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Malaria at AIDS2014

July 20th, 2014

Malaria and HIV/AIDS interact on several fronts from the biological, clinical, pharmacological to the service delivery levels.  The ongoing 20th International AIDS Conference in Melbourne, Australia (July 20-25, 2014) provides an opportunity to discuss some of these issues. Abstracts that are available as of 20th July are mentioned below and deal largely with integrated health service delivery issues. Details can be found at http://www.aids2014.org/. Also keep up to date on twitter at https://twitter.com/AIDS_conference, and on Facebook at https://www.facebook.com/InternationalAIDSConference.

8577_760104147337737_5024191_n1. Increasing HIV testing and counseling (HTC) uptake through integration of services at community and facility level (TUPE358 – Poster Exhibition). E. Aloyo Nyamugisa, B. Otucu, J.P. Otuba, L. Were, J. Komagum, F. Ocom, C. Musumali (USAID/NU-HITES Project, Plan International – Uganda, Gulu, Uganda).

HTC integration at community outreaches and facility service points increases service uptake by individuals, families and couples that come to access the different services that are offered concurrently such as immunization, family planning, cervical cancer screening, circumcision, Tuberculosis, malaria, nutrition screening services and other medical care.

2. Asymptomatic Malaria and HIV/AIDS co-morbidity in sickle cell disease (SCD) among children at Mulago Hospital, Kampala, Uganda (TUPE074 – Poster Exhibition). B.K. Kasule, G. Tumwine, (Hope for the Disabled Uganda, Kampala, Uganda, Watoto Child Care Ministries, Medical Department, Kampala, Uganda, Makerere University, College of Veterinary Medicine, Animal Resources & Bio-security, Kampala, Uganda).

The prevalence of HIV/AIDS and asymptomatic malaria in children attending SCD clinic were quite high with the former exceeding the national prevalence supporting the view than Ugandan children with SCD die before five years. Children were significantly stunted and underdeveloped which could have made them prone to increased clinic visits. National health programmes should focus on the health needs of children with SCD by integrating HIV/AIDS care, nutritional therapy, and malaria control programmes.

3. Technical support (TS) needs of countries for preparation of funding requests under the Global Fund’s new funding model (NFM) (THPE427 – Poster Exhibition). A. Nitzsche-Bell, B. Hersh (UNAIDS, Geneva, Switzerland).

The results of this survey suggest that there is very high demand GF funding in 2014 and a concomitant high demand for TS to assist in the preparation of funding requests. TS priority needs span across different technical, programmatic and management areas. Increased availability of funding for TS and enhanced partner coordination through the Country Dialogue process are needed to ensure that countries have access to timely, demand-driven, and high-quality TS to maximize mobilization of GF resources under the NFM.

4. Optimizing the efficiency of integrated service delivery systems within the existing scaled-up community health strategy in Kenya: pathfinder/USAID/APHIAplus Nairobi-Coast program experience (THPE351 – Poster Exhibition). V. Achieng Ouma, D.M. Mwakangalu, P. Eerens, J. Mwitari, E. Mokaya, J. Aungo Bwo’nderi, S. Naketo Konah (Pathfinder International, Nairobi, Kenya, Pathfinder International, Service Delivery, Mombasa, Kenya, Ministry of Health, Division of Community Health Strategy, Nairobi, Kenya, Pathfinder International, Research and Metrics/Strategic Information Hub, Nairobi, Kenya, University of Portsmouth, Geography, Portsmouth, United Kingdom).

APHIAplus (a USAID sponsored health program in Kenya) supports the implementation of integrated government strategies that center around HIV, AIDS, and tuberculosis prevention, treatment, and care; integrated reproductive health and family planning services; and integrated malaria prevention and maternal and newborn health services. Lessons learned include the finding that integrated outreach holds potential to meet clients’ needs in an efficient, effective manner. For example, during a single contact with a service provider, a mother obtains immunization services and growth monitoring for her infant, counseling and testing for HIV, counseling on family planning, cervical cancer screening, and treatment of minor ailments. Results indicate better integration of HIV prevention, care, and treatment within complementary efforts that address key drivers of mortality and morbidity. Success in integration was fostered by a stronger focus on outcomes throughout the APHIAplus implementation cycle.

5. Long term outcomes of HIV-infected Malawian infants started on antiretroviral therapy while hospitalized (THPE070 – Poster Exhibition). A. Bhalakia, M. Bvumbwe, G.A. Preidis, P.N. Kazembe, N. Esteban-Cruciani, M.C. Hosseinipour, E.D. Mccollum (Albert Einstein College of Medicine and Children’s Hospital at Montefiore, Pediatrics, Bronx, United States, Baylor College of Medicine Abbott-Fund Children’s Clinical Centre of Excellence, Lilongwe, Malawi, Baylor College of Medicine, Pediatrics, Houston, United States, University of North Carolina Project, Lilongwe, Malawi, Johns Hopkins School of Medicine, Pediatrics, Division of Pulmonology, Baltimore, United States).

AIDS2014 bannerOne-year retention rates of HIV-infected infants diagnosed and started on ART in the hospital setting are comparable to outpatient ART initiations in other Sub-Saharan countries. Further studies are needed to determine if inpatient diagnosis and ART initiation can provide additional benefit to this population, a subset of patients with otherwise extremely high mortality rates.  Of the 16 children who died, median time from ART initiation to death was 2.7 months. Causes of death include pneumonia, diarrhea, fever, anemia, malnutrition, malaria and tuberculosis.

6. Killing three birds with one stone: integrated community based approach for increasing access to AIDS, TB and Malaria services in Oyo and Osun States of Nigeria (MOPE435 – Poster Exhibition). O. Oladapo, E. Olashore, K. Onawola, M. Ijidale. (PLAN Health Advocacy and Development Foundation, Programs, Ibadan, Nigeria, Civil Society for the Eradication of Tuberculosis in Nigeria, Programs, Ibadan, Nigeria, Community and Child Health Initiative (CCHI), Programs, Ibadan, Nigeria, Community Health Focus (CHeF), Programs, Ibadan, Nigeria).

Community Systems Strengthening (CSS) is a tested and successful strategy for providing integrated AIDS, TB and Malaria (ATM) services in resource-limited settings. 20 selected community based organizations (CBOs) working on at least one of AIDS, TB or Malaria were trained by PLAN Foundation on basics of ATM-related project management including monitoring and evaluation; demand generation through active referrals; and community outreaches. Empowering CBOs is an effective and low-cost strategy for increasing demand for ATM services in resource-limