Malaria and Stillbirths – preventable scourges

January 19th, 2016

silence around stillbirthsThis month The Lancet is publishing a series of articles and commentaries about the unspeakable silence around the problem of stillbirths. Luc de Bernis and co-authors state the political side of the equation: “Stillbirths have had even less political attention than other important public health issues, such as HIV or malaria, even though the burden is greater and solutions exist that would benefit women and children.” By their estimate in, “sub-Saharan Africa … malaria in pregnancy is estimated to be associated with about 20% of stillbirths.”

A summary of the series makes it clear that, “Most result from preventable conditions such as maternal infections (notably syphilis and malaria), non-communicable diseases, and obstetric complications.” The key role of malaria is not surprising since “75% (of stillbirths occur) in sub-Saharan Africa and south Asia” where malaria is endemic.

DSCN8010 Providing IPTp in ANCAs part of the Lancet Series Joy Lawn and colleagues explain that, “Many disorders associated with stillbirths are potentially modifiable and often coexist, such as maternal infections (population attributable fraction: malaria 8·0% and syphilis 7·7%).” Of course action against malaria takes recognition of the problem. In a commentary as part of the Lancet series Juliet Kiguli et al. present a case study of a woman who reported several bouts of malaria prior to her stillbirth, but they lamented that a greater understanding of social and cultural factors is needed because in many communities people attribute stillbirths to spirits and super-natural forces and may fail to see a simple solution like preventing malaria in pregnancy.

Unfortunately methods to prevent malaria in pregnancy through intermittent preventive treatment and insecticide treated nets lag far behind targets. The Global Call to Action to defeat malaria in pregnancy reported that …

  • While IPTp increased from <5 % (2003) >20 % (2010) average coverage rates have stagnated between 22 % and 24 %, which is very much lower than global targets o 80 % by 2010, and 100 % (universal coverage) by 2015
  • ITN coverage is comparatively better that IPTp but is still unacceptably low at 38 % overall

Women do attend antenatal care clinics where these preventive services are offered, but health systems failures such as poor commodity planning lead to stockouts. Community delivery of MIP services helps, but only if health staff accept community partnership and make commodities available. Until we can break the silence on stillbirths and the lack of action of malaria in pregnancy prevention, unborn children and their mothers will continue to suffer.

Lassa Fever in Nigeria

January 17th, 2016

Fever brings to mind ‘malaria’ for most health workers often resulting in dangerous nmis-diagnoses. Not all fevers are alike, and when health workers do not practice infection procedures in examining a febrile patient, they put themselves, their families and all people at their clinic at risk.

lassa-distribution-map smWitness the Ebola outbreak in Guinea, Liberia and Sierra Leone where health workers disproportionately died. And just as happened with Ebola, the Guardian reported that, “A medical doctor in Rivers State has been confirmed dead after being diagnosed of See WHO’s Lassa fever fact sheetin the state’s apex hospital, the Brewaithe Memorial Specialist Hospital (BMH), Port Harcourt.”

As of 9th January the death toll rose to 35 with 81 cases. The Guardian Newspaper noted that “Non-Specific Symptoms Of Ailment Threaten Interruption Efforts, ” and that at the rate the current Lassa Fever outbreak is ravaging in the country, the federal government may soon have no option but to declare an emergency to hasten containment.”

By January 16th the number of deaths had risen to 44 as reported by MENAFN.com. They also explained that Lassa is “transmitted through the faeces, urine and blood of rats (and subsequently) human bodily fluids,” of those infected via rats. Rats closely inhabit spaces with humans, while fruit bats that carry Ebola are more confined to forests (which unfortunately have been pushed back through human activity).

Lassa is endemic in Nigeria and West Africa across to Liberia, Sierra Leone and Guinea where some suspected the initial Ebola cases might have been Lassa. The first cases were CDC: documented in Nigeria in 1969, and as the AllAfrica.Com, Guardian: Ministry of Health noted, “Lassa fever which has over the years registered its presence in the country, supposed not to have taken us by surprise.”

The US Centers for Disease Control and Prevention/CDC provides the following useful information showing that while infectious, Lassa may not be as dangerous as Ebola:

  • “Signs and symptoms of Lassa fever typically occur 1-3 weeks after the patient comes into contact with the virus. For the majority of Lassa fever virus infections (approximately 80%), symptoms are mild and are undiagnosed. Mild symptoms include slight fever, general malaise and weakness, and headache. In 20% of infected individuals, however, disease may progress to more serious symptoms including hemorrhaging (in gums, eyes, or nose, as examples), respiratory distress, repeated vomiting, facial swelling, pain in the chest, back, and abdomen, and shock. Neurological problems have also been described, including hearing loss, tremors, and encephalitis. Death may occur within two weeks after symptom onset due to multi-organ failure.”

7 pricks finger for blood collection 2Finally CDC cautions health workers to protect themselves and not assume every fever is malaria. “When caring for patients with Lassa fever, further transmission of the disease through person-to-person contact or nosocomial routes can be avoided by taking preventive precautions against contact with patient secretions (called VHF isolation precautions or barrier nursing methods). Such precautions include wearing protective clothing, such as masks, gloves, gowns, and goggles; using infection control measures, such as complete equipment sterilization; and isolating infected patients from contact with unprotected persons until the disease has run its course.”

