tag:theconversation.com,2011:/institutions/kenya-medical-research-institute-2753/articlesKenya Medical Research Institute2024-01-29T13:09:18Ztag:theconversation.com,2011:article/2221272024-01-29T13:09:18Z2024-01-29T13:09:18ZNeglected tropical diseases persist in the world’s poorest places: four reads about hurdles and progress<p>It’s sobering to reflect that “neglected tropical diseases” are referred to as “neglected” because they persist in the poorest, most marginalised communities even after being wiped out in more developed parts of the world.</p>
<p>A variety of pathogens, including viruses, bacteria, parasites, fungi and toxins, cause neglected tropical diseases, which include dengue, chikungunya, leprosy, lymphatic filariasis and yaws.</p>
<p>They inflict tremendous suffering because of their disfiguring, debilitating and sometimes deadly impact. Patients often experience stigma, social exclusion and superstition. </p>
<p>The good news is that there is reason for hope as some African countries have made significant progress in eradicating these diseases. </p>
<p>We have put together some essential reads from The Conversation Africa over the past year highlighting a scourge that still affects more than <a href="https://www.who.int/news-room/questions-and-answers/item/neglected-tropical-diseases#:%7E:text=It%20is%20estimated%20that%20NTDs,often%20related%20to%20environmental%20conditions.">1 billion people </a> today. </p>
<h2>Patients’ beliefs about illness matter</h2>
<p>Would you take medication for an illness you didn’t believe you had? Or if you disagreed with healthcare workers about the cause of your condition?</p>
<p>This is the dilemma of many people who live in rural areas of Ghana where a mosquito-borne disease called lymphatic filariasis, often referred to as elephantiasis, continues to spread. Researchers found that only 18% of respondents understood lymphatic filariasis as a disease. Fewer than 7% believed it to be a disease spread by mosquitoes.</p>
<p>Instead, people held a range of alternative beliefs attributing the condition to spiritual causes (curses, witchcraft, evil spirits), cold or rainy weather, and other illnesses.</p>
<p>The team of experts, that carried out the research, suggest that understanding patients’ belief systems would help healthcare workers treat patients more effectively. </p>
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Read more:
<a href="https://theconversation.com/patients-beliefs-about-illness-matter-the-case-of-elephantiasis-in-rural-ghana-216838">Patients' beliefs about illness matter: the case of elephantiasis in rural Ghana</a>
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<h2>100 million Nigerians are at risk</h2>
<p>A quarter of the people affected by neglected tropical diseases in Africa live in Nigeria. An estimated 100 million Nigerians are at risk for at least one of these diseases and there are several million cases of people being infected with more than one of them.</p>
<p>There has been progress, writes Uwem Friday Ekpo. By January 2023 the country had eradicated Guinea worm disease and two states had eliminated onchocerciasis. </p>
<p>One of the interventions was door-to-door visits by volunteers to administer medicines. Teachers also played a similar role when medicines were distributed in schools. </p>
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Read more:
<a href="https://theconversation.com/100-million-nigerians-are-at-risk-of-neglected-tropical-diseases-what-the-country-is-doing-about-it-198320">100 million Nigerians are at risk of neglected tropical diseases: what the country is doing about it</a>
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<h2>Leprosy, scabies and yaws: Togo’s neglected skin diseases</h2>
<p>Skin conditions caused by some bacteria, viruses, mosquitoes or mites are common neglected tropical diseases. </p>
<p>Research in schools and rural areas in Togo, west Africa, found a large number of these infections including scabies, leprosy, yaws and Buruli ulcer.</p>
<p>These are stigmatised and can be difficult to diagnose. There are typically few, if any, dermatologists in areas where they are common. Children with these diseases often refuse to go to school. </p>
<p>Michael Head, Bayaki Saka and Palokinam Pitche suggest authorities make the treatment of these diseases free of charge. Health promotion and education are also critical.</p>
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Read more:
<a href="https://theconversation.com/leprosy-scabies-and-yaws-togos-neglected-tropical-skin-diseases-need-attention-201301">Leprosy, scabies and yaws - Togo's neglected tropical skin diseases need attention</a>
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<h2>Reasons for hope</h2>
<p>Togo did have reason to celebrate though. In 2022 it became the first country in the world to have eliminated four neglected tropical diseases. The country stamped out Guinea worm disease in 2011, lymphatic filariasis in 2017, sleeping sickness in 2020 and trachoma in 2022.</p>
<p>It achieved its milestone through a combination of measures. These included door-to-door mass drug administration, training of healthcare staff, sustained financing and strong political support.</p>
<p>Other African countries also made significant progress in tackling neglected tropical diseases in 2022. Benin, Rwanda and Uganda managed to eliminate sleeping sickness. Malawi eliminated trachoma and the Democratic Republic of Congo eliminated Guinea worm disease.</p>
<p>But the global health community and African governments cannot rest on their laurels. There is still a long way to go, writes Monique Wasunna. </p>
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Read more:
<a href="https://theconversation.com/eliminating-neglected-diseases-in-africa-there-are-good-reasons-for-hope-198543">Eliminating neglected diseases in Africa: there are good reasons for hope</a>
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<img src="https://counter.theconversation.com/content/222127/count.gif" alt="The Conversation" width="1" height="1" />
Neglected tropical diseases are often associated with social exclusion as well as physical suffering. One billion people around the world suffer from these diseases.Nadine Dreyer, Health & Medicine EditorLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1985432023-01-26T13:34:59Z2023-01-26T13:34:59ZEliminating neglected diseases in Africa: there are good reasons for hope<figure><img src="https://images.theconversation.com/files/506411/original/file-20230125-16-drokh2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Head nurse Luke Kanyang'areng' with a visceral leishmaniasis patient at the Kacheliba Sub-County Hospital in Kenya.</span> <span class="attribution"><span class="source">Rowan Pybus-DNDi</span></span></figcaption></figure><p>Togo had reason to celebrate in 2022 when it became the first country in the world <a href="https://www.theguardian.com/global-development/2022/aug/25/togo-achieves-major-feat-of-eradicating-four-neglected-tropical-diseases">to eliminate four neglected tropical diseases</a>. The west African nation stamped out <a href="https://www.cdc.gov/parasites/guineaworm/index.html">Guinea worm disease</a> in 2011, <a href="https://www.cdc.gov/parasites/lymphaticfilariasis/index.html">lymphatic filariasis</a> in 2017, <a href="https://www.cdc.gov/parasites/sleepingsickness/">sleeping sickness</a> in 2020, and <a href="https://www.cdc.gov/hygiene/disease/trachoma.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fhealthywater%2Fhygiene%2Fdisease%2Ftrachoma.html">trachoma</a> last year. </p>
<p>These diseases are transmitted in various ways. Guinea worm disease, for instance, is water-borne while sleeping sickness is transmitted by the tsetse fly. </p>
<p>They are just a few among a host of neglected tropical diseases, which mostly affect impoverished communities and that are exacerbated by instability, climate change, and poor living conditions. Every year, <a href="https://www.who.int/news/item/16-07-2020-neglected-tropical-diseases-treating-more-than-one-billion-people-for-the-fifth-consecutive-year">1.7 billion</a> people are affected by these diseases. They cause immense suffering, stigma, disability – and sometimes death. </p>
<p>Togo achieved its milestone through a combination of measures. These included door-to-door mass drug administration, training of healthcare staff, sustained financing, and strong political support. </p>
<p>Other African countries also made significant progress in tackling neglected tropical diseases in 2022. Benin, Rwanda and Uganda managed to <a href="https://www.who.int/news/item/24-05-2022-benin--uganda-and-rwanda-eliminate-human-african-trypanosomiasis-as-a-public-health-problem">eliminate sleeping sickness</a>. Malawi <a href="https://www.who.int/news/item/21-09-2022-malawi-eliminates-trachoma-as-a-public-health-problem">eliminated trachoma</a> and the Democratic Republic of Congo (DRC) <a href="https://www.who.int/news/item/15-12-2022-the-democratic-republic-of-the-congo-certified-free-of-dracunculiasis-transmission-by-who">eliminated Guinea worm disease</a>. </p>
<p>On another continent, in India, Prime Minister Narendra Modi applauded his country’s success in eliminating smallpox, polio and Guinea worm disease, while expressing confidence it could “<a href="https://www.freepressjournal.in/india/mann-ki-baat-pm-modi-talks-about-eradicating-kala-azar-what-is-it-what-are-its-symptoms">soon</a>” eliminate another neglected tropical disease, visceral leishmaniasis.</p>
<p>All of this means there’s plenty of reason to celebrate. But the global health community cannot rest on its laurels. These diseases are still present in some areas. </p>
<p>The insects that transmit many of these diseases don’t respect borders – so no one is safe until everyone is. The COVID-19 pandemic gravely disrupted control programmes, <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(22)00360-6/fulltext">delaying the achievement of elimination goals by years</a> for some diseases. Some countries are also struggling to tackle neglected tropical diseases because of instability and conflicts that hinder control efforts, or because they have large remote regions that are difficult to reach.</p>
<p>Adequate funding is needed to support drug distribution, training of healthcare staff, and raising awareness. Funding for research and development is crucial, too, so that the promising innovations emerging from African laboratories and clinical trial sites can reach doctors and patients.</p>
<h2>Improved treatments</h2>
<p>One of the challenges in tackling many neglected tropical diseases is the absence of adequate treatments. Existing medicines are often not effective enough or are difficult to administer, such as regular injections that require hospitalisation. Some treatments are very painful. Others are downright toxic. For some diseases, such as a fungal infection called <a href="https://dndi.org/diseases/mycetoma/facts/">mycetoma</a>, which is endemic in Sudan, there are no effective treatments at all – amputation is often the only option.</p>
<p>Because these diseases affect the poorest communities and there is little profit to be made from developing new drugs, they have been historically ignored by traditional pharmaceutical research.</p>
<p>But the abundance of good news last year has given me hope. 2022 was an incredible year for visceral leishmaniasis, which is endemic in eastern Africa and is <a href="https://theconversation.com/innovation-and-research-are-key-to-killing-off-neglected-tropical-diseases-in-africa-153914">my field of expertise</a> as a physician and specialist in infectious diseases and tropical medicine.</p>
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Read more:
<a href="https://theconversation.com/innovation-and-research-are-key-to-killing-off-neglected-tropical-diseases-in-africa-153914">Innovation -- and research -- are key to killing off neglected tropical diseases in Africa</a>
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<p>The disease is fatal if left untreated. It’s the deadliest <a href="https://www.reuters.com/article/global-health-disease-idAFL3N2O9075">parasitic killer</a> after malaria. Those infected with visceral leishmaniasis suffer from fever, weight loss and intense fatigue. Many are unable to work, which means a loss of income for their families.</p>
<p>But in September 2022, a <a href="https://www.nature.com/articles/d44148-022-00138-0">shorter, more effective new treatment</a> was announced. Developed with several partners, including Médecins Sans Frontières, this treatment partially removes the need for daily injections. </p>
<p>In June, the World Health Organization also <a href="https://www.npr.org/sections/goatsandsoda/2022/07/07/1110146123/a-nasty-disease-is-even-nastier-for-patietnts-with-hiv-now-theres-encouraging-ne?ft=nprml&f=">recommended</a> an improved treatment specifically for people who are co-infected with HIV and visceral leishmaniasis. This gives hope for the thousands of patients – often young seasonal migrant workers – who respond poorly to standard treatment.</p>
<p>Promising results for a new, one-dose drug for sleeping sickness were also <a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(22)00660-0/fulltext">announced</a> last year following clinical studies conducted in the DRC and Guinea by Congolese and Guinean researchers. This new medicine would be a significant improvement over existing drugs and could open the door to sustainably eliminating the disease. This is a remarkable achievement. I still remember when the only drug available to my fellow doctors in the DRC was an arsenic derivative so toxic it <a href="https://www.doctorswithoutborders.org/latest/fire-veins-still-injecting-arsenic-derivatives-treat-african-sleeping-sickness">killed 5%</a> of their patients.</p>
<h2>Collaboration and partnerships</h2>
<p>However, research and development efforts alone are not enough. Collaboration and partnerships are key. These are not just buzzwords: past successes in tackling neglected tropical diseases have been rooted in close-knit partnerships between national health authorities, international donors, medical research institutes, universities and industry.</p>
<p>The new treatments I mentioned above were all developed thanks to such coalitions. I am the director of the Eastern Africa office of a global non-profit medical research organisation called <a href="https://dndi.org/">Drugs for Neglected Diseases Initiative</a>, which took an active role in all these research and development collaborations.</p>
<p>The good news is that new partnerships keep being formed. In 2022, we established LeishAccess, a regional collaboration in Eastern Africa working to <a href="https://news.scienceafrica.co.ke/new-program-to-scale-up-access-to-leishmaniasis-treatments-launched/">promote access to visceral leishmaniasis treatments</a> and remove the obstacles that still prevent half of patients from accessing the life-saving drugs they need.</p>
<p>All these advances give me hope. These extraordinary efforts will eventually pay off. I am convinced that, in a not-so-distant future, people will stop dying from leishmaniasis, and will be safely cured thanks to simple oral drugs.</p>
<p>Many gaps remain, with millions of people still suffering from diseases that could be cured. And neglected tropical diseases that are slowly disappearing can suddenly come back with a vengeance, fuelled by conflicts, economic crises, increased poverty, or climate change.</p>
<p>But if sustained investment is coupled with African political leadership and scientific excellence, there’s good reason to hope for the elimination of neglected tropical diseases on the continent.</p><img src="https://counter.theconversation.com/content/198543/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Monique Wasunna is the director of the Drugs for Neglected Diseases initiative Africa Regional Office.</span></em></p>Every year, 1.7 billion people, most in the world’s poorest areas, are affected by NTDs. The diseases cause suffering, stigma, disability and sometimes death.Monique Wasunna, Researcher, Kenya Medical Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1977992023-01-14T09:53:17Z2023-01-14T09:53:17ZWhy cholera continues to threaten many African countries<figure><img src="https://images.theconversation.com/files/504431/original/file-20230113-17-bb62ey.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Key to preventing cholera is a good supply of water.</span> <span class="attribution"><span class="source">Getty images</span></span></figcaption></figure><p><em>Many African countries are periodically affected by outbreaks of cholera. For instance, Malawi’s current outbreak, the <a href="https://www.bloomberg.com/news/articles/2023-01-12/worst-cholera-outbreak-in-decades-kills-750-people-in-malawi">worst</a> in two decades, has claimed <a href="https://www.theeastafrican.co.ke/tea/rest-of-africa/cholera-outbreak-kills-620-in-malawi-4073880#:%7E:text=Malawi%20has%20recorded%2018%2C222%20cholera,Health%20Minister%20Khumbize%20Chiponda%20announced">hundreds</a> of lives and forced the closure of schools and many businesses. Cholera deaths have now been <a href="https://www.bloomberg.com/news/articles/2023-05-22/south-african-capital-hit-by-cholera-outbreak-with-10-dead">reported</a> in South Africa too.</em></p>
<p><em>Microbiologist Sam Kariuki, the director of Kenya’s Medical Research Institute, explains what cholera is and why it’s so hard to control in Africa.</em></p>
<h2>Why is cholera still such a big issue for African countries?</h2>
<p>Cholera is a disease <a href="https://www.gtfcc.org/research/cholera-prevention-preparedness-and-control-in-kenya-through-hotspot-mapping-genotyping-exposure-assessment-and-wash-oral-cholera-vaccine-interventions/">caused and spread by</a> bacteria – specifically <em>Vibrio cholerae</em> – which you can get by eating or drinking contaminated food or water. </p>
<p>It’s an <a href="https://books.google.co.ke/books?id=qpjshPr7HVcC&pg=PA197&lpg=PA197&dq=cholera+and+bangal&source=bl&ots=4htxUE4c61&sig=S52TKJb0YKHttBcyNZt2jJRtLcY&hl=en&sa=X&redir_esc=y#v=onepage&q=cholera%20and%20bangal&f=false">old disease</a> which has mostly <a href="https://www.ncbi.nlm.nih.gov/pubmed/2857326">affected</a> developing countries, many of which are in Africa. Between 2014 and 2021 Africa <a href="https://reliefweb.int/report/world/who-and-partners-revamp-war-against-cholera-africa">accounted for</a> 21% of cholera cases and 80% of deaths reported globally.</p>
