(April 2008) The global health community is mounting an unprecedented effort against the deadly scourge of malaria. The Democratic Republic of Congo poses unique and daunting challenges to the massive efforts required for effective malaria control.

During a PRB Discuss Online, Matthew Lynch, Global Health Council, answered participants’ questions about the challenges facing the Democratic Republic of the Congo in its fight against malaria.

April 24, 2008 1 PM EST

Transcript of Questions and Answers

Frank P. Amoyaw: What are some of the possible ways to improve malaria surveillance in our region by employing appropriate and effective technologies of our times?
Matthew Lynch for Antoinette Tshefu: Hi, All, Matt Lynch here from Hopkins-Center for Communication Programs (http://www.jhuccp.org/).I’m the Director of the Global Program on Malaria. Unfortunately, Dr. Tshefu is unable to join us today, so I am filling in. In regards to your question, its a good one. There are some interesting projects using cellphone technology in other African countries to address this issue. A project in Tanzania run by the Mennonite Economic Development Associates (www.meda.org/) that is monitoring distribution of insectiside treated nets from antenatal clinics. Also, in Mali, NGOs in the field are assisting the National Malaria Control program by reporting stock outs of drugs and other distribution problems to the NMCP. So there are some interesting developments out there in this field.

Gasoni jeannette: Je m’excuse je suis francophone, je comprends l’anglais mais m’exprimer en anglais m’est un peu difficile, je pense que vous allez comprendre. Pourquoi les médicaments de taritement de la malaria ne sont pas donnés gratuitement comme on le fait pour les médicament du SIDA et de la tuberculose, alors que la malaria touche un grand nombre de personnes par rapport à ces deux autres maladies, et elle touche beaucoup plus les populations les plus pauvres qui n’ont pas de moyens pour se faire soigner, et je pense aussi que le médicament pour traiter la malaria est moins cher par rapport aux médicaments de ces deux autres maladies. C’est pourquoi beaucoup de personnes continuent à mourrir car ils n’ont pas de moyens pour se faire soigner et avant de mourrir ils contiminent d’autres. Merci de me répondre à cette question. [trans: Please excuse my asking the question in French. Why are medications for treating malaria not given free of charge, as they are for AIDS and tuberculosis treatments? Malaria affects a large number of people compared to these other illnesses, and it affects more poor people who don’t have the means to care for themselves. I also think the medications for treating malaria are less expensive than those for treating the other illnesses. That’s why a lot of people continue to die, because they don’t have the means to pay for their care, and before they die, they contaminate others. Thank you for responding to my question.]
Matthew Lynch for Antoinette Tshefu: Of course, both malaria and HIV/AIDS are serious diseases that require investment. The amount of distribution is determined by the willingness of donors to invest, and at this time there is less support for malaria than HIV/AIDS. However, that is changing as more and more donor organizations recognize the importance of malaria and commit to join the fight. There are also strategies being developed to create a global subsidy which is intended to help bring the price of drugs down.

Lorraine: Are DDT sprays still used in Kinshasa and in other urban areas in the DRC as part of the malaria prevention program?
Matthew Lynch for Antoinette Tshefu: While DDT is one of the 12 WHO approved insectisides for malaria control, due to the high cost and operational complexity, DRC does not use any kind of indoor residual spraying at this time.

Dr. John. G. Laah: How widespread is the ownership of mosquito nets in Congo? and how committed is the government to the roll-back malaria programmes?
Matthew Lynch for Antoinette Tshefu: With the right funding partners and methods, net ownership has been on the rise in the DRC. Recently mass campaigns linked to measles vaccination efforts have been an effective tool for increasing net ownership. While there are challenges in distribution in DRC, we have seen some success- for example, a Global Fund and World Bank program from 2006 successfully distributed over 3 million nets. A larger challenge, however is ensuring availabilty on a regualar basis- due to supply chain issues. Here, partnerships with the private sector are an attractive option to solve this problem.

Coll Hutchison: Is malaria treatment and prevention combined with other health issues (especially in relation to maternal & child health)? What is your opinion on RBM’s plan for Global elimination of Malaria?
Matthew Lynch for Antoinette Tshefu: Yes, strong malaria programs depend on integration with antenatal services and quality treatment services. RBM’s plan is an ambitious plan that is important and well worth doing. For the next few years, the focus must be on rapidly expanding proven control measures, such as long lasting insecticide treated nets, intermittent preventative treatment for pregnant women, prompt and effective treatments, and indoor residual spraying. The plan also importantly includes the need for educational efforts – the technical assistance that managers and health workers need to use the tools for fighting malaria effectively. In terms of funding, this support must come from donors. In the past USAID has been a leading and successful provider of these needed educational efforts.

Victoria Ibanga: Malaria is one of the biggest problems. Why are children under five susceptible? Pure water satchets, which litter our streets have been identified as “homes” where mosquitoes are bred, how can this be checked?
Matthew Lynch for Antoinette Tshefu: Litter which contains standing water is a serious public health issue- the mosquitoes that breed in these types of areas can carry dengue and encephilitis. However, the mosquitoes that carry malaria do not breed in these types of areas. Your question raises the importance of accurate and actionable information on public health threats. With the right infromation, people can protect themselves effectively from many of these public health problems. That is why it is so important to continue to dedicate resources to educational efforts in addition to funding needed medicines, nets, and other commodities.