While health workers at the front line are encouraged to use malaria Rapid Diagnostic Tests to determine or exclude a diagnosis of malaria, they must remember that RDTs involve blood. Protective materials are always required, even for ‘simple’ malaria. Health systems – public and private – need to ensure health workers have these life saving materials.

Does Malaria Meet the Criteria for Eradication?

December 29th, 2015

World Malaria Report 2015 CoverWhat it is that makes a disease “eradicable,” or more correctly what makes it possible to eliminate malaria in each country leading to the total eradication world-wide. Bruce Aylward and colleagues identified three main sets of factors by drawing on lessons of four previous attempts to eradicate diseases (including the first effort at malaria eradication in the 1950s and ‘60s).[1]

  1. biological and technical feasibility
  2. costs and benefits, and
  3. societal and political considerations

So far smallpox is the only success because as Aylward et al. pointed out biologically, humans were the only reservoir and on the technical side a very effective vaccine was developed. The eradication campaign was promoted in clear terms of economic and related benefits. While the early malaria eradication efforts started with political will and recognition of the potential economic benefits of malaria eradication, the will was not sustained over two decades. On the technical side at that time there was only one main tool again malaria, indoor residual insecticide spraying, and mosquitoes quickly developed resistance to the chemicals. Are we better able to meet the three eradication criteria today?

Today’s technical challenges are embodied in intervention coverage problems. The World Malaria Report of 2015[2] (WMR2015) explains that the problem is most pronounced in the 15 highest burden countries, and consequently these showed the slowest declines in morbidity and mortality over the past 15 years. Use of insecticide treated nets and intermittent preventive treatment for pregnant women hovers around 50%, while appropriate case management of malaria lags well below 20%, a far cry from the goals of universal coverage. A further explanation of the technical challenges as outlined in the WMR2015 lies in “weaknesses in health systems in countries with the greatest malaria burden.”

The economic benefits criteria should be most pronounced in the high burden countries, but these are also generally ones with low personal income. Ironically, the WMR2015 points out that it is the high costs of malaria care and the malaria burden that further weaken health systems. More investment is needed in order to see more economic benefits.

Biological challenges to elimination are also identified in the WMR2015. Examples of existing and arising biological difficulties include –

  • Plasmodium vivax malaria which requires a more complicated regimen to affect a cure.
  • “Since 2010, of 78 countries reporting (insecticide resistance) monitoring data, 60 reported resistance to at least one insecticide in one vector population.
  • “P. falciparum resistance to artemisinins has now been detected in five countries in the Greater Mekong subregion.” Historically chloroquine and sulfadoxine-pyrimethamine resistance spread from this area and now artemisinin resistance marks a ‘Third Wave” of resistance emanating from the region.[3]
  • “Human cases of malaria due to P. knowlesi have been recorded – this species causes malaria among monkeys in certain forested areas of South-East Asia,” and so far human-to- human transmission has not been documented.

On the positive side greater political support to elimination efforts has been expressed by the African Leaders Malaria Alliance (ALMA) who met at the African Union Leaders Summit in Addis Abba early in 2015 and resolved to eliminate malaria by 2030.[4] This call to action was backed up with an expansion of ALMA’s quarterly scorecard rating system of African countries’ performance to include elimination indicators.[5]

In conclusion, political will exists, but needs to be backed with greater financial investment in order to produce economic benefits. Time is of the essence in taking action because biological and technical forces are pressing against elimination. 2030 seems far, but we cannot wait another 15 years to take action against these challenges to malaria elimination.

[1] Aylward B, Hennessey KA, Zagaria N, Olivé J, Cochi S. When Is a Disease Eradicable? 100 Years of Lessons Learned. American Journal of Public Health, 2000; 90(10): 1515-20.

[2] World Health Organization. World Malaria Report 2015. WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland, 2015.

[3] IRIN (news service of the UN Office for the Coordination of Humanitarian Affairs). “Third wave” of malaria resistance lurks on Thai-Cambodia border. August 29, 2014. http://www.irinnews.org/report/100549/third-wave-of-malaria-resistance-lurks-on-thai-cambodia-border

[4] United Nations Secretary-General’s Special Envoy on MDGs. African Leaders Call for Elimination of Malaria by 2030. Feb. 3, 2015. http://www.mdghealthenvoy.org/african-leaders-call-for-elimination-of-malaria-by-2030/

[5] African Malaria Leaders Alliance. ALMA 2030 Scorecard Towards Malaria Elimination, December 2014. http://alma2030.org/sites/default/files/sadc-elimination-scorecard/alma_scorecards_poster_english.pdf

Pneumonia and Malaria – similar challenges and pathways to success

November 12th, 2015

ConcentrationOfPneumoniaDeathsWorld Pneumonia Day (WPD) helps us focus on the major killers of children globally. While Pneumonia is responsible for more child mortality across the world, in tropical malaria endemic areas both create nearly equal damage (see WPD graphic showing Nigeria and DRC which are both have the highest burden for pneumonia, but also malaria). Of particular concern is case management at the clinic and community level where there is great need to differentiate between these two forms of febrile illness so that the right care is given and lives are saved.

WPD_2014_logo_portraitDiagnostics are a particular challenge. While we now have malaria rapid diagnostic test kits that can be used at the community level, we must rely on breath counting for malaria. The Pneumonia Diagnostics Project (see video) “is working to identify the most accurate and acceptable devices for use by frontline health workers in remote settings in Cambodia, Ethiopia, South Sudan and Uganda.”

