Forecasting Malaria

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On March 30, Kjersti Brown from SIU presented our malaria research in Ethiopia:

Researchers from Ethiopia and Norway have developed a new model for forecasting malaria epidemics.

Climate change is presenting major challenges in Africa. Malaria, one of the big killers of African children, is a disease directly linked to temperature and rainfall. In Ethiopia, malaria occurs seasonally. Every four to six years there are huge epidemics, affecting as many as several hundred thousand people. Global warming now seems to be changing the pattern of malaria. Will high-land Ethiopia experience more malaria in the future? And if so, will it be possible to predict epidemics in time for people to prepare?

 

You can read the full presentation here.

Malaria mortality

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A new study published in The Lancet suggests that malaria kills almost twice as many people as the World Health Organisation estimates 1.

The researchers, led by Professor Christopher Murray at the University of Washington, assessed death statistics for 105 countries since 1980. Their method included examining registration statistics and verbal autopsy data, and correcting possible misclassifications of deaths from categories such as “fever” and attributing them to malaria.

They concluded there were 1.24 million deaths from malaria in 2010, nearly double the 655,000 given by the WHO. The authors found that were also far more adult deaths outside Africa, than were previously estimated.

In a study from rural Ethiopia, we found that malaria represents the leading cause of death among people aged 10 to 24 years old 2. Our study showed the leading perceived causes of death were malaria (0.85 per 1,000 person years), diarrhoea (0.5 per 1,000 PY) and tuberculosis (0.36 per 1,000 PY). Other causes accounted for 1.25 deaths per 1,000 PY and unknown causes for 0.39 deaths per 1,000 PY, as reported by family care givers.

I hope future malaria studies in Africa and Asia also try to estimate malaria deaths.

If these findings are accepted, there will be important consequences for global funding of initiatives to combat the parasite.

References 

1.         Murray CJL, Rosenfeld LC, Lim SS, et al. Global malaria mortality between 1980 and 2010: a systematic analysis. The Lancet 2012;379:413-31.

2.         Molla M, Byass P, Berhane Y, Lindtjorn B. Mortality Decreases among Young Adults in Southern Central Ethiopia. Ethiopian Journal of Health Development 2008;22:218-25.

Malaria in a highland-fringe area of Ethiopia

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Prevalence of malaria infection in Butajira area, south-central Ethiopia

Adugna Woyessa, Wakgari Deressa, Ahmed Ali and Bernt Lindtjorn

Malaria Journal 2012, 11:84

Abstract

Background

In 2005, the Ethiopian government launched a massive expansion of the malaria prevention and control programme. The programme was aimed mainly at the reduction of malaria in populations living below 2,000 m above sea level. Global warming has been implicated in the increase in the prevalence of malaria in the highlands. However, there is still a paucity of information on the occurrence of malaria at higher altitudes. The objective of this study was to estimate malaria prevalence in highland areas of south-central Ethiopia, designated as the Butajira area.

Methods

Using a multi-stage sampling technique, 750 households were selected. All consenting family members were examined for malaria parasites in thick and thin blood smears. The assessment was repeated six times for two years (October 2008 to June 2010).

Results

In total, 19,207 persons were examined in the six surveys. From those tested, 178 slides were positive for malaria, of which 154 (86.5%) were positive for Plasmodium vivax and 22 (12.4%) for Plasmodium falciparum; the remaining two (1.1%) showed mixed infections of Plasmodium falciparum and Plasmodium vivax. The incidence of malaria was higher after the main rainy season, both in lower lying and in highland areas. The incidence in the highlands was low and similar for all age groups, whereas in the lowlands, malaria occurred mostly in those of one to nine years of age.

Conclusion

This study documented a low prevalence of malaria that varied with season and altitudinal zone in a highland-fringe area of Ethiopia. Most of the malaria infections were attributable to Plasmodium vivax.

Podoconiosis: a form of elephantiasis

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Recently I read the following text in a new and good website about Podo:

“Podoconiosis (or simply ‘podo’) is a form of elephantiasis or swelling of the lower leg triggered by prolonged exposure to irritant minerals in red clay soils. There is no infectious or contagious agent: no parasite, no bacterium, no virus is involved. It was classified as a Neglected Tropical Disease by the World Health Organisation in 2011.

