WHAT'S NEW THIS SUNDAY: CIRCUMCISION; GOING LIVE WITH IPTi IN IMMUNIZATION; MATERNAL MORTALITY TRENDS; NTD CONTROL

Friday, 25th of May 2012

WHAT’S NEW THIS SUNDAY: MALE CIRCUMCISION IN SWAZILAND; GOING LIVE WITH IPTi DURING ROUTINE IMMUNIZATION VISITS; MATERNAL MORTALITY TRENDS, 1990-2010; SELECTED SUCCESSES IN THE CONTROL OF NTDs

MALE CIRCUMCISION IN SWAZILAND

http://www.youtube.com/watch?v=CS00H1FJLpA

GOING LIVE WITH IPTi DURING ROUTINE IMMUNIZATION VISITS

From Africa Health; full text is at

http://www.africa-health.com/articles/may_2012/Malaria.pdf

Excerpts:

“The basic [WHO]recommendation addressed the co-administration of SP-IPTi with DTP2, DTP3 and measles immunisation to infants, through routine EPI in countries in sub-Saharan Africa, in areas:

• with moderate-to-high malaria transmission (Annual Entomological Inoculation Rates ≥10), and

• where parasite resistance to SP is not high – defined as a prevalence of the ‘pfdhps 540’ genetic mutation of <50%.

. . . In Mali, Dicko and colleagues in a large-scale intervention involving over 5000 children during a 2-year period report that, ‘The implementation of the IPTi-SP resulted in a substantial reduction in all-cause mortality in children. The results of this study support the adoption and the implementation of IPTi-SP as malaria control strategy.’18

In the context of malaria control and elimination, no one intervention is applied alone but in combination with others including ITNs and proper case management with ACTs. Now that the tools and guidance are available for implementing IPTi, it is up to countries, or even provinces or states within countries that have high and stable malaria transmission, to adopt and roll out this strategy and save children’s lives.”

MATERNAL MORTALITY TRENDS, 1990-2010

Executive summary

The high-level Commission on Information and Accountability for Women’s and Children’s

Health included among its 10 recommendations one that is specific to improving

measurement of maternal (and child) deaths. This recommendation requires that “by 2015,

all countries have taken significant steps to establish a system for registration of births,

deaths and causes of death, and have well-functioning health information systems that

combine data from facilities, administrative sources and surveys”. Considering that only

a third of countries are characterized as having a complete civil registration system with

good attribution of cause of death, it is imperative that countries with incomplete civil

registration systems take steps to strengthen those systems. This will tremendously

improve the estimation of maternal mortality and monitoring of the Millennium Development

Goal (MDG) 5: Improve maternal health. The two targets for assessing MDG 5 are reducing

the maternal mortality ratio (MMR) by three quarters between 1990 and 2015, and

achieving universal access to reproductive health by 2015.

The estimates on maternal mortality presented in this report are the sixth in a series of

exercises by the United Nations agencies. For the second time, the Maternal Mortality

Estimation Inter-Agency Group (MMEIG), comprising the World Health Organization (WHO),

United Nations Children’s Fund (UNICEF), United Nations Population Fund (UNFPA), the

United Nations Population Division, and The World Bank, together with a team at the

University of California at Berkeley, United States of America have been working together

to generate internationally comparable MMR estimates. A technical advisory group (TAG)

provides independent technical advice to MMEIG. Based on the achievement from the last

round, newly available data collected by MMEIG and obtained during country consultation

were incorporated, and trend estimates from 1990 to 2010 were generated.

Globally, an estimated 287 000 maternal deaths occurred in 2010, a decline of 47% from

levels in 1990. Sub-Saharan Africa (56%) and Southern Asia (29%) accounted for 85% of

the global burden (245 000 maternal deaths) in 2010. At the country level, two countries

account for a third of global maternal deaths: India at 19% (56 000) and Nigeria at 14%

(40 000).