Ease of use at low cost must be achieved. One approach to solve the pneumonia diagnostics challenge at community and front line clinic level is to find “mobile phone applications or alternative energy for pulse oximetry,” to test low oxygen levels.

PneumoniaCareVaccine development for both diseases is underway. The challenge for malaria results from the different stages of the parasites life-cycle. Lack of affordable vaccines for pneumonia limits at present widespread preventive action, though public-private partnerships offer hope.

Dispersable and correct dose for age prepackaged malaria drugs are already available. Now more child-friendly medicines for pneumonia are being developed. In low resource settings, “amoxicillin dispersible tablets are a better option, particularly for children who can’t swallow pills. They have a longer shelf-life, are cost-effective, don’t need refrigeration, and are easy to administer.”

Similarities in the problems and solutions to control these two diseases require that interventions must continue to be developed and implemented jointly in order to benefit children the most. As can be seen again from the WPD graphics (right), many children do not get needed treatment. Integrated case management at all levels is the answer.

The quantitative impact assessment of community health projects in selected African countries by using Lives Saved Tool

November 5th, 2015

Park 1Chulwoo (Charles) Park who has been undertaking the Masters of Science in Public Health at the Johns Hopkins Bloomberg School of Public Health is sharing herein his experiences with the LiST tool in African countries.

The Lives Saved Tool (LiST) is a computer-based tool that estimates the impact of scaled up health intervention packages in a quantitative manner. By modeling complex mathematical relationship of coverage difference among interventions for maternal, neonatal and child health (MNCH), LiST shows us quantitative results, such as mortality rates, incidence rates, number of cases averted, percentage of stunting and wasting, number of cause-specific death and lives saved.

Especially, LiST can project and run multiple scenarios for subnational target population in the country not only to evaluate existing MNCH project but also prioritize investments for the future based on the quantitative results. World Vision International (WVI) has implemented LiST analysis to strengthen its evaluation and strategic planning methods for MNCH projects since 2013.

Recently, the mid-term evaluations for Access to Infant and Maternal (AIM)-Health project in Kenya, Mauritania, Sierra Leone, Tanzania, and Uganda were conducted through mixed methods analysis, both qualitative research (in-depth interview and focused group discussion) and quantitative research (LiST) from June to September of 2014.

Park 2Subsequently, LiST was solely utilized to quantify the retrospective impact of Water, Sanitation, and Hygiene (WASH) project in Southern Africa Region (SAR), Malawi, Mozambique and Zambia between 2010 and 2014. The significant impact indicates that the combined effect of all five WVI WASH interventions (improved water source, home water connection, improved sanitation, hand washing with soap, and hygienic disposal of children’s stools) have prevented 989,745 diarrhoeal cases among the under-five target population of 506,019 children.

In other words, every single young child prevented 1.96 cases of diarrhea, and prevention rate for diarrhoea was 13% throughout the implementation period. Another results indicate that WVI’s WASH project contributed a 209% mean increase in percentage of under-five lives saved and 15.5% mean decrease in under-five mortality rates across SAR.

  • Chulwoo (Charles) Park, MSPH ’15
  • Johns Hopkins Bloomberg School of Public Health, Department of International Health, Division of Global Disease Epidemiology and Control
  • For more information write to e-mail: park@jhmi.edu

An Ideation Model: Attitudes, Beliefs and Practices Relevant to Malaria Prevention and Treatment in Madagascar and Liberia

November 4th, 2015

Stella Babalola, Nan Lewicky, Grace Awantang, Michael Toso, Hannah Koenker, Arsene Ratsimbasoa, Monique Vololona of the Johns Hopkins Center for Communication Programs and the Division for Malaria Control, Madagascar Presented findings on how local perceptions help predict uptake of malaria interventions at the 143rd American Public Health Association Annual Meeting, October 31 – November 4, 2015, in Chicago. Their presentation on Liberia and Madagascar is summarized below.

While Liberia has an average malaria parasitemia prevalence of 28%, malaria is considerable less common in Madagascar and varies by region and altitude. This difference provides an interesting opportunity to observe similarities and contrasts in community perceptions of the disease.

Slide6Theoretical basis of the research is based on the Ideation model which has been described as follows and as seen in the attached figures:

  • “New ways of thinking and the diffusion of those ways of thinking by means of exposure to mass media and social interactions in local, culturally homogeneous communities” – Kincaid, 2000
  • “views and ideas that people hold individually” – van de Kaa 1996

Slide7The ideation model has successfully predicted current use of a contraceptive method as well as accessing childhood immunization. The team took up the challenge to learn whether this model would be applicable to malaria interventions.

Malaria-related ideation was proposed to consist of: Malaria knowledge (cause, symptom, prevention); Perceived susceptibility to malaria; Perceived severity of malaria; Perceived self-efficacy to prevent malaria; and Social interactions about malaria. These may lead to uptake of malaria interventions.

Slide10Items for measuring bed net ideation could include – knowing where to procure a bed net, Willingness to pay for bed net, Having a positive attitudes towards bed net (derived from ten attitudinal statements), Perceived response-efficacy of bed nets, Perceived self-efficacy for procuring and using bed nets, Participation in household decisions about bed nets, Descriptive norm about bed net use and Social interactions about bed net use.

Percent of female caregivers that slept under an ITN on the night before survey increased by level (score) of bed net ideation as seen in the graph. Results (odds ratio) of logistic regression of sleeping under an ITN on bed net ideation and other covariates showed a similar trend.