An estimated 4 million people in highland tropical Africa are affected with podoconiosis, and evidence suggests widespread endemicity in more than 15 countries throughout the world.

Although the disease is both preventable (by avoiding contact with irritant soil) and treatable (through simple, inexpensive foot hygiene and protection), there are as yet no government-backed assistance programs for addressing prevention and treatment of podoconiosis.

Individuals afflicted with podoconiosis suffer debilitating physical effects, including attacks when the leg becomes warm, painful and even more swollen, and are ostracised from their communities because of misconceptions about the cause of podoconiosis”.

You can read more about this important public health problem at: http://www.podo.org/

New publication: EMAPS project on climate and malaria

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Ellen Viste and Asgeir Sorteberg. Moisture transport into the Ethiopian highlands. Int. J. Climatol. (2011)  DOI: 10.1002/joc.3409 (pdf file)

ABSTRACT: The Ethiopian summer rains occur as air masses of various origins converge above the Ethiopian plateau. In this study, the relative importance of different moisture transport branches has been estimated using the Lagrangian trajectory model FLEXPART, and ERA-Interim reanalysis data, to backtrack air reaching the northern Ethiopian highlands in July–August 1998–2008. The Indian Ocean, the Congo Basin and the Red Sea were found to be important moisture source regions; for air from the Indian Ocean aided by a considerable moisture uptake along routes across the African continent. The following main transport branches were identified: (1) Flow from the Gulf of Guinea, (2) Flow from the Indian Ocean, and (3) Flow from the north; from the Mediterranean region across the Red Sea and the Arabian Peninsula. The largest contribution to the moisture transport into, and release of moisture within, the northern Ethiopian highlands, was associated with air traveling from the Indian Ocean and from the north. This was partly due to the relatively high mean specific humidity of this air, and partly because a large proportion of the air that reaches the highlands, follows these routes. As a total, the amount of moisture brought into the highlands from the north is 46% higher than from the south, whereas the contribution to moisture release within the highlands is about equal for air coming from the south and from the north. While previous studies have emphasized the importance of the Gulf of Guinea, we find that despite the high specific humidity of the low-level flow of air from the Gulf of Guinea, the amount of moisture carried into and released within the northern Ethiopian highlands through this branch, is much smaller than from the other branches – about 1/8 of that from the Indian Ocean. This is due to the fact that normally only a small proportion of the air reaching Ethiopia comes from the Gulf of Guinea

Sensitivity of SWAT simulated streamflow to climatic changes within the Eastern Nile River basin

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Recently Dereje T. Mengistu and Asgeir Sorteberg published a paper on the river flows in the Eastern Nile basin. This study is a part of the EMAPS research. (pdf file)

The paper is published in:Hydrology and Earth System Sciences 2012; 16: 391–407.

The Abstract of the paper is.

The hydrological model SWAT was run with daily station based precipitation and temperature data for the whole Eastern Nile basin including the three subbasins: the Abbay (Blue Nile), BaroAkobo and Tekeze. The daily and monthly streamflows were calibrated and validated at six out- lets with station-based streamflow data in the three different subbasins. The model performed very well in simulating the monthly variability while the validation against daily data revealed a more diverse performance. The simulations in- dicated that around 60 % of the average annual rainfalls of the subbasins were lost through evaporation while the esti- mated runoff coefficients were 0.24, 0.30 and 0.18 for Ab- bay, BaroAkobo and Tekeze subbasins, respectively. About half to two-thirds of the runoff could be attributed to surface runoff while the other contributions came from groundwater.

Twenty hypothetical climate change scenarios (perturbed temperatures and precipitation) were conducted to test the sensitivity of SWAT simulated annual streamflow. The result revealed that the annual streamflow sensitivity to changes in precipitation and temperature differed among the basins and the dependence of the response on the strength of the changes was not linear. On average the annual streamflow responses to a change in precipitation with no temperature change were 19 %, 17 %, and 26 % per 10 % change in precipitation while the average annual streamflow responses to a change in temperature and no precipitation change were

47 temperature and precipitation scenarios from 19 AOGCMs participating inCMIP3 were used to estimate fu- ture changes in streamflow due to climate changes. The cli- mate models disagreed on both the strength and the direc- tion of future precipitation changes. Thus, no clear conclu- sions could be made about future changes in the Eastern Nile streamflow. However, such types of assessment are impor- tant as they emphasise the need to use several an ensemble of AOGCMs as the results strongly dependent on the choice of climate models.