<iframe id="noa-web-audio-player" style="border: none" src="https://embed-player.newsoveraudio.com/v4?key=x84olp&id=https://theconversation.com/why-cholera-continues-to-threaten-many-african-countries-197799&bgColor=F5F5F5&color=D8352A&playColor=D8352A" width="100%" height="110px"></iframe>
<p>In several African countries, cholera is the leading cause of severe diarrhoea. In 2021, the World Health Organization <a href="https://reliefweb.int/report/world/who-and-partners-revamp-war-against-cholera-africa">reported</a> that Africa experienced its highest ever reported numbers – more than 137,000 cases and 4,062 deaths in 19 countries.</p>
<p>It has persisted in Africa partly because of <a href="https://www.washingtonpost.com/politics/2022/01/28/is-africa-losing-ground-battle-water-sanitation/">worsening</a> sanitation, poor and unreliable water supplies and worsening socioeconomic conditions. For instance, when people’s incomes can’t keep up with inflation they’ll move to more affordable housing – often this is in congested, unsanitary settings where water and other hygiene services are already stretched to the limit.</p>
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Read more:
<a href="https://theconversation.com/kenyas-urban-poor-are-being-exploited-by-informal-water-markets-144582">Kenya's urban poor are being exploited by informal water markets</a>
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<p>In addition, in the last decade, many African countries have witnessed an <a href="https://www.afdb.org/en/documents/africas-urbanisation-dynamics-2022-economic-power-africas-cities">upsurge in population migration</a> to urban areas in search of livelihoods. Many of these people end up in poor urban slums where water and sanitation infrastructure remains a challenge. </p>
<p>Displaced populations – a major concern in several African countries – are also very vulnerable to water and food contamination. </p>
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<img alt="" src="https://images.theconversation.com/files/504400/original/file-20230113-17-rju7ae.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/504400/original/file-20230113-17-rju7ae.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/504400/original/file-20230113-17-rju7ae.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/504400/original/file-20230113-17-rju7ae.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/504400/original/file-20230113-17-rju7ae.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/504400/original/file-20230113-17-rju7ae.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/504400/original/file-20230113-17-rju7ae.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Sadiki Sabimana, an internally displaced person, holds water he believes is contaminated with cholera, in the DRC’s Masisi area.</span>
<span class="attribution"><span class="source">Alexis Huguet/AFP</span></span>
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<p>It’s important to control cholera because it can cause severe illness and death. In mild cases cholera can be managed through oral rehydration salts to replace lost fluids and electrolytes. Severe cases may require antibiotic treatment. It’s vital to diagnose and treat cases quickly – cholera can <a href="http://www.who.int/mediacentre/factsheets/fs107/en/">kill within hours</a> if untreated. </p>
<p>In 2015, it was <a href="https://bmjopen.bmj.com/content/11/3/e044615">estimated that</a> over one million cases in 44 African countries resulted in an economic burden of US$130 million from cholera-related illness and its treatment. </p>
<h2>What’s missing in the response?</h2>
<p>African governments must acknowledge that the burden of cholera is huge. In my opinion, governments in endemic areas don’t recognise cholera as a major issue until there’s a big outbreak, when it’s out of control. They treat it as a once off. </p>
<p>The burden of cholera could get worse unless governments put measures in place to control and prevent outbreaks. They need to address water and hygiene infrastructure. </p>
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Read more:
<a href="https://theconversation.com/cholera-how-african-countries-are-failing-to-do-even-the-basics-74445">Cholera: how African countries are failing to do even the basics</a>
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<p>There must also be community engagement. For instance, widespread messaging that encourages hand washing, boiling water and other preventive measures. Community health <a href="https://www.cdc.gov/mmwr/volumes/65/wr/mm6503a7.htm">extension workers</a> are key in getting these messages across and distributing supplies during an outbreak.</p>
<p>For the most vulnerable populations we must apply oral cholera vaccines. Data on cholera hotspots from surveillance studies will be vital to ensure critical populations are targeted first. </p>
<p>There are various brands and variation of the oral cholera vaccine, and they are all easy to administer because they are taken orally. They have an effectiveness rate of <a href="https://www.cdc.gov/cholera/vaccines.html#:%7E:text=The%20vaccine%20manufacturer%20reports%20Vaxchora,3%E2%80%936%20months%20after%20vaccination.">between</a> 60% to 80% but require a yearly booster. There’s not been a concerted vaccination campaign in many countries, however, because governments are not taking the prevention and control of the disease seriously. </p>
<p>Finally, the issue of drug resistance needs to be addressed. Drug resistance has made it possible for these cholera strains to stay longer in the environment. </p>
<p>I was part of a team that conducted a <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0074829">study</a> in Kenya which found that bacteria that causes cholera has become resistant to some antibiotics. Some types of drug resistance are caused by a natural interaction of the <em>Vibrio cholerae</em> bacteria with other drug resistant bacteria in the environment. </p>
<p>The overuse of antibiotics also contributes to drug resistance. Government agencies should develop ways to monitor the use of antibiotics and restrict their prescription. Regulation of antibiotic use in animals should also be improved. Healthcare workers also need to be trained in the proper use of antibiotics.</p>
<h2>Have there been any recent advances?</h2>
<p>One important one has been the development of rapid diagnostic tests that can be used by health workers in the field. These kits are available at costs far lower than lab culture costs. Using them makes it possible to confirm outbreaks promptly so treatment can be initiated. </p>
<p>In addition, more countries are now adopting the oral cholera vaccine for prevention and control. </p>
<p>What is lacking is a concerted effort for all endemic countries – which I consider to be all countries in sub-Saharan Africa – to have joint measures to tackle cross-border transmission and persistence of cholera outbreaks. </p>
<p>Some countries are still in denial about outbreaks. This is partly due to fears about repercussions on trade and tourism. But in an interconnected world this attitude isn’t helpful. </p>
<p>I am optimistic that we can control cholera in African settings. In the short term this could be done through raising awareness among vulnerable populations and interventions like the oral cholera vaccine.</p>
<p>In the long term African countries need improved water hygiene infrastructure, housing and enhanced socioeconomic conditions. But there must be a strong will by relevant government ministries to work together to realise these goals.</p><img src="https://counter.theconversation.com/content/197799/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Samuel Kariuki does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Cholera has persisted longer in Africa largely due to worsening hygiene and sanitation situations in urban areas.Samuel Kariuki, Chief Research Scientist and Director, Centre for Microbiology Research, Kenya Medical Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1938672022-11-06T10:50:26Z2022-11-06T10:50:26ZHow climate change influences the spread of disease – four essential reads<figure><img src="https://images.theconversation.com/files/493454/original/file-20221104-25-m7lhsw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Darren Stewart/Gallo Images via Getty Images</span></span></figcaption></figure><p>Climate change has led to <a href="https://www.epa.gov/climate-indicators/weather-climate">extreme weather events</a> such as floods and drought. These events have become more frequent and more severe. Natural disasters associated with climate change have a devastating effect on people’s lives, destroying homes, roads and others key infrastructure. </p>
<p>They also put <a href="https://www.who.int/news-room/fact-sheets/detail/climate-change-and-health#:%7E:text=Climate%20change%20is%20already%20impacting,diseases%2C%20and%20mental%20health%20issues.">people at risk</a> of injury and death, and alter the prevalence and distribution of illnesses and infectious diseases. </p>
<p>Over the years, health and climate researchers have written important articles for The Conversation Africa highlighting the links between climate change and diseases in people. Many have also proposed solutions. We’ve pulled together four essential reads.</p>
<h2>Impacts of climate on everyday life</h2>
<p>Most people don’t experience extreme weather events like floods. But record peaks in temperature have an impact on everyday life in subtle ways. Inequalities drive these impacts. People who are poor are already vulnerable to ill health and malnutrition. </p>
<p>Medical anthropologist Lenore Manderson explains how changes in weather patterns have knock-on effects on health. For instance, changes in water supply can affect commercial food and subsistence production. This in turn affects food security and the price of food. Diet affects health.</p>
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Read more:
<a href="https://theconversation.com/how-global-warming-is-adding-to-the-health-risks-of-poor-people-109520">How global warming is adding to the health risks of poor people</a>
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<p>The health problems associated with climate change need a whole-of-society solution. Many diseases are related to inadequate water availability. Researchers and officials have to work closely together to improve basic service delivery and fill knowledge gaps. </p>
<p>Manderson argues that experts in social, biological and physical sciences as well as the humanities and arts need to come up with ways to interrupt disease transmission in the context of global warming. </p>
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Read more:
<a href="https://theconversation.com/climate-change-water-and-the-spread-of-diseases-connecting-the-dots-differently-103111">Climate change, water and the spread of diseases: connecting the dots differently</a>
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<h2>Impacts on infectious disease</h2>
<p>It’s difficult to predict where droughts will happen. But research suggests that some areas of Africa are likely to see more intense and longer droughts. </p>
<p>Infectious diseases such as cholera are linked to droughts. People in displacement camps and those living in settings with poor sanitation are most at risk of the illness. </p>
<p>Researcher Gina Charnley argues that the most effective way to reduce the impacts of drought and resultant cholera outbreaks is to alleviate population vulnerabilities before the hazard occurs.</p>
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Read more:
<a href="https://theconversation.com/droughts-create-fertile-ground-for-cholera-plans-are-needed-to-face-more-dry-periods-170660">Droughts create fertile ground for cholera. Plans are needed to face more dry periods</a>
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<p>As climate change increases the risk of epidemics and disease outbreaks, it is up to government authorities to provide the services needed to prevent and treat infectious diseases – especially in vulnerable communities. </p>
<p>Medical entomologist Andrew Githeko warns that weak public health institutions at the frontline of disease outbreaks are highly vulnerable to the effects of climate change. Policy responses should be expanded to include other stakeholders, increased capacity to evaluate risk and adequate resources.</p>
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Read more:
<a href="https://theconversation.com/response-to-climate-change-is-critical-as-risk-of-disease-outbreaks-grows-70066">Response to climate change is critical as risk of disease outbreaks grows</a>
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<img src="https://counter.theconversation.com/content/193867/count.gif" alt="The Conversation" width="1" height="1" />
Natural disasters associated with climate change put people at risk of injury and death, and alter the prevalence and distribution of illnesses and infectious diseases.Moina Spooner, Assistant EditorIna Skosana, Health + Medicine Editor (Africa edition)Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1725152021-11-28T09:08:44Z2021-11-28T09:08:44ZThe people most at risk of HIV in Kenya aren’t using preventive drugs: we asked why<figure><img src="https://images.theconversation.com/files/433692/original/file-20211124-19-1tp8spg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">GettyImages</span> <span class="attribution"><span class="source"> Brent Stirton/Getty Images for the GBC</span></span></figcaption></figure><p>There has been a <a href="https://phia.icap.columbia.edu/wp-content/uploads/2020/04/KENPHIA-2018_Preliminary-Report_final-web.pdf">gradual decline</a> of new HIV cases overall in Kenya – from a high of <a href="https://aidsinfo.unaids.org/">230,000</a> new infections in 1992 to 33,000 in 2020. But there are particular population groups that are at higher risk of contracting HIV than the general population. In these groups, new HIV cases remain unacceptably high. </p>
<p>This is especially true among gender and sexual orientation minorities, including men who have sex with men and transgender women. Transgender women – individuals assigned male gender at birth, but who currently identify as female – have been documented to have the <a href="https://pubmed.ncbi.nlm.nih.gov/23260128/">highest risk</a> for HIV infection globally.</p>
<p>Data from sub-Saharan Africa on transgender women remain limited. But recent findings from <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6563853/">Kenya</a>, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7527771/">Nigeria</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/33000918/">South Africa</a> provide corroborating evidence of increased risk of HIV infection in transgender women.</p>
<p>The increased risk for HIV infection in transgender women is <a href="https://pubmed.ncbi.nlm.nih.gov/24322537/">driven</a> by a combination of factors. The mismatch between their current identity and government issued documents makes transgender women more likely to be unemployed, engage in sex work, and face violence from clients or even law enforcement. </p>
<p>Additionally, receptive anal sex has previously been <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3929859/">shown</a> to be an independent predictor of HIV acquisition. Stigma and criminalisation of same-sex relationships makes it difficult for either transgender women or men who have sex with men to seek preventive services in public healthcare facilities. This further <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3929859/">compounds</a> their risk for <a href="https://pubmed.ncbi.nlm.nih.gov/23260128/">infection with HIV</a>.</p>
<p>Since 2017, the Health ministry in Kenya has been promoting use of pre-exposure prophylaxis (<a href="https://www.cdc.gov/hiv/basics/prep/about-prep.html">PrEP</a>) as part of HIV prevention efforts. These preventive medicines are recommended for use in both the general populations and those at increased <a href="https://www.who.int/news-room/fact-sheets/detail/hiv-aids">risk</a> for HIV acquisition. Transgender women and men who have sex with men would be ideal candidates for PrEP use.</p>
<p>However, <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0244226">recent data</a> from Kenya demonstrated subdued uptake and adherence to PrEP in men who have sex with men. Additionally, <a href="https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(20)30285-6/fulltext">retention in PrEP</a> care for those who take it up is reduced with high rates of loss to follow-up.</p>
<p>In our <a href="https://pubmed.ncbi.nlm.nih.gov/33465090/">recent study</a>, my colleagues and I set out to explore the opinions of healthcare providers, leadership of community-based organisations and current PrEP users. We wanted to find out what they thought about Kenya’s PrEP programme. We sought to understand the perceived or experienced barriers to joining and staying on PrEP programmes. We were also interested in their views on how to improve PrEP provision.</p>
<h2>What we did</h2>
<p>Data were collected between February 2018 and April 2019 in coastal Kenya. Healthcare providers working in an HIV clinic at a public hospital were invited to participate in two focus group discussions, at the start of PrEP rollout at the facility and again a year later. The leaders of community-based organisations that have programmes for either men who have sex with men or transgender women were invited to separate focus group discussions. Finally, we invited transgender women and men who have sex with men to in-depth interviews. They were either currently on PrEP or had defaulted. </p>
<p>The discussions and interviews explored for PrEP knowledge, perceived or actual challenges to PrEP uptake and retention in care, and how to improve PrEP programming. Data from all three sources were used to paint a complete picture of the PrEP provision landscape in Kenya.</p>
<h2>What we found</h2>
<p>Four major themes emerged out of the analysis. </p>
<p>First, healthcare providers admitted to feeling ill-prepared for the massive PrEP roll-out in Kenya. They felt bombarded with targets without enough training or consideration of the increased workload. A year later they seemed less combative, but more passive about PrEP programming. Rather than proactively driving demand, they preferred that potential users present themselves to the facility and ask for PrEP. One said,</p>
<blockquote>
<p>While the research may have been done and it showed that PrEP works, we are lacking follow-up systems … I feel like we were not ready for the implementation.</p>
</blockquote>
