Fighting malaria: It takes a family, a village, and more

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By Christine Mubiru

I have experience with malaria, but this is not an enviable position to be in. The disease has affected almost all members of my family to varying degrees and has become increasingly expensive to treat. Fighting malaria requires tremendous support—within our families, from neighbors, and especially from our government. We need to pay greater attention to preventive measures, and I would urge our politicians to take a leading role in sensitizing the public to take advantage of existing methods to combat the disease and to be open to new interventions when they come along.

Malaria episodes grew less frequent for me but more expensive
Growing up in the 1960s, malaria episodes were common, but the consequences seemed less dire than today. Many times, I would miss a day or two of school. Treatment mainly came in the form of injections or pills—usually the bitter quinine kind—and neither was desirable to a child. I would feel weak and dizzy and really hated the idea of lab testing, which usually meant having technicians repeatedly prick my arms in search of blood. They would say it was difficult to get a hold of my veins and sometimes would postpone this painful process to another warm day. But because I knew all the malaria symptoms, I would find a way to get medicine, sometimes turning to self-medication, a practice embraced by many who lacked adequate funds or who were hoping to reduce the time spent at a health facility.

As I grew older, malaria episodes became less frequent—though very expensive. As I pursued a Master of Sciences degree in the U.K., I was surprised at certain questions that appeared on doctors’ forms, such as, “how often have you had malaria?” I thought then that the disease was so common that nobody would be interested in its frequency.

All the children in the family, including my nieces and nephews, cried in the presence of uniformed nurses, whom they hated more than the doctors, as the nurses were the ones responsible for administering injections. My youngest sister was seriously affected with the disease as a child. My parents worried that malaria would eventually cause her mental disability. She would have unconnected talk, convulsions, and cerebral malaria episodes, and she would be hospitalized for at least a week at a time. It was expensive for my civil servant father, who at times had to seek private health care, without the benefit of insurance. After primary school, my sister appeared to develop some immunity to the disease, and her situation improved.

Payment for treatment was always an issue
In the 1980s, my young daughter and first born had fewer episodes than her brother. One explanation in our family was that she had a good appetite and therefore a stronger body to fight disease. But one day while I was at work, she started convulsing. The maid carried her to the nearest local clinic only to be turned away by the doctor in charge because he was not assured of payment. In those days, mobile phones were not yet on the market and public transportation was not easily available. The doctor advised the maid to take the baby to the hospital, but this was a challenge for her, considering that the hospital was quite a distance away and that she neither had the money nor the know-how to deal with emergencies and hospital bureaucracy. My daughter was saved by a young visiting doctor, who injected her with Valium while waiting for my arrival.

My son had a rough time during his primary school years in the 1990s. School administration would call me from time to time to have him taken for treatment. He was usually so talkative and playful that it would be easy to notice he was sick, as he would get quiet and would want go to bed at unusual times. His situation improved when he advanced to secondary school. I remember being called no more than twice in six years to pick him up for treatment. Since then, treatment has become far more expensive, with introduction of the artemisinin-based combination therapy Coartem, which the schools can’t afford. Bed nets are always among the items on the list given to parents when their children are admitted to school—particularly boarding school.

Many in my family have been treated by my brother-in-law, who is a doctor. My children and I have also attended the clinic of a family doctor close to where we live. Both are considerate with regard to payment, as those who do not have enough funds at the time of their visits are allowed to pay the balance soon after.

We need an enabling policy environment to beat malaria
Today, as a policy analyst, I see the need to create awareness about current malaria control measures. We also need an enabling policy and legislative environment that allows the allocation of adequate funding to research new malaria interventions, that evaluates the various interventions currently in use, and that allows the most effective ones to be scaled up. It is also important to prepare policymakers and health care providers for timely decisions, should a malaria vaccine become available. Given the suffering and cost of malaria, it is imperative to continue to use the tools we have and to seek additional, effective ways of combating the disease in the interest of finally controlling the disease.

*Christine Mubiru is a policy analyst in Uganda

Why I Work to Develop Malaria Vaccines

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By Dr. Lucas Otieno Tina

There’s a common saying in my community: ‘‘It’s better to start early than go to a witch doctor.” By this, we mean, it’s better to prevent the disease than to treat it when it’s often too difficult, or too late.

My community is a town called Kisumu, which is located in western Kenya along the shores of Lake Victoria. There, I work as a physician and researcher at the Kenya Medical Research Institute/US Army Medical Research Unit/Kenya collaboration program, otherwise known as the KEMRI/Walter Reed Project.

I work to protect children against big killers 

Every day, I work to protect African children against the big killers in our region: pneumonia, diarrheal diseases and—particularly for us at the KEMRI/Walter Reed Project—malaria. And every day, when I see these children and their parents suffering, I feel compelled to do something. First, to treat the disease, and second to prevent it.

