Bottlenecks slow Ethiopia’s fight against malaria

Two ring-form Plasmodium vivax trophozoites inside a red blood cell Copyright: CDC / Steven Glenn, Laboratory & Consultation Division

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Ethiopia is working hard to combat malaria, report Julie Clayton and Kennedy Abwao, but delays and gaps in the system still threaten lives.

The rainy season is nearly over in Ethiopia, and in many parts the vegetation is lush and green. For the 75 million people in this country whose livelihoods depend largely on agriculture, it’s a welcome sight.

But the rains also cause a deadly threat to loom larger at this time of year. About 40,000 Ethiopians die from malaria every year, more than die from HIV and tuberculosis.

The government is determined to break the hold that malaria has on Ethiopia. But besides challenges with distribution and supply of tools, malaria in Ethiopia is highly unpredictable — the numbers of cases vary across the country at different times, often leaving the authorities unprepared.

On top of the yearly peak in malaria cases during Ethiopia’s rainy season, there are the malaria epidemics that occur every three to four years. During the last, in 2003, the usual 6 million cases shot up to 16 million, and over 100,000 people died.

Malaria incidence also varies according to differences in the terrain and climate across the country, because these affect mosquito numbers.

But there is currently no way of telling where the biggest outbreaks are likely to occur at a particular time, or when they will lead to an all-out epidemic.

Stockpiling against malaria

In September, a group of around 20 Ethiopian journalists witnessed Ethiopia’s efforts to tackle malaria, and the enormous difficulties the country is facing.

In Ethiopia’s capital Addis Ababa, they visited a warehouse operated by the international support agency UNICEF, packed with supplies awaiting distribution. These include over 500,000 insecticide-treated bednets.

The distribution programme will piggyback onto another one delivering measles vaccines and vitamin A to make use of existing transport, staffing and monitoring. This means that the insecticide-treated nets will not be distributed until November — well into peak season for malaria cases — by which time thousands of people might already have malaria.

Rory Nefdt, Malaria Project Officer for UNICEF in Ethiopia, acknowledges the frustration of delay, but defends the strategy.

"We have to do that job properly. If we don’t, then in one year’s time we wouldn’t get more funding," he says.

Insecticide-treated bed nets are now a major
intervention for malaria control
Credit: CDC

The warehouse also contains thousands of boxes of Coartem, an artemisinin-based therapy that the World Health Organization (WHO) recommends as the first-line treatment for malaria, and test kits to diagnose malaria in remote areas. The goal is to provide prompt and effective treatment to 60 per cent of the population at risk of malaria within 24 hours of the onset of fever, and so halve its malaria burden by 2010.

But there have been crucial delays in distribution, and at the time of the visit some of the Coartem packs were already halfway towards their expiry date of September 2007. After that they will have to be destroyed.

Remote communities

After visiting the warehouse, the journalists travelled to a health post in Adama, about 120 kilometres outside Addis Ababa. The post frequently deals with malaria cases. Health workers there had only a sparse supply of Coartem, and their RDTs were beyond the expiry date, making them less reliable.

According to Nefdt, it is impossible to distribute sufficient test kits and drugs to meet the needs of remote communities in advance of the malaria season, because there is no way to predict which areas will be hit hardest, particularly during an epidemic.

While the government has health posts in all rural areas, each covering around 1,000 households, it has to wait for news of a malaria outbreak to filter up through the district and regional surveillance teams before authorising the distribution of additional test kits and drugs from centralised stockpiles.

Nefdt explains: "There is no system to get drugs from the lower level to a higher level to distribute them in an outbreak. Some health posts may only have three boxes [of Coartem]."

He says that to drive around and pick up those boxes for the sake of redistributing to other places where they are now needed is just not feasible.

"The malaria surveillance system is theoretically there, but it’s not functioning properly," says Nefdt. He mentions the lack of charts for recording malaria cases, and a preoccupation with other types of healthcare delivery.

The limitations of this situation became all too apparent during the last epidemic, when the health post at Adama experienced a surge in the number of malaria cases from some 15 a week to over 100. It took about a month for the Ministry of Health to gather the necessary data from around the country before responding.

Government action

Overcoming the obstacles will be a massive task, but the government is moving on. To help meet the need for personnel, for instance, it is training 30,000 health workers, of which there is a shortage. There will be two women per health post serving 5,000 people; they will liaise with locals, educate them about the risks and treatments, perform rapid diagnostic tests and provide medication.

Rapid diagnostic tests are one way around the shortages in staff and equipment. Accurate diagnosis is critical for treatment to be cost-effective. The gold standard is using microscopes to examine blood samples and pin down which malaria parasite — Plasmodium falciparum or Plasmodium vivax — is present, if any. Treatments can then be tailored to avoid unnecessary costs.

For instance, many feverish patients will not have malaria: only two out of every ten are even likely to have it, in fact. Giving Coartem to every patient with fever — at US$2 per treatment — would be wasteful, so an accurate diagnosis is key.

Identifying which parasite people with malaria are harbouring is also vital because they are best treated with a different drug. The majority of malaria cases, and the severest, are caused by P. falciparum. This parasite is largely resistant to chloroquine — one of the oldest and cheapest malaria drugs — and so has to be treated with Coartem.

P. vivax, on the other hand — which causes about 40 per cent of malaria cases in Ethiopia — is still treatable with chloroquine, at only 50 cents per treatment.

But microscopy requires trained personnel and equipment. While UNICEF is currently attempting to boost the availability of microscopes in district-level health clinics, this will not meet the demand at smaller, more numerous, rural health posts.

Handy diagnostics

Instead, health workers at rural posts can use portable rapid diagnostic test packs (or ‘RDTs’) to positively identify P. falciparum malaria. The RDTs use a dipstick that produces a visible line if parasite proteins are present. The small packs are easy to transport and operate, and can be performed by less specialised health workers.

RDTs’ sensitivity — if stored correctly — is as good as that of microscopy. Each costs around 60 cents and so is cost-effective, allowing Coartem to be used for only the cases that require it.

Still, obstacles remain: many health posts have yet to even receive their assignment of RDTs. And the biggest issue remains surveillance. Without this, the unpredictability of malaria in Ethiopia makes it difficult to cope even with the best systems in place for diagnosis and treatment.

Last year the country had a lucky reprieve: a series of outbreaks from April 2005 onwards had the authorities poised for a full-scale epidemic, which then never materialised. They may not be so lucky next time. Time and the experience of a real epidemic will tell how quickly the authorities are able to respond.