<p>Second, we found differences in motivation for PrEP uptake between men who have sex with men and transgender women. Transgender women seemed to be strongly motivated by recognition of their increased risk for HIV infection and desire to remain HIV negative. A transgender woman said,</p>
<blockquote>
<p>I wish to remain HIV negative. I know that being a trans is putting me at risk for HIV. So, when I heard that PrEP was available here (hospital), I was among the first to ask for it.</p>
</blockquote>
<p>For men who have sex with men, the motivation to use PrEP was to facilitate condomless sex. One of the men remarked:</p>
<blockquote>
<p>… before I knew about PrEP, I had two partners. When I started using PrEP, I added two more (partners), as I felt protected (by PrEP). Now I have four partners. </p>
</blockquote>
<p>Third, healthcare providers did not consider transgender women to be at any increased risk for HIV infection. And they did not understand a need to give transgender women additional attention. This was reflected in the view of one healthcare provide:</p>
<blockquote>
<p>… they (transgender women) are just at the same level as anybody else exposed to HIV … They are not at a very high risk of acquiring HIV. </p>
</blockquote>
<p>Fourth, all respondents seemed to agree that the public hospital was not an ideal venue for PrEP provision. A leader of one community-based organisation felt PrEP uptake and retention would be better if there were additional incentives.</p>
<blockquote>
<p>There are some specific needs like those hormones, therapy, legal, because it is very expensive … that can be a plus for us.</p>
</blockquote>
<h2>Recommendations</h2>
<p>PrEP is available. But access continues to be limited. The limited access is due to a combination of healthcare provider attitudes and the sentiment among men who have sex with men and transgender women who feel unwelcome in public health facilities. There is an urgent need for alternative PrEP dispensing environments. These must be spaces where men who have sex with men and transgender women can feel free to access comprehensive HIV prevention services. </p>
<p>Healthcare providers need to be trained to accommodate the needs of these populations. Programming guidelines must recognise transgender women as an at-risk population.</p>
<p>Working with community-based organisations may help create tailor-made solutions that are available to the populations that most need them.</p><img src="https://counter.theconversation.com/content/172515/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Makobu Kimani is a SANTHE (Sub-Saharan African Network for TB/HIV Research Excellence) Fellow.</span></em></p>Stigma and criminalisation of same-sex relationships makes it difficult for transgender women and men who have sex with men to seek preventive services. This compounds their risk for HIV infection.Makobu Kimani, Post-doctoral researcher, KEMRI-Wellcome Trust Research Program, Kenya Medical Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1677192021-09-21T14:25:23Z2021-09-21T14:25:23ZProgress against a neglected tropical disease in east Africa is under threat<figure><img src="https://images.theconversation.com/files/421300/original/file-20210915-19-1ml0pdk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A nurse at Amudat Hospital in Northern Uganda, checks on a child being treated for kala-azar. The disease mostly affects children and young adults.</span> <span class="attribution"><span class="source">Lameck Ododo</span></span></figcaption></figure><p>Eleven years ago, in the rugged hills of West Pokot County in Kenya, Mary Alamak, a mother of four, fell ill with the parasitic disease kala-azar while she was pregnant. Her weight fell from 80 to 45 kgs in a matter of weeks. She feared for the life of her baby and her own. At the Kacheliba District Hospital, she could get diagnosed, and treated with AmBisome injections. She was cured and regained weight – and her baby was saved.</p>
<p>I have met many patients like Mary in my 30-year experience in the field. </p>
<p>Across Kenya, Sudan, and Ethiopia, weak and feverish patients are being taken to hospitals by their worried families, stricken by a parasitic killer. It might sound like malaria, but these patients are in fact affected by a lesser-known parasitic disease, <a href="https://www.who.int/news-room/fact-sheets/detail/leishmaniasis">visceral leishmaniasis</a>, also known as kala-azar.</p>
<p>Kala-azar is the <a href="https://news.northeastern.edu/2018/06/06/this-tropical-disease-is-second-only-to-malaria-as-a-parasitic-killer-so-why-havent-you-heard-of-it/">second deadliest parasitic killer</a> in the world after malaria. The World Health Organisation (WHO) estimates that <a href="https://www.who.int/news-room/fact-sheets/detail/leishmaniasis">50,000 to 90,000 people</a> globally are infected each year. Without treatment, it is almost always fatal.</p>
<p>Decades of efforts by ministries of health, doctors and medical organisations have led to great advances in controlling the disease. Better treatments have been developed and the number of cases has been greatly reduced in some parts of the world, particularly in <a href="https://www.bmj.com/content/364/bmj.k5224">South Asia</a>. </p>
<p>In Kenya, there was significant progress in 2021, “…the first in many years during which an annual outbreak of kala-azar… did not occur,” <a href="https://msfaccess.org/bmj-global-health-control-visceral-leishmaniasis-east-africa-fragile-progress-new-threats">said</a> Dr Sultani Matendechero, head of the neglected tropical diseases division of the Ministry of Health in Kenya. But to maintain this progress, <a href="https://msfaccess.org/bmj-global-health-control-visceral-leishmaniasis-east-africa-fragile-progress-new-threats">access to diagnostic test kits and efficacious</a> treatments must be sustained.</p>
<p>This is now under threat. Kala-azar, already one of the most neglected diseases on the planet, is in danger of becoming even more neglected.</p>
<p>To raise the alarm, the health ministries of Ethiopia, Kenya, Sudan and South Sudan, Doctors Without Borders (MSF) and my own organisation, the Drugs for Neglected Diseases initiative, recently issued a call to action in a <a href="https://gh.bmj.com/content/6/8/e006835">comment piece</a> in the BJM journal.</p>
<p>We wrote the commentary to highlight the fact that the environment – including the diagnosis and treatment – that saved Mary’s life and countless others is under grave threat. </p>
<p>This is due to a perfect storm of indirect effects of the COVID-19 pandemic, disengagement by pharmaceutical companies and major donor budget cuts. Combined, these are putting tens of thousands of lives across Eastern Africa at risk in countries where the disease is endemic. </p>
<h2>About to become more neglected</h2>
<p>First, kala-azar control progress is threatened by an acute shortage of an important “second-line” medicine given to patients when the standard treatment does not work. Known as AmBisome, this anti-fungal treatment is used for vulnerable kala-azar patients such as pregnant women or for severe cases. Recently it has been used in India to treat the deadly “<a href="https://www.downtoearth.org.in/news/health/covid-19-hundreds-of-black-fungus-patients-await-ambisome-injections-at-bihar-hospitals-77306">black fungus</a>” disease seen in COVID-19 patients. </p>
<p>Faced with <a href="https://www.downtoearth.org.in/news/health/covid-19-hundreds-of-black-fungus-patients-await-ambisome-injections-at-bihar-hospitals-77306">increased global demand</a>, generic manufacturers have not been able to produce enough doses.</p>
<p>At the same time, the US pharmaceutical giant Gilead repurposed its AmBisome manufacturing plant to produce a broad-spectrum antiviral named remdesivir. This new situation is not having an impact yet on supplies in eastern Africa yet, but doctors in Ethiopia, Sudan and South Sudan, where the kala-azar peak season is about to start, are expressing deep concerns.</p>
<p>A second threat comes from the drastic <a href="https://unitingtocombatntds.org/news/a-tragic-blow-for-global-britain-and-the-worlds-most-vulnerable-people/">cuts</a> announced by the UK foreign aid budget last November. These cuts have already led to the <a href="https://www.reuters.com/article/global-health-disease/corrected-feature-uk-aid-cuts-spark-fears-over-parasitic-killer-that-stalks-the-poor-idUSL3N2O9075">termination of an important programme</a> for neglected tropical diseases. This included funding for the purchases of a life-saving kala-azar drug. </p>
<p>Unless other funders step up soon, <a href="https://www.reuters.com/article/global-health-disease-idUSL3N2O9075">thousands could die</a>.</p>
<p>Diagnostics is another major cause for concern. The American diagnostics company Bio-Rad announced that in 2022 it will discontinue production of the <a href="https://www.bio-rad.com/sites/default/files/webroot/web/pdf/cdg/literature/16490_B-IT_LEISH-EN.pdf">“IT-leish” rapid test</a>. It is the only test with <a href="https://pubmed.ncbi.nlm.nih.gov/22942208/">high enough sensitivity</a> in Eastern Africa to detect kala-azar <a href="https://www.who.int/tdr/publications/documents/vl-rdt-evaluation.pdf">in Eastern Africa</a>.</p>
<p>Without adequate diagnostics, tens of thousands of kala-azar cases will go undetected.</p>
<p>Bio-Rad argues that it is too expensive to comply with the new European requirements for rapid tests such as IT-leish. But the consequences will be catastrophic if no solution is found to transfer these technologies and produce the tests on the African continent.</p>
<p>“We urge the international community not to turn away from this fatal illness and the people it affects. Lifesaving funding and access to the best tests and medicines are absolutely critical for tackling the disease,” <a href="https://msfaccess.org/bmj-global-health-control-visceral-leishmaniasis-east-africa-fragile-progress-new-threats">wrote</a> Dr Mousab Siddig Elhag, an neglected tropical disease advisor from the Ministry of Health in Sudan, a country with one of the highest kala-azar burdens in the world. </p>
<p>He recently <a href="https://msfaccess.org/bmj-global-health-control-visceral-leishmaniasis-east-africa-fragile-progress-new-threats">urged</a> the international community not to turn away from the fatal disease.</p>
<h2>What’s needed</h2>
<p>Kala-azar is neglected because it is a disease of poverty: transmitted by the bite of a female sandfly, it affects the poorest communities who are often living in arid and semi-arid areas. </p>
<p>Kala-azar epidemics are aggravated by climatic conditions, co-infections such as HIV, and population displacement such as large refugee movements during conflict. For example, in the months following the onset of the 2013 civil war in South Sudan, MSF observed a “<a href="https://www.msf.org/south-sudan-10-msf-record-consequences-violence">major outbreak</a>” of kala-azar in the Lankien region – the number of patients MSF treated more than doubled in a year.</p>
<p>A similar outbreak is now feared in Ethiopia, where the devastating Tigray civil conflict is causing malnutrition, displacing millions, blocking aid and where 400,000 people are facing famine-like conditions <a href="https://reliefweb.int/report/ethiopia/statement-acting-humanitarian-coordinator-ethiopia-grant-leaity-operational">according to the UN</a>. The closure of clinics is impacting kala-azar programmes.</p>
<p>Tens of thousands of lives are at risk. We need to act now. Donor and kala-azar endemic countries must step in. The industry must prioritise kala-azar treatment and diagnostics production. The consequences of any other course of action will be no short of a humanitarian catastrophe.</p><img src="https://counter.theconversation.com/content/167719/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Monique Wasunna is the director of the Drugs for Neglected Diseases initiative Africa Regional Office.</span></em></p>Kala-azar, already one of the most neglected diseases on the planet, is in danger of becoming even more neglected.Monique Wasunna, Researcher, Kenya Medical Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1539142021-01-29T06:13:09Z2021-01-29T06:13:09ZInnovation – and research – are key to killing off neglected tropical diseases in Africa<figure><img src="https://images.theconversation.com/files/380888/original/file-20210127-19-11dkly6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A laboratory technician patient samples at the Amudat Hospital, Uganda. Laboratories are central to the delivery of high quality data in clinical trials.</span> <span class="attribution"><span class="source">Paul Kamau </span></span></figcaption></figure><p>As a young medical doctor over 30 years ago, I had an experience no doctor wants to have. One of my patients, a young boy, died in my arms as we rushed him to the referral hospital in Nairobi, Kenya, to receive treatment.</p>
<p>He had visceral leishmaniasis, a disease also known as kala-azar, which is transmitted by female sandflies. He had been brought 250 km from his village in Baringo because at that time the treatment was only available at our clinical trial site hospital in Nairobi. But we were too late.</p>
<p>Visceral leishmaniasis is an infectious disease that is not rare: <a href="https://www.sciencedaily.com/releases/2018/07/180726085645.htm">600 million people</a> in the world are at risk. Yet it is classified as a neglected tropical disease – a group of 20 preventable diseases that threatens more than 1.7 billion people globally. Africa carries <a href="https://www.afro.who.int/media-centre/statements-commentaries/africa-elimination-neglected-tropical-diseases-finally-within">almost 40%</a> of the worldwide burden.</p>
<p>In 2012 the World Health Organisation (WHO) <a href="https://www.who.int/neglected_diseases/NTD_RoadMap_2012_Fullversion.pdf">set targets</a> to control, eliminate or eradicate neglected tropical diseases. This attracted a lot of commitment and investments. <a href="https://unitingtocombatntds.org/progress/">More than 30 countries</a> have since eliminated at least one neglected tropical disease as a public health problem. For example, in 2020, Togo became the first African country <a href="https://www.afro.who.int/news/togo-first-african-country-end-sleeping-sickness-public-health-problem">to end sleeping sickness</a> as a public health problem. And Malawi is one of the countries that has <a href="https://www.who.int/news/item/29-10-2020-lymphatic-filariasis-reporting-continued-progress-towards-elimination-as-a-public-health-problem">eliminated elephantiasis</a>. </p>
<p>But there still aren’t enough tools to diagnose, treat, and prevent all these diseases. Neglected tropical diseases continue to cause tremendous suffering and death. Innovation is urgently needed to fill the diagnostic and treatment gaps and support is required for medical research.</p>
<h2>Challenges and progress</h2>
<p>These diseases <a href="https://www.who.int/news-room/q-a-detail/neglected-tropical-diseases">largely affect people</a> in the poorest regions, living in remote areas, urban slums or conflict zones. In many cases the only treatments that exist have a <a href="https://atm.eisai.co.jp/english/ntd/mycetoma.html">low cure rate</a> and some have <a href="https://dndi.org/diseases/chagas/facts/">side effects</a> so severe they can kill some patients. Effective, accessible, and safe treatments are sorely lacking.</p>
<p>Ineffective therapeutics are not only difficult for patients to take but also have a devastating impact on their social and economic life. For example, a patient with visceral leishmaniasis in Eastern Africa still has to spend <a href="https://www.afrikadia.org/afrikadia-project/treatment/">over 17 days in a hospital</a> to receive two daily injections of sodium stibogluconate and paromomycin. This is an improvement from the previous 30-day sodium stibogluconate injections alone, but patients must still endure the daily injections and hospitalisation throughout the treatment. </p>
<p>And in Sudan and neighbouring countries, <a href="https://dndi.org/stories/2016/mycetoma-the-faces-of-neglect/">mycetoma</a>, a disease transmitted by a simple thorn prick, slowly nibbles the flesh and limbs of a patient, before causing death. Existing treatments have only a 35% cure rate and amputation is usually the only “treatment” available.</p>
<p>But it’s not a hopeless situation.</p>
<p>One example is the advancement in the <a href="https://stories.dndi.org/sleepingsickness-doctors-dream/?fbclid=IwAR0xTLA5B_4BN_DPngjuXlWJWQE-b4yngyldRB6H1UDXB2atSOxuelQKh5g">treatment for second-stage sleeping sickness</a>. Previously, the treatment was a highly toxic drug that killed 1 in 20 patients. But my non-profit research and development organisation, the <a href="https://dndi.org/">Drugs for Neglected Diseases initiative</a> (DNDi), and its partners have developed a <a href="https://www.theeastafrican.co.ke/tea/science-health/and-now-a-new-drug-for-sleeping-sickness-1407518">simple all-oral treatment</a> that can cure all stages of the disease with just a few pills. </p>
<p>Another example is the treatment of visceral leishmaniasis. Twenty-two years ago the best treatment was a highly toxic 30-day treatment. Now there’s a <a href="https://www.theeastafrican.co.ke/tea/science-health/sand-fly-bringing-life-threatening-kalaazar-to-semi-arid-counties-1426824">17-day treatment</a>. Hospital stays are reduced and treatment is cheaper. <a href="https://dndi.org/press-releases/2019/wellcome-commits-10million-develop-new-generation-oral-drugs-leishmaniasis/">Clinical studies</a>for easy-to-administer oral treatments are currently in the initial stages.</p>
<p>One of the key ingredients for success has been sustained commitment to research, development and innovation. For example, in the Democratic Republic of Congo, new tools and unwavering control strategies have brought the number of <a href="https://www.who.int/health-topics/human-african-trypanosomiasis#tab=tab_1">new cases for sleeping sickness</a> down from tens of thousands per year to under 1,000.</p>
<p><a href="https://stories.dndi.org/sleepingsickness-doctors-dream/?fbclid=IwAR0xTLA5B_4BN_DPngjuXlWJWQE-b4yngyldRB6H1UDXB2atSOxuelQKh5g#group-the-clinical-sites-clSAiMizKr">Clinical trials</a> were successfully conducted in remote regions for a fraction of the traditional pharmaceutical cost and led to the development of the breakthrough drug fexinidazole. This was achieved through partnership between the Congolese government, local researchers, the pharmaceutical company Sanofi, and DNDi. </p>
<p>Partnerships like this demonstrate how far medical research and political leadership can go in addressing the needs of neglected patients.</p>
