Kenya Must Change Tack to Tackle Malaria

Did anyone reading this blog attend the Pan African Mosquito Control Association conference in Nairobi, held on October 3rd? Kenya Must Change Tack to Tackle Malaria People are at last talking publicly about the limitations of bed nets.

Left to right: Nick Athembo, Ben Abong'o, Leah Dodge, Jeanne Gazel, Rob McCann, Mona Nizad, and Sam Corden.

Here is a discussion on the Malaria World web site about the relative merits of home screening:

Why screening

--Cliff

A few weeks after the house screening trial, I did a brief visit to see the condition of the screened houses. I was very exited to find the screen in very good shape as though with a promise to stay forever. Apart from this, the testimonies from the residents got me more enthusiastic to get the actual work started. I can't just wait to see this rolled out. The residents have actually  note a remarkable reduction in mosquito densities in their houses after screening. 

Now, having been in a position to collect mosquitoes from houses over time for other studies, such a report from the residents of the screened houses is an exiting one. I have witnessed many cases when I go to a village and explain to the residents my intention of collecting mosquitoes from their houses for certain studies. The fist impression I usually receive from some individuals is one of a surprise. Such individuals are first unsure if there are mosquitoes in their houses, leave a lone the greater surprise question they always ask of 'how are you going to catch them?' You can't imagine the kind of surprise that usually strike these residents after I catch mosquitoes in their houses and show to them how many of those little creatures they share with habitation. However, the surprise is more often mingled with joy and a sigh of relief  as though to say, 'the enemy is taken away forever.' You only wish that no more mosquitoes would enter those houses again. But never! Therefore, such a knowledge the presence and much more of a remarkable reduction in mosquito numbers following implementation of an intervention is quite something. 

Apart from all these, some thing else almost made me jump with joy. It was the sight of an Anopheles mosquito resting on the eave screen from outside the house. Clearly that vector had been restrained on its route into the house for a blood meal. This what we all look forward to, that we may reduce if possible to zero all chances of human vector interaction especially in the house which is the principal point of this interaction. I see and hear already tokens of great achievements in malaria control with installation of eave screen. 

Lets go for it, support this idea and do all in our powers get this work done. I am convinced, improved housing will take us beyond where the bed-nets have brought us in malaria control, given the challenges of  lack daily compliance to bed net use, universal coverage and the dreaded insecticide resistance Anopheles mosquitoes.

Ben

Mona drilling.

This is the first of a series of photos. The actual project has not yet begun, however, with a few volunteers, a group practiced applying screens to eaves on several homes.

So finally the house screening project is almost starting, most probably this week. The interns from Michigan State university are here to help with the house screening project. Words cannot express how truly blessed and happy i am to finally start this project. Last week the team went to identify the houses that we will be screening. It was incredible how welcoming and hospitable the community is. Women were very enthusiastic about the whole idea and we look forward to working with this community.

Now that the project is almost underway i will definitely keep everyone on the loop.

Blessings,

Mona

I wrote to Marc Maxson at Global Giving after reading an interview with him. Marc and others at Global Giving have built an enormous database of stories. These stories tell about episodes when people have tried to bring about change, such as controlling malaria. If one types in "malaria" as a search term, 475 stories appear. Many of them take place in Kenya and several in, or around, Kisumu.

Here is one such story:

"Malaria Kills
"Malaria is a killer disease in many tropical countries including Kenya. Over the past few years, the Kenyan government has provided its citizens with free mosquito nets in order to reduce the prevelance rate of malaria in the country. Like in Kisumu, the killer disease has reduced due to the campaign to create public awareness besides the use of the nets. This has helped reduced deaths unlike in the past."

Full Malaria Kills story

Note that the "story took place more than 2 years ago." That may mean more than two years before the story was recorded.

I am still sifting through the stories to see what I can learn. By downloading the data file, I can find out what organizations were involved with the interventions. Marc believes that by accumulating many stories, hundreds or even thousands of stories, it is possible to see patterns that speak to what is helpful, or at least what is regarded as helpful.