And that is where we find the beauty of immunization with vaccines. We’ve learned from various diseases, including the classic cases of polio and smallpox, that prevention is better than cure. Vaccination, typically easier and cheaper than curing, averts the suffering of children and the burden on the family and community.

Across the road from my research center, you will find the Kombewa District Hospital, where we treat the participants in our clinical trials and other members of the public. In the course of my work, I have repeatedly witnessed the problems of poverty, lack of access to proper healthcare, and resource limitations. It’s been especially troubling to watch the medical personnel and facilities struggling with illnesses that are mostly preventable and treatable. These are primarily infectious diseases—malaria, tuberculosis, diarrhea, and HIV/AIDS—and malnutrition.

I have gained invaluable experience in several large trials

We’ve known for 40 years that a vaccine against malaria is biologically feasible. The KEMRI/Walter Reed Project has been in the thick of this research and has worked on malaria and various vaccine candidates for many decades. Through my work with them, I have gained invaluable experience in several large trials of malaria vaccines. I consider our contribution a great achievement given that a malaria vaccine has the potential to change the face of the war against malaria forever.

I’m happy to say, we are completing a Phase 3 clinical trial on the most advanced malaria vaccine candidate to date: RTS,S. No other vaccine candidate has made it this far in the development process. Walter Reed worked with GSK in the early development of RTS,S in the 1980s. In 2009, a unique public/private partnership involving the PATH Malaria Vaccine Initiative (MVI), GSK and 11 African research centers—including my center in Kombewa—launched this large-scale trial with over 15,000 infant and young child participants.

In the results so far, clinical malaria cases were reduced by about half in young children ages 5 months to17 months and by about a quarter in infants 6 weeks to 12 weeks after 18 months of follow-up. We’re very much looking forward to the trial’s final results at the end of this year or early 2015, which will provide 30 months of follow-up and give us data on the effects of a booster dose.

Looking ahead

So where do we see RTS,S in the months to come?

Later this year, GSK plans to submit a regulatory application for RTS,S to the European Medicines Agency (EMA). If the data and public health information is deemed satisfactory, and the EMA gives a positive opinion, the WHO has indicated that a policy recommendation for the RTS,S malaria vaccine candidate is possible by the end of 2015. This would pave the way for local regulatory submissions and decisions by African nations regarding implementation of the vaccine through their national immunization programs.

With this in mind, in Kenya, as in other countries in my part of Africa, like Tanzania and Uganda, efforts are already underway to ensure a timely decision on whether to adopt this new tool, if it is licensed and recommended for use. If we have an effective and approved tool for use against this terrible disease, I’d hate to see it sit on the shelf when I do my rounds in the pediatric ward full of sick kids.

It’s been a very gratifying experience to work with WRAIR and our partners on this “big picture” intervention—a vaccine—for one of our biggest and most persistent public health problems—malaria.

Dr. Lucas Otieno is a medical doctor working as a Research Officer and Certified Physician Investigator with the Kenya Medical Research Institute (KEMRI)/Walter Reed Project in Kenya. He is currently a Principal Investigator for the Phase III malaria vaccine trials of RTS,S.

 

 

 

Menace of Malaria: A Tale of Two Cities

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By: Dr. Muhammed Afolabi

As a family care provider in the densely populated West African city of Osogbo, some 200 kms south of Lagos in Nigeria, up to 6 out of 10 patients attending my clinic between 2002 and 2009 presented with symptoms and signs of malaria. Given various logistical challenges, including poor laboratory facilities and a lack of rapid malaria diagnostic kits, my malaria diagnosis was based on a high index of clinical suspicion.

Menanceofmalaria-blogThe anti-malaria treatment I prescribed included various brands of artemisinin-based combination therapy, but my patients usually came back with additional episodes of malaria within two to three weeks of completing their treatment. I then spent more time re-diagnosing and re-treating these patients. And while I routinely encouraged patients to sleep under insecticide-treated bed-nets, they indicated a lack of motivation, telling me they felt like “fish inside a net.” My own family did not escape the distress of recurring malaria episodes. My wife suffered repeated bouts that occurred as frequently as every four weeks, causing her to refer to them as her “monthly sickness.”

“Sadly, though, the reduction in the overall number of cases here appears to be accompanied by waning malaria immunity.”

 

In mid-2009, fate took us to another city in West Africa—Fajara in the Gambia—where I currently work on a malaria vaccine. While there is no doubt about the bad effects of malaria on the children, pregnant women, and other adults here, we are lucky that malaria control efforts like insecticide-treated nets, indoor residual spraying, and effective antimalarial drugs have brought cases of malaria to a low level. As a result, my wife and other members of my family had no malaria for the first two years of our stay in the city.

Sadly though, the reduction in the overall number of cases here appears to be accompanied by waning malaria immunity in the Gambia. For the past two years, we have seen in our clinics and trial centres, severe forms of malaria among older children and adults—groups who would normally be expected to have developed some degree of natural protection against the disease.