Slide15Intermittent Preventive Treatment of Malaria in Pregnancy ideation measures included the following:

  • Knows name of the drug for malaria prevention during pregnancy
  • Knows the timing of first dose of IPTp
  • Has positive attitudes towards ANC and IPTp (derived from four attitudinal statements)
  • Perceived response-efficacy of IPTp
  • Woman participates in decisions about own health
  • Social interactions about malaria and pregnancy
  • Descriptive norm about ANC visits

Slide21The percent of women who took at least two doses of IPTp during their most recent pregnancy also increased by level of IPTp ideation Likewise the results (odds ratio) of logistic regression of obtaining at least two doses of IPTp on IPTp ideation and other covariates were highest among those with highest levels of ideation.

Items for measuring case management ideation included –

  • Perceived response efficacy of malaria diagnostic test
  • Perceived self-efficacy for detecting uncomplicated malaria
  • Perceived self-efficacy for detecting severe malaria
  • Descriptive norm about prompt treatment of malaria in children
  • Social interactions about malaria treatment
  • Participation in household decisions about child health
  • Positive attitudes towards appropriate malaria treatment

Slide27Again the percent of children sick with fever in past two weeks who received prompt ACT treatment by caregiver’s increased with increasing level of treatment ideation. As before the results (odds ratio) of logistic regression of prompt ACT treatment on caregiver’s treatment ideation and other covariates shows highest levels of ideation were associated with greated treatment seeking.

The team concluded that the same ideation model with demonstrated validity for family planning, child immunization, WASH and other health behaviors is relevant for malaria prevention and treatment. Strategically designed messages and interventions addressing ideational variables can help foster adoption of health-protective malaria prevention and treatment behaviors.

The authors acknowledge The US President’s Malaria Initiative (PMI) for technical guidance on the implementation of the surveys and The Ministry of Health and Social Welfare in Liberia and the Ministry of Health in Madagascar for their collaboration on the surveys.

Case Management of Malaria: A Review and Qualitative Assessment of Social and Behavior Change Communication Strategies in Four Countries

November 2nd, 2015

Kamden Hoffmann1 and Michael Toso2 presented a poster today at the 143rd annual meeting of the American Public Health Association in Chicago. Their findings are posted below.

report coverIntroduction. With the introduction and growing availability of combination therapy and rapid diagnostic tests, case management of malaria has evolved and expanded in scope. Social and behavior change communication (SBCC) activities have been developed to influence prompt care seeking behavior, adherence to test results, and completion of full treatment regimens. This review describes SBCC programming, and the extent to which it has been evaluated for impact, in Zambia, Ethiopia, Rwanda, and Senegal.

Objectives. The purpose of this review is to identify promising SBCC practices related to case management at both community and service provider levels in the four focus countries: Zambia, Ethiopia, Rwanda and Senegal. Essential for any large-scale communication strategy is a form of impact assessment. Impact assessments aim to answer the question, “Did the communication strategy achieve the specified objectives?” Impact assessments look at the difference that the strategy made in the overall program environment. The indicators can vary depending on the approach and channels used in the strategy.

An example of an impact indicator for malaria case management could be: the proportion of children under five years old with fever in the last two weeks for whom treatment was sought. Typical data sources include:

  • Population-based household surveys, such as the Demographic and Health Survey, the Malaria Indicator Survey, or the Multiple Indicator Cluster Survey.
  • Sub-national household surveys, particularly in areas where malaria communication activities were targeted.

Countries Picture1

Methods. An initial review was undertaken, consisting of a thorough PubMed search for articles related to malaria case management that mentioned SBCC, in the four countries. Malaria case management country-level documents, project reports and related SBCC materials were also collected. Implementing partner reports were gathered from each country related to SBCC and/or malaria case management. A comprehensive list of search terms were used for all four countries.

Qualitative analysis consisted of Key Informant Interviews (KIIs) with members of NMCP SBCC/BCC units within the Ministry of Health, USAID implementing partners, and President’s Malaria Initiative staff. A semi-structured questionnaire was used to gather information related to perceptions and first-hand experiences. A total of nine interviews and four written responses were collected. All interviews were recorded and transcribed. The transcribed interviews and written responses were entered into NVivo 10. An initial codebook was developed based on the semi-structured interview guide. Open and axial coding enhanced the initial codebook as themes were generated in the software.

Countries Picture2

Conclusions. The review was not able to find a substantial amount of material to show gains in the ability to measure impact of SBCC interventions in malaria case management outcomes. Several programs were able to measure changes in care-seeking behavior and uptake of ACTs; however, these types of programs need to be refined in order to measure the specific contribution of malaria SBCC interventions. Each country reviewed presented a program related to either the care group model or a model with a strong community component, and holds promise for further exploration in terms of launch points to expand the measurement of SBCC impact.

MToso IMG_0503Author Affiliations.

1 Insight Health, 710 Sutter Gate Lane, Morrisville, North Carolina 27560

2 Johns Hopkins Bloomberg School of Public Health, Center for Communication Programs, 111 Market Place Suite 310, Baltimore, MD 21202, USA

Funding for this study was provided by the US President’s Malaria Initiative.

References.

1 Kidane G, Morrow R. Teaching mothers to provide home treatment of malaria in Tigray, Ethiopia: a randomized trial. The Lancet 2000.