The global MMR in 2010 was 210 maternal deaths per 100 000 live births, down from 400

maternal deaths per 100 000 live births in 1990. The MMR in developing regions (240) was

15 times higher than in developed regions (16). Sub-Saharan Africa had the highest MMR

at 500 maternal deaths per 100 000 live births, while Eastern Asia had the lowest among

MDG developing regions, at 37 maternal deaths per 100 000 live births. The MMRs of the

remaining MDG developing regions, in descending order of maternal deaths per 100 000

live births are Southern Asia (220), Oceania (200), South-eastern Asia (150), Latin

America and the Caribbean (80), Northern Africa (78), Western Asia (71) and the Caucasus
and Central Asia (46).

A total of 40 countries had high MMR (defined as MMR ≥300 maternal deaths per 100 000

live births) in 2010. Of these countries, Chad and Somalia had extremely high MMRs

(≥1000 maternal deaths per 100 000 live births) at 1100 and 1000, respectively. The other

eight highest MMR countries were: Sierra Leone (890), the Central African Republic (890),

Burundi (800), Guinea-Bissau (790), Liberia (770), the Sudan (730), Cameroon (690) and

Nigeria (630). Although most sub-Saharan African countries had high MMR, Mauritius (60),

Sao Tome and Principe (70) and Cape Verde (79) had low MMR (defined as 20–99 maternal

deaths per 100 000 live births), while Botswana (160), Djibouti (200), Namibia (200),

Gabon (230), Equatorial Guinea (240), Eritrea (240) and Madagascar (240) had moderate

MMR (defined as 100–299 maternal deaths per 100 000 live births). Only four countries

outside the sub-Saharan African region had high MMR: the Lao People’s Democratic

Republic (470), Afghanistan (460), Haiti (350) and Timor-Leste (300).

Sub-Saharan Africa had the largest proportion of maternal deaths attributed to HIV at

10%, while the Caribbean had the second largest at 6%. Of the 19 000 maternal deaths

due to HIV/AIDS worldwide, 17 000 (91%) are in sub-Saharan Africa, while 920 (5%)

occurred in Southern Asia. Further, for some countries in Southern Africa, such as

Botswana, Lesotho, Namibia, South Africa and Swaziland, MMR increased from the year

1990 to 2000, mainly as a result of the HIV epidemic; in these countries, the MMR is now

declining as antiretroviral therapy is becoming increasingly available.

The fifth MDG aims to improve maternal health, with a target of reducing the MMR by 75%

between 1990 and 2015. The percentage reductions for the 10 countries that have

already achieved MDG 5 by 2010 are: Estonia (95%), Maldives (93%), Belarus (88%),

Romania (84%), Bhutan (82%), Equatorial Guinea (81%), Islamic Republic of Iran (81%),

Lithuania (78%), Nepal (78%) and Viet Nam (76%). For the remaining countries, one way

to gauge progress is to examine whether they have had the expected average annual

decline of 5.5% in the MMR from 1990 to 2010. Among countries with MMR ≥100 in 1990,

nine countries are “on track”, in addition to those mentioned above: Eritrea (6.3%), Oman

(6.2%), Egypt (6%), Timor-Leste (6%), Bangladesh (5.9%), China (5.9%), Lao People’s

Democratic Republic (5.9%), Syrian Arab Republic (5.9%) and Cambodia (5.8%). Further,

Poland (6.1%) and Turkey (5.8%) have experienced average annual declines of more than

5.5% but because the MMR in 1990 was <100 maternal deaths per 100 000 live births,

they are not categorized as being on track. Moreover, 50 countries are “making progress”.

Conversely, 14 countries have made “insufficient progress”, and 11 are characterized as

having made “no progress” and are likely to miss the MDG target unless accelerated

interventions are put in place.

Full text is at http://www.unfpa.org/webdav/site/global/shared/documents/publications/2012/Trends_in_maternal_mortality_A4-1.pdf

Maternal Deaths Plunged Over 2 Decades, to About 287,000 in 2010, U.N. Reports

By DONALD G. McNEIL Jr.