Recently, I’ve observed that the number of patients with malaria in the health centre where I work is increasing by leaps and bounds. I’ve also noticed that these patients have severe malaria and that the hospital beds are occupied by several older children and young adults who would be expected to have developed immunity against severe forms of the disease.  Two of these older children died following episodes of convulsion and loss of consciousness. About the same time, my 10-year old daughter contracted severe malaria, and I was even more deeply touched by the devastating effects of the disease.

“We must continue to expand the use of current malaria control strategies even as we press for expanded malaria research and development efforts.”

 

Because of the high patient burden and my own family distress occasioned by the scourge of malaria, I have renewed my commitment to working with individuals, communities, and key stakeholders to control this perennial menace. We must continue to expand the use of current malaria control strategies even as we press for expanded malaria research and development efforts, including the development of malaria vaccines.

At the individual level, I work passionately in the search for an effective malaria vaccine. I also plan to do what I can to help to galvanise support for more research funding and support for malaria vaccine trials.

As a scientist, I believe I have a big role to play in this regard. We always assume that stakeholders understand our work, follow our progress, and understand scientific language the way we do; however, they need information to be delivered in a simplified, rational manner. Engagement of scientists with key stakeholders will help to ensure that our important research and development work is well understood and eventually translated into policies and interventions in a timely way—at the appropriate time.

Advocacy Skills Are Important for Scientists

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By: Dr. Felicia Owusu-Antwi

I work with the World Health Organization Ghana country office as the National Professional Officer for Malaria. My work entails technical support to the National Malaria Control Program (NMCP) in collaboration with other health and development partners in malaria control.

I also coordinate the Malaria Vaccine Decision-Making Framework process in Ghana, together with the NMCP. The Decision-Making Framework is a tool that assists countries in identifying data needs and processes required for decisions on the use of a successful malaria vaccine candidate. Information-sharing, facilitation of policy dialogues, advisory support, and advocacy are the main requirements for this coordination.

In June 2011, our technical advisory group meeting had the participation of parliamentarians for the first time, something I attribute to the advocacy skills I acquired. This development led to positive political engagement with the parliamentarians and a greater willingness on their part to assist in solving some of the challenges faced by the trial teams. The parliamentarians also expressed interest in participating in working group sessions.

I have learned a number of lessons as an advocate:

  • We assume that our policymakers understand scientific language the way we do; however, they need information to be delivered in a simplified, rational manner.
  • Advocacy skills are important for scientists. These skills ensure that some of the important research findings are translated into policies and interventions—and in good time.
  • Policymakers will never endorse an initiative with which they are not comfortable. It is important to engage them early enough for their buy-in.
  • Scarcity of resources makes policymakers very pragmatic. Therefore, the cost-effectiveness of any initiative or intervention should be the advocate’s major focus, clearly demonstrating that saving lives also translates into wealth.

Dr. Felicia Owusu-Antwi is the National Professional Officer for Malaria at WHO’s Ghana country office.

Preparing for Vaccine Decisions Takes Time

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By: Dr. Ramadhani Abdallah Noor

I am a Tanzanian physician with public health training from the Harvard School of Public Health. My experience is in malaria vaccine research. Working with the African Malaria Network Trust, I have actively contributed to a number of malaria vaccine trials in Africa.

I am a member of a technical advisory group that brings on board different stakeholders for malaria vaccine development and deployment in the country. This committee works closely with the PATH Malaria Vaccine Initiative on adoption of the Malaria Vaccine Decision-Making Framework, a tool that is necessary for timely introduction of a malaria vaccine into the existing malaria control tools matrix, once a vaccine becomes available.

In close collaboration with malaria control stakeholders in Tanzania and under the leadership of Dr. Salim Abdulla of the Ifakara Health Institute, we put together an annual Tanzania Malaria Control Forum, which began in 2010. This forum brings together experts from the scientific field, programs, services, academia, media, parliament, and the public to discuss comprehensive malaria control efforts, and to share results, challenges, and opportunities for individual malaria interventions and tools.

My advocacy on the need to prepare early for malaria vaccine decisions included presentations in 2011 to the Africa Caribbean Pacific – European Union Joint Parliamentary Assembly Committee on Social Affairs and Environment in Brussels; a Friends of the Global Fund meeting on vaccines in Paris; and the Parliamentary Forum for Eastern and Southern Africa in Lusaka, sponsored by the Roll Back Malaria Partnership.

My take-home messages are that:

  • Malaria vaccines are potential tools for control and eradication.
  • Progress has been made in malaria vaccine research;
  • We have hope for a first-generation vaccine.
  • Ensuring accessibility of a vaccine is nearly as challenging as developing the vaccine itself.
  • Timely introduction of malaria vaccines needs early country-level planning.

Dr. Ramadhani Abdallah Noor is a Tanzanian physician with African Malaria Network Trust.