<h2>Looking ahead</h2>
<p>The WHO has set new targets to control and eliminate neglected tropical diseases by 2030 <a href="https://www.who.int/publications/i/item/WHO-UCN-NTD-2020.01">in a new Roadmap</a>.</p>
<p>African leaders have already shown the initial commitment. For the first time <a href="https://unitingtocombatntds.org/news/alma-ntds-2018/">a neglected tropical disease index</a> was included in the African Leaders Malaria Alliance scorecard for accountability and action two years ago. The inclusion of neglected tropical diseases was seen as recognition of the severity of these illnesses in member states. It provided a unique opportunity to increase political will, investment and <a href="https://alma2030.org/wp-content/uploads/2020/05/2.-2020-African-Union-Malaria-Progress-Report.pdf">accountability for these diseases</a>. </p>
<p>This was a good initial first step. </p>
<p>But current and future leaders need to be more involved. They can influence innovation and shape the policies that will lead to the control, elimination or eradication of neglected diseases. With commitment to find better tools that diagnose and treat these diseases, the unacceptable suffering of patients and neglected communities can finally be brought to an end.</p><img src="https://counter.theconversation.com/content/153914/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Monique Wasunna is the director of the Drugs for Neglected Diseases initiative Africa Regional Office.</span></em></p>Many of these diseases cause tremendous suffering and death – yet there’s still a lack of effective tools to diagnose, treat, and prevent them.Monique Wasunna, Researcher, Kenya Medical Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1497732020-11-11T14:55:31Z2020-11-11T14:55:31ZStrong leadership fought COVID-19 in Africa: the next step is to harness research<figure><img src="https://images.theconversation.com/files/368833/original/file-20201111-19-2wscsj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A response led by scientists and researchers must be central to any current and future threats.</span> <span class="attribution"><span class="source"> Donwilson Odhiambo/SOPA Images/LightRocket via Getty Images</span></span></figcaption></figure><p>African countries are still reeling from the effect of measures, such as lockdowns, taken to contain the spread of COVID-19. Though painful, they were a vital part of the successful public health response mounted by many African leaders.</p>
<p>The quick responses by most African countries meant that they were able to avoid the large-scale loss of life seen elsewhere. The 1.8 million infections and 44,000 deaths <a href="https://africacdc.org/covid-19/">recorded</a> on the continent by mid-November are a great loss. They are, nevertheless, far from the <a href="https://www.nature.com/articles/d41586-020-00405-w">catastrophic predictions</a> made back in March and April. </p>
<p>But the fight is not yet over: the Africa Centres for Disease Control has recently <a href="https://ewn.co.za/2020/10/29/africa-cdc-time-is-now-to-prepare-for-virus-second-wave">warned</a> of a fresh wave of infections, reporting almost 9,000 cases a day. With lockdowns easing and borders opening this figure will certainly rise.</p>
<p>If good public health measures helped Africa tackle its first COVID-19 wave, a response led by scientists and researchers must be central to any current and future threats. This was emphasised by several top African scientists gathered at a <a href="https://www.youtube.com/watch?v=GVQGCIltzE8&utm_source=Comms+Webinar+Registrants&utm_campaign=2b15a7a29f-EMAIL_CAMPAIGN_2020_11_WebinarFollowUp&utm_medium=email&utm_term=0_8fbb9b7e7c-2b15a7a29f-">recent webinar</a> convened to discuss next steps to contain the pandemic.</p>
<p>The strong leadership displayed by many African countries during the pandemic is certainly a lesson for others. But strong leadership needs good science. For Africa, this means that research for treatments and vaccines for COVID-19 must take place here, led by African scientists and tailored to this specific context.</p>
<h2>Lessons from Africa</h2>
<p>Global solidarity might be lacking in the fight against COVID-19 but regional cooperation is not, especially in Africa. As the director of the Africa Centres for Disease Control, John Nkengasong, pointed out, “the continent came together very quickly”. </p>
<p>Under his leadership, 55 health ministers gathered in Addis Ababa in February to develop a joint African strategy for the COVID-19 outbreak. </p>
<p>One of the decisions taken was to develop a platform to train 100,000 health workers and for the common procurement of diagnostics medical supplies. Called the “<a href="https://www.thelancet.com/journals/lanmic/article/PIIS2666-5247(20)30118-X/fulltext">Partnership to Accelerate COVID-19 Testing in Africa (PACT)</a>”, the initiative was set up for multiple countries and <a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30708-8/fulltext">has led to 12 million tests being conducted</a>.</p>
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Read more:
<a href="https://theconversation.com/what-developing-countries-can-teach-rich-countries-about-how-to-respond-to-a-pandemic-146784">What developing countries can teach rich countries about how to respond to a pandemic</a>
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<p>Many countries closed borders and implemented lockdowns. South Africa instituted one of the world’s strictest. For its part the Democratic Republic of Congo (DRC) instituted a lockdown and suspended all flights into the country – the main way cases were being introduced.</p>
<p>A number of countries also developed impressive testing programmes. One was Senegal, whose Institut Pasteur in Dakar was one of the only two laboratories with COVID-19 testing capacity when the pandemic began. Results are now available in hours. The country has also trained health workers elsewhere on the continent, and the Institut is developing <a href="https://www.bbc.com/news/world-africa-54388340">home-test kits</a> which should be available soon.</p>
<p>In South Africa, an army of health workers with experience in HIV and tuberculosis were used as contact tracers for COVID-19. </p>
<p>Another feature of the response in some countries was getting the buy-in of communities. Steve Mundeke Ahuka, the incident manager for the COVID-19 outbreak in the Democratic Republic of Congo, said the country drew on its past experience in managing the Ebola response.</p>
<p>This involved using social scientists and epidemiologists to study perceptions of Ebola in the community because of the distrust of outsiders. These insights were used to create and adapt communications to combat fake news and support vaccination and contact tracing. After two difficult years, the strategies paid off: <a href="https://www.who.int/news/item/25-06-2020-10th-ebola-outbreak-in-the-democratic-republic-of-the-congo-declared-over-vigilance-against-flare-ups-and-support-for-survivors-must-continue">over 300,000 people</a> were vaccinated.</p>
<p>Similar strategies were used for COVID-19. </p>
<h2>Research on COVID-19</h2>
<p>Most of the research taking place for COVID-19 is happening in North America and Europe. Large, well-organised clinical trials that were launched months ago are <a href="https://www.vox.com/2020/10/28/21528116/covid-19-death-rates-hospitalizations-icu-beds">already saving lives</a>.</p>
<p>This intensity of research is needed on the continent.</p>
<p>There are a number of reasons for this.</p>
<p>The first is that Africa has a different genetic profile. According to Helen Rees, executive director of the Wits Reproductive Health and HIV Institute in South Africa, who is leading COVID-19 vaccine efforts in South Africa,</p>
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<p>Populations have different genetic backgrounds, and they are exposed to different infections such as HIV and malaria. We need to know if future vaccines will be safe and effective in our populations.</p>
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<p>Another reason for more research on the continent is that it can help drive policy. As Borna Nyaoke Anoke, senior clinical project manager and medical manager at DNDi, argues:</p>
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<p>We need large, well-conducted, randomised clinical trials in Africa to support policy change for treatments.</p>
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<p>One of the most urgent priorities is the need for treatment for mild to moderate cases to avoid mass hospitalisations that would overwhelm already overburdened health systems. DNDi will soon be launching a large clinical trial with a number of African and European partners to fill this gap. A number of treatments that can be given to patients with mild symptoms <a href="https://www.heraldlive.co.za/news/2020-11-03-finding-covid-19-treatments-is-key-as-world-pins-hope-on-a-vaccine/">will be tested</a>.</p>
<p>Lastly, African countries need to be active in the research arena to ensure that they are not last in the queue for life-saving treatments and vaccines.</p>
<p>African countries have proved that they have the skills and expertise to provide local solutions to this global pandemic. They need to build on this success together to keep the pandemic at bay.</p><img src="https://counter.theconversation.com/content/149773/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr Monique Wasunna is the director of the Drugs for Neglected Disease initiative Africa regional office.</span></em></p>African countries have proven that they have the skills and expertise to provide local solutions to this global pandemic. They need to build on this success together to keep the pandemic at bay.Monique Wasunna, Researcher, Kenya Medical Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1365152020-04-22T06:25:35Z2020-04-22T06:25:35ZHow the Spanish flu affected Kenya – and its similarities to coronavirus<figure><img src="https://images.theconversation.com/files/329373/original/file-20200421-82645-10elwvu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Kenya's government have issued a directive that people must wear masks while in public places.</span> <span class="attribution"><span class="source">Boniface Muthoni/SOPA Images/LightRocket via Getty Images</span></span></figcaption></figure><p>The 1918 influenza pandemic – called the “Spanish flu” – remains <a href="https://www.cdc.gov/flu/pandemic-resources/1918-pandemic-h1n1.html">the most</a> significant public health event ever recorded in human history. It’s estimated that half a billion people were infected, and that between <a href="https://doi.org/10.1353/bhm.2002.0022">20 million and 100 million people died</a>. Most deaths occurred in Asia (36 million). In Africa 2.5 million died, Europe 2.3 million and North America 1.6 million. </p>
<p>The exact origin of the flu is still unclear. Some <a href="https://archive.org/details/influenzaepidemi00vauguoft/page/n1/mode/2up">reports indicate</a> that it first occurred and spread within the US in 1918. A more <a href="https://doi.org/10.1177/0968344513504525">recent study</a> suggests the pandemic originated in China in 1917, and was introduced into Canada and the US by Chinese labourers. Soldiers, returning home after the end of World War I, then brought it to Europe and the rest of the world. </p>
<p>The Spanish flu is believed to have <a href="https://elibrary.ru/item.asp?id=7411876">come to Kenya with returning</a> veterans who docked in the <a href="https://www.jstor.org/stable/44447656">Mombasa port</a>. The country was still a British colony at the time. In nine months the epidemic killed about 150,000 people, between <a href="https://www.academia.edu/31804192/Spanish_Influenza_in_Kenya.pdf">4% and 6% of the population</a> at the time. </p>
<p>In a <a href="https://www.mdpi.com/2414-6366/4/2/91">recent study</a>, my colleagues and I examined the impact of the Spanish flu in coastal Kenya. We chose the coastal province because it was the colony’s most critical administrative area, due to its port in Mombasa. It also had better administrative and health records.</p>
<p>Vital data from this period is incomplete and biased, so we examined narratives of how the pandemic affected people’s lives. We saw that there were various forms of social and economic disruption, ranging from social distancing to the suspension of nonessential services, paralysed administrative operations, widespread food shortages, commercial losses, and an overwhelmed healthcare sector. </p>
<p>Kenya is battling a new pandemic: COVID-19. Even though it’s 100 years later, the new coronavirus has echoes of those experiences a century ago.</p>
<h2>The flu spread rapidly</h2>
<p>For our study we used colonial records and correspondence from Kenya’s National Archives Library in Nairobi. The interactions between district and provincial level administrations on the pandemic were key sources. They included the minutes of local chiefs’ weekly meetings, health facility case and death summaries, case report forms, district officers’ letters and routine district briefs. </p>
<p>In the same period (1912-1925), the entire Coast Province (seven districts) had a population that ranged between 170,000 and 243,841 people. We focused on five of the seven districts with data on pandemic cases: Kilifi (previously Nyika), Kwale (previously Vanga), Mombasa, Taita Taveta and Malindi.</p>
<p>Before the Spanish flu came, patient visits to healthcare facilities varied between 9 and 33 for every 1,000 people per year. By 1918 this had increased five-fold, to 146.8 visits. </p>
<p>Similarly, trends of mortality increased sharply from 1918, from less than five deaths per 1,000 people per year to 25 deaths. This high mortality rate continued through to 1925. </p>
<p>We found that the Spanish flu spread rapidly, and had a high mortality rate. In just nine months – from September 1918 to June 1919 – there were approximately 31,908 cases and 4,593 deaths associated with the Spanish flu in Kenya’s coastal province. In the same period, 150,000 deaths were <a href="https://www.academia.edu/31804192/Spanish_Influenza_in_Kenya.pdf">reported</a> across the country. </p>
<p>A letter from the Kwale assistant district commissioner in 1919 explained who was most susceptible: </p>
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<p>Death occurred mostly among the old men and women, and judging from the number of elders of council reported to have died must have run into hundreds…and…Very few of the young and middle aged…</p>
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<p>In 1919, the Kilifi district commissioner also described the conditions that led to more cases:</p>
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<p>I consider the deaths have been augmented when either of the following two conditions have been present. (a) Overcrowding, as in Malindi, Mambrui and Roka. (b) Normally difficult conditions of life. I mean when food has been hard to come by or water far removed from villages…</p>
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<h2>Health interventions</h2>
<p>To tackle the pandemic, colonial authorities developed guidelines for healthcare workers, including social distancing, personal hygiene practices and medical treatment. The ultimate goal was to reduce community transmission. </p>
<p>Healthy people were told to avoid contact with sick individuals and to take prophylactic remedies, such as gargling with potassium permanganate, and oral quinine. </p>
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Read more:
<a href="https://theconversation.com/south-africa-bungled-the-spanish-flu-in-1918-history-mustnt-repeat-itself-for-covid-19-133281">South Africa bungled the Spanish flu in 1918. History mustn't repeat itself for COVID-19</a>
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<p>Those already sick were advised to seek bed rest, home nursing and proper nourishment, in addition to oral quinine three times a day. These rudimentary prescriptions did very little.</p>
<p>For most local Kenyans, who couldn’t access or afford medication, the recommendations included home nursing, a teaspoon of paraffin oil three times a day and eating meals that were high in starch and enriched with milk. </p>
<p>Prolonged bed rest and a slow return to work was advised, and for patients with depression, a tonic treatment was prescribed.</p>
<h2>Social and economic disruption</h2>
<p>In four of the five district administrative offices, absenteeism due to sickness led to several disruptions of public service provision.</p>
<p>Among the local Kenyans, the illness caused job losses, increased food insecurity and affected households’ ability to pay colonial taxes. Consequently, many suffered reduced “vitality” and low incomes. </p>
<p>For those depending on subsistence farming, the total or partial crop failure occasioned by poor weather in 1918 and lack of seed supplies worsened the poor health of the population. </p>
<p>Economic disruption was also reported in large commercial farms. These suffered massive losses due to unprecedented labour shortages. </p>
<p>In the healthcare sector, the situation was grave. Understaffed facilities were overwhelmed with the influx of patients, low reserves of medical supplies and little colonial administration support. The scale of the problem caused such panic that the authorities allowed the use of placebo therapeutics to pacify residents’ anger.</p>
<p>A century ago, the Spanish flu caused untold suffering and social disruption to hundreds of thousands of locals. We can argue that the mitigation efforts and medical advances of the time did little. In addition, what brought it into the country – global war and colonial rule – were beyond the control of locals. </p>
<p>But what stands out is that the actions of locals, individually and collectively, contributed to the sickness and death. We found that most locals disregarded quarantine measures and, in the peak of the outbreak, went to their rural villages. This amplified community transmission. </p>
<p>In the COVID-19 pandemic, we can draw parallels and learn from our past.</p><img src="https://counter.theconversation.com/content/136515/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Fred Andayi received funding from French science and technology research institute (Institut de Recherche pour le Developpement (IRD), France.
Disclaimer: The findings and conclusions in this article are those of the author and do not necessarily represent the official position of his past or present affiliate institutions.
