsy prevalence that reported the epilepsy treatment gap, defined as the proportion of people with epilepsy who require but do not receive treatment. The study found that the treatment gap was over 75% in low-income countries and over 50% in most lower middle- and upper middle-income countries, while many high-income countries had gaps of less than 10%. However, treatment gaps varied widely both between and within countries. The dramatic global disparity in the care for epilepsy between high- and low- income countries, and between rural and urban settings, calls for immediate attention, according to the study. It urged for a broadening of current understanding of the factors affecting the treatment gap and recommended that future investigations should explore other potential explanations of this gap.
A Kenyan initiative to use mobile phones to improve health systems indicates that the use of mobile phones to track patients may help relieve the burden of overworked health workers. 'Eighty percent of those [health workers] we talked to in Nairobi and Kajiado said they feel relieved - health workers need that kind of relief,' said Sarah Karanja, study coordinator of the Weltel Project. 'Patients, on the other hand, feel they are cared for which is good for their health and wellbeing.' Weltel uses a weekly text message to study mobile-phone effectiveness for health. The message to the patient reads 'Mambo', Swahili for 'How are you?' to which the patients can respond 'Sawa' ('OK') to show they are fine, or 'Shida', which means 'problem', to show they need attention. Patients who respond Shida and non-responders are followed up with a call from the clinic nurse to identify and handle any problems. Initial study findings reveal that 80% of patients are comfortable with the use of mobile phones to manage their HIV care and treatment. Mobile phone use in Kenya has risen rapidly from 200,000 users in 2000 to an estimated 17.5 million today, offering great potential for expanding the use of mobile phones for health services.
This report presents for the first time the treatment outcomes from all sites providing complete data for new and previously treated multi-drug-resistant TB (MDR-TB) patients. Ten of the 27 high MDR-TB burden countries reported treatment outcomes. A total of 71 countries and territories provided complete data for treatment outcomes for 4,500 MDR-TB patients. In 48 sites documenting outcomes, patient management and drug quality were found to conform to international standards. Treatment success was documented in 60% of patients overall. The report found that treatment success in MDR-TB patients remains low, even in well-resourced settings because of a high frequency of death, treatment failure and default, as well as many cases reported without definitive outcomes. New findings presented in this report give reason to be cautiously optimistic that MDR-TB can be controlled. While information available is growing and more and more countries are taking measures to combat MDR-TB, urgent investments in infrastructure, diagnostics, and provision of care are essential if the target established for 2015 – the diagnosis and treatment of 80% of the estimated M/XDR-TB cases – is to be reached.