2 Innovation for Scale: Enhancing Ethiopia’s Health Extension Package in the Southern Nations and Nationalities People’s Region (SNNPR) Shebedino and Lanfero Woredas, October 1 2007-September 30 2012. Report of the Final Evaluation. December 2012.

3 Linn AM, Ndiaye Y, Hennessee I, et al. Reduction in symptomatic malaria prevalence through proactive community treatment in rural Senegal. Trop Med Int Health. 2015;20(11):1438-1446.

4 Landegger, J., et al. CHW Peer Support Groups for Integration of Health Service Delivery and Improved Performance: Learning from a Peer Group Model in Rwanda

5 Limange, J., et al., Evaluation: Mid-Term Evaluation of the USAID/Zambia Communications Support for Health Program, January 2013, USAID.

6 Salvation Army/Zambia (TSA), Salvation Army World Service Organization (SAWSO), and TSA Chikankata Health Services Chikankata Child Survival Project (CCSP), 2005?2010, Final Evaluation Report. December 2010.

Community Directed Interventions to Enhance PHC and MCH

November 1st, 2015

William Brieger of the Department of International Health, JHU Bloomberg School of Public Health, delivered the keynote address to the Community Based Primary Health Care Working Group at the 2015 American Public Health Association in Chicago. The focus was on Community Directed Interventions (CDI) as a way to enhance implementation of primary health care and maternal and child health. Some excerpt from the talk follow.

Ivermectin coverageThe origins of the CDI Approach are based in Onchocerciasis Control and the implementation research done by the Tropical Disease Research (TDR) Program of WHO and collaborating agencies to help establish the foundational guidance of the African Program for Onchocerciasis Control in 1995. Since then we have seen an expansion of CDI into other health issues

We should start discussion with an understanding of ‘community’ which Rifkin et al. (1988) defined as a group of people living in the same defined area sharing basic values, organization, and interests. White (1982) proposed that community is an informally organized social entity which is characterized by a sense of identity. Manderson et al. (1992) in their work for TDR defined community as a population which is geographically focused but which also exists as a discrete social entity, with a local collective identity and corporate purpose.

Communities are people sharing values and institutions. Community is based on locality (geographic), interdependent social groups, interpersonal relationships expressed through social networks and built on s culture that includes values, norms, and attachments to the community as a whole as well as to its parts. Prior to developing any community intervention we must understand the boundaries, composition and structure of a community from the perspectives of its own members, as their local knowledge and participation are central to success.

community systemsCommunity Systems Strengthening has been taken up by the Global Fund in order to enhance coverage of various health interventions such as HIV drugs and bednets to prevent malaria. Community systems are community?led structures and mechanisms used by communities through which community members and community based organizations and groups interact, coordinate and deliver their responses to the challenges and needs affecting their communities. Many community systems are small?scale and/or informal. Others are more extensive – they may be networked between several organizations and involve various sub?systems. For example, a large care and support system may have distinct sub?systems for comprehensive home?based care, providing nutritional support, counselling, advocacy, legal support, and referrals for access to services and follow?up.

Efficacy, Social Control and Cohesion are important characteristics of communities that enable them to take on project and solve problems. Collective Efficacy is a perceived ability to work together. Social control provides evidence that communities are able to enforce their norms. Cohesion describes social interaction that brings people together. A strong sense of identity and a sense of belonging describe communities that can get things done. These characteristics lead to community competency to collaborate effectively in identifying the problems/needs of the community, achieve a working consensus on goals and priorities, agree on ways and means to implement the agreed-upon goals, and collaborate effectively in the required actions.

Communities chooseIt is important to distinguish between Community Based Intervention (CBI) and Community Directed Intervention. CBI takes place in the community but a Health/Development agency exercises authority over decisions on project design and implementation. Project activities (e.g., service delivery dates and procedures) are designed by the agency. Activities simply happen in the community.

With CDI the community exercises authority over decisions and decides on acceptable method to implement projects. This ensures sensitivity to local decision-making structures and social life. Activities happen both in and by the community; the community is in control.

CDI was pioneered for Onchocerciasis (River Blindness) Control as community directed treatment with ivermectin (CDTI). When communities are in charge, coverage is better than when ivermectin distribution is centrally organized by a health agency. The original 1995 CDI field testing showed better ivermectin coverage when the community was in charge of distribution. Since the beginning of CDTI, over 200,000 villages in 18 African countries have been distributing ivermectin annually through their own efforts. Lessons learned over the years are that CDI works best when 1) the smallest level of an organized community is the basis of action (e.g. a hamlet, a clan/kin group) and 2) communities are encouraged to choose as many CDDs as they think they need to get the job done. This means that the community is in charge, not individual volunteers who can be replaced anytime the community finds the need.

With CDI for onchocerciasis or any other health program, Communities plan and chose how to deliver services. This may be house-to-house, central place distribution or a combination. Health workers provide training and supervision to volunteer village health workers called community directed distributors (CDDs).

CDI study 2008TDR observed that CDI naturally expanded to include other services wanted by the community such as immunization, community development, water and sanitation, agriculture and forestry, HIV-AIDS, family planning, guinea worm, Vitamin A. TDR and APOC then decided that CDI with other service components should be systematically tested. The project sites added in a systematic manner other interventions to existing CDTI programs including home management of malaria, ITN distribution & promotion, TB DOTS, Vitamin A in addition to continued ivermectin distribution. These services varied in complexity and communities responded by dividing the work among several different volunteers.