Cori KIefer: What is the greatest difficulty facing those trying to combat malaria in Congo?
Matthew Lynch for Antoinette Tshefu: Dr Tshefu discussed this eloquently in her presentation yesterday, which you can watch here online: http://www.kaisernetwork.org/healthcast/ghc/23apr08. There are many challenges facing the DRC, including poverty, lack of infrastructure, and political instability. The biggest problem is lack of resources to implement campaigns that use proven methods to fight malaria. The DRC has very little govenrment investment in health, and the recieves very little donor money compared to other sub-saharan African nations. Dr. Tshefu told us she was confident that with investment, there could be significant progress in fighting malaria in DRC. She also specifically noted the need for more schools of public health in the DRC.

James Miller: I lived in Kinshasa 1989-1991. While there I was friends with a researcher on anopholes who I remember telling [me] that there were several – many – varieties of anopholes within the city of Kinshasa itself. My question : is this true? Are they all equal vectors of plasmodium? Does the special variation of anopholes affect the nature of the illness?
Matthew Lynch for Antoinette Tshefu: Anopholes is a genus of mosquito with various species. Some species are more effective at spreading the disease than others.

Willy Kabuya: To which extent the ACT treatment is currently implemented in DRC. What have been the trends in the malaria burden with this treatment ? What are the next steps ?
Matthew Lynch for Antoinette Tshefu: Availabilty of ACTs in DRC is still a major problem. Most countries in subsaharan Africa have adopted the policy of using ACTS, but availabilty remains a problem. In the DRC, the short shelf life of ACTS is a particular problem because of the weak distribution systems and supply chain issues.

Otula Owuor: What is the incidence of malaria in Congo? Which regions are hardest hit? Are ITNs easily available? Who suppLies the nets? Are drugs like ACT available and who are the suppliers? Do you have problems with counterfeits? Which is the leading medical research institte on malaria in Congo? Have conflicts intered with the war against malaria?Thanks Otula Owuor ootulah@yahoo.com
Matthew Lynch for Antoinette Tshefu: There are approximately 60 million people in the DRC, and 100% of them are at risk to develop malaria. Because the transmission season is year round in the majority of the country, prevalence is high. ITNs are generally not easily avaialble in the DRC except during large scale campaigns. Nets are supplied by a variety of sources including NGOs donors via mass campaigns and in the private sector, as they are sold in shops. The Kinshasa School School of Public Health is the only public health school in the DRC. Conflicts have contributed to the challenges in fighting malaria- with people displaced they are more vulnerable to developing malaria, the supply chain is disrupted. Generally, the risk increases at the same time availabilty of treatment decreases.

Armand L. Utshudi: (1)In addition to Global Fund, Who else is providing support to the DRCongo malaria control program?(2)What is the DRCongo doing to be included in the Presidential Malarial control Initiative (PMI)? This is important because the DRCongo is a very large country that requires a lot of financial resources and drugs to provide population adequate coverage for malaria control activities.
Matthew Lynch for Antoinette Tshefu: USAID, the World Bank are two other supporters of the malaria program in the DRC. Currently, while the DRC is not included as a PMI country, what Dr. Tshefu requested in her presentation yesterday was greater resources in the non-PMI USAID budget devoted to DRC.

Sarah R. Kaslow: What are some of the success stories and horror stories of malaria control programs? How effective has DDT been at eliminating the vector?
Matthew Lynch for Antoinette Tshefu: Successes have largely occurred to date in countries with relatively well developed infrastracture, such as Italy, Thailand, and South Korea. Effective malaria control depends on identifying and implementing the correct mix of interventions for each individual setting. For example in the DRC, indoor residual spraying is most likely to be used effectively in the eastern mountainous region, whereas insecticide treated nets are more easily distributed in isolated rural communities. DDT, and other insecticides, work best in more densely populated areas where houses are close together and many can be sprayed in one day.

Armand L. Utshudi: (1)What is the current official strategy for malaria control in the DRCongo? (2)What are the country’s guidelines for treatment of uncompolicated malaria at health center level? (3)Does the current malaria control strategy include vector control? If so what is being recommended for the community at large?
Matthew Lynch for Antoinette Tshefu: The National Malaria Control Program of DRC, developed in consultation with WHO and RBM, which call for the use of artemisinin and amodiaquine at that level. The current strategy does include vector control—insecticide treated nets are being recommended, and indoor residual spraying is being considered for the eastern highlands.

Olusola Orimogunje: How are Government in the developing and underdeveloped nations effectively spending the fund designated to combat malaria and is there any improvement in the status, can it be eradicated at all? when and how?should its victims keep on using the drugs mostly believed to have a better cure with its adverse reactions such as ‘quines’?
Matthew Lynch for Antoinette Tshefu: More attention is being given to the effective use of funds for malaria control. Increasingly, the use of the coordinated National Malaria Control Program in each country has improved the process for implementing effective and coordinated efforts. In addition, the NMCPs have strengthened their capacity for financial management. This is reflected in the number of grants issued by the Global Fund for malaria- all Global Fund grants take into account performance for continued funding, and last year we saw the highest ever number of Global Fund grants for malaria.