Insecticide treated nets, a fishy subject

January 25th, 2015

Not long ago I had written a blog posting suggesting that widespread misuse of ITNs/LLINs was probably not a major problem. To date the main official published information on the topic came from a community near Lake Victoria that had received an DSCN0189abundance of nets through uncoordinated donor activity and the excess was being used to dry fish on the shore.

True, newspaper articles over the years have featured Ministry of Health officials in numerous countries berating their citizens not to use nets for fishing, agriculture and other non-disease control needs, but evidence had not been forthcoming in the numerous national demographic, health and malaria surveys over the years. There is also the acknowledged possibility that old nets are being repurposed since there are inadequate disposal mechanisms available.

Such concerns are not idle. We also documented misuse of LLINs in Akwa Ibom State with photographs LLINs for goal post 3of nets used to make football goals, protect seedlings in a nursery, cover small kiosks selling food items and penning animals. This occurred in areas where there was inadequate partnership, planning and follow-up with the community by health officials.

Now the New York Times has stirred up the controversy again with strong visual evidence of a fishing communities in Zambia and Tanzania using ITNs for not only fishing, but also making chicken pens, ropes, footballs and football goals. People in that community explain their economic needs which are huge in this poor area of the world, and present the hard choice between augmenting their livelihoods and sleeping under an ITN. The environmental impact of the insecticides when nets are misused was also highlighted. The immediate thought is that malaria control efforts must be integrated into health and development efforts in a country.

The US President’s Malaria Initiative has issued a statement of concern. PMI recognizes that misuse of nets can depend on the particular environment (e.g. near water), but also recognizes the need, as mentioned above, of collaborating with the community to get things right in the first place. These problems will persist until national malaria control programs focus less on the total numbers of nets distributed and more on the actual factors that influence net use.

Malaria Care: Can We Achieve Universal Coverage?

December 13th, 2014

uhc-day-badgeIn New York on 12 December 2014, a new global coalition of more than 500 leading health and development organizations worldwide was launched to advocate for universal coverage (UC) and urged “governments to accelerate reforms that ensure everyone, everywhere, can access quality health services without being forced into poverty.” This marked Universal Health Coverage Day which fell on the “two-year anniversary of a United Nations resolution … which endorsed universal health coverage as a pillar of sustainable development and global security.”

According to WHO delivery of UC involves four components:

  1. A strong, efficient, well-run health system
  2. Affordable care
  3. Accessible care
  4. A health workforce with sufficient capacity to meet patient needs

To this list we might add a functioning and timely procurement and supply management system, and not trust people to read between the lines on component #1 to consider this need.

DSCN2885aWhile much attention in malaria control is appropriately on prevention through various vector control measures, we cannot forget the importance of prompt and appropriate case management, especially as cases decline (according to the new 2014 World Malaria Report) and case detection assumes greater importance.

In 2000 Roll Back Malaria sponsored the Abuja Summit where targets were set for malaria intervention coverage. The goals were established at 80% for insecticide-treated nets (ITNs), intermittent preventive treatment and prompt and appropriate malaria treatment. In 2009, the United Nations declared a goal of universal coverage for ITNs. The potential for UC in malaria case management remained vague, but the new international push for US can certainly include malaria. It would not be coming too late because as we can see from the chart, many endemic countries are far from adequate malaria treatment coverage, let alone UC.

Slide1Frequent surveys help us track progress toward RBM goals and UC – Demographic and Health Survey, Malaria Information Survey, Multi Indicator Cluster Survey. Their helpfulness depends on the questions asked. The 2013 MIS from Rwanda gets closest to finding out what is really happening (Chart 2). We might infer a sequence of events that while not everyone seeks care for their febrile child, those who do are screened by the health worker (including volunteer community health workers); those suspected of malaria are tested (microscopy in clinics, RDTs in communities); and only those found positive are given ACTs.

Slide2Equity is a major concern for advocates of UC. Health insurance is one method to address this. In Ghana around 60% of people have taken part in the National Health Insurance Scheme, but only around 5% in Nigeria where 60% of health expenditure comes from out-of-pocket purchases. Rwanda has a system of mutuelles – community insurance schemes. Insurance does not meet the full need for malaria case management, and thus efforts to expand outlets for affordable quality malaria medicines through the Affordable Medicines Facility malaria (AMFm) was piloted in several countries.