Malaria research during 2011

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The Ethiopian Malaria Prediction System (EMaPS) combines information about weather and water with demographic data to predict mosquito development and malaria risk.

Climate variability and changes may influence socio-economic development in Africa by affecting human health through extreme weather events and by bringing about changes in the ecology of infectious diseases. Malaria is a major climate sensitive public health problem in Ethiopia. Unfortunately, there are no practical tools for predicting malaria epidemics based on weather and climate information. Such tools would be useful in making a more efficient use of the limited resources for malaria control.

The project is a collaborative multidisciplinary research project. Researchers from Ethiopia and Norway work together to develop and validate models for predicting malaria transmission and set up an early warning by combining information on climate, water, epidemiological and entomological data. By the end of the project period, EMaPS will try to provide an implementation approach for early malaria warning. The project also aims to strengthen research, and improve interdisciplinary research capacity in Ethiopia and Norway.

The project contains several disciplines (see figure).

The project combined new population-based malaria transmission data with climate and land use variability data to develop early warning to predict malaria epidemics in Ethiopia. Such information is useful for the public and public institutions about the risk of malaria transmission and thus prevents malaria-related deaths.

Overall, eight PhD candidates (six Ethiopians and two Norwegians) take part in the project. The NUFU project funds four of these students, and four are funded by the University of Bergen. They collaborate and share data between the project parts.

We completed the data collection in 2010. During 2011, we mainly focused on data analysis, write-up and publication of the study findings. We expect all PhD candidates to defend their PhD thesis in 2012, and their works are briefly described below.

Abebe Animut is studying malaria mosquitoes in the highlands. He has described the occurrence of Anopheles arabiensis at altitudes as high as 2200m. He has also described the risk of malaria transmission at varying altitudes between 1700 and 2200 m altitude. His study provides good evidence that malaria transmission often occurs in the Ethiopian highlands.

Dereje Tesfahun has evaluated how rainfall and other factors affect the flow of the major rivers in Ethiopia. He has used a model to assess how sensitive the flows of the major river basins are affected by the weather and by possible land use changes. His research shows that Ethiopian rivers are sensitive to precipitation with a 10% change in precipitation giving a 20-30% response in annual stream flow.

Diriba Korecha has studied seasonal weather forecast for Ethiopia. He has re-classified the climatic zones in Ethiopia, worked on models to improve seasonal weather forecasting and validated the result of 10 years of seasonal forecasting in Ethiopia. His research shows that seasonal weather forecasting in Ethiopia is difficult.

Adugna Woyessa has studied the prevalence and risks for malaria using prospective community-based surveys in Butajira in the south central Ethiopian Highlands. His study confirms that malaria is present at altitudes as high as 2200 m, and the malaria prevalence increases towards the lowlands. Malaria occurs throughout the year, but mainly after the main rains. One important finding is that he shows that malaria varies much between villages and within households at all altitudes.

Eskindir Loha studies malaria in the holoendemic Arba Minch area. One of his studies shows that models of climate-malaria link vary from place to place, and one model cannot fit all locations. Malaria modelling may need the inclusion of non-climatic causes. In a follow up study he shows that risk of getting malaria varies much both in time and space within villages. He now works on a paper to describe the influence on rainfall, temperature, socioeconomic factors on the incidence on malaria in these lowlands.

Fekadu Massebo is describing the association between resting behaviour, human blood index and entomological inoculation rates of Anopheles arabiensis in south Ethiopia. The studies include analysis on how mosquito density is associated with malaria cases and how it is influenced by temperature and rainfall. He also assesses insecticide resistance pattern, and if simple house screening will reduce risk of malaria infection.

Torleif Markussen Lunde works on the malaria prediction model. He uses information collected from several disciplines of our project. He has developed a validated malaria prediction model. In the coming months, he will produce malaria distribution maps for Ethiopia, and try to estimate how the new IPPC climate scenarios will affect malaria in the coming years.

