Tuesday, 29 November 2011

MALARIA: Kenya: Targeted Malaria Control Is the Better Option

Tabitha Mwangi : 29 November 2011
In a Daily Nation article titled 'Vague policies blamed for flop in malaria war', health experts meeting in Mombasa were quoted as suggesting that the government's approach of targeting malaria prophylaxis only at women at the greatest risk was wrong and that all pregnant women in the country should be given malaria prophylaxis.
In this case, the health experts were wrong -- the government had done its homework and its approach was appropriate.
Disease control programmes ought to be evidence-based in order to bring maximum benefit to those most at need, and this is the tenet that the government followed.
In 2009, Dr Abdisalan Noor and his colleagues at KEMRI, in collaboration with the Division of Malaria Control developed a malaria risk map for Kenya.
The map was developed from data collected from a total of 2,600 malaria survey reports, 50 per cent by the Ministry of health.
The malaria infection surveys were conducted among children under 10 years of age in the country since 1975.
"In Kenya, there are about 80 districts with very high malaria transmission, almost all around Lake Victoria. There are a few hot spots at the Coast and in North-western Kenya. Only 21 per cent of the Kenyan population is under intense malaria transmission," said Dr Noor, a senior malaria research scientist, based on their findings.
There are two approaches to preventing malaria in pregnancy; intermittent preventive treatment (IPTp) and use of insecticide treated bed nets.
IPTp involves providing pregnant women with three protective doses of a safe antimalarial drug.
The most commonly used drug is the sulfadoxine-pyrimethamine combination generally known as SP.
"The availability of the risk maps from Dr Noor, make it unnecessary to expose pregnant women with little risk of malaria to IPTp. Efforts should be focused to ensure that 100 per cent of the pregnant women in those high risk areas, get IPTp,' said Prof Bob Snow, a renown malaria expert.
The Division of Malaria Control in Kenya used the map that Dr Noor and his team developed to set priorities and target resources efficiently.
The Division, which was then headed by Dr Elizabeth Juma, had been involved in the research process from the beginning and was therefore swift in using the malaria risk map to target interventions where they were most needed.
"Through antenatal clinics, IPTp is being focused in the three regions with intense malaria transmission. These are Western, Nyanza and Coast province. However insecticide treated bed nets distribution for pregnant women will continue in all regions where it is ongoing,' said Dr Elizabeth Juma.
The logic of giving IPTp to all pregnant women, irrespective of malaria risk, is perhaps based on the fact that the drug is cheap.
But the wastage involved in mass distribution of the drugs is huge. These resources would be better used in ensuring that those pregnant women at high risk of malaria actually receive IPTp on time. This has not been happening.
Kilifi, for example, is within the high risk zone where pregnant women are expected to receive three doses of IPTp during their pregnancy, but the figures are not encouraging.
"When I look at my register, there are very few pregnant women who have taken the three doses and just a few more have received two doses. The majority of the women pay a single visit to the antenatal clinic and therefore receive only one dose," says Gladys Etemesi, the nurse-in-charge at the maternal health clinic at the Kilifi District hospital.
To reap maximum benefits from IPTp, a pregnant woman needs to take a minimum of two doses.
"Women will do anything to bring their child for vaccinations, whether they deliver at home or in hospital. Very few women fail to bring their children for vaccination because most now understand the value of immunizations. If it is emphasised that failure to come for antenatal care also places their babies at risk, they are more likely to come,' says Ms Etemesi.
In this case of Kilifi, and in other high risk areas, funds that would otherwise be spent on buying and distributing the drugs to mothers in low-risk areas who do not need them, they can be used to increase awareness in order to have more mothers and children benefit from the drugs.
At the same time, the funds can be used to ensure that those who fail to show up for repeat IPTp visits at the antenatal clinic are followed up at home and given the medicine and also encouraged to sleep under an insecticide treated bed net.
In March this year, the Ministry of Public Health and Sanitation launched the first community mass net distribution campaign in Kenya that targeted whole populations in the regions identified as carrying the highest burden of malaria on the malaria risk map.
These efforts would be made more cost-effective if linked with efforts to ensure that all the pregnant women in these areas also get their IPTp doses.

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