A combination of approaches is needed to achieve UC in malaria case management. Public and private sources are requires. Low cost, subsidized and free care must to be part of the mix. Over half a million people, mostly children, are still dying from malaria annually. Solving the UC challenge for malaria is crucial.

Update on Malaria and HIV/AIDS

December 2nd, 2014

63719_10152358606695936_7047535049294543967_nWorld AIDS Day is a time to reflect on the broader impact of HIV and its interactions with other infectious and chronic conditions that must be managed through an integrated health system. The past few months have yielded a variety of published studies on the HIV-Malaria link ranging from pharmacological, and physiological to health systems issues. A brief summary follows.

Having HIV does have consequences on malaria infection. Serghides et al. studied malaria-specific immune responses are altered in HIV/malaria co-infected individuals. Fortunately these researchers learned about “the importance of HIV treatment and immune re-constitution in the context of co-infection.”

Malaria, HIV and Pregnancy

Pregnant women are an important group in the population to protect from both HIV and malaria. The link between the diseases may not be one of influencing each other but in the fact that they both appear in the same population with similar negative consequences. Women are at increased risk of anemia in pregnancy due to malaria and/or HIV infection according to Ononge and co-workers. Normally a pregnant woman in a malaria endemic area passes on malaria antibodies to their newborns.

Moro et al. learned that, “Placental transfer of antimalarial antibodies is reduced in pregnant women with malaria and HIV infection.” Chihana and colleagues studied HIV status in Malawian pregnant women and follow-up their children. They reported that, “Maternal HIV status had little effect on neonatal mortality but was associated with much higher mortality in the post-neonatal period and among older children.”

Drug Interactions and Issues

Hoglund and colleagues studied interactions between common antimalarial and HIV medications. They found that, “There are substantial drug interactions between artemether-lumefantrine and efavirenz, nevirapine and ritonavir/lopinavir. Given the readily saturable absorption of lumefantrine, the dose adjustments predicted to be necessary will need to be evaluated prospectively in malaria-HIV coinfected patients.”

DSCN4994 AngolaDrugs taken during pregnancy to prevent malaria are influenced by HIV status. It is known that Intermittent Preventive Treatment with sulfadoxine-pyrimethamine should not be administered to HIV-positive pregnant women taking cotrimoxazole prophylaxis. González et al. wanted to learn whether mefloquine (MQ) could be used by HIV+ pregnant women. Unfortunately they learned that, “MQ was not well tolerated, limiting its potential for IPTp … (and) … MQ was associated with an increased risk of mother to child transmission of HIV.”

Health Systems Issues

Haji and co-investigators reported that malaria care seeking was delayed in Ethiopia because “Children whose guardians believed that covert testing for HIV was routine clinical practice presented later for investigation of suspected malaria.”

The need to adjust clinical guidance and practice as prevalence of malaria changes was addressed by Mahende et al. in Tanzania. They observed that, “Although the burden of malaria in many parts of Tanzania has declined, the proportion of children with fever has not changed.” More accurate diagnosis is needed as demonstrated by the various causes of febrile illness they found including in addition to malaria, respiratory illnesses, blood infections, urine infections, gastrointestinal illness and even HIV.

Finally Mbeye and colleagues report that cotrimoxazole prophylactic treatment reduces incidence of malaria and mortality in children in sub-Saharan Africa and appears to be beneficial for HIV-infected and HIV-exposed as well as HIV-uninfected children. This lesson from HIV programming can have broader implications for malaria control strategies.

Integrated control of infectious diseases is essential for population health, especially at the primary care level. Hopefully research as shown above can assist in planning better services for people living in areas that are endemic to both malaria and HIV.

Malaria Diagnostic Service Availability – Mapping of Nigerian Private Sector Service Delivery Outlets

November 30th, 2014

maps logoThis study was undertaken in seven US President’s Malaria Initiative supported Nigerian States through the Malaria Action Program for States (MAPS) project. Authors include Abiodun Ojo, Bolatito Aiyenigba, Sonny Johnbull, Adamu Onu, Olabanji Ipadeola, Muhammad Salihu, Kolawole Maxwell, Ebenezer Baba, and Abba Umar. Their presentation appeared at the recent annual meeting of the American Society of Tropical Medicine and Hygiene.