Appropriate malaria treatment CDI studyCoverage of interventions like malaria case management, ITN promotion and Vitamin A distribution was higher in the intervention areas compared to the delivery of these services through the routine health system. TB DOTS presented the only challenge because of the social stigma associated with the disease. The study concluded that CDI can effectively incorporate high impact, evidence based interventions while at the same time maintaining and increasing ivermectin coverage. Since CDI does not rely on one volunteer but whole community effort, the problem of overburdening on community health worker did not arise. Other incterventions ould benefit from CDI such as Misoprostol, Intermittent Preventive Treatment, Deworming, Oral Rehydration solution, Zinc, Cotrimoxazole, Amoxicillin, Soap for handwashing and WaterGuard treatment kits.

MIPJhpiego an NGO affiliate of the Johns Hopkins University used CDI to deliver malaria in pregnancy (MIP) prevention services in Nigeria including Intermittent Preventive Treatment and Insecticide Treated Nets. Contrary to fears that CDI would detract from antenatal care attendance, the work of CDDs actually ensured that ANC attendance increased over time. Through CDI IPTp coverage increased compared to control communities and more pregnant women slept under ITNs regularly.

Community-Clinic modelJhpiego next expanded CDI for MIP into integrated Community Case Management (iCCM), thus taking community case management beyond community based care. Giving communities responsibility for organizing and managing their services using the CDI approach meant greater access to services whenever people need them. Using the CDI approach to iCCM CDDs reached 7,504 clients who presented signs and symptoms of malaria. CDDs successfully conducted malaria diagnosis using the rapid diagnostic test (RDT) kits. Overall, 47.8% tested positive while 52.2% tested negative. CDDs adhered to guidelines and all the 3,587 clients with positive RDT results received appropriate anti-malarial medicines. As appropriate 21.0% were treated for diarrhoea, 11.0% for pneumonia (of whom 68.0% were referred to the health facility)

CDDsA Supervisory Checklist and Performance Standards were developed and used for Assessing CDD performance. The results were discussed at monthly CDD meetings at their nearest health facilities. This led to further improvements in History taking, Examination, Conducting RDTs for Malaria and Illness Management.

TDR has done further scoping to learn if CDI would be acceptable by health workers and community members in Urban, Nomadic and Underserved Rural Communities. CDI was favorable received. In conclusion we have learned over the years that CDI can involve women, families and communities in meeting their own health needs.

Malaria Sessions at APHA15

October 31st, 2015

65cd3DCO_400x400The 143rd Annual Meeting of the American Public Health Association (#APHA15) Begins formally on 31st October 2015 in Chicago. This year’s theme, “Health in All Policies” recognizes that “many nontraditional health partners, such as housing, transportation, education, air quality, parks, criminal justice, energy, and employment agencies” contribute to healthy people and communities. Quality of housing and content of education influence malaria transmission. To the list we can add environment, agriculture and water resources.

2015_AM_logoOf interest to those working in tropical health and malaria there are many sessions, presentations and posters on malaria. See a list below. If you are in Chicago for #APHA15 take advantage of these sessions.

…..

328782 Examining the impacts of environmental context on the efficacy of a malaria vector control intervention Tuesday, November 3, 2015 : 4:45 p.m. – 5:00 p.m. Marie Lynn Miranda, PhD, School of Natural

335281 Rise of vector resistance and insecticide costs: An assessment of insecticide change for indoor residual spraying (IRS) and malaria burden in Zimbabwe Tuesday, November 3, 2015 : 5:30 p.m. – 5:45 p.m. Beth Brennan, MPH, Abt Associates, Inc., Bethesda,

325708 Tackling malaria through a Champion Communities approach in Zambia: Using data to change behaviors and improve health outcomes Monday, November 2, 2015

333754 Can a malaria service delivery project improve gender equality? Wednesday, November 4, 2015 : 9:22 a.m. – 9:35 a.m. Elana Fiekowsky, MALD, International

338009 Is 1+1<2? Exploring Disinhibition Theory and Malaria Prevention Interventions in Angola Tuesday, November 3, 2015 Karishma Furtado, MPH, Brown School of Social Work, Washington University, St. Louis,

334502 Attitudes Beliefs and Practices Relevant to Malaria Prevention and Treatment in Madagascar and Liberia Tuesday, November 3, 2015 : 5:15 p.m. – 5:30 p.m. Stella Babalola, Associate

333934 Case Management of Malaria: A review and qualitative assessment of social and behavior change communication strategies in four countries Monday, November 2, 2015 Michael

331507 Malaria misdiagnosis and the re-emergence of viral fevers: The case for improved surveillance and diagnostics of acute undifferentiated febrile illness in

334115 Using Nollywood to Change Malaria and Family Planning Behaviors Tuesday, November 3, 2015 : 4:30 p.m. – 4:45 p.m. Babafunke Fagbemi, Executive Director at Center

334531 Setting New Standards for Transparency & Accountability: Using Mobile Technology for Data Collection and Mapping of Malaria Net Distributions in DRC Tuesday, November 3, 2015 Crystal Stafford, MPH, IMA World Health, DR Congo, Kinshasa, Congo-Kinshasa Purpose Malaria

4430.0 Malaria & vector-borne diseases Tuesday, November 3, 2015: 4:30 p.m. – 6:00 p.m. Oral Malaria is a major public health challenge and causes