</span></em></p>In Kenya, the Spanish flu caused various forms of social and economic disruption, ranging from social distancing to the suspension of nonessential services and widespread food shortages.Fred Andayi, Research Associate, Kenya Medical Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1334512020-03-18T14:32:25Z2020-03-18T14:32:25ZWhy the elimination of malaria needs much greater involvement of women<figure><img src="https://images.theconversation.com/files/320573/original/file-20200315-50583-18wx98r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Women are often primary caregivers in their communities.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>I was born and bred in the western part of Kenya, an area endemic of malaria. I have been sick from malaria not once, not twice, but more times than I can count. In my village, outbreaks were normal – the entire village would get sick, especially after the rains. I watched many people die, including classmates, relatives and even my own family members.</p>
<p>As a child, I watched mothers in my village work frantically to make sure their families were protected from the disease. They dressed the kids up to protect them from mosquito bites and cold weather. If someone contracted malaria, they would boil concoctions from traditional plants, cook finger millet (<em>wimbi</em>) porridge and ensure the patient would frequently shower to control fever. Sometimes they even carried the patient on their back to the hospital. When a family member was sick, the mother would practically be held hostage.</p>
<p>Unfortunately, the situation in my Kenyan village is not unique on this continent. Sub-Saharan Africa continues to carry an unreasonably high global burden of disease. <a href="https://www.who.int/news-room/feature-stories/detail/world-malaria-report-2019">In 2018</a>, the region was home to 93% of the world’s malaria cases. Most of the deaths (94%) were recorded in sub-Saharan Africa. Women bear the brunt of the disease, with children and pregnant women carrying the highest risk.</p>
<p>I am now a scientific researcher focused on malaria – partly because of my childhood experiences almost 30 years ago. I trap mosquitoes to <a href="https://malariajournal.biomedcentral.com/articles/10.1186/s12936-020-3108-0">monitor their behaviour</a>, and how they develop <a href="https://www.ncbi.nlm.nih.gov/pubmed/29304805">insecticide resistance</a>. I <a href="https://malariajournal.biomedcentral.com/articles/10.1186/s12936-019-3032-3">investigate</a> new insecticides we could use to counter mosquito resistance to the current chemicals. In villages across Kenya, I participate in the distribution of bed nets, spraying of houses with insecticides, conduct health education and screen for malaria infections.</p>
<p>I also participate in high-level meetings about controlling malaria and other vector-borne diseases in Kenya and beyond. Unfortunately, the number of women present in such meetings is low. This is a problem because women are primary caregivers and the key implementers of community-level interventions. But they are missing from top leadership or managerial positions. </p>
<p>If we’re serious about malaria elimination in Africa, women must be included at decision making levels to advise on development, designing, delivery and implementation of tools that target health issues that affect them – especially malaria.</p>
<h2>The role of women</h2>
<p>Women are clearly in charge in the villages I travel to for <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5838394/?">field work</a>. They implement the plans the men create in their faraway high-level meetings.</p>
<p>A 2016 report by the <a href="https://www.pamca.org/">Pan-African Mosquito Control Association</a> showed that very few women were part of workforces dealing with vector control. Last year the association convened a meeting in Cameroon of 29 women from 20 African countries to identify the gaps and challenges of addressing malaria and vector-borne diseases. Overall, there was an outcry that women were not considered for leadership positions, mostly due to African cultural norms in which they were viewed as the weaker sex. Even if they tried to step up, women reported being mostly ignored.</p>
<p>This is in direct contrast from my personal observations as a researcher. In communities, women ensure that high-quality bed nets are available and that everyone sleeps under them. If houses are sprayed with insecticides, women are the ones who ensure that the walls are not smeared or painted until the end of the shelf life of the chemical. Women also ensure that their children are treated in case of malaria infection and that they complete their doses.</p>
<p>Controlling malaria and other vector-borne diseases is complex. It needs integrated approaches and a range of voices. </p>
<h2>Way forward</h2>
<p>To harness its full potential, Africa must dismantle gender stereotypes. Incorporating women in the design, delivery and adoption of malaria interventions will enhance acceptance and compliance because women are the key implementers at community levels. And there should be concerted efforts to ensure they are part of policy making because they’re better equipped to build programmes with women in mind.</p>
<p>Excluding women -— particularly when making decisions on health issues that affect them, their children and the entire family — will continue to delay the realisation of malaria elimination on the continent. It will also be an impediment to economic development.</p><img src="https://counter.theconversation.com/content/133451/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Damaris Matoke-Muhia is a molecular biologist. She is a senior research officer at Kenya Medical Research Institute (KEMRI) and director of capacity building, gender mainstreaming & career progression at Pan-African Mosquito Control Association (PAMCA). She is a Fellow with the Aspen New Voices programme.</span></em></p>Women must be included at decision making levels to advise on development, designing, delivery and implementation of tools that target health issues that affect them especially malaria.Damaris Matoke-Muhia, Senior Research scientist, Kenya Medical Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1330972020-03-08T07:46:23Z2020-03-08T07:46:23ZThe way we measure iron deficiency in children needs to change. Here’s why<figure><img src="https://images.theconversation.com/files/318882/original/file-20200305-106579-sx76bw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>A deficiency of iron for normal body function is the <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32279-7/fulltext">most common nutritional disorder in the world</a>. Iron deficiency is the <a href="https://www.ncbi.nlm.nih.gov/pubmed/24297872">main cause of anaemia</a> and is associated with poor brain development and long-term impairment of behavioural and cognitive performance in children. </p>
<p>Common symptoms of iron deficiency include pallor of the skin, eye and beds of nails, weakness, difficulty breathing, dizziness, headache, hair loss, dry or rough skin and cravings for non-food items such as ice, paper, dirt, or clay.</p>
<p>Iron deficiency is commonly diagnosed using laboratory blood tests that mainly measure levels of <a href="https://www.healthline.com/health/ferritin#ferritin">ferritin</a>, a protein that stores iron. In Africa, the tests can be misleading because ferritin levels go up in a person’s body during inflammation or infections such as malaria. This means that a person who is iron deficient may appear iron replete if they’re carrying an infection. </p>
<p>It is therefore challenging to estimate the burden of iron deficiency in settings such as sub-Saharan African where infections are common.</p>
<p>But accurate estimates of the burden of iron deficiency are important for designing public health interventions dealing with nutritional iron levels. Giving iron supplements based on poor data can lead to the wrong children being targeted. This could include children who should be getting supplements but aren’t, and those who don’t need them being given supplements with possible adverse effects.</p>
<p>To help overcome this problem <a href="https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-020-1502-7">we set out to calculate</a> more reliable estimates of the burden of iron deficiency in African children. </p>
<p><a href="https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-020-1502-7">Our study</a> highlighted that a huge burden of iron deficiency may be missed out given the current tools used to measure it. This is important for governments to properly plan, monitor, and target effective interventions to deal with iron deficiency on the continent.</p>
<p>We analysed data for 4,853 children from communities in Kenya, Uganda, South Africa, Burkina Faso and The Gambia. We used statistical modelling to correct for the effects of malaria and inflammation on iron biomarkers. We found that over half (52%) of the African children were iron deficient. </p>
<p>We also found that <a href="https://www.sciencedirect.com/topics/medicine-and-dentistry/transferrin-saturation">transferrin saturation</a>, an indicator of transferrin-bound iron in the bloodstream, may more accurately estimate the burden of iron deficiency in African children. This is because transferrin saturation was the iron biomarker least influenced by infections. We found that transferrin saturation below 11% may indicate iron deficiency in African children. Transferrin saturation is easy to measure in routine laboratory tests.</p>
<h2>The implications</h2>
<p>We found that ferritin levels may be elevated even before children are defined as having inflammation. We also found that malaria infection influenced ferritin levels independently of inflammation.</p>
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<img alt="" src="https://images.theconversation.com/files/318883/original/file-20200305-106589-7ccg6.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/318883/original/file-20200305-106589-7ccg6.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=445&fit=crop&dpr=1 600w, https://images.theconversation.com/files/318883/original/file-20200305-106589-7ccg6.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=445&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/318883/original/file-20200305-106589-7ccg6.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=445&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/318883/original/file-20200305-106589-7ccg6.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=559&fit=crop&dpr=1 754w, https://images.theconversation.com/files/318883/original/file-20200305-106589-7ccg6.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=559&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/318883/original/file-20200305-106589-7ccg6.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=559&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Source: Author.</span>
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<p>The influence of malaria infection on ferritin levels is not accounted for in the World Health Organisation’s <a href="https://www.who.int/vmnis/indicators/serum_ferritin.pdf">definition of iron deficiency</a>. In addition, its <a href="https://www.who.int/vmnis/indicators/serum_ferritin.pdf">definition of iron deficiency</a> accounts for the effect of inflammation by applying an arbitrary higher cut-off of ferritin levels in individuals with inflammation.</p>
<p>Using the World Health Organisation definition, the overall prevalence of iron deficiency was 34%. But this is an underestimate of the burden of iron deficiency (52%) that we found. </p>
<p>In some communities, where the prevalence of infections was high, over a quarter of the children were misclassified as iron replete whereas they were iron deficient.</p>
<p>This has huge implications for the rollout of nutritional iron programmes. The World Health Organisation uses the prevalence of anaemia as a proxy of iron deficiency or need in a population. The organisation recommends that <a href="https://www.who.int/nutrition/publications/micronutrients/guidelines/daily_iron_supp_childrens/en/">daily iron supplementation</a> should be provided to all children if the prevalence of anaemia is more than 40%. In places where malaria is prevalent, the iron supplementation should be provided in conjunction with effective malaria controls and treatment measures since giving iron may increase the risk of malaria infection. </p>
<p>In <a href="https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-020-1502-7">our study populations</a>, the prevalence of anaemia was more than 40%. Therefore, based on the <a href="https://www.who.int/nutrition/publications/micronutrients/guidelines/daily_iron_supp_childrens/en/">World Health Organisation recommendations</a>, all children would receive iron supplementation although we found that approximately half of the children were iron deficient. Half of the children would needlessly take iron supplements. This suggests that the prevalence of anaemia is a poor indicator of iron need.</p>
<p>Giving iron supplements to children who are not iron deficient may predispose them to infections, including malaria. A <a href="https://www.ncbi.nlm.nih.gov/pubmed/16413877">large study</a> in Pemba, Tanzania, showed that iron supplemented children were more likely to die or be admitted to hospital. In <a href="https://www.ncbi.nlm.nih.gov/pubmed/16413877">that study</a>, iron supplementation increased the risk of malaria-related events by 16%. However, in iron deficient children, iron supplementation was not harmful. </p>
<h2>How to manage iron deficiency</h2>
<p>There are multiple causes of iron deficiency in children. These can include eating diets low in iron, impaired absorption of iron, excessive loss of iron through injury, increased iron need for growth, or genetic factors. </p>
<p>Iron in foods such as meat, fish and poultry is easily absorbed while iron found in plant foods, such as vegetables, cereals, beans and lentils, is poorly absorbed. Eating fruits rich in vitamin C enhances iron absorption. Grains and tea contain substances that inhibit iron absorption.</p>
<p>The need for iron varies. For example, iron requirements increase during the first year of a child’s growth. This means that weaning children should be supplemented with foods rich in iron.</p>
<p>In sub-Saharan Africa, chronic infections such as <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32279-7/fulltext">malaria, HIV, and TB are common</a>. These diseases may be an underlying cause of iron deficiency. This is because they can cause a blockade of dietary iron absorption. Thus, even iron supplements may not be effectively absorbed in the presence of infections. The <a href="https://academic.oup.com/ajcn/article/92/6/1406/4597520">fortification of foods has also been associated with gut disorders</a> since unabsorbed iron favours the growth of bad bacteria.</p>
<p>What this shows is that managing iron deficiency is complex and an integrated approach is required. <a href="https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-020-1502-7">Our study</a> suggests that improved control of malaria and other infections would also improve assessment of iron status in African children. </p>
<p>Improved control of infections may also improve absorption of iron although future research should quantify the benefits of such an approach in addressing iron deficiency.</p><img src="https://counter.theconversation.com/content/133097/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr John Muthii Muriuki does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>In some communities, over a quarter of the children were misclassified as iron replete whereas they were iron deficient.Dr John Muthii Muriuki, PhD Fellow, Open University (UK), Kenya Medical Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1204642019-07-18T14:38:01Z2019-07-18T14:38:01ZHIV in Kenya: high risk groups aren’t getting the attention they need<figure><img src="https://images.theconversation.com/files/284705/original/file-20190718-116547-1pv9tck.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Women walk past a mural painted to raise awareness on HIV and AIDS in Kibera slum in Nairobi, Kenya.</span> <span class="attribution"><span class="source">EPA/Dai Kurokawa</span></span></figcaption></figure><p>Efforts to manage the HIV epidemic in much of sub-Saharan Africa need to specifically target sections of the population that are most vulnerable to HIV infection. Two such <a href="https://www.unaids.org/en/topic/key-populations">key populations</a> include men who have sex with men and transgender women. But <a href="https://www.news24.com/Africa/News/anti-gay-laws-widespread-in-africa-despite-gains-20190220">in many countries</a> on the continent same sex relationships – and transgender identities – are criminalised. </p>
<p>Kenya is one such country where the culture is conservative and homosexuality is generally a taboo subject. Gay people who are open about their sexuality are subjected to significant stigma and discrimination. This <a href="https://theconversation.com/homosexuality-remains-illegal-in-kenya-as-court-rejects-lgbt-petition-112149">legal status</a>, coupled with social stigma, makes it difficult for at-risk populations to seek preventive services in public health care facilities. In Kenya, key populations, including men who have sex with men and transgender women, contribute <a href="https://www.avert.org/professionals/hiv-around-world/sub-saharan-africa/kenya">a third of new HIV infections</a>. </p>
<p>In 2017, the Kenyan ministry of health launched a <a href="https://theconversation.com/kenya-embraces-new-prevention-efforts-to-reduce-hiv-infection-80483">programme</a> to provide Pre-exposure prophylaxis (PrEP) to people at increased risk of HIV infection. PrEP is the use of anti-retroviral medication in HIV negative people as prevention against HIV. The aim of the programme is to make PrEP available at public health facilities. But this model may have shortcomings as men who have sex with men and transgender people <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3852126/">may not feel comfortable</a> in public health settings. Additionally, health care providers may not be prepared to provide services to key populations. </p>
<p>Health care providers refer to the <a href="https://www.nascop.or.ke/?page_id=2744">national guidelines</a> to determine who needs PrEP. But the guidelines don’t address anal sex. This is a major omission given that it carries the highest risk for HIV acquisition. And the guidelines assume that sexual behaviour is the same for all men who have sex with men. But, some may exclusively have sex with men, while others may also have sex with women. This difference in sexual behaviour has been shown to affect <a href="https://insights.ovid.com/pubmed?pmid=23079811">the risk of HIV acquisition</a>. </p>
<p>We conducted a <a href="https://www.ncbi.nlm.nih.gov/pubmed/31194291">study</a> to estimate HIV incidence among men who have sex with men exclusively, men who have sex with men and women as well as transgender women. We also wanted to assess how much interest there was in PrEP and what barriers there were to people accessing them. </p>
<p>Our research adds to existing knowledge about how behavioural differences can affect the risk of HIV acquisition. Our findings support the need to revise guidelines to better target PrEP at those that would most benefit for it. </p>
<h2>The research</h2>
<p>As part of the research we followed a cohort of men who have sex with men between 2016 and 2017 in Malindi on the coast of Kenya. We collected social demographic, sexual orientation and gender identity data that allowed us to classify participants as being either men who have sex with men and women or men who have sex with men exclusively or transgender women. We also explored participants’ knowledge and desire to take up PrEP. </p>
<p>Additionally, we assessed the factors associated with HIV acquisition. Finally, we held focus group discussions with HIV negative participants that were segregated by sexual orientation and gender identity. </p>
<p>Overall, the risk for HIV acquisition in this cohort over a one year period was 5%. But in transgender women this risk was extremely high at 20%. HIV acquisition was associated with a number of factors including exclusive receptive anal intercourse and history of a sexually transmitted infection. </p>
<p>A majority (98.8%) of the participants were interested in initiating PrEP. Transgender women expressed concern that actual PrEP provision may cause them to engage in condomless anal or group sex more frequently.</p>
<p>These results show a number of significant patterns. These include confirmation of a much higher risk of HIV acquisition in transgender women than in men who have sex with men.</p>
<p>Globally, <a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(12)70315-8/fulltext">studies</a> have shown that transgender women have the highest risk of HIV acquisition. They also bear a disproportionate burden of HIV prevalence. The existence of transgender women has been generally ignored in most of sub-Saharan Africa. Transgender women are not a recognised key population in Kenya and may have previously been classified incorrectly as men who have sex with men exclusively.</p>
<h2>Way forward</h2>
<p>Our findings confirm that transgender women would benefit most from PrEP. But legal barriers and stigma mean that they are invisible and under-served in Kenya.</p>
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Read more:
<a href="https://theconversation.com/homosexuality-remains-illegal-in-kenya-as-court-rejects-lgbt-petition-112149">Homosexuality remains illegal in Kenya as court rejects LGBT petition</a>
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<p>We believe that our findings could be used to inform policy makers on the need to revise national guidelines to better target the intended recipients of the PrEP programme in Kenya. We hope to raise awareness on the need to recognise the existence of transgender women and the need for their inclusion in HIV prevention activities in Kenya.</p><img src="https://counter.theconversation.com/content/120464/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Makobu Kimani is a SANTHE (Sub-Saharan African Network for TB/HIV Research Excellence) Fellow.</span></em></p>The government needs to revise national guidelines to better target PrEP at those that would most benefit from it.Makobu Kimani, PhD candidate at the University of Amsterdam and researcher , Kenya Medical Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1116712019-02-17T09:25:49Z2019-02-17T09:25:49ZWhat mapping Kenya’s child deaths for 50 years revealed – and why it matters<figure><img src="https://images.theconversation.com/files/258683/original/file-20190213-90497-10qs9qm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">In 50 years, Kenya has experienced an overall decline in under 5 mortality.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>The number of children who die before reaching their fifth birthday is closely monitored as a marker of social well-being and <a href="http://www.childmortality.org/">national development</a>. It best summarises the social, economic, environmental and health care systems that children are born into and thus used as the basis of planning health strategies, programmes and interventions. It’s also an important tool for evaluating the success of a country’s child health policies. </p>
<p>There has been <a href="http://www.childmortality.org/">remarkable progress</a> in improving child survival over the last three decades. But there’s a long way to go: globally, <a href="https://data.unicef.org/topic/child-survival/under-five-mortality/">5.4 million</a> children died before reaching their fifth birthday in 2017. This is equivalent to 15,000 child deaths per day. And the burden is unevenly distributed: sub-Saharan Africa region recorded 14 times more of these deaths compared to high-income countries. The region is home to all six countries in the world that recorded child mortality rates above 100 deaths per 1000 live births. </p>
<p>Kenya performed well above average, with a rate of 46 deaths per 1,000 live births compared to an average of 76 across sub-Saharan Africa region. </p>
<p>Our <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-019-6474-1">Kenyan study</a> set out to estimate child mortality rates in each of the country’s 47 counties every year since 1965. This allowed us to explore changes over time, disparities in child survival by county and progress and gaps towards achieving global targets of <a href="https://www.unicef.org/wsc/goals.htm#Child">2000</a> and <a href="http://www.un.org/millenniumgoals/">2015</a> at different times over the last 30 years. We achieved this by assembling all mortality related data in Kenya and applied a range of techniques to generate child mortality rates.</p>
<p>The findings suggest that, while national trends may be useful for regional and global policy advocacy, they can also be misleading. This is because within-country differences are masked by the national aggregate levels of child mortality. </p>
<p>Identifying counties where mortality remains higher than the national average is valuable for at least two important reasons. It can lead to governments properly directing suitable interventions that are most likely to bring down child mortality rates. It can also ensure effective and equitable resource allocation to reduce inequalities. This is specifically relevant to Kenya where health is now managed by county governments. </p>
<h2>What we found</h2>
<p>Our findings showed that, shortly after independence in 1963, one in every seven Kenyan children born alive, died before the age of five. More than five decades later, mortality has declined significantly. But it remains high, with one in every 19 children not reaching their fifth birthday. The overall decline over this period was 62% but it was uneven over time. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/258510/original/file-20190212-174873-15k5c6g.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/258510/original/file-20190212-174873-15k5c6g.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=317&fit=crop&dpr=1 600w, https://images.theconversation.com/files/258510/original/file-20190212-174873-15k5c6g.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=317&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/258510/original/file-20190212-174873-15k5c6g.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=317&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/258510/original/file-20190212-174873-15k5c6g.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=399&fit=crop&dpr=1 754w, https://images.theconversation.com/files/258510/original/file-20190212-174873-15k5c6g.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=399&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/258510/original/file-20190212-174873-15k5c6g.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=399&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Source: Author provided.</span>
</figcaption>
</figure>
<p>We found that the rate declined steadily from the early 1970s to late 1980s and again from early 2000 to 2013. But there was stagnation or reversal between these declines during the 1990s. More alarming is that Kenya fell short of the 2000 milestones set during the world summit for children aimed at reducing child mortality by a third (1990-2000) or to 70 deaths per 1000 live births by 2000 and only managed a 48% reduction against a target of 67% in the millennium development goal 4 monitoring period (1990 to 2015).</p>
<p>County-level results showed that in 1965, 11 counties – mainly in coastal or arid and semi-arid areas – had mortality rates over 200 per 1000 live births. During this time only four counties had rates below 75 deaths per 1000 live births.</p>
<p>Over 50 years, there have been significant reductions. But the success has been variable, with reductions ranging between 19% and 80%. Counties with high mortality in 1965 witnessed massive declines compared to counties that had lower starting rates, but these same high mortality counties still had the highest rates of mortality in 2013. By 2013 there was a 3.8 times difference between high mortality and low mortality counties, a reduction from five-fold in 1965.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/258511/original/file-20190212-174890-8ynd61.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/258511/original/file-20190212-174890-8ynd61.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=431&fit=crop&dpr=1 600w, https://images.theconversation.com/files/258511/original/file-20190212-174890-8ynd61.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=431&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/258511/original/file-20190212-174890-8ynd61.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=431&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/258511/original/file-20190212-174890-8ynd61.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=542&fit=crop&dpr=1 754w, https://images.theconversation.com/files/258511/original/file-20190212-174890-8ynd61.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=542&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/258511/original/file-20190212-174890-8ynd61.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=542&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Source: Author provided.</span>
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<p>Finally, the results showed that at the county level, Kenya performed sub-optimally in meeting the goals set during the world summit for children for the period 1990 to 2000. Only 25, or half of all counties, achieved the 2000 goals by reducing child mortality to a rate less than 70 or by a third. </p>
<p>More worrying is that no county achieved the goals under millennium development goal 4 by 2015. </p>
<h2>Set local targets</h2>
<p>These findings come at a time when Kenya has launched further initiatives to improve child survival and populations well being. Most notable is the <a href="http://www.president.go.ke/">universal health care programme</a>. It aims to provide individuals and communities with access to health services they need without suffering financial hardship. This is expected to reduce inequalities and will need to be monitored.</p>
<p>In the current decentralised form of governance, all the 47 county governments have been keen to set local targets to monitor and reduce child mortality through county integrated development plans and statistical plans. Our results are invaluable for setting informed baselines and tracking local county specific goals as well as the 2015 sustainable development goals framework. Goal 3.2 of this framework partly aims to reduce child mortality to at most 25 deaths per 1000 live births by 2030. </p>
<p>At the national level, the allocation and distribution of health related resources could be better informed through these findings. </p>
<p>Counties need to focus on rolling out targeted packages of intervention tailored to individual contexts, alongside existing interventions, if they are to record further declines.</p><img src="https://counter.theconversation.com/content/111671/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Macharia receives funding from the Initiative to Develop African Research Leaders as a PhD student (# 107769). The authors also acknowledge the support of the Wellcome Trust for the Kenya Major Overseas Programme (# 203077)</span></em></p><p class="fine-print"><em><span>Emelda Okiro receives funding from the Wellcome Trust as an intermediate research fellow (# 201866).