The private sector’s role in health services in Nigeria has increased in recent times, and provides approximately 60% of health services. The PMI Malaria Action Program for States (MAPS) project currently supports the implementation of parasitological confirmation of malaria cases in public health facilities only in selected states. A mapping exercise was carried out to identify private facilities providing malaria diagnostic services and determine the gaps in existing malaria diagnostic capacity with the aim of designing a strategy for improvement

Questionnaires were administered to the private health facility owners and location data collected using handheld Global Positioning System (GPS) device. Data were collected from all private health facilities in the state capital of each MAPS supported states (Benue, Cross River, Ebonyi, Kogi, Nasarawa, Oyo and Zamfara) in October 2013.

Private sector staff distributionThe questionnaire was designed to assess human resource capacity, method of malaria diagnosis and patient/client workload in the health facility. Data collectors and supervisors were trained on tools and methodology of the survey.

Results revealed that 394 private health facilities in 7 state capitals were mapped. Only 24.6% health workers had received training on malaria diagnosis in the last 12 months preceding the survey, while 35% had no formal or on-the?job training.

Private sector malaria servicesSeventy-one health facilities had no routinely available malaria diagnostic services; 55 (77.5%) of these, referred patients to other health facilities where there is availability of malaria diagnosis, 6 (8.5%) prepared microscopy slides and sent to other laboratories for malaria examination, and 10 (14.1%) took no diagnostic action.

Using outpatient and laboratory statistics for the 3 months preceding the survey we found that the overall prevalence of clinically diagnosed malaria in the outpatient clinics was 70.3%. The malaria slide positivity rate was 78.8%. An antimalarial drug was prescribed on average 1.2 times out of every 10 negative malaria test results.

A good pool of human resources exist in private health facilities and their capacity needs to be built on malaria diagnosis especially mRDT for non laboratory staff. Quality of malaria microscopy could be improved with re?training of Laboratory Scientists.

A policy framework that provides for access to quality malaria diagnostic services and commodities while also creating an enabling environment for use of diagnostic results is needed to support the massive scale up of campaigns for malaria control towards elimination

[The contents of the poster/presentation are the responsibility of the Malaria Action Program for States Nigeria and do not necessarily reflect the views of the US Government.]

Is Mosquito Net Mis-Use Exaggerated

November 28th, 2014

Health Officials commonly berate community members for misusing insecticide treated nets (ITNs) given out during malaria prevention campaigns and programs. Villagers are blamed for doing everything from using nets to catch or dry fish, protect crops or poultry, make football goals and cover their market goods.

For example, The Nairobi Star of 12 March 2012 reported that health officials in Nyanza, Kenya were disturbed that people were using their ITNs to protect their gardens from pests and their kitchens from rodents. The officials threatened to prosecute anyone misusing their nets.

LLINs for goal post 3Likewise the Lusaka Times published a story on 10 July 2011 that ITNs were being misused to made wedding dresses/veils and for fishing. “North-Western Province Minister Daniel Kalenga has directed District Commissioners in the province to report any misuse of Insecticide Treated mosquito Nets (ITNs) to the police as it is an offense under the public health Act.” A similar story appeared in April 2014.

There is some theoretical logic to net misuse. Keita Honjo and colleagues concluded from a modeling exercise that, “ITN use for malaria protection can be thwarted in settings of extreme poverty, where an increase in labour productivity by an alternative ITN use can offset the perceived benefits of avoiding malaria infection.”

One has often suspected these challenges to net use border on myth at times. Eisele and colleagues leveled the following critique against the media: “There are a number of potentially damaging misconceptions about insecticide-treated mosquito nets (ITNs) in Africa that have been propagated in media
reports, almost all of which are based on anecdotal accounts.”

Therefore, we were quite interested to learn of a newly published study that analyzed ITN use with “Data from 14 sub-national post-campaign surveys conducted in Ghana, Senegal, Nigeria (10 states), and Uganda between 2009 and 2012 (that) were pooled,” to find out what happens to “lost” nets.