New York Times, Published: May 16, 2012

The number of women dying from pregnancy and childbirth has dropped sharply in the last two decades, according to a report by a consortium of United Nations agencies set to be released on Wednesday.

Maternal deaths fell to about 287,000 in 2010, the report said. The decline is attributable to increases in contraception and in antiretroviral drugs for mothers with AIDS, and to greater numbers of births attended by nurses, doctors or midwives with medical training.

The agencies said the deaths had fallen by 47 percent from the United Nations’ 1990 estimate of 543,000, but the organization has been revising its historical estimates in response to skeptical research by a rival group of epidemiologists at the University of Washington.

Two years ago, that group, the Institute for Health Metrics and Evaluation, which was founded by the Bill and Melinda Gates Foundation as a sort of check on the World Health Organization, contradicted a long-held United Nations finding that maternal deaths had remained stubbornly above 500,000 a year.

In a widely publicized study in the journal The Lancet in April 2010, the institute estimated that 343,000 maternal deaths took place in 2008. It used three times as much data from census and death records, scientific studies and other sources as previous United Nations reports had.

In response, five months later, the United Nations said it had “revised and improved” its own statistics and concluded that there were 358,000 deaths in 2008.

“When they saw our results, they changed their strategy,” said Dr. Rafael Lozano, an epidemiologist at the institute.

Last fall, the institute estimated that deaths would fall to 274,000 in 2011. The new United Nations estimate of 287,000 is within the same statistical boundaries, Dr. Lozano said.

The United Nations report also concludes that deaths are falling quickly in East Asia but slowly in Africa.

The Asian reduction is attributed largely to China, which has a one-child policy, a very high use of contraceptives and a health care system that is improving as the nation gets richer.

Southern African countries have seen the beginnings of a reversal, according to the United Nations report, which was compiled by the World Health Organization, the United Nations Children’s Fund, the United Nations Population Fund, the United Nations Population Division, the World Bank and a team from the University of California, Berkeley. A decade ago, maternal deaths in southern Africa were rising because of AIDS. As more women get drugs that restore their immune systems, deaths are dropping.

Just two countries, India and Nigeria, account for one-third of the world’s maternal deaths. Others with very high numbers include the Democratic Republic of Congo, Pakistan, Sudan, Indonesia, Ethiopia, Tanzania, Bangladesh and Afghanistan.

“There were rumors at a U.N. conference last fall that the new numbers would be in the 200,000s,” said Christy Turlington Burns, a former fashion model who founded Every Mother Counts to fight global maternal mortality after she nearly died in childbirth.

“I’m delighted to see them come down,” she added after speaking at a health conference in New York on Tuesday. “It didn’t do any good when different reports diverged by 100,000 — or when the drop seemed so rapid. That sent a message that it’s easier to save lives than it is.”

SELECTED SUCCESSES IN THE CONTROL OF NEGLECTED TROPICAL DISEASES

Extract from a longer paper, with full text at http://www.parasitesandvectors.com/content/4/1/234

The Allen and Parker paper [10] on page 94 asks two questions; "Can they [NTDs] be so readily controlled and what has been achieved so far? Our answer to the latter two questions is that, perhaps not surprisingly, things are very much more complicated than is claimed". Below are documented accounts of the successes of NTD programmes, which refute the suggestion that NTDs cannot be readily controlled.

