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Sustainable Malaria Control

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Clive Shiff
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Sustainable Malaria Control

I am greatly concerned with the current philosophy about malaria control, and would like to start a conversation to build upon this controversial subject.

Too often the message discussed takes the perspective from the writer, and we tend to be possessive. However realistically and in the long run the control operations are necessarily the domain of the local Ministry of Health. Certainly if the operations are to be sustained it will be their responsibility. They have to cut the suit according to the cloth, so realistically the strategies must be designed to suit local situations.

Then who is there to design such interventions? In most endemic countries there is a dearth of local scientists, hardly any epidemiologists are employed in the MoH and so a lack of personnel to become familiar with the extent and distribution of the disease. Most programmes are run by medical officers (and in deference) they see health issues differently from those in public health.

There needs to be a great deal of integration between the medical and biological approach in setting a strategic plan. In my own case, in Rhodesia when we ran a successful malaria control operation for nigh on 50 years!, the programme was locally designed, based on local expertise and dealt with issues like insecticide resistance in mosquitoes etc. The strategy was based on IRS done systematically and under strict supervision with effective distribution of chloroquine. The fatality rate and transmission of malaria during that period was microscopic and can be referenced in the annual reports of the Secretary for Health. These are located in the National Archives in Harare.

These days, much of the interventions are designed as projects, there are a variety of donors each will their own agenda and the MoH is not in the position to plan locally (without upsetting one or other donor). How does the International body deal with this?

Certainly in my experience, there are few places where there is a plan even to replace spent bed nets. In conversation with experts who shall be unnamed! I was told "We cannot replace them, what will we do with all the spent nets?" Is this a strategy?

In fact there is no short cut, there is a need for local expertise to plan for and design sustainable interventions, so my suggestion first, is to address this lack of trained local personnel. There should be a plan to set up courses in malaria epidemiology in the broad sense in local Universities so as to train entomologists and epidemiologists. These people as they become employed in dealing with the problem and interacting with the expatriate scientists working locally will them become the source of local expertise to which the MoH can address so as to plan the interventions.

While there are still funds being allocated to malaria, this training is what should be a major priority.

Perhaps this can be the starting point for a discussion, lets see!

Thanks, Clive Shiff.

Clive Shiff
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Why should there be an emphasis on local traininig
I hate to be a single voice in all this but in order to add to the last posting, I feel sure that there must be greater effort made to consider the long term sustainability of malaria control. The process needs to be integrated into the normal health system operating in the endemic areas. If this can be the focus, then we will in the end have malaria under control. To do this it is necessary to muster the various health centres in the country and start a process to involve them not only in clinical work but also in data collection. The RDT has put a diagnostic ability in the hands of the grass roots health system. Every positive (or negative) test is a piece of information that will be of value to the local or district office. With cell phone connectivity, these data can be sent weekly to the District office, and if there is a trained epidemiologist handling the information, s/he can analyse the data and report to the central authority. Information in real time can indicate just where outbreaks are occuring, and help indicate to the authorities just where resources need to be made available and just what should be deployed and where this can be done. This is not a major new infrastructure that is needed, all the players are in place excpet for the scientific personnel that must be trained and offered decent jobs. It doesnt depend on expensive transport to visit cases adn provide treatment, this can be done by local staff with bicycle transport, which is usually seen at rural health centres. So when a case happens to be diagosed, it would be simmple to follw the person to home, adn then either test and treat the "malaria focus" or just treat all the people who also live in the homestead. Done systematically over time it would get at the reservoirs of malaria and slowly eliminate the parasites from the human population. One doesnt need to expand too much on this, but it is easy to see just how feasible and cost effective it will be.

Clive Shiff

Wallace Peters
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The human factor
Greetings Clive. It is a welcome change to read a message from someone such as you with a lifetime of practical experience in what I call the "management" of malaria. I, like you no doubt, have just read the programme for the forthcoming Keystone Symposium on malaria. The impressive list of contents indicates that there will be a very thorough and provocative examination of the state of the art in our field. However, as always, there is hardly a hint of what I and, I am sure, you and a few others believe to be the most important factor all - namely human nature and its failings. Or am I just becoming old and cynical? Best wishes. Wallace Peters

Wallace Peters

Clive Shiff
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Dear Wallace, what a pleasure
Dear Wallace, what a pleasure to hear from you and read your comments. I must say I feel like a voice crying in the wilderness, so much has become lost in the plethora of "great" research. One wonders whether the outcome should be measured with the number of publication is Nature or Science, or in terms of successful control, however we measure it! Keep well and in touch.. It is important to keep the human factor in mind, and properly train the enxt generation... Clive

Clive Shiff

Guy Reeves
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what to teach?
I have a question, when you talk of training how does one chose the techniques that are taught.? I am not trying to be mischievous but, do you have a list of techniques that you think should be taught (how did you come up with the list)? Or do envisage professionals in the disease endemic countries choosing which techniques they want to become failure with? You maybe interested in the following article which overlaps somewhat with yours. http://www.guardian.co.uk/global-development/poverty-matters/2012/jul/25/innovation-development-funding-capability