Nets Lost to Household KoenkerWhile 16% of 25,447 nets were no longer serving their original purpose, only 6.2% of those were being used for another purpose. Importantly, over 3/4 of those had been damaged prior to re-purposing. The fact that the major reason why nets left the household was because they were given to other users (e.g. relatives) implied that better assessment of community need for nets was required.

In fact re-purposing of old nets may be a natural response to failure of health agencies to devise an environmentally safe way of disposing of ITNs that have passed their natural lifetimes. Therefore WHO recommends that National malaria control and elimination programs should work with national environment authorities work together to ensure proper removal of old nets no longer in use to prevent malaria.

This reassuring article certainly takes precedence over newspaper reports of misuse, but we should still be on the look out for net use problems. A classic example appeared in Malaria Journal in 2008 documenting with data and photos the use of ITNs to dry fish along the shores of Lake Victoria. In that case the root cause of the problem was lack of coordination among agencies such that the villages were supplied more nets than they needed. This appears to have been a one-of-a-kind study.

What is more likely to happen, it seems is that households acquire their nets but for various reasons do not always hang them, as was the case with nearly 30% of recipients in a small study in Rivers State, Nigeria. Malaria control programs need to pay more attention to helping people actually hang and use their nets correctly and regularly than simply being satisfied with reporting the numbers distributed.

Understanding Child Illness and Malaria Care Seeking in Bauchi State Nigeria

November 19th, 2014

Bright Orji, Masduk Abdulkarim, William Sambisa, Amos Paul Bassi, Solomon Thliza, and William Brieger shares a poster at the 2014 American Public Health Association Annual Meeting that focuses on a baseline study for child illness interventions under the USAID Targeted States High Impact Project (TSHIP). The authors work with John Snow International and Jhpiego. The poster abstract follows:

Bright at APHA IMG_6630Seeking of appropriate and quality care for childhood illnesses is a major challenge in much of Africa including Bauchi State, Nigeria. In advance of an intervention to improve available care in the most common points of service (POS), government primary health care centers (PHCs) and patent medicine vendors (PMV), a survey was done of child caregivers in four districts concerning responses to febrile illness, suspected malaria, acute respiratory disease and diarrhea.

The ethical review committee in the Bauchi State Ministry of Health approved of the study. A total of 3077 children below the age of five were identified in the households sampled.

treatmentTheir mothers, fathers or other caregivers consented and were interviewed. Among the children 74% had any Illness, 57% had fever, 26% had cough, and 15% had diarrhoea. Only 8.7% of 1186 febrile children had their blood tested. Care seeking from PMVs varied from 45% with fever, 40% with cough to 36% with diarrhoea.

DSCN2924 wideCare from public sector POS varied from 26-33%. Treatment that might be considered ‘appropriate’ for each also varied with 30% receiving antimalarial drugs for suspected malaria, 20% getting oral rehydration solution for diarrhoea and 50% being given an antibiotic for a suspected acute respiratory illness.

The results show that providing quality case management with appropriate commodities through PHCs and PMVs can improve the illness care of a majority of children in Bauchi State, and interventions are currently being planned to do this.

Severe malaria case management practices in selected states in Nigeria: Need for urgent intervention

November 7th, 2014

At the recently concluded American Society of Tropical Medicine and Hygiene 2014 Annual Meeting, USAID’s MAPS Project presented a poster on severe malaria in Nigeria. The authors, Yetunde Oke, Banji Ipadeola, Bolatito Aiyenigba, Grace Nwankwo, Justice Adaji, Olatunde Olotu, Aniefiok Akpasa, and Abba Umar, share their findings below.

maps logoSevere malaria is a life threatening medical condition that requires emergency interventions including prompt and effective treatment to prevent death (WHO 2000). The AQUAMAT* study showed a relative reduction in mortality of 22.5% with use of parenteral artesunate compared to quinine in the management of severe P. falciparum malaria and the Nigeria national policy on malaria diagnosis and treatment has been revised based on this evidence.

However, implementation of this guideline is still a challenge. The goal of this study was to determine baseline capacity and management practices for severe malaria in selected secondary health facilities in Nigeria with the aim of designing interventions to address specific gaps identified.