Lymphatic Filariasis has been successfully controlled in China in a population of 350 million people and in the Republic of Korea (South Korea); transmission has also been arrested in several countries where it is no longer a public health problem [54]. WHO [31] has reviewed the status of 9 countries originally classified as endemic but found not to require MDA (Burundi, Cape Verde, Costa Rica, Mauritius, Rwanda, Seychelles, Solomon Islands, Suriname, and Trinidad and Tobago) as there was no evidence of transmission [31]. However, Egypt [70], Togo, Yemen, Cambodia, Vietnam, Maldives, Sri Lanka and 7 Pacific Island nations who implemented MDA early in the programme have reduced transmission and met the criteria of stopping MDA. These countries require transmission assessment surveys as recommended by WHO. WHO has reported that around 500 million treatments are being distributed each year [26] with savings of US$ 24 billion between 2000-2008 [71]. Annual treatments of ivermectin and albendazole are given in Africa where onchocerciasis is co-endemic. In the rest of the world the drugs used are diethylcarbamazine (DEC) and albendazole. Ivermectin and albendazole also have a significant impact against intestinal worms. As a result of the programme up to 2008, 66 million newborns have been prevented from becoming infected, 2.2 million protected from developing clinical disease and 28.7 million who have problems of existing infection have seen their clinical symptoms diminish and not progress to further disability. The most recent data from WHO [31] reported that by the end of 2010, 53 countries had implemented drug distribution programmes of the 72 now recognised endemic countries. Country data reported to WHO for 2010 showed that 622 million people had been targeted for MDA and 466 million had been treated giving a reported coverage of 75%. However, several countries are yet to initiate MDA in Africa.

River Blindness (onchocerciasis) has been eliminated as a public health problem and as a disease of socio-economic importance in 10 West Africa countries, the original area of the Onchocerciasis Control Programme (OCP) protecting a population of some 50 million people; the benefits of the OCP have been quantified as 600,000 cases of blindness prevented, 18 million born free of the risk of blindness, 25 million hectares of arable land reclaimed for settlement and agricultural production. This programme which started in 1974 and continued with uninterrupted donor support until 2002 has been widely recognised as one of the most successful health and development programmes ever executed both in terms of health and development gains but in terms of World Bank investment [72]. Control of blindness and skin disease via the donated drug ivermectin (Mectizan; donated by Merck & Co. Inc) is now reaching over 68 million people each year in 17 countries by the APOC supported by national governments and Non Governmental Development Organisations through over 748,000 community workers trained in 120,000 communities since 1995. In Africa there is evidence that 15-17 years annual distribution of ivermectin has eliminated transmission in Mali and Senegal [73] providing strong evidence that elimination is possible with ivermectin alone. Onchocerciasis is also endemic in 6 countries in Latin America where twice yearly distribution of ivermectin has arrested transmission in 4 foci. in Colombia, Guatemala and Mexico and interrupted transmission in a further 6 other foci [74].

Domestic transmission of Chagas disease due to Trypanosoma cruzi has been controlled in five South American countries by domestic spraying of insecticide against the vector Triatoma infestans, providing economic rates of return of around 30% on the investment in vector control. In Central America, progress has been reported through control of Rhodnius prolixus. Transmission by blood transfusion has been substantially reduced throughout Latin America. Sustaining the advances made and maintaining an effective surveillance system are necessary whilst research for new and effective drugs continues to be a high priority to treat those infected.

Leprosy has been reduced as a public health problem as a result of the use of multidrug therapy of three donated drugs- rifampicin, dapsone and clofazimine. Of the 122 countries considered endemic for leprosy, WHO states that 119 have eliminated the disease as a public health problem (defined as 1 case per/10,000). The 213,000 cases reported are confined to 17 countries reporting more than a 1000 cases/year. The figures suggest a reduction of 90% in endemic countries through case finding and multidrug therapy, which have prevented disabilities in between 1 and 2 million people. Since 1985 some 14.5 million people have been cured through multidrug therapy. The numbers of new cases per year have fallen dramatically [8,41].

Guinea Worm is moving towards eradication. The numbers of cases have been dramatically reduced from over 1 million in 1988 to 1797 in 2010 [42]; countries with ongoing indigenous transmission are Chad, Ethiopia, Mali and Sudan. There are several countries, which have not reported cases during the previous year (Burkina Faso, Cote d'Ivoire, Ghana, Kenya, Niger, Nigeria, Togo) and are considered to be in the pre-certification phase awaiting formal certification as being free of transmission. Post-certification, there is a continued need for surveillance until global eradication is declared. The Weekly Epidemiological Record (WER) of WHO provides monthly reports on data from the remaining endemic countries and those yet to be certified as free of transmission - the pre-certification countries. The latest WER reporting all the country data reported to WHO from 2010 can be found in [42].

