Battling malaria in western region

One-year-old Cosmas Wambua lies unconscious on the bare hospital mattress with IV tubes draining into his weak body. He is in a critical condition following a severe attack of malaria. He is also malnourished.

His mother watches over him, barely moving from her seat, afraid of the worst, but hoping and praying for her son's recovery.

"His condition has stabilised," says Acquills Achieng, a nurse. "We did not expect him to make it when he was admitted last night."

Cosmas is lucky: one in 10 children diagnosed with severe malaria at the Nyanza Provincial hospital in Kenya's western port city of Kisumu dies, according to medical staff.

Malaria is one of the leading causes of morbidity and mortality in the area, accounting for 40 percent of all out-patient hospital attendances. Mosquitoes are plentiful in Kisumu, where the humid climate makes the area a prime breeding ground for the female anopheles mosquito, the vector for the disease.

On 8 July, Kisumu saw the launch of a week-long campaign to increase the number of children sleeping under nets treated with insecticide.

A visit to the main hospital, the Nyanza, puts malaria prevalence into perspective. More than 100 patients attend the hospital daily, with at least 40 receiving treatment for malaria, says Milton Omondi of the hospital's pediatric unit.

The pediatric unit receives 10-15 cases of severe malaria, which is often complicated by other life-threatening conditions such as anemia and malnutrition.

Among the more than one million people the disease kills annually in the world, hundreds of thousands are children under the age of five – the majority in sub-Saharan Africa.

"Parents bring in their children when they are too sick," Omondi says. "They try home-based remedies first to see if the child's condition will improve."

The treatment of choice at the hospital is Quinine - a drug that is effective 60 percent of the time. But there are no mosquito nets at the facility, exposing the children to a risk of re-infection.

"Those who can afford bed nets bring them during admission," Nurse Achieng says.

A study conducted in the mid-1990s by the Centre for Disease Control (CDC) on net efficacy in Gem and Asembo areas of Nyanza established that sustained usage of bed nets greatly reduced child mortality.

According to the CDC's Mary Hamel, there is a need to look into alternative malaria control mechanisms, including pyrethroids for spraying mosquito breeding grounds; Kenya has not approved the chemical DDT for mosquito control.

The centre is also investigating vaccinating children against malaria at 10 weeks, 14 weeks and 10 months.

Nets expensive and education lacking

For many here, however, poverty remains a major contributing factor to the prevalence of malaria since they cannot afford bed nets treated with insecticide. Lack of information about the disease is another problem.

A beneficiary of the free net campaign, Ezekiel Otakwa, says he brought his children, aged four and five, to be vaccinated a second time so they would receive free bed nets. "They had been vaccinated before but there were no free nets then," Otakwa, a resident of Nyalenda slum in Kisumu, said.

But reports indicate that at least five children died from a vaccine overdose during the campaign. Parents allegedly took their children for the measles jab up to four times so as to get free bed nets every time the vaccine was administered.

There is also widespread ignorance on the use of bed nets, with some people using them as wedding veils and curtains, and others linking the use of insecticide-treated nets to infertility.

The communities affected often lack access to proper treatment. Hospitals are few and far between and often ill-equipped. In addition, some people in Kisumu still do not take their children to hospital when they fall ill, attributing the disease to witchcraft.

Beliefs

While acknowledging that the threat of malaria is real, Mary Achieng, 30, also attributes the disease to ‘juok’ or witchcraft. "I can tell if my child has malaria or is under the spell of ‘juok’ or ‘u juok wang’ [has been looked at with the evil eye]," Achieng says. "If the condition of the child does not improve after visiting the hospital, when I can afford it, that is juok."

Despite this, she turned up to have her children vaccinated at the Kibos GK Prison Camp, 8km east of Kisumu, because there were free bed nets. "I got two nets. The boys will sleep under one and the girls will use the other," the mother of five said.

"It is criminal that children are dying of malaria in the 21st century yet there are drugs for this," says Louis da Gama, the malaria advocacy director at the Global Health Advocates. "This is a disease that is curable and preventable."

The Member of Parliament for Kisumu Rural, Anyang Nyongo, suggests proper urban planning is key to malaria control.

There is a need for proper use of urban space, which will go a long way towards reducing habitats for the breeding of vector parasites, Nyongo said during the campaign in Kisumu.

"We can only prevent malaria if we control the breeding of mosquitoes," he said.

The integrated approach to malaria control, insecticide-treated bed nets, ACTs, environmental control and community mobilisation had been successful in other affected countries, such as Zambia and Tanzania, officials say.

Global fund

So far, the Global Fund to fight Malaria, HIV/Aids and Tuberculosis remains the largest financier of malaria-related projects worldwide. The fund has made US$98 million available in two grants to Kenya, specifically for malaria control.

The money is for the purchase of insecticide-treated bed nets, doctor training and artemisinin-based combination therapies (ACT), which have proven to be 90 percent effective against malaria.

Unfortunately, ACTs cost 10 to 15 times more than chloroquine and sulfadoxine pyrimethamine (SP), formerly the most effective anti-malarials.

ACTs are also not available for the most vulnerable groups - children under the age of five and expectant women. No ACT has been approved for use in infants weighing less than 9kgs, says Mark Grabosky, the Malaria Programme Manager at the Global Fund.

Fansidar is still used to prevent malaria at pregnancy but is being phased out. The treatment notably reduces incidences of anemia and low birth weight.

Some African countries have also failed to access Global Fund grants due to "a lack of improvement in their health systems". Kenya is one of 17 countries accused of failing to move "fast enough" in malaria control.

"Even after the funds have been [drawn down] there are loop holes, accountability problems and unnecessary delays in the procurement process," says Oliver Sabot, a communications adviser to the Executive Director at the Global Fund.

Sabot is optimistic about the campaign results: "People will attend such campaigns for various reasons - if the service is free, so much the better."

However, the campaign faces the challenge of sustainability; with the Global Fund having a funding deficit of US$2.1 billion, there is no guarantee of funds for a sustainable malaria control programme.

The integrated Kisumu campaign comes against a background of the resurgence of measles, another deadly disease in Kenya. In the last eight months, 42 children have died of measles. In addition, polio has made a re-appearance for the first time in 22 years.

One of the causes of the resurgence of preventable diseases is the influx of Somali refugees, says Wilfred Machage, Kenya's Assistant Minister of Health. The country is home to at least 135,000 refugees, 65,000 asylum seekers, and 60,000 unregistered refugees.

At present, only 25 percent of Kenyan children sleep under long-lasting insecticide-treated bed nets. The campaign aims to increase this coverage to 70 percent.

About 1.7 million bed nets will be distributed in the week-long campaign in western Kenya alongside polio and measles vaccination and the provision of Vitamin A and deworming medicine. A similar number of bed nets will be distributed in the Coast province next month.

aw/mw/eo