Ellen Viste has used weather analysis to describe and analyse from where moisture to Ethiopia comes from.  The Indian Ocean, the Congo Basin and the Red Sea are important moisture source regions. The results suggest that most of the air – humid or not – that enters the Ethiopian highlands from the south has travelled through the Indian Ocean, by the African continent, reaching the Ethiopian highlands from the south-west, or through the Turkana channel.

Some conclusions:

The research will reach its research objectives by the end of 2012, and will have produced eight PhDs and over 20 master theses. Based on our experience we conclude the following challenges remain:

Research challenges include:

  • Improve seasonal weather forecasting for Ethiopia
  • Further develop and field-test malaria prediction in close collaboration with national meteorology and health authorities
  • Possibly add new disciplines such as studies on climate – food production and nutrition.

Educational challenges include:

  • Strengthen PhD training in advanced epidemiology and mathematical modelling (both in geophysics and in health research)
  • Strengthening training in medical entomology (masters level)

These are parts we wish to include in plans for a possible extension of our project.

Avoiding maternal deaths

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A recent report in The New York Times highlight the poor states and failures of hospitals in Uganda. They write about pregnant women arriving at hospitals in time to deliver, but when complications arise, no one is there to help them. The tragic events at Arua Hospital is unfortunately not a unique event.

Such failures are unfortunately not seldom. The New York Times article point to the lack of priority given by the Ugandan Ministry of Health. In my view it also points to a failure over many years by the international donor communities.

Where as much emphasis has been given to HIV work, and immunisations, donors and NGOs have been reluctant to support and strengthen institutions. Hospitals are essential to reduce maternal deaths. Most deaths would be averted if the pregnant women would deliver at hospitals near to their homes, and such a hospital need to have trained staff to do Comprehensive emergency obstetric care (see figure for more information).

Many NGOs and donor government unfortunately believe that providing antenatal coverage is enough to reduce maternal deaths. Unfortunately, such logic is only true to a certain extent. Good antenatal services will reduce maternal deaths if it works jointly with hospitals. Antenatal work in the communities and at peripheral health posts must in time refer women in need of comprehensive emergency obstetric care. Experience from many countries show that antenatal care as stand-alone work will not reduce maternal deaths.

In our project in Ethiopia we try to improve the quality of hospitals, and support the Ministry of Health to upgrade health centres to small hospitals so pregnant women can get use essential services near to their homes. The aim is there should be one well-functioning institution providing comprehensive emergency obstetric care for every 150.000 people.

 

 

Excellent for Centre for International Health

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Recently, The Research Council of  Norway evaluated health research in Norway.

The core research groups at Centre for International Health both received the grade “Excellent” by an international expert panel which evaluated medicine and health research in Norway.

The evaluation panel concludes that “the Centre for International Health is the leading research centre within international and global health in the Nordic countries, and one of the leading centres in Europe”.

CIH combines biomedical and public-health research. Both the Child Health and Nutrition, and the HIV and TB Research group received “excellent” grades. Both research groups address important research questions, and base their research on long-term collaboration with universities in Asia and Africa. The research also addresses  the needs of the population, and translates research findings into improved treatment and better control of diseases.

Read the full evaluation report here.

 

Can we improve health policy?

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This is a central question in public health research. Epidemiological research aims to improve our understanding of diseases, or to improve health. Improving health often needs policy changes, either at institutional, regional or national level.

Operational research is defined as: “The search for knowledge on interventions, strategies, or tools that can improve the quality, effectiveness, or coverage of programmes in which the research is being done” 1.

Operational research involves descriptive, case–control, and cohort analysis. Some say that basic science research and randomised controlled trials is not operational research. However, effectiveness trials show if an intervention works, and should in my view form an integral part of operational research. Results from such randomised trials can benefit in diverse settings of routine care.

Many researchers believe that doing good research and publishing the results in high-quality journals lead to policy change. Unfortunately, this is a naive view. Here I present a few examples showing that policy change is more that doing good research: it wants a close cooperation with policy-makers.

Improving tuberculosis control

Although tuberculosis treatment success rates have improved in Ethiopia, low case notification rate, mainly because of inability to access the health service, remains a challenge. Using community health workers, we enrolled health extension workers in providing health education, sputum collection and treatment. This improved treatment, case detection, occurs because of increased access to the diagnostic services 2. This approach also reduced costs by 63%, and is economically attractive to the health service and patients, caregivers and the community 3.