MPI, Plön (Germany)

Clive Shiff
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Thanks for the comment Guy, I
Thanks for the comment Guy, I am actually thinking of training at local universities to stress the importance of epidemiology. In the Health Centres, one usually finds personnel with adequate to good training in primary care. They need regular support and reinforcement. Where there is a deficiency is at the advanced level. Our experience in Zambia shows that health centre operators can collect data and using SMS transmit the information regularly (weekly in our case) to the lab. So we know each week how many posiitve diagnoses were made last week. Such information in real time is extremely valuable in managing outbreak epidemiology. What is needed are the personnel who can receive the data, interpret it and pass it to the cnetral authority to use for planning and more targeting interventions. In a way this also deals with the comment by the person prior to yourself, as it places more emphasis on targeted rather than scale up interventions. What we need at the universities are courses that will deal with this particular branch of epidemiology (and jobs for the professionals when they are trained!) Clive

Clive Shiff

Guy Reeves
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central authorities do provide effective responses when alerted?
If I understand correctly, your reply indicates, that at least in your experience, central authorities have personel trained in methods and the resources to provide an effective response when alerted to the need for intervention. What you are arguing for is that the skills and resources for effective monitoring should not be neglected. If I have correctly grasped what you are saying, could I ask if most malaria endemic countries have a central authority which has the personel trained in methods and the resources to provide an effective responses? I really have never traveled in malarious countries and it is difficult to gauge to what extent the skills, resources and methods are already in place (and to what extent the pursuit of new control strategies and resources is needed). Thanks Guy

MPI, Plön (Germany)

Clive Shiff
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In point of fact, malaria
In point of fact, malaria control of any sort that is planned to be effective needs an infrastructure. This was well voiced by Socrates Litsios in his book the Tomorrow of Malaria. If there is no health system, then no real control can be carriod out. Perhaps mass drug administration or whatever, but it will have no sustained impact. My thesis to promote training of local personnel in epidemiology, adn to employ them in the health infrastructure. This is an essential step in the development of a control structure. (as epidemiologists that can serve multiple purposes as well) but for malaria control the expertise MUST be local and trained locally or regionally in appropriate universities. There is need to move away fro expatriate advisors to local implementors. Then the strategies that have already been developed can be put ito practice. I hope this clarifies things, Clive

Clive Shiff

William Jobin
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training epidemiologists helps control all diseases
Congratulations Clive, In your focus on training front-line people for work on malaria, you have also identified the value of training epidemiologists as a way of strengthening the health care infrastructure, something that bednets, drugs and biocides do not. Snowden identified the need for a health care infrastructure as basic to the success of malaria control in Italy. The same is true in Africa. Broad health measures that control malaria will also help in controlling other diseases, thus a cost-benefit analysis would show that the additional benefits of training epidemiologists, improving and screening houses, and organizing community health efforts, are even more valuable than single-benefit actions such as bednets.

William Jobin Director of Blue Nile Associates

Ole Skovmand
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infrastructure, context, malaria
dear discussion group. The general approach of Clive that MoH lacks epidemiologist, health planners etc is very right. Basically, most African countries lack all kinds of planners except military ones and a few other categories. It is because of this lack of infrastructure that NGOs and international donors build their own systems and place experts like Clive in local MoH. These are people already trained and they will stay in that function. Often, experts of local training are not so well paid and they quickly see that better paid jobs are either in the private system (as for example international NGOs) or higher up in the ministerial system with more political- administrative function. Also because they do not have the means to do what they know should be done. I gues what I try to say is that you cannot take just one group of experts in a system, give them high qualification and then think it will work, because now they know what to do. Eradication of malaria in Italy, Israel, Palestina etc shows it can be done, but is also done in countries with a lot less malaria and a lot more infrastructure. It is very likely that we cannot eradicate malaria from many African countries without first having such infrastructure, but that should not prevent us from reducing it with the tools we have. I do agree that insecticide treated bednets are not golden bullets, but still this tool has saved hundred of thousand of African children and pregnant women from dying from malaria. Contrast that to a potential, yet unproven sideeffect of deltamethrin and permethrin, to put things into perspective. In GF projects, it is possible to include an arm of health system reserach, insecticide resistance research and many other aspects that could finance that local expertice develop their qualifications and improve the background for decisions. However, these are the first to be cut, when budget reduction is demanded. It is indeed very difficult to choose between long term advantage and short term benefits ( e g number of bednets distributed) when it is about life and death. I hope this will serveto show that the choises and solutions are not that easy and that the current players are not stupid, but face difficut choises with very limited tools
Anton Alexander
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Malaria a local problem.
The eradication of malaria in Palestine (possibly the first successful national malaria-eradication campaign ever) was conducted on the basis that the problem was local. The solution was local and the approach worked. See http://www.malariaworld.org/blog/how-was-malaria-100-years-ago-eradicated-palestineisrael-and-without-vaccine
William Jobin
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Malaria suppression without bednets, drugs or vaccines
Yes Anton, I like your analysis. Not only did malaria control in Palestine use local knowledge, but it started with environmental management and thus could minimize use of drugs and biocides. The environmental management consisted of turning malarious swamps into productive farmland, also raising farmers income so they could afford to screen their houses. To add to your points, they did this without a vaccine, and without long-lasting treated bednets! So it not only offers us reasons for optimism, as you affirm, but also points out that good epidemiology and identification of the mosquito vectors and their habitat requirements can replace the fantasies generated by modern science about magic drugs, vaccines and other high-tech (and expensive and unsustainable) solutions. I think Clive Shiff will agree that finding or training good epidemiologists and entomologists should be the first step in developing a sustainable and gradually expanding program to suppress malaria. What does this say about the US Presidential Initiative which zooms into new countries with little information, and just blindly applies the current WHO strategy?