II Dr. Betty Mpeka, Uganda Indoor Residual Spraying Project Phase II, Abt Associates Inc., K, Uganda Albert P. Okui, National Malaria Control Program, Ministry of Health, Uganda Ranjith De Alwis, Africa Indoor Residual Spraying (AIRS) Program, Division of International Health, Abt

health workers (CHWs) aims to reduce under five child mortality rates (U5MR) in remote communities. Kono District had a high malaria burden and U5MR. In 2009, iCCM for children aged 2-59 months expanded district-wide. We evaluated the effect of iCCM on

contacts, interstate travel plans, and EVD exposure risk. Through gained experience this expanded to include pet ownership, personal vehicle access, malaria prophylaxis, and determination of mandatory travel/work restrictions. “Low (but not zero) risk” PUM reported temperature, symptoms, and antipyretic use twice

showed CHWs to be effective in improving coverage of key MNCH practices, assessing mothers and children, and initiating treatment for malaria and diarrhea. Results indicate that a supervision process to monitor, improve and maintain clinical skill performance by CHWs within a

years of work experience in implementing and Research of Public health programs in Nigeria, particularly in HIV, reproductive Health and Malaria. I have the educational qualification and I currently work in one of the leading organizations in public health in Nigeria

initiated to improve access to quality care through private medical vendors (PMVs), a baseline survey on household experiences in managing malaria, diarrhea, and cough with difficult breathing was done in four local government areas (LGAs). A total of 3,077 children under

the participants any off-label or experimental uses of a commercial product or service discussed in my presentation. Back to: 4430.0: Malaria & vector-borne diseases Main Menu and Search Browse by Day Browse by Program Author Index Affiliation Index Disclosure Index Personal

Giridhar Mallya, MD, MSHP, Meagan Pharis, Mei Zhao, BS, Steven Zhu and Qiaoling Zeng, PhD Board 6 Case Management of Malaria: A review and qualitative assessment of social and behavior change communication strategies in four countries    Michael Toso, MSH Board

Sarah Jane Holcombe, PhD, MPPM, MPH, Sahai Burrowes, PHD, MALD, Danielle Niculescu, MPHc and Dube Jara, MPH Board 5 Tackling malaria through a Champion Communities approach in Zambia: Using data to change behaviors and improve health outcomes    Andrew Tuttle, Master

Dahn, MD MPH, Ministry of Health, Liberia, Monrovia, Liberia Objectives:  Intravenous (IV) Artesunate has become first line treatment for complicated malaria, reducing mortality by up to 35% relative to IV Quinine. The World Health Organization (WHO) changed its guidelines favoring IV

p.m. Poster Board 1 Setting New Standards for Transparency & Accountability: Using Mobile Technology for Data Collection and Mapping of Malaria Net Distributions in DRC    Crystal Stafford, MPH Board 2 Comparative Analysis of WHO Essential Medicines Listed for Diabetes among

Among the neonatal mortality patterns, severe birth asphyxia/perinatal asphyxia was the most common cause of early neonatal deaths, while severe malaria constituted the most common cause of death in children aged under-5. Conclusion: The findings revealed that place of residence is

Rajulu, Master of Science, Ling Wang, PhD and Lou Smith, MD, MPH Board 7 Is 1+1<2? Exploring Disinhibition Theory and Malaria Prevention Interventions in Angola    Karishma Furtado, MPH Board 8 Findings from a Quantitative Study to Create a Transition Guide

PhD 9:09am Gaza 2014-What did we learn?    Charles W. Cange, PhD, MSc and Karen Kelly, MD 9:22am Can a malaria service delivery project improve gender equality?    Elana Fiekowsky, MALD and Niyati Shah, MIPP See individual abstracts for presenting author’s

theory of youth peer crowds and its influence on risk behaviors. Moderator: David Bickham, PhD 4:30pm Using Nollywood to Change Malaria and Family Planning Behaviors    Babafunke Fagbemi, Executive Director at Center for Communication Programs Nigeria 4:45pm Hip Hop Stroke: Developing

Indoor Residual Spraying Project Phase II, Dr. Betty Mpeka, Uganda Indoor Residual Spraying Project Phase II, Albert P. Okui, National Malaria Control Program, Ministry of Health, Uganda, Ranjith De Alwis, Africa Indoor Residual Spraying (AIRS) Program, David F. Hoel, Centers for

was associated with reductions in children’s illness.  Control children of all ages (0-17) were 1.5 times more likely to contract malaria or pneumonia (p<0.05).  Positive but insignificant results were detected for under-5 illness incidence.  No significant results were detected for children

high food insecurity in Kenya Tuesday, November 3, 2015 Muhamed Akulima, BA in Anthropology, MA in project Planning and Management(continuing), HIV/AIDS-TB,MALARIA programme, Amref Health Africa in Kenya, Nairobi,, Kenya Background  An estimated 500,000 orphans and vulnerable children live in Central and Eastern

and providers, more efficacious medicine and adaptation to a changing environment, alert to emerging diseases like chikengunya virus, reintroduction of malaria, alongside cardiovascular and sickle cell disease, increasingly impacting women of reproductive age.  The need for complex interventions create opportunities for

providers, including the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria, also rely on affordable generic medicines to provide treatment to millions of people worldwide. In spite of the proven role

Cambodian population grew by only 13%. In 2013, road crashes accounted for 20 times more deaths in Cambodia than landmines, malaria, and dengue fever combined. Helmets are proven to reduce the risk of death by 42% and serious injury by 69%,

Seasonal Malaria Chemoprevention Implementation in Senegalese Children

October 29th, 2015

20151028_123042-1Dr Mamadou L Diouf and colleagues[1] from the National Malaria Control Program, Dakar Senegal and the President’s Malaria Initiative/USAID, Dakar, Senegal presented their experiences with Seasonal Malaria Chemoprevention among children aged 3-120 months in four southern regions of Senegal at the 64th Annual Meeting of the American Society of Tropical Medicine and Hygiene. Their findings are outlined below.