The Ministry of Health Ethiopia recently backed this approach, and Health Extension Workers now take part in tuberculosis control in Ethiopia.

The policy change was mainly brought about by close communication and involvement of key policy people in carrying out the research.

Antiretroviral treatment in district hospitals

About  ten years ago we started antiretroviral treatment in south Ethiopia. Our question was: Is antiretroviral treatment possible to do at rural hospitals? Our group showed that antiretroviral treatment in resource limited settings  is possible 4, and cost-effective 5.

It is important for HIV infected patients to take their drugs regularly. Interruptions in treatment lead to viral strains that are resistant to the cheapest medications, and to higher rates of illness and death. Unfortunately, many AIDS patients do not return to collect their antiretroviral medications (“lost to follow-up”).

In a recent review of 2191 adult HIV patients in south Ethiopia, we show that patients now start at earlier stages of their illness. Early treatment start improved survival 6. Unfortunately, 25 per cent were lost before they started treatment. This percentage has increased during recent years. Forty per cent of those lost to follow up had died.

This are examples of research that provides  information on how antiretroviral treatment programmes work in the country,

Health care financing

About 14 years ago we started a work to make the hospital sustainable managerially and financially. These were previous mission run hospitals. Over the years, the hospitals managed to become managerially and financially sustainable within a regional context.

And, this model of hospital finance formed a part of the evidence for health care financing in Ethiopia.  The evidence came from evaluations of the hospital services and accounts, as well as external independent audits. There were no formal peer-reviewed publications.

Reducing maternal deaths

In line with the Millennium Development Goal for maternal health (MDG-5), we have since 2008 been running a health programme to reduce maternal mortality in south-west Ethiopia. Based on experience from other countries, we aimed to develop a decentralised delivery of care. Staff at remote rural health centres should be able to carry out comprehensive emergency obstetric care, and these services should be available to and used by pregnant women.

Through this public health project we train staff from many rural hospitals and health centres to do comprehensive emergency obstetric care. We also equip the institutions, and regularly carry our supervision of the work. The project strengthens the antenatal services so the health extension workers can help normal deliveries and identify and refer women in need of help during delivery to health institutions. We enable these health institutions to practise safe delivery. As most maternal deaths occur with delivery, particular attention is on intrapartum care.

After four years, the number of the health care coverage has increased from 1 per 1,3 million people (2 hospitals  for  a population of 2,6 million people) to 1 per  270.000 people (11 institutions  for a population of 2,9 million). The future success of such a programme is that local hospitals start training staff, and supervise staff at the remote health centres and hospitals.

This project is mainly an education programme, and serves as a pilot model for the region. We have presented our experiences at several meetings, and publications will soon be available. But more important, representatives from other regions visit us, and plan to use our experiences in their efforts to reduce maternal deaths.

Conclusions

These examples from practical health work and research in Ethiopia show we should inform people in position to change policy. Engaging policy makers in the work is often more important than publications.

References

1. Zachariah R, Harries AD, Ishikawa N, et al. Operational research in low-income countries: what, why, and how? Lancet Infect Dis. 2010;9:711–717.

2. Datiko DG, Lindtjørn B. Health extension workers improve tuberculosis case detection and treatment success in southern Ethiopia: a community randomized trial. PLoS ONE. 2009;4(5):e5443.

3. Datiko DG, Lindtjørn B. Cost and cost-effectiveness of smear-positive tuberculosis treatment by Health Extension Workers in Southern Ethiopia: a community randomized trial. PLoS ONE. 2010;5(2):e9158.

4. Jerene D, Naess A, Lindtjørn B. Antiretroviral therapy at a district hospital in Ethiopia prevents death and tuberculosis in a …. AIDS Research and Therapy. 2006.

5. Bikilla AD, Jerene D, Robberstad B, Lindtjørn B. Cost-effectiveness of anti-retroviral therapy at a district hospital in southern Ethiopia. Cost effectiveness and resource allocation : C/E. 2009;7:13.

6. Mulissa Z, Jerene D, Lindtjørn B. Patients present earlier and survival has improved, but pre-ART attrition is high in a six-year HIV cohort data from Ethiopia. PLoS ONE. 2010;5(10):e13268.