Schistosomiasis affects some 200 million people. Intensive control in Egypt has reduced prevalence from around 20% to less than 1-2% using the drug praziquantel (now 0.32 US$/treatment) over the last two decades of both S. mansoni and S. haematobium [59]. Schistosomiasis transmission in Egypt has been largely eliminated over the last five years and control focuses on hotspots of transmission and the result has been a massive reduction in incidence of bladder cancer. China has also made considerable progress and now there are less than 1 million people reported to be infected [75]. Programmes in Africa are now reaching school age children in 17 countries in Africa and initial results show that dramatic reduction in prevalence over a period of 4 years of annual treatment.

A Trachoma programme has been established to eliminate blinding trachoma by 2020 through the SAFE strategy (S = surgery; A = antibiotics; F = facial cleanliness through washing; E = environmental control). Trachoma is endemic in 57 countries and the cost of the disease in terms of lost productivity is estimated at US$ 2.9-5.3 billion/annum. The antibiotic azithromycin (Zithromax) is donated. Three countries have reported reaching their ultimate intervention goal targets (Iran, Morocco and Oman). There is a need for further upscaling in the highest burden countries such as Ethiopia, Nigeria and Sudan. There were 37 million treatments of donated zithromax in 19 countries in 2010 [62].

Human African Sleeping Sickness. Over the period 1999-2009 the numbers of reported new cases of both Trypanosoma brucei rhodesiense and T. b. gambiense sleeping sickness has declined by 65%, the numbers of new cases reported falling from over 28,481 to 9,878. However, these figures are likely to be underestimates because of the remoteness of many endemic areas that may not be covered by regular surveillance. There is evidence that the disease is no longer present in many West African countries probably due to climate change and population pressure on habitat of the tsetse fly vector, Glossina. The problem remains focussed in Central Africa. In 2009 only 2 countries reported over 1,000 cases - DRC and Central African Republic followed by Chad (510 cases), Sudan (376) and Angola (247) - of T. b. gambiense; more extensive surveillance and the availability of treatment provided through WHO of donated drugs is the likely cause of the reduced incidence reported. There remains a need to maintain effective surveillance in historic foci and provide diagnostic tests. There has also been a reported decline in cases of acute T. rhodesiense of 58% in East and Southern Africa 1999-2009, from 619 to 190, a 70% decrease http:/ / www.who.int/ gho/ neglected_diseases/ human_african_trypanosomiasis/ en/ index.html website. The adoption of a cattle treatment and insecticide spraying of cattle as a strategy to reduce the reservoir of human infective parasites in Uganda has had a major impact on transmission of T. rhodesiense to humans [76].

Soil transmitted helminth control targets three nematode worms, which inhabit the gut; hookworm (Necator and Ancylostoma), whipworm (Trichuris) and roundworm (Ascaris) and whose global prevalence is probably greater than all the other NTDs combined. Some 882 million children are estimated by WHO [77] to need preventive chemotherapy (273 million pre school age and 609 million school age). WHO reported that 109.7 million pre-school children (proportion of total 33.7%) and 204 million school age (proportion 29.9%) were treated. The overall coverage around 30% is below the global target number treated, which was 313.7 million in 2009, an increase of over 100 million since 2008. Annual mass drug distribution of the drugs mebendazole or albendazole through deworming programmes usually by school-based delivery have a significant impact on educational achievement, increased growth and weight gain, cognitive and physical performance [32,36,37]. Deworming of pregnant women in the second and third trimester of pregnancy increased child survival at the age of 6 months by over 40% in areas of hookworm endemicity. The costs of these deworming programmes in South East Asia are of the order of 2 US cents/year [63]. The onchocerciasis and lymphatic filariasis programmes also act as deworming programmes as the drugs used have powerful effects on the worms of the gut.