Malaria Stories

Solving a Malaria Mystery

Follow the link below or read on  this page to catch the real story about Malaria situation in western Kenya.

http://www.cdc.gov/globalhealth/countries/kenya/blog/malaria.htm

Solving a Malaria Mystery
CDC IN KENYA BLOG
April 25, 2012 5:00 pm ET - U.S. CDC-Kenya Office

(left) Dr Simon Kariuki, (right) Dr Meghna Desai
In late 2007, researchers at the KEMRI/CDC Field Research Station in Nyanza province in the western part of Kenya noticed a worrisome change in the rate of malaria infections. Malaria in this region had been declining since the 1980’s but was now rising again for reasons that were not clear.
To look at why this was happening we start thirty-two years ago, at the beginning of collaboration between CDC and the Kenya Medical Research Institute (KEMRI), when a research facility was built in Nyanza province to focus primarily on malaria research. Located on the coast of Lake Victoria, Nyanza province was, and still is, the hottest area in Kenya for malaria infections. And eventually the Health and Demographic Surveillance System (HDSS) was created which precisely monitors the health and socio-economic well-being of 225,000 people in this area every 4 months.
In the mid 2000’s survey data began to show a decline in malaria parasite prevalence. It seemed three interventions coincided to facilitate this decline. First was the implementation of insecticide treated bed nets in a landmark bed net study among pregnant women and children, reaching 90% coverage at one point, then there was the adoption of Intermittent Presumptive Treatment in pregnancy and lastly a policy change to use a more effective malaria medication. Over time, the effects of these three interventions have been dramatic. Malaria in under 5 year olds living in the communities as measured in the HDSS went from 80% in the 1980’s to 28% by 2008.
Then, in 2009, the community prevalence in under 5 year olds increased to 39% and has remained there to this day. “We were not sure what was happening and began a systematic evaluation of our data,” said Dr Meghna Desai, Deputy Director for Science and CDC Senior Technical Advisor to the Malaria Branch. “We wanted to know, for example, was there a change in bed net usage in the community or were there medicine stock outs in the clinics and hospitals. It turns out that, yes, there were sporadic stock outs and suboptimal usage of ITNs especially among school-aged children who seem to bear the highest prevalence of malaria infections in recent surveys.” But these things alone do not explain the sustained high levels of malaria infections.
Dr. Simon Kariuki, Chief of the KEMRI/CDC Malaria Branch said, “We also looked at what was happening in the mosquito population and found the type of mosquitoes carrying malaria parasites had changed since the 1980’s.” Originally, the A. funestus and gambiae mosquitoes were the dominant carriers but were almost completely wiped out by the high coverage of insecticide treated bed nets. Very quickly though they were replaced by the A. arabiensis mosquito as the primary carrier. Are the original malaria vector species making a comeback? “It turns out there is actually an increase in the A. funestus mosquito population, but it is still unclear right now if this is a contributing factor.” said Dr Kariuki.
With these new clues on hand scientists from KEMRI/CDC organized a meeting with representatives from CDC in Atlanta, the Kenyan Ministry of Health, the Presidents Malaria Initiative, and others. Many attending scientists had personal history with the field research station over the years. What emerged was a sense that there might be a ceiling on the effectiveness of currently accepted interventions and to push prevalence down further a new generation of interventions would be needed.
So a proposal created by KEMRI and CDC outlining a large-scale study took shape to look at some of these new possibilities. One intervention showing promise is Indoor Residual Spraying (IRS). A recent KEMRI/CDC study appears to be highly effective but is expensive and logistically difficult to implement at a wide-scale. And there is new thinking about transmission too. Thirty percent of the population in the HDSS may have malaria parasites in their blood but show no symptoms. These asymptomatic people are hard to locate yet are still able to transmit parasites to a biting mosquito.
Dr Desai said, “One of the ideas outlined in our study proposal is to test and treat everyone in the community for malaria 2-3 times in a year, this way we’d find and treat those asymptomatic people. We’d also be able to uncover transmission hotspots, if they exist.” Hotspots are pockets of high infection rates in a community. Hotspots have been identified in areas with lower malaria prevalence, like the highlands of western Kenya, but it is not known if they exist in areas with high and continuous malaria transmission in the lowlands. “If we found hotspots in the HDSS we think this might be the most cost effective and impactful place to implement Indoor Residual Spraying.” Dr Kariuki said.
Support for this new malaria study is building, as everyone is aware that Nyanza’s stubborn malaria problem is not unique. All over Africa there are pockets where malaria prevalence remains high in spite of interventions. Dr Kariuki said “In Nyanza, the current interventions have been able to push prevalence down to 40% overall. We think a new intervention, possibly ideas outlined in our proposed study, could have the impact ITNs had in the late 1990s and early 2000s. If they are proven effective adding them to current practices could dramatically reduce prevalence. And, maybe by then a vaccine will be available to extinguish what remains.”