</span></em></p>Only half of Kenya’s 47 counties achieved the 2000 goal on reducing child mortalityPeter Macharia, PhD Candidate: The Open University UK and, Kenya Medical Research InstituteEmelda Okiro, Head, Population Health Unit, KEMRI, Kenya Medical Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1033912018-09-17T21:52:11Z2018-09-17T21:52:11ZÁfrica: algunas soluciones para aminorar el largo camino al hospital<figure><img src="https://images.theconversation.com/files/236691/original/file-20180917-158243-1ft3si9.jpg?ixlib=rb-1.1.0&rect=3%2C0%2C665%2C437&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Un pequeño hospital en el distrito de Wakiso, en la región central de Uganda.</span> <span class="attribution"><a class="source" href="https://sp.depositphotos.com/169955120/stock-photo-hospital-in-uganda-africa-at.html">Depositphotos / Delmash Lehman</a></span></figcaption></figure><p>Casi la mitad de todas las muertes y alrededor de un tercio de las discapacidades en países de ingresos bajos y medios podrían evitarse si la gente tuviera acceso a una asistencia médica de urgencia. En África, las principales causas de urgencias son los accidentes de tráfico, las complicaciones durante el embarazo, las enfermedades graves y las enfermedades no transmisibles.</p>
<p>Durante los últimos 18 años, <a href="https://afem.africa/">la Federación Africana de Medicina de Emergencia</a>, un grupo de apoyo, ha estado fomentando el desarrollo de sistemas de atención médica de urgencia en el continente. Las fallas que ha identificado incluyen transportes y servicios hospitalarios decentes.</p>
<p>Sin embargo, para abordar estos desafíos se necesitan datos sobre el número de hospitales, sus ubicaciones, así como la población marginada. La mayoría de los países africanos no tienen esta información. Carecen de inventarios básicos sobre los servicios sanitarios, incluido el número de hospitales.</p>
<p><a href="http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(17)30488-6/fulltext?utm_campaign=lancet&utm_content=66283296&utm_medium=social&utm_source=facebook">Nuestro estudio</a> se propuso abordar este problema realizando la primera evaluación de los servicios hospitalarios en África subsahariana, a través de la cual se calculó el acceso de la gente a la atención sanitaria.</p>
<p>Los resultados –incluyendo cuánto se tarda en llegar a un hospital– muestran dónde se requiere inversión para mejorar el acceso. Se necesitan varias intervenciones, y estas deberían incluir la construcción de nuevos hospitales, la mejora de la atención ambulatoria, la construcción de nuevas carreteras y la reparación de las existentes.</p>
<p>Pero la acción más urgente es que los países actualicen su directorio de hospitales, incluyendo una evaluación de la capacidad y la competencia para proporcionar asistencia médica de urgencia y una actualización del sector privado. Nuestra investigación trata, en cierta manera, de contribuir a que se inicie este proceso. Hemos construido una <a href="https://dataverse.harvard.edu/dataset.xhtml?persistentId=doi:10.7910/DVN/JTL9VY">base de datos</a> a la que se puede acceder de forma gratuita y que se puede utilizar para evaluar la disponibilidad de los servicios de cada país.</p>
<h2>Construyendo la base de datos</h2>
<p>La lista de hospitales cubre 48 países e islas de África subsahariana.
Para desarrollar la lista se utilizaron datos de numerosas fuentes, incluyendo los ministerios de sanidad, los sistemas de información sanitaria, las organizaciones nacionales e internacionales de todos los países e islas. En la mayoría de los casos, las fuentes estaban disponibles en la red, pero en algunos países también utilizamos contactos personales para obtener los datos hospitalarios.</p>
<p>Cerca del 50% de los hospitales de la lista no tenían coordenadas GPS que pudieran ayudar a localizarlos con precisión. Para superar el problema les asignamos atributos de ubicación únicos usando herramientas como <a href="https://earth.google.com">Google Earth</a> y <a href="https://www.openstreetmap.org">OpenStreetMap</a>.</p>
<p>Esta auditoría localizó 4.908 hospitales del sector público a los cuales se les asignó con precisión atributos de ubicación (Figura 1).</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/234990/original/file-20180905-45178-l6s510.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/234990/original/file-20180905-45178-l6s510.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/234990/original/file-20180905-45178-l6s510.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=574&fit=crop&dpr=1 600w, https://images.theconversation.com/files/234990/original/file-20180905-45178-l6s510.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=574&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/234990/original/file-20180905-45178-l6s510.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=574&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/234990/original/file-20180905-45178-l6s510.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=721&fit=crop&dpr=1 754w, https://images.theconversation.com/files/234990/original/file-20180905-45178-l6s510.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=721&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/234990/original/file-20180905-45178-l6s510.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=721&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Mapa de hospitales públicos en África.</span>
<span class="attribution"><span class="source">Author supplied</span></span>
</figcaption>
</figure>
<p>Nigeria, que representa cerca de una quinta parte de la población de África subsahariana, tiene el mayor número de hospitales, con 879. Otros países con un número significativamente alto de hospitales públicos son la República Democrática del Congo (435), Kenia (399) y Sudáfrica (337).</p>
<p>Las regiones más pequeñas, como Cabo Verde, Zanzíbar y Santo Tomé y Príncipe son los que tienen un menor número de centros hospitalarios. Esta información se utilizó como punto de partida para calcular el acceso geográfico a los servicios sanitarios.</p>
<h2>Acceso fácil</h2>
<p>Medimos la accesibilidad geográfica por duración de trayecto al hospital público más cercano. Lo hicimos calculando cuánto tiempo se tardaría en llegar por carretera basándonos en los principales medios de transporte de la región.</p>
<p>Ensamblamos redes viarias de Google Earth y OpenStreetMap, y asignamos velocidades de viaje a lo largo de las carreteras. Entonces, diviendo la superficie en hectáreas, desarrollamos un modelo que calcula el tiempo que lleva a un paciente viajar desde cualquier lugar al hospital más cercano.</p>
<p>Especialmente tuvimos muy en cuenta que una proporción significativa de mujeres necesita acceso a la atención hospitalaria durante el parto y determinamos cuánto tiempo tardarían en llegar al hospital más cercano.</p>
<p>Los resultados revelan que menos de un tercio (29%) de la población total, y el 28% de las mujeres en edad de tener hijos, vivía a más de dos horas de los hospitales más cercanos. El umbral de dos horas es una recomendación ampliamente promovida por la <a href="http://www.who.int/reproductivehealth/publications/monitoring/9789241547734/en/">OMS</a> y la <a href="http://www.lancetglobalsurgery.org/">Comisión Lancet</a> de Cirugía Global para definir, respectivamente, el acceso a la atención obstétrica y quirúrgica de urgencia. </p>
<p>Además, los parámetros internacionales de la Comisión Lancet en Cirugía Global recomiendan tener al 80% de cualquier población viviendo a menos de dos horas del hospital más cercano como un elemento fundamental para asegurar la cobertura sanitaria en 2030.</p>
<p>El resultado más sorprendente fue la enorme diferencia entre países. Por ejemplo, más del 75% de la población de Sudán del Sur vivía fuera del umbral de las dos horas. Otros países con deficiente atención hospitalaria resultaron ser la República Centroafricana, Chad y Eritrea. Más de la mitad de sus poblaciones vivían fuera del umbral.</p>
<p>Las áreas mejor atendidas eran en su mayoría islas, como Zanzíbar, Comoras y Santo Tomé y Príncipe. Más del 95% de sus poblaciones se encontraba a menos de dos horas de un centro hospitalario. Países grandes como Kenia, Sudáfrica y Nigeria también tenían buenos índices de acceso, con más del 90% de sus habitantes dentro del umbral.</p>
<p>Todos los países de nuestra encuesta, 48, han suscrito el objetivo de desarrollo sostenible que busca lograr cobertura sanitaria universal para 2030, una prestación que implica el acceso a los hospitales. Nuestra investigación puede ayudar a los países a concretar lo que necesitan hacer para convertir el objetivo en una realidad cuando se trata de atención de urgencia. Sin embargo, aún queda mucho camino por recorrer: solo 16 países de nuestra encuesta lograron un 80% de cobertura en el acceso a un hospital en un plazo de dos horas.</p>
<hr>
<p><em>Este artículo, publicado originalmente en <a href="https://theconversation.com/africa">The Conversation África</a>, ha sido traducido con la colaboración de <a href="http://www.casafrica.es"><strong>Casa África</strong></a>. <strong>Traducción</strong>: Guillermo Ramos Pérez.</em></p>
<hr><img src="https://counter.theconversation.com/content/103391/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Ouma recibe fondos de la Iniciativa para el Desarrollo de Líderes de Investigación Africanos como estudiante de doctorado. El trabajo también contó con el apoyo de la beca Wellcome Trust Principal Fellowship para Robert W. Snow y el Departamento para el Desarrollo Internacional (Reino Unido) - Proyecto sobre el fortalecimiento del uso de datos para la toma de decisiones sobre el paludismo en África. Los autores también reconocen el apoyo del Wellcome Trust para el Programa Mayor de Kenia en el Extranjero.
</span></em></p><p class="fine-print"><em><span>Emelda Okiro recibe fondos del Wellcome Trust como becaria de investigación intermedia.</span></em></p>Sólo 16 de los 48 países e islas africanas tienen acceso a servicios hospitalarios dentro del umbral de las dos horas establecido por la OMS.Paul Ouma, PhD Fellow, Kenya Medical Research InstituteEmelda Okiro, Head, Population Health Unit, KEMRI, Kenya Medical Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1025852018-09-13T14:10:05Z2018-09-13T14:10:05ZPeople across Africa have to travel far to get to a hospital. We worked out how far<figure><img src="https://images.theconversation.com/files/234987/original/file-20180905-45135-p8f2jz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A small hospital in Wakiso district in the central region of Uganda.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Nearly half of all deaths and about a third of disabilities in low and middle-income countries could be avoided if people had access to <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(18)30026-3/fulltext">emergency care</a>. In Africa the main causes of emergencies are road accidents, obstetric complications, severe illnesses and non-communicable diseases.</p>
<p>Over the past 18 years the <a href="https://www.afem.info/">African Federation for Emergency Medicine</a>, an advocacy group, has been encouraging the development of emergency care systems on the continent. The gaps it has identified include decent transport and hospital services. </p>
<p>But to address these challenges data is needed on the number of hospitals, their locations as well as the population marginalised. Most countries in Africa don’t have this information. They lack basic inventories of health care service providers, including the number of hospitals. </p>
<p><a href="http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(17)30488-6/fulltext?utm_campaign=lancet&utm_content=66283296&utm_medium=social&utm_source=facebook">Our study</a> set out to address this problem by producing the first ever assessment of hospital services in sub-Saharan Africa, and used it to work out peoples’ access to care. </p>
<p>The results – including how long it takes to get to a hospital – show where investment is needed in improving access. Various interventions are necessary. These should include building new hospitals, improving ambulatory care, building new roads and fixing existing ones. </p>
<p>But the most urgent action is that countries must update their hospital lists, including assessment of capacity and capability to provide emergency care and updating of the private sector. Our research goes someway to helping them start this process. We have built a database which can be accessed for <a href="https://dataverse.harvard.edu/dataset.xhtml?persistentId=doi:10.7910/DVN/JTL9VY">free</a> and used for assessing service availability at national levels.</p>
<h2>Building the database</h2>
<p>The hospital list covers 48 countries and islands of sub-Saharan Africa. </p>
<p>To develop the list we used numerous sources for the data, including ministries of health, health information systems, national and international organisations from all the countries and islands. In most cases, the sources were available online but we also relied on personal contacts to obtain hospital data in some countries. </p>
<p>Close to 50% of the hospitals on the list didn’t have GPS coordinates that could aid in precisely locating them. To overcome the problem we assigned them unique location attributes using online mapping tools such as Google earth and OpenStreetMaps. </p>
<p>This audit located 4908 public sector hospitals which were precisely assigned location attributes (Figure 1). </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/234990/original/file-20180905-45178-l6s510.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/234990/original/file-20180905-45178-l6s510.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/234990/original/file-20180905-45178-l6s510.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=574&fit=crop&dpr=1 600w, https://images.theconversation.com/files/234990/original/file-20180905-45178-l6s510.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=574&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/234990/original/file-20180905-45178-l6s510.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=574&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/234990/original/file-20180905-45178-l6s510.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=721&fit=crop&dpr=1 754w, https://images.theconversation.com/files/234990/original/file-20180905-45178-l6s510.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=721&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/234990/original/file-20180905-45178-l6s510.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=721&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Map of public hospitals in Africa.</span>
<span class="attribution"><span class="source">Author supplied</span></span>
</figcaption>
</figure>
<p>Nigeria, which accounts for close to a fifth of sub-Saharan Africa’s population had the highest number of hospitals at 879. Other countries with significantly high numbers of public hospitals were the Democratic Republic of Congo (435), Kenya (399) and South Africa (337). </p>
<p>The least were in smaller countries such as Cape Verde, Zanzibar, and São Tomé and Príncipe. This information was used as a starting point to calculate the geographic access to the hospital services. </p>
<h2>Timely access</h2>
<p>We measured geographic accessibility by travel time to the nearest public hospital. We did this by calculating how long it would take to travel by road based on the major means of transport in the region. </p>
<p>We assembled road networks from Google earth and OpenStreetMaps, and assigned travel speeds along the roads. We then developed a model that calculates the time it would take for a patient to travel from any 100m by 100m square grid of location to the nearest hospital. </p>
<p>More specifically, a significant proportion of women need access to hospital care when in labour and we additionally determined how long they would take to get to the nearest hospital. </p>
<p>Results reveal that, less than a third (29%) of the total population and 28% of the women of child bearing age, lived more than two hours from the nearest hospitals. The two-hour threshold is a widely used recommendation by the <a href="http://www.who.int/reproductivehealth/publications/monitoring/9789241547734/en/">WHO</a> and the <a href="http://www.lancetglobalsurgery.org/">Lancet Commission for global surgery</a> for defining access to emergency obstetric and surgical care respectively. In addition, international benchmarks by the Lancet commission for global surgery recommends having 80% of any given population within two hours as critical in ensuring universal health coverage by 2030.</p>
<p>The most surprising outcome was the huge differences between countries. For example, more than 75% of the population in South Sudan lived outside the two-hour threshold. Other poorly served countries included Central African Republic, Chad and Eritrea. More than half of their populations lived outside the two-hour threshold. </p>
<p>The best served countries were mostly islands like Zanzibar, Comoros and São Tomé and Príncipe. More than 95% of their populations were within two hours of a hospital. Large countries such as Kenya, South Africa and Nigeria also had good access indices, with more than 90% within the two-hour band. </p>
<p>All 48 countries in our survey have signed up to the sustainable development goal of delivering universal health care by 2030, part of which involves access to hospitals. Our research can help countries work out what they need to do to make this a reality when it comes to emergency care. There’s still a long way to go. Only 16 countries in our survey achieved 80% coverage in access to a hospital within two hours.</p><img src="https://counter.theconversation.com/content/102585/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Ouma receives funding from the Initiative to Develop African Research Leaders as a PhD student (# 107769). The work was also supported by Wellcome Trust Principal Fellowship to Robert W Snow (# 103602) and the Department for International Development (UK) – Project on Strengthening the Use of Data for Malaria Decision Making in Africa (DFID Programme Code # 203155). The authors also acknowledge the support of the Wellcome Trust for the Kenya Major Overseas Programme (# 203077). </span></em></p><p class="fine-print"><em><span>Emelda Okiro receives funding from the Wellcome Trust as an intermediate research fellow (# 201866). </span></em></p>Only 16 out of 48 African countries and islands have access to hospital services within the WHO’s two-hour time threshold.Paul Ouma, PhD Fellow, Kenya Medical Research InstituteEmelda Okiro, Head, Population Health Unit, KEMRI, Kenya Medical Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/900942018-03-06T12:17:42Z2018-03-06T12:17:42ZMalaria control strategies reduce the caseload - but bring new challenges<figure><img src="https://images.theconversation.com/files/201913/original/file-20180115-101495-z6ksid.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Treated bed nets are effective in preventing malaria where mosquitoes bite indoors and late at night.</span> <span class="attribution"><span class="source">Katrina Manson /Reuters</span></span></figcaption></figure><p>Kenya’s <a href="https://theconversation.com/kenyan-study-shows-why-reusing-old-mosquito-nets-should-be-encouraged-76358">two major malaria prevention strategies</a> – indoor residual spraying of homes in high transmission areas and the issuing of insecticide treated nets – have led to a significant <a href="https://malariajournal.biomedcentral.com/articles/10.1186/s12936-017-2119-y">reduction in malaria transmission</a>.</p>