Malaria is major cause of disease and death in infants and children, with seasonal transmission, highest in the southern and eastern regions which are the wettest areas. SMC is administration of a complete treatment course of AQ+SP at monthly intervals to a maximum of 4 doses during the malaria transmission season to children aged between 3 and 59 months in areas of highly seasonal malaria transmission (where both drugs retain sufficient antimalarial efficacy).

Health post nurse training volunteersTarget areas for implementation are areas where more than 60% of clinical malaria cases occur within a maximum of 4 months, the clinical attack rate of malaria is greater than 0.1 attack per transmission season in the target age group, and AQ+SP remains efficacious (>90% efficacy).

Adoption of SMC in 2013 as a new intervention in malaria control policy. Four south-eastern regions eligible according to WHO criteria for SMC (Tambacounda, Kédougou, Sédhiou and Kolda) chosen

The poster presented Senegal’s experience implementing SMC and focuses particularly on process, challenges and lessons learned. Available information generated from the national SMC implementation guidelines, technical documents, field activity reports, and SMC impact evaluation survey were reviewed.

The medication distribution strategy relied on a door to door campaign strategy with community volunteers. On the first day, the volunteers, trained by health workers, administer drugs to the children under surveillance of their mothers or guardians. For the 2 remaining days, mothers administer the medication.

campaign resultsIn 2014, the SMC Campaign was conducted in the four regions for three months covering the high transmission season (August, September, October, and November). Kedougou, was the only region that conducted 2 SMC rounds as it started implementing in 2013.

The target was extended to children from 3 to 120 months (624,139 estimated in target age group). This age group extension, compared with WHO recommendations (3 to 60 months,) was based on shift of vulnerability towards the ages from 60 to 120 months shown by the epidemiologic data on malaria morbidity in Senegal.

Administrative coverage rates for the 3 passages respectively was 98.6%, 97.9% and 98.0%. Information was obtained from the SMC impact evaluation survey in the south of Senegal, 2015 July by Dr JL Ndiaye.

SMC districtsKey interventions and process began with the National and regional Steering Committees involving NMCP, health staff, donors/partners and researchers. There was development and update of tools and materials (guidelines, planning forms, data collection and analysis support. Training of staff took place at all levels and operational actors

Early field planning was held with staff at regional and district level: identification of activities, dates, estimation of household/child targets, estimation of resources needed (budgets, HR, logistics, etc.). Early delivery of drugs, tools, supports was ensured to be available at health post level at least 1 week before the 1st campaign day.

Rigorous selection of volunteers and supervisors was based on specific criteria. Develop communications activities took place at least 2 weeks before and during the campaign period focusing on SMC gains, HH census, administration by mothers for the 2 remaining days, and possible side effects.

New casesCampaign roll out included supervision of the process at the districts and health posts (organization model, administration). There was mobilization of logistics for transportation of volunteers, drugs, and materials. Day to day monitoring took place with regional debriefing to analyze data from districts, geographical progression, target coverage progression and identify issues and challenges. Daily electronic distribution of “SMC bulletin” to health staff and partners helped to disseminate information on districts performances.

Post campaign evaluation took place at all levels: workshops for sharing and validating data and information, identification of key issues, lessons learned, and formulation of recommendations to improve future campaigns. Local health agents, NMCP staffs, partners and authorities were involved.

Spontaneous pharmacovigilance system tracked and treated side effects. This consisted of distribution of yellow cards to health facilities, case notification by health agents, availability of a side effects line listing, and immediate and free-of-charge case management.

The following key challenges were faced:

  • Correct availability of drugs and tools at health posts
  • Complete coverage of all households and children
  • Completion of 2nd and 3rd doses by guardians of children
  • Availability of children and guardians during harvest period and class time
  • Comprehensive communication for population particularly in possible occurrence of side effects
  • Case management of side effects free of charge
  • Availability and promptness of data
  • Long term logistic availability

Rainy SeasonFinally there were some outstanding questions. Can we switch SMC from campaign to routine system at health post level? Can we expand SMC to other regions and with what targets? Also, can we improve formulation and taste of drugs for enhancing children’s compliance?

Financial support: This work was made possible through support provided by the United States President’s Malaria Initiative, and the U.S. Agency for International Development, under the terms of an Interagency Agreement with the Centers for Disease Control and Prevention (CDC). The opinions expressed herein are those of the authors and do not necessarily reflect the views of the U.S. Agency for International Development or the Centers for Disease Control and Prevention.

[1] Dr Mamadou L Diouf, Mr Medoune Ndiop, Dr Mady Ba, Dr Ibrahima Diallo, Dr Moustapha Cisse, Dr Seynabou Gaye, Dr Alioune Badara Gueye, Dr Mame Birame Diouf