The long rainy season is coming to an end in many places of western Kenya. This means the rains are reducing in intensity while the mosquito numbers are rising dramatically. The point is this, the rains leave behind many pools of water which are perfect mosquito breeding habitats and because there isn't much rain on daily basis, the mosquito eggs laid in the pools have opportunity to hutch into larvae which successfully develop into adult mosquitoes with little interference on the habitats as surface run off is reduced. Besides, the high temperatures around L. Victoria make it all conducive for these developments.

This explains the kind of trouble I have every night in my small house in Kisian village, western Kenya. I am always compelled to cloth every part of my body from toe to head to be a little safe from mosquitoes before I go under the protection of my bed net. However, the blood thirsty insects at times even bite through the clothing, serious!

In my house, I use bed net every night through out the year. But still, for the past four years I have had malaria attacks at least once every year. It is almost indisputable that much of mosquito feedings leading malaria transmission occur just before bed time for those who diligently use their bed nets. The situation gets worse in cases where people don't use the bed nets.


This have been my observation in a field situation in western Kenya. I do a lot of mosquito collection from people's houses in the early mornings. It is however very interesting the level of variability in the indoor mosquito densities among houses in the same locality. I have seen cases where two houses which are three meters a part, in one you get no vectors at all while in the other, you realize up to twenty vectors at a time. The houses being similar in structural design, the difference only comes in presence or absence of insecticide treated net (ITN). Mosquitoes somehow identify houses without ITNs and such they visit and have successful blood meals. This is very possible and has been established.

One would wonder why anybody would sleep without a bed net at such a time, unless there is none. The tragedy is that many people have bed nets in western Kenya but never use them. The greatest among such are young people who are school going. If you would ask why so, the answers give include silence, that is no reason at all, others complain of nets making the house hot and yet others talk of the difficulty of spreading the net every night.

Such impose serious draw back in the use of ITNs for protection for malaria control. It is time to begin thinking of other control strategies, may be integrated vector management?

I had an interesting chat with Leigh Tally yesterday. Leigh is a Peace Corp volunteer working on malaria issues from Kisumu. I asked Leigh how progress in the region around Kisumu (Nyanza Province) compares with other places. She said substantial reduction of malaria has been reported along the coast, but it seems there is less dramatic reduction in Nyanza. That struck me as a contrast with the general picture of substantial reductions in malaria cases across Africa, as declared by the World Health Organization's 2011 annual report.

Leigh and I agreed that good data is hard to obtain. She explained that while guidelines call for diagnostic testing before treating for malaria, in practice, many cases of fevers are assumed to be malaria and treated without ideal testing.

It is amazingly sad to see how many people are either affected or die
of malaria in western Kenya. I am a young Kenyan woman living in
Kisumu, Kenya.  Kisumu is a small urban town located next to an
impressive fresh water lake, Lake Victoria, which comes both as a huge
blessing and a curse to the people of this region. It is a blessing in
the sense that its a source of livelihood  and employment to my people and
it is a curse in that it is is home to many mosquitoes, hence the high
rate of malaria cases in in this region. Kisumu is situated in a hot
and wet environ that is an ideal home to numerous mosquitoes.

It is quiet evident that many of the cases in the local hospitals are cases of
malaria. You go to a hospital and the cries of small children awakens
all the emotions in you. You immediately want to help them, but how?
My heart aches with pain when I walk into a general hospital. By
"general hospital" I mean a health facility that poor people can
access. Hence, it is packed; all these people want attention
from our overtaxed health workers. So there are long queues and long
days of waiting in understaffed general hospitals.

My heart goes out to those living below the poverty line, who have to
wait in this long queue, waiting for treatment to something that can
be reduced, if not completely prevented.

For the longest time I have been wanting to do something about it. I
look forward to the month of July when I, together with people who
have the same vision, will begin our work. We hope to reduce the
number of malaria cases in an area west of Kisumu. Thanks to G.Y.E.C
(the organization that I work for), Cliff, Ned, and several other
people for making this possible.

--Mona

Here is one family's story about their encounter with malaria, recently posted on ONE.org's blog:

True Story

I currently have malaria. It's very ironic because I will be working on a malaria project in a few months. I  think there's a reason behind my falling sick now. I think it's to remind me how important and necessary the malaria project will be in community.

Mona Nizad