William Jobin Director of Blue Nile Associates

Satoko Noritake (not verified)
The current strategy in
The current strategy in Malaria control emphasizes too much on LLINs and IRS. Drug resistance, however, is the great concern. In MWJ, many people began to think it should be re-examined, and more effective and sustainable way should be taken. My opinion is the same. I work for Japanese NGO that has been distributing conventional nets as malaria prevention in Guinea and Guinea-Bissau for several years. The reason for distributing not LLIN but conventional net is we are very concerned about the adverse effect of LLIN and IRS especially on infants and children. Under the advocacy by RBM and WHO, billions of dollars were invested on LLIN and IRS, and furthermore WHO calls for additional donation for more LLINs. This scenario reminds me of H1N1 out break two years ago. During that period, one German scientist argued that excessive threat was brought by WHO, and consequently a lot of vaccine were overstocked in some countries. (http://www.wodarg.de/english/3022481.html) Pyrethroid is generally, according to WHO and its affiliated organizations, “harmless” to human being. However, on the other hand, some scientists warn the toxicity especially for infants and children.(http://jpet.aspetjournals.org/content/295/3/1175.full) (http://onlinelibrary.wiley.com/doi/10.1002/tox.20758/abstract). Recently, Sumitomo, Olyset Net maker, announced that their new product called Olyset Plus passed WHOPES, and will be on market. What we need to pay attention is, to enhance the efficacy, they added PBO (Piperonyl Butoxide)! http://www.olyset.net/resourcecenter/news/20120711_1/ Regarding PBO, this chemical was very harm for children: it affects prenatal children (http://www.endocrinedisruption.org/files/H25124Horton2011.pdf) Children are vulnerable because they have no barrier in their brain. WHO and their people highlight only short-term effect of LLIN and IRS, but we should take consideration on long-term adverse effect. It’s about time to stop drug dependency. We have alternatives such as environmental management, vaccine, medical development, nutrition development etc.
Emmanuel Temu
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Potential for adverse effect of LLIN and IRS on infants
All pesticides are toxic by nature and present risks of adverse effects that depend on toxicity of the chemical and the degree of exposure. The WHO assert that if prescribed precautions are followed, field use of LLINs and application of IRS using insecticide at recomended concentrations, these interventions pose little or no hazard to people. Although other risk assessment of the use of deltamethrin on nets largely supports this view of the WHO, a relatively high chronic risk (beyond the US EPA standard of 0.01 mg. active ingredient/kg/body weight) was shown to exist for newborns sleeping under ITNs (Barlow et al., Risk assessment of the use of deltamethrin on bednets for the prevention of malaria. Food and Chemical Toxicology 2001; 39:407) It is unfortunate there is not much research going to understand the potential harmful effect of using pesticide for public health intervention. This is likely to be a concern to many malaria experts and we tried to discuss the problem in a recent book "Insecticides - Advances in Integrated Pest Management ISBN 978-953-307-780-2, Published by InTech: January 05, 2012 DOI: 10.5772/2447" chapter 30 obtained at this link http://www.intechopen.com/books/insecticides-advances-in-integrated-pest-management/insecticides-for-vector-borne-diseases-current-use-benefits-hazard-and-resistance
Anton Alexander
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I read your article with
I read your article with interest. I thought I saw some similarities in your approach for malaria control with the approach of Dr Kligler in Palestine in the 1920s when he successfully tackled the subject of malaria control. The funding in Palestine in those days was forthcoming because he could demonstrate that his methods worked - he considered each malaria outbreak a local problem requiring a local solution, his approach was systematic and it was thorough. He dealt with all of this without vaccines and without reliance on bednets, and he tackled the breeding grounds of the mosquito. You mention you have been running a successful malaria control programme for 50 years, so why in your opinion have others not followed your procedures and methods, and the path you have taken. I detect a sense of disappointment that others haven't imitated your methods. Could you please share with us what these disappointments are?