A cross?sectional study was conducted to assess twenty?four secondary public health facilities in three states (Benue, Kogi and Oyo States) in Nigeria in August 2013. Data on the capacity of health care providers; malaria services provided at different service delivery points (three months preceding the survey).

Medical supplies were collected using modified WHO severe malaria assessment tools. Data  entry was done  using the SPSS software programme and analysis done with STATA version 10.0.

Prev Severe MalTotal number of confirmed malaria cases reported in the three states over the three months preceding the assessment was 18, 695 and diagnosis of severe malaria was made in 8.6% of the total malaria cases. Out of the severe malaria cases, 75.9% were discharged, 3.8% referred and 1.5% died.

Fifty per cent of the health care providers had attended training on malaria case management 12 months preceding the survey. The majority of providers managed severe malaria with injectable artemether (45.8%), quinine (37.5%) compared with artesunate (29.2%).

Routine antimalarialsMost of the health facilities (95.8%) practiced parasite-based diagnosis of malaria but only (29.2%) monitored the parasite clearance of patients with severe malaria. 70% of the facilities did not have basic supplies for ancillary management of severe malaria. 66.7% and 30% of the health facilities experienced stock?out of parenteral artesunate and parenteral  quinine respectively  in the previous three months.

Health system strengthening with emphasis on capacity building of health care providers, medical commodity security and improvement in supportive/ancillary management of severe malaria is needed to reduce the mortality attributable to severe malaria.

Health Systems Strengthening: Achieving Lasting Results for IPTp

November 7th, 2014

call to action IPTAt the Call to Action for Intermittent Preventive Treatment of Malaria in Pregnancy (IPTp) during the just concluded American Society of Tropical Medicine and Hygiene Annual Meeting, Elaine Roman of Jhpiego/MCSP advocated for strengthened health systems as a basic approach to enhancing IPTp coverage. Below is a summary of her remarks.

Why should we strengthen the Health System? Addressing the health system at all levels leads to improved outcomes and comprehensive coverage. Increasing IPTp uptake requires strengthening antenatal care (ANC) and other components of the health system.

ANC within a strong health system provides an opportunity to improve the health of pregnant women and their newborns. Malaria in pregnancy (MIP) is a maternal and newborn health issue. When health systems are weak, there is greater likelihood of negative consequences on mother and newborn.

Elaine Picture1Improving Health Systems for enhanced IPTp addresses the following health systems components:

  1. Integration: Reproductive Health Programs and National Malaria Control Programs
  2. Policies and Guidelines: Consistency across national documents
  3. Capacity Development: Bother In-Service Training and Pre-Service Education
  4. Quality Assurance: Linked directly with support supervision
  5. Community Engagement: Promotion of early ANC and Promotion of IPTp uptake
  6. Commodities: Ensuring availability at ANC of sulfadoxine-pyrimethamine (SP) and supplies, as well as long-lasting insecticide-treated bed nets
  7. Monitoring and Evaluation: Facility-level data collection and Data for decision- making
  8. Finance: Sustained and comprehensive services

Elaine Picture2Systems strengthening works. Strengthened Health Systems for IPTp in Kenya resulted from community engagement, training, supervision: leading to IPTp1 coverage of 91.6% and IPTp2 (or more doses) coverage at 61.1%.

In Ghana, Capacity development, commodities, community engagement improvements resulted in IPTp2 (or more doses) coverage of 44% to 65%

In Zambia development of clear policy, integrated training, supervision led to IPTp2 (or more doses) coverage increasing from 63% in 2007 to 72% in 2012.

Moving forward we must advocate for strengthening health systems that will lead to increased IPTp uptake and lasting gains. We must focus on ANC, complemented by efforts at community and policy levels. Finally we must address each health system component, based on country context.

Expanding Health Ministry Capacity to Deliver Malaria and Other Health Commodities at the Community Level in Nigerian States

November 5th, 2014

Bright Orji of Jhpiego‘s Nigeria office presents a poster at the American Society of Tropical Medicine and Hygiene 2014 Annual Meeting at noon on 5th November. The poster represents Jhpiego’s technical assistance provided to seven Nigerian States as part the World Bank Malaria Booster Program. The abstract follows:

CDI ModelThe highly participative process of community directed interventions (CDI) was first pioneered in 1996 by the African Program for Onchocerciasis Control for the delivery of ivermectin. CDI was further tested and found effective in delivering other health commodities.