<p>The two methods were introduced in the country’s western highlands, traditionally considered a high transmission area, about a decade ago and have resulted in the disease’s caseload <a href="https://malariajournal.biomedcentral.com/articles/10.1186/s12936-017-2119-y">decreasing by about 80%</a>. </p>
<p>But the drop in cases has brought a new challenge: people have begun <a href="https://www.ncbi.nlm.nih.gov/pubmed/9186382">losing their immunity to the disease</a>. The consequence is that they are prone to contracting more complicated forms of the malaria that could result in death.</p>
<p>There are two types of immunity that people are able to develop naturally: clinical immunity and parasitological immunity. </p>
<p>People living in high transmission areas develop clinical immunity naturally after being exposed to the parasite and receiving successful treatment. Their bodies are able to resist infection. </p>
<p>They are also able to develop parasitological immunity. After being bitten by many infected mosquitoes over a long period, their bodies are able to withstand higher numbers of parasites in their blood. </p>
<p>When people don’t have parasitological immunity, they face the risk of becoming severely ill when the number of parasites in the blood increases. This can take the form of severe anaemia, cerebral malaria and eventually death. Children are particularly susceptible. </p>
<p>In our <a href="https://malariajournal.biomedcentral.com/articles/10.1186/s12936-017-2119-y">study</a> we focused on parasitological immunity in children. We wanted to understand how malaria prevention interventions such as bed nets and indoor spraying were preventing people from developing parasitological immunity. </p>
<p>We found that children who were less exposed to malaria as they grew up had lower levels of parasitological immunity. This exposed them to developing more severe strains of malaria.</p>
<p>Our findings should be taken on board as part of Kenya’s broader malaria prevention strategies. The government needs to maintain strong monitoring and surveillance networks to ensure that existing interventions are still sufficient. And it needs to work out new interventions to deal with the consequences of its interventions. </p>
<h2>Our study</h2>
<p>There is no functional test to measure the level of immune protection a person has developed. Some people have higher levels of immunity with fewer parasites in their blood. </p>
<p>Even though it’s not possible to pin down how individuals will react to malaria it is nevertheless possible to work out a person’s parasitological immunity. </p>
<p>Parasitological immunity is established by measuring the proportion of red blood cells that are infected in the body. Most people who get malaria have less than 1% of their red blood cells infected with the parasite, which rapidly multiplies. A person with 5% of their red blood cells infected is considered severely toxic. </p>
<p>We compared two sets of children, looking at the relationship between age and parasite density. We did two sets of surveys nine years apart. The first was done between June 2002 and December 2003 and the second between January 2012 and February 2015. School children between the ages of six and 13 were tested for malarial parasites in both periods. </p>
<p>When we did the first set of tests, malaria prevention tools had not yet been introduced in the highlands. The second set of children were exposed to the prevention tools. </p>
<p>We recorded the blood parasite densities – and thus infections trends – in each of the age groups. By doing this we were able to compare how the parasite density had changed between those who had grown up with bednets and indoor spraying or taken anti-malarial drugs, and those who hadn’t. </p>
<p>We found that people who had not experienced early interventions had high levels of immunity. </p>
<h2>A new gap</h2>
<p>But there’s a knock-on effect that complicates the scenario even further. People who hadn’t taken anti-malarial medicines or used treated bed nets were more likely to <a href="http://www.who.int/ith/diseases/malaria/en/">infect mosquitoes</a> because they continued to carry parasites in their blood. </p>
<p>This makes the rest of the population more susceptible to infections, with implications for the country’s broader malaria prevention strategy. </p>
<p>The risk of increased infection brings added complexity to government’s efforts. The only way to meet the challenge is to ensure that there are sufficient monitoring and surveillance strategies. </p>
<p>Another reason monitoring and evaluation matters is because mosquitoes are able to evolve and <a href="https://www.ncbi.nlm.nih.gov/pubmed/22861380">develop resistance to insecticides</a>. In addition malaria parasites can <a href="https://www.ncbi.nlm.nih.gov/pubmed/11517439">become resistant</a> to anti-malarial drugs.</p>
<p>Mosquitoes have also been shown to <a href="https://www.ncbi.nlm.nih.gov/pubmed/26209103">change their behaviour</a>, such as avoiding contact with insecticide treated surfaces. Where bed nets are used they have been shown to change from night time feeding to <a href="https://malariajournal.biomedcentral.com/articles/10.1186/s12936-015-0763-7">daytime or evenings before people go to sleep</a>. </p>
<p>If the government does not pick up these new trends early, as well as new and more severe infections, it will lose the gains it’s made against fighting malaria.</p><img src="https://counter.theconversation.com/content/90094/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Githeko receives funding from NIH.</span></em></p><p class="fine-print"><em><span>Ednah Ototo does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Kenya has managed to reduce the number of malaria cases in parts of the country. But this, in turn, has led to immunity levels dropping.Andrew Githeko, Chief Research Officer, Kenya Medical Research InstituteEdnah Ototo, PhD Candidate , Medical Parasitologist, Kenya Medical Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/861202017-10-25T12:18:34Z2017-10-25T12:18:34ZPrompt response to malaria outbreak is critical as risk of disease spreads<figure><img src="https://images.theconversation.com/files/191347/original/file-20171023-1728-1tvijhi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Changes in climatic conditions have led to an increase in malaria in East Africa.</span> <span class="attribution"><span class="source">Adriane Ohanesia/Reuters</span></span></figcaption></figure><p>A malaria outbreak has <a href="http://www.nation.co.ke/news/Malaria-cases-go-up-as-over-1-000-test-positive/1056-4145796-8hy8fx/index.html">killed 26 people</a> in <a href="https://www.google.com/url?url=http://www.kenya-information-guide.com/marsabit-county.html&rct=j&frm=1&q=&esrc=s&sa=U&ved=0ahUKEwj6n9yL4oTXAhVDbhQKHa05DN4QFggnMAI&usg=AOvVaw3UqudjtUM3PCF49kdFuZUK">Marsabit</a> in northern Kenya over the past one month. Over 1,000 people have been treated for the disease. </p>
<p>The outbreak, which is worse than previously recorded in the area for this time of year, can be attributed to a number of factors. These include a dysfunctional health service: there aren’t any qualified health workers to test for malaria and there is a shortage of drugs to treat the disease. The situation has been made worse by a four-month <a href="https://www.standardmedia.co.ke/health/article/2001257465/why-nurses-union-stalemate-could-be-resolved">long strike by nurses</a> in public hospitals.</p>
<p>But the main reason for the spike in cases seems to be that health services were caught off guard by off-season rains. Unlike in the highlands of Western Kenya, there are no malaria epidemic early warning systems for arid and semi-arid regions in the country. </p>
<h2>Malaria in low risk areas</h2>
<p>Malaria control in low risk areas like Marsabit is mainly based on prompt diagnosis and effective treatment rather than preventative measures such as the use of treated bed nets and indoor residual spraying. </p>
<p>Unfortunately during the rainy season, there is a surge of malaria cases and deaths due to people’s <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3117811/">low immunity</a> and delays in seeking treatment. Other factors that affect people being treated successfully is poor <a href="https://malariajournal.biomedcentral.com/articles/10.1186/PREACCEPT-23175627763684">access to health facilities</a>. It’s not uncommon for health centres to be 10 kilometres or more apart. </p>
<p>The availability of drugs at the primary health care facilities also influences whether patients seek medical help.</p>
<p>Malaria should be treated within 24 hours of the onset of symptoms. But some health workers in low risk malaria areas are not familiar with the symptoms. Improving malaria diagnosis should be a top priority in all rural health centres.</p>
<p>On top of this is the fact that facilities are poorly staffed. Managing malaria relies heavily on functional health facilities. These health facilities rely on skilled workers such as doctors, clinical officers, nurses and laboratory staff. The <a href="https://www.capitalfm.co.ke/news/2017/08/beds-empty-public-hospitals-nurses-strike-enters-second-month/">ongoing four month nurses’</a> strike has affected health services. Patients have been forced to go to <a href="https://www.standardmedia.co.ke/article/2001242591/helpless-patients-jam-private-health-facilities-in-kakamega">private facilities</a> and those that cannot afford to pay return home unattended.</p>
<p>Additional challenges that communities in Marsabit face is the fact that there’s poor drainage which increases malaria mosquito breeding areas. Drains should be <a href="http://www.who.int/water_sanitation_health/hygiene/settings/hvchap5.pdf?ua=1">properly designed and maintained</a> to ensure that water flows away quickly, smoothly and is properly disposed.</p>
<h2>Climate change and increasing malaria cases</h2>
<p><a href="https://www.standardmedia.co.ke/health/article/2000196872/climate-change-linked-to-recent-cholera-hepatitis-a-outbreaks">Climate change</a> is predicted to increase the severity of droughts and floods. This <a href="https://link.springer.com/chapter/10.1007/978-1-4020-6174-5_4">increases the risk of epidemics and outbreaks</a>. Arid lands are prone to flooding and their aquatic systems have become reservoirs of diseases like malaria and cholera.</p>
<p>Changes in climatic conditions have also led to an increase of malaria cases in the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3429085/">Kenya’s east African highlands</a>. Highland areas were considered <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3429085/">free of malaria cases</a> during the 19th century. But in the last two decade malaria has spread to the central Kenya highlands including Nyeri county which is 1,800 metres above sea level. The annual temperature has increased from <a href="https://en.climate-data.org/location/4370/">17.1°C</a> to above 18°C which is suitable for local malaria transmission.</p>
<h2>Moving forward</h2>
<p>There should be functional health facilities countrywide to effectively control malaria. This can be done by ensuring that an effective vector control programme and active field based <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4674909/">malaria surveillance programme</a> are in place. This complements the existing passive health facility surveillance system.</p>
<p>The surveillance system should be designed to identify malaria transmission <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001993">hot spots</a> for the roll out of preventive measures like insecticide treated bed nets or <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3372949/">indoor residual spraying</a>. The use of long lasting chemicals that <a href="https://malariajournal.biomedcentral.com/articles/10.1186/1475-2875-8-234">kill mosquito larvae</a> to discourage breeding in homesteads should also be explored more keenly.</p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/10065206">Community based health facilities</a> should be improved to avoid long distance travels to seek health services. Enhanced <a href="https://www.standardmedia.co.ke/health/article/2000197998/understanding-diseases-caused-by-mosquitoes">public health education</a> may also contribute to more people recognising the malaria symptoms and seeking treatment immediately. It could also reduce reliance on ineffective herbal medicines. </p>
<p>The use of radios and other forms of communication should be used to educate people about impending malaria outbreaks. Residents could learn to associate unusually heavy rains and flooding to an expected malaria outbreaks so they can take precautionary measures.</p>
<p>And the feasibility of increasing mobile health clinics in remote arid areas should be explored.</p>
<p>A combination of these actions would help minimise malaria outbreaks.</p><img src="https://counter.theconversation.com/content/86120/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Githeko receives funding from IDRC/DFID, NIH, WHO</span></em></p><p class="fine-print"><em><span>Ednah Ototo works for Kenya Medical Research Institute</span></em></p>Malaria is a major public health problem that affects 106 countries globally. A rigorous and systematic approach to predict and control malaria transmission is needed.Andrew Githeko, Chief Research Officer, Kenya Medical Research InstituteEdnah Ototo, PhD Candidate , Medical Parasitologist, Kenya Medical Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/817682017-10-08T10:04:42Z2017-10-08T10:04:42ZMapping hepatitis in Kenya shows where action is needed<figure><img src="https://images.theconversation.com/files/186595/original/file-20170919-22657-2cazow.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Hepatitis is a public health concern globally.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>A study of the different kinds of hepatitis in Kenya showed areas where the government can focus its efforts to prevent infections. One of the findings was a surprise – giving adults the Hepatitis vaccination has been ignored. This is a waiting time bomb, and an area for action that could have been overlooked.</p>
<p>Hepatitis is defined as inflammation of the liver. One symptom is yellowish eyes and skin (jaundice). The most common cause of hepatitis is viral infection. </p>
<p>Viral hepatitis is a <a href="http://www.who.int/immunization/topics/hepatitis/en/">public health concern</a> globally. It is difficult to <a href="http://www.who.int/mediacentre/commentaries/better-estimates-hepatitis/en/">count</a> exactly how many people get hepatitis or how many die from it. One reason is that the infection is caused by five types of virus, named from A to E, and they are passed on in different ways. The other reason is that most hepatitis deaths are not linked directly to the liver infection. Death may result from gradual damage to the liver. </p>
<p>The number of people affected worldwide is known to be hundreds of millions, though.</p>
<p>Our <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4774020/">study</a> set out to discover how common hepatitis A to E is among patients with symptoms of liver disease in different regions of Kenya. It was the first study of its kind in Kenya.</p>
<h2>The Kenyan study</h2>
<p>We studied 389 patients with jaundice at four hospitals:<a href="http://knh.or.ke/">Kenyatta National Hospital</a> (Nairobi), <a href="http://www.mtrh.or.ke/">Moi Teaching and Referral Hospital</a> (Eldoret), New Nyanza Provincial General Hospital (Kisumu) and Coast General Hospital (Mombasa). We collected blood samples from the patients and tested them for acute and chronic hepatitis A to E viruses. </p>
<p>The results showed that the main cause of the disease in this group was chronic hepatitis B infection. A chronic infection is one that stays in the patient for a long time or keeps coming back. The second most common cause was acute hepatitis A. This type of infection is sudden. In this study population, we found no recent infection of hepatitis C, D or E.</p>
<ul>
<li>Hepatitis A virus</li>
</ul>
<p>The study found that 6.3% of the total group of patients were infected with hepatitis A. Kisumu had 9.2% , the capital city , Nairobi had 6.3 % and Mombasa had 5.0%.</p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/6439821/">Previous studies</a> have shown that by the age of 10 years, nine out of every 10 children in areas where hepatitis A is common are <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/hepatitis-a">immune</a> to the infection. Therefore due to this immunity, the number of adults who get the disease, reduces. </p>
<p>We did not expect to find that so many adults – 6.3% out of 382 could still get the hepatitis A infection. </p>
<p><a href="http://www.who.int/mediacentre/factsheets/fs328/en/">This virus</a> is passed on in water and food. It can remain in the environment for a long time and can survive processes such as filtration process that are supposed to make food safe. </p>
<p>The finding suggests that adults should be immunised. Prevention efforts should also focus on managing the environment, water and waste.</p>
<ul>
<li>Hepatitis B virus</li>
</ul>
<p>About half (50.6%) of the patients tested had hepatitis B virus. Eldoret in Western Kenya had the highest number of cases at 92.9% of all Hepatitis B patients followed by Mombasa (81.8%), Kisumu (79.8%) and Nairobi (33.8%). Patients with chronic infections numbered 128 out of the 168.</p>
<p><a href="http://www.who.int/immunization/diseases/hepatitisB/en/">Hepatitis B</a> is transmitted through infected blood or other body fluids of an infected person.. It can cause liver cancer and cirrhosis, the long term injury of the liver.</p>