In 2007 Jhpiego began a proof of concept project in Akwa Ibom State, Nigeria and learned that CDI could be a useful vehicle for increasing access to and coverage of malaria in pregnancy interventions. Building on this success, Jhpiego expanded this work to include integrated community case management of malaria, diarrhoea and pneumonia. through community led efforts.

Number trainedThe World Bank Malaria Booster Program, observing Jhpiego’s efforts in Akwa Ibom State, asked the Nigeria National Malaria Control Program to enlist Jhpiego’s help in building the capacity of seven State Ministries of Health (MOH) to organize CDI for what was termed the malaria plus package consisting of community case management and health promotion activities. The scale-up process started with workshops for state CDI implementation teams consisting of staff from malaria control and primary health care in the MOHs.

services providedThen these state teams developed their own intervention packages and organized workshops for local government teams, who in turn trained staff from their front line health facilities. These facility staff mobilized communities in their facility catchment areas (wards) to select volunteers for training on the CDI process and intervention package.

Although technical assistance was provided to each state, challenges arose including commodity supplies and coordination among different program units within the state MOHs. In conclusion, state teams can train local government teams, ultimately cascading CDI to the community in order to scale up maternal and child health interventions.

A role for the private sector increasing uptake of intermittent preventive treatment for malaria in pregnancy in Kenya

November 4th, 2014

Jhpiego staff will again present a poster at the Tuesday noon (Nov 4) session of the American Society of Tropical Medicine and Hygiene Annual Meeting. Augustine M. Ngindu, Muthoni M. Kariuki, Sanyu Kigondu, Johnstone Akatu, Isaac M. Malonza, with support from USAID’s Maternal and Child Health Integrated Project (MCHIP) will share experiences with a poster titled, “Improving maternal and neonatal health: Complementary role of the private sector increasing uptake of intermittent preventive treatment for malaria in pregnancy in Kenya.” The abstract is provided below.

director's memoMalaria in pregnancy (MIP) is associated with poor pregnancy outcomes including maternal anaemia, intrauterine growth retardation and low birth weight. Kenya changed its policy on intermittent preventive treatment using Sulfadoxine Pyrimethamine (IPTp-SP) in 1998. However, IPTp coverage rates have remained low: 4% in 2003, 14% in 2007, 15% in 2008 and 25 % in 2010.

To increase the coverage rate, MCHIP supported malaria control and reproductive health divisions of the ministry of health, first to harmonize knowledge among service providers on provision of IPTp-SP in 2011, and second to train community health workers (CHWs) on sensitization of pregnant women to start early antenatal care (ANC) attendance in 2012.

Job AidA community survey conducted in 2013 showed a significant increase in the proportion of pregnant women receiving two or more IPTp doses from 25% to 63%, the highest increase in IPTp uptake since 1998. Following the successful scale up of IPTp, one sub-county conducted an assessment of its health facilities to determine quality of data on ANC clients accessing IPTp-SP.

A total of 15 (58%) out all 26 health facilities in the sub-county (public – 6 out of 8, faith-based – 2 out 3 and private – 7 out of 15) were selected. Data on new ANC clients, revisits and IPTp doses given was collected from the ANC registers.

Among thservices providede assessed health facilities 13 (87%) out of the 15 were registering new ANC cases, revisits and provided IPTp-SP (public 6, faith based 2, private 5. One private clinic provided ANC services to revisits and IPTp2 doses only after the clients had been registered in public facilities, the second did not offer ANC services.

In 2013 the government declared provision of free maternity services in public facilities but ANC clients have continued to utilize services from the private sector. This is an indication of the untapped potential in the private sector in increasing access to high impact interventions and importance of supporting the sector by all partners to provide these interventions.

Such complementary efforts if implemented will not only result in enabling the country to move towards achievement of set targets but also improve pregnancy outcomes through reduction in effects of
malaria in pregnancy.