<p>Globally, about <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3321493/">two billion</a> people have been infected with hepatitis B virus and about <a href="http://www.who.int/immunization/diseases/hepatitisB/new_vaccine/en/index3.html">350 million</a> of them have the virus for life. The World Health Organisation has categorised Kenya as an <a href="http://apps.who.int/iris/bitstream/10665/246177/1/WHO-HIV-2016.06-eng.pdf?ua=1">endemic area</a>.</p>
<ul>
<li>Hepatitis C, D and E viruses</li>
</ul>
<p>Of all the samples collected, 3.9% were positive for Hepatitis C, when the positives were confirmed none was positive indicating exposure to the virus without active infection. </p>
<p>Types <a href="http://www.who.int/mediacentre/factsheets/fs164/en/">C</a> and <a href="http://www.who.int/mediacentre/factsheets/hepatitis-d/en/">D</a>, like <a href="http://www.who.int/immunization/diseases/hepatitisB/en/">B</a>, are passed on in blood.</p>
<p>All specimens in the study were negative for hepatitis D virus. </p>
<p>The prevalence of the exposure to hepatitis E virus was 8.1% this is higher than the 6.3% for hepatitis A, which was mentioned above as the second biggest cause of hepatitis and it affected more women than men. Hepatitis E is severe in women than men and in expectant mothers. it causes death among 20% of those infected. </p>
<p><a href="http://www.who.int/mediacentre/factsheets/fs280/en/">Type E</a> is also carried in water and food. In 2015, the World Health Organisation estimated that hepatitis E caused approximately <a href="http://www.who.int/mediacentre/factsheets/fs280/en/">44 000 deaths globally</a> – 3.3% of the deaths due to viral hepatitis. </p>
<h2>Dealing with hepatitis A and B</h2>
<p>Hepatitis A and B are the most serious types of this disease. In our study, the hepatitis A virus was reported in cities where people are crowded into substandard housing without clean water and food.</p>
<p><a href="http://www.who.int/biologicals/areas/vaccines/hepatitis/en/">Sanitation</a> in urban areas needs to be improved urgently. Infections in adults can further be prevented through <a href="https://www.cdc.gov/vaccines/vpd/hepa/public/index.html">vaccination</a>. </p>
<p>Hepatitis B needs urgent attention. People at risk include injecting drug users, unborn babies of pregnant women who have tested positive to the virus and people with kidney failure because of repeated dialysis which is a risk of contracting the disease. A hepatitis B <a href="https://www.cdc.gov/vaccines/hcp/vis/vis-statements/hep-b.html">vaccine </a> is available for these risk groups. This vaccine is mandatory for all health workers.</p>
<h2>Kenya’s hepatitis milestones</h2>
<p>Kenya has put in place the following preventive measures to manage hepatitis related infections.</p>
<ul>
<li><p>developing <a href="http://www.health.go.ke/download/guidelines/">national guidelines</a> on the prevention and management of viral hepatitis</p></li>
<li><p>screening all donated blood and its products for transfusions</p></li>
<li><p>vaccination of <a href="https://pdfs.semanticscholar.org/26ab/b4c3b27691b2d884dbac2f97f506e18d7cf3.pdf">health workers</a> against hepatitis A and B.</p></li>
<li><p>providing safe sterile needles and syringes</p></li>
<li><p>introduction of hepatitis B virus vaccine in the <a href="http://e-cavi.com/wp-content/uploads/2014/11/KENYA-NATIONAL-POLICY-ON-IMMUNIZATION-2013.pdf">immunisation schedule in 2003</a> to prevent mother to child transmission. </p></li>
</ul>
<h2>Way forward</h2>
<p>Public health awareness is needed to avert hepatitis A <a href="https://www.iamat.org/country/kenya/risk/hepatitis-a">outbreaks</a>, as reported in Coastal Kenya where 21 people were admitted to hospital. This means explaining why people should keep their households and surroundings clean.</p>
<p>The hepatitis B infections can also be reduced by encouraging responsible sexual behaviour screening all pregnant women and providing rehabilitation services for injecting drug users.</p>
<p>The government needs to work with other agencies to increase coverage of immunisation for hepatitis B, especially among the most vulnerable people.</p><img src="https://counter.theconversation.com/content/81768/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Hepatitis viruses are serious infections that damage the liver. There is an urgent need to deal with increased Hepatitis B infections in Kenya.Ochwoto Missiani, Research Officer, Kenya Medical Research InstituteJulius Oyugi, University of NairobiSimeon Mining, Professor of Immunology and Director of Research, Moi University Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/812742017-07-24T19:43:40Z2017-07-24T19:43:40ZKenya’s cholera outbreak highlights fears about antibiotic resistance<figure><img src="https://images.theconversation.com/files/178986/original/file-20170720-23983-1u3f6ek.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Drug resistance to cholera causing bacteria affects treatment especially in developing countries.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p><em>A cholera outbreak in Kenya’s capital, Nairobi, has prompted the health authorities to withdraw all <a href="https://world.einnews.com/article__detail/region/east-africa/393166707-cholera-worsens-as-70-patients-admitted-to-knh?vcode=Qg-r">medical licences</a> issued to food handlers countrywide. About 336 cholera cases have been treated in Nairobi since May this year. The Conversation Africa’s Health and Medicine Editor Joy Wanja Muraya spoke to Sam Kariuki on the need for an improved rapid response when there is an outbreak and how to deal with drug resistance of some cholera medicines.</em></p>
<p><strong>Why is cholera a public health concern?</strong></p>
<p>Cholera is an <a href="https://books.google.co.ke/books?id=qpjshPr7HVcC&pg=PA197&lpg=PA197&dq=cholera+and+bangal&source=bl&ots=4htxUE4c61&sig=S52TKJb0YKHttBcyNZt2jJRtLcY&hl=en&sa=X&redir_esc=y#v=onepage&q=cholera%20and%20bangal&f=false">old disease</a> that first occurred in the Bengal region of India, near Calcutta starting in 1817 through 1824. </p>
<p>Since then it has mostly <a href="https://www.ncbi.nlm.nih.gov/pubmed/2857326">affected </a> Africa and other developing countries particularly in informal settlements that have poor sanitation and water supply infrastructure. </p>
<p>Cholera is caused by a gram negative bacterium called <a href="http://www.who.int/topics/cholera/about/en">Vibrio cholerae</a> usually transmitted through contaminated water or food in areas <a href="http://www.who.int/cholera/technical/prevention/control/en/index2.html">with poor sanitation and lack of clean drinking water</a>.</p>
<p>Cholera outbreaks are likely to increase as more people <a href="http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(97)04486-3.pdf">migrate</a> from rural areas to the city in search of jobs. The low starting income limits most of the young job seekers to live in poorly developed and crowded urban slums. </p>
<p>Cholera is easily managed usually by giving oral rehydration salts to replace lost fluids and electrolytes. Some severe cases may require antibiotic treatment. But there’s a need for timely diagnosis and immediate treatment for anyone who tests positive to cholera. Cholera can <a href="http://www.who.int/mediacentre/factsheets/fs107/en/">kill within hours</a> if untreated.</p>
<p><strong>How big is the threat of resistance to antibiotics?</strong></p>
<p>Drug resistance to the bacteria that causes cholera would be a big blow to the treatment of the disease, especially in developing countries.</p>
<p>Our <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0074829">study</a> found out that bacteria that causes cholera has become resistant to some antibiotics needed to treat the disease effectively.</p>
<p>In the last 10 years, we investigated antimicrobial resistance in Vibrio cholerae strains. The <a href="https://www.ncbi.nlm.nih.gov/pubmed/24066154">findings</a> showed that it had become resistant to nalidixic acid, trimethoprim, sulphamethoxazole, streptomycin and furazolidone.</p>
<p>Whereas these medicines can no longer treat cholera, the good news is that it is still <a href="https://www.ncbi.nlm.nih.gov/pubmed/20040104">treatable</a> with doxycycline, which has remained a preferred drug of choice. </p>
<p>The observed strains of cholera that occurred during outbreaks between 2012 and 2016 in Kenya were resistant to ceftriaxone in a class of antibiotics known as third generation cephalosporins. This is a reserve drug commonly used to treat severe infections. The resistance was first observed in patients with salmonella, a type of bacteria that cause bloodstream infections especially in people with low immunity.</p>
<p>Some types of drug resistance are caused by a natural interaction of the Vibrio cholerae bacteria with other drug resistant bacteria in the environment. The overuse of antibiotics by people also contributes to drug resistance. </p>
<p>Although <a href="https://www.ncbi.nlm.nih.gov/pubmed/12022154">tetracyclines</a> are currently used to treat cholera, ceftriaxone resistant strains have been found to transmit resistance to other bacteria. Drug resistance has made it possible for these cholera strains to stay longer in the environment where they are more likely to cause disease.</p>
<p><strong>What is the way forward?</strong></p>
<p>Preventing outbreaks is the first step. This can only be done by having a <a href="http://www.the-star.co.ke/news/2017/07/19/kidero-to-blame-for-cholera-outbreak-in-city-kenneth_c1599106">multi sectoral</a> approach to public health intervention including messages that encourage hand washing, boiling water and other preventive measures.</p>
<p>Community health <a href="https://www.cdc.gov/mmwr/volumes/65/wr/mm6503a7.htm">extension workers</a> are key in getting these messages across as well as for distributing supplies during an outbreak.</p>
<p>Drug resistance is a survival mechanism for bacteria which have no boundaries. We need to use antibiotics prudently. Drug resistance encourages further spread of infections, making treatment longer and more expensive. </p>
<p>Government agencies should develop ways to monitor the use of antibiotics and restrict their prescription. Regulation of antibiotic use in animals should also be improved.</p>
<p>Health care workers also need to be trained on the proper use of antibiotics to ensure they are given to patients responsibly.</p>
<p>And finally, the effective management of cholera begins with better surveillance to diagnose and treat infections promptly. Better record keeping and data management at health care facilities is vital for this to happen.</p><img src="https://counter.theconversation.com/content/81274/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Samuel Kariuki does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Cholera is caused by a lack of access to clean drinking water and unhygienic conditions. Misuse of antibiotics makes it difficult and expensive to treat outbreaks.Samuel Kariuki, Researcher Microbiology/Infectious Diseases, Kenya Medical Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/802812017-07-18T14:44:40Z2017-07-18T14:44:40ZA new vaccine is promising to advance the frontier of eliminating malaria<figure><img src="https://images.theconversation.com/files/176381/original/file-20170630-8190-11ktn0z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A malaria vaccine will be piloted in Ghana, Kenya and Malawi to assess its suitability.</span> <span class="attribution"><span class="source">Siegfried Modola/Reuters.</span></span></figcaption></figure><p>More than <a href="http://www.who.int/immunization/policy/position_papers/malaria_pp_jan2016_summary.pdf">30 malaria vaccine</a> candidates are at various stages of development. The <a href="http://www.malariavaccine.org/malaria-and-vaccines/first-generation-vaccine/rtss">RTS,S</a> vaccine is at the most advanced stage.</p>
<p>The World Health Organisation has <a href="http://www.un.org/sustainabledevelopment/blog/2017/04/ghana-kenya-and-malawi-to-pilot-malaria-vaccine-trial-un/">recommended</a> the introduction of the vaccine in Ghana, Kenya and Malawi as a pilot programme to assess its suitability in expanded immunisation programmes.</p>
<p>The vaccine could prove to be a powerful tool in sustaining the gains made in the last decade in reducing malaria related cases and deaths. Between 2000 and 2015, new malaria cases <a href="http://www.who.int/malaria/media/world-malaria-report-2015/en/">fell</a> by 37% globally, and by 42% in Africa. This has been achieved through key interventions such as using treated bed nets, spraying houses with insecticides and effective antimalarial drugs. </p>
<p>Combined with existing malaria interventions, the vaccine would have the potential to save tens of thousands of lives in Africa. It’s important for two other reasons too. </p>
<p>Firstly, it would reduce the cost of managing malaria. Historically, vaccines are more <a href="https://www.ncbi.nlm.nih.gov/pubmed/23142307">cost-effective</a> in <a href="http://www.who.int/heli/risks/vectors/malariacontrol/en/">preventing</a> the spread of diseases compared to other methods.</p>
<p>Secondly, the vaccine could deal with <a href="http://www.who.int/malaria/areas/drug_resistance/overview/en/">resistance</a> to both drugs and insecticides that’s on the rise.</p>
<h2>The vaccine’s history</h2>
<p>The RTS,S malaria vaccine <a href="http://www.malariavaccine.org/sites/www.malariavaccine.org/files/content/page/files/RTSS%20vaccine%20candidate%20Factsheet_FINAL.pdf">was created</a> in 1987 by scientists working at GlaxoSmithKline laboratories. Early clinical development of the vaccine was conducted in collaboration with the Walter Reed Army Institute for Research.</p>
<p>In January 2001, GlaxoSmithKline and PATH’s Malaria Vaccine Initiative entered into a public-private partnership to develop RTS,S for infants and young children living in malaria-endemic regions of sub-Saharan Africa. </p>
<p>Phase I and II clinical trials allowed an initial assessment of the safety and efficacy of the vaccine, <a href="https://www.ncbi.nlm.nih.gov/pubmed/26919472">initially</a> in adult volunteers in the US and Belgium. </p>
<p>This was <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4829262/">followed by</a> adults, adolescents, children, and then infants living in malaria-endemic regions in Africa.</p>
<p>The results from the Phase II proof-of-concept trials in Mozambique, published in <a href="http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(13)70005-7/abstract">The Lancet </a>in 2004 and 2007, demonstrated that the vaccine provided partial protection against malaria to African children and infants. </p>
<p>This paved the way for a pivotal <a href="http://www.nejm.org/doi/pdf/10.1056/NEJMe1606007">Phase III</a> efficacy and safety trial in 15,459 infants and young children at 11 sites in seven African countries. These were Burkina Faso, Gabon, Ghana, Kenya, Malawi, Mozambique, and Tanzania. The trial started in May 2009 and ended in early 2014.</p>
<p>The <a href="http://www.malariavaccine.org/files/MVI-GSK-RTSSfactsheetFINAL-web.pdf">results</a> of the phase III trial were submitted to regulatory authorities and in July 2015 RTS,S received a <a href="https://www.malarianomore.org.uk/news/malaria-vaccine-approved-use-european-medicines-agency">positive scientific opinion</a> from the European Medicines Agency. </p>
<p>In January 2016, the WHO recommended introduction of RTS,S through a pilot implementation programme in 3 to 5 African countries. Its recommendation called for a four dose series of the vaccine. The first dose to be administered as close as possible to 5 months of age, followed by doses two and three at one month intervals and a fourth dose 15 to 18 months after dose three.</p>
<p>The pilot implementation, will evaluate:</p>
<ul>
<li><p>the operational feasibility of providing RTS,S at the recommended four-dose schedule, </p></li>
<li><p>the impact of the vaccine on malaria specific deaths, and </p></li>
<li><p>the safety of the vaccine.</p></li>
</ul>
<h2>Choosing the pilot</h2>
<p>Ghana, Kenya, and Malawi were selected based on a number of factors. They have high coverage of long-lasting insecticidal nets, well-functioning malaria and immunisation programmes, a high malaria burden and have taken part in an earlier phase of the vaccine trial. </p>
<p>Because malaria can vary from one region to another – even within a country – the three countries will decide on the districts and regions to be included in the pilots. High malaria burden areas will be prioritised. </p>
<p>The piloting of the malaria vaccine in these three countries is a major milestone in vaccine research as it will pave way for the next steps in making decisions about whether it will be widely deployed elsewhere. </p>
<p>If that happens, the vaccine has the potential to play a role in reducing the malaria burden. </p>
<p>The vaccine is meant to complement rather than replace existing proven malaria interventions. But there’s a growing threat of malaria parasites becoming resistant to antimalarial drugs and mosquitoes developing resistance to insecticides used in bednets and indoor residual spraying.</p>
<p>Once it’s licensed and becomes widely available, the vaccine will be a vital new intervention that can help mitigate these developments.</p>
<p>The pilot provides an opportunity to evaluate the vaccine in real-life situation. The next steps will involve regulatory authorities reviewing the results and making recommendations for wide deployment.</p>
<h2>Way forward</h2>
<p>The RTS,S vaccine is a first generation malaria vaccine. This means there’s still room to improve its capability to protect against malaria. But it won’t be the silver bullet which is why other studies into new drugs and interventions are important.</p>
<p>New prevention strategies – such as a new generation insecticide-treated nets that use a combination of insecticides to protect against mosquito resistance – are being explored. And single dose antimalarial drugs to ensure people complete the recommended dosage are also being explored.</p>
<p>Finally, the use of antimalarial drugs that target the sexual stages of the parasite are also being explored.</p><img src="https://counter.theconversation.com/content/80281/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon Kariuki does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Stronger malaria prevention like a vaccine is urgently needed for effective response in endemic regions.Simon Kariuki, Chief Research Officer, Malaria Branch Chief in the KEMRI, CDC and London School of Tropical Medicine Collaborative Program, Kenya Medical Research InstituteLicensed as Creative Commons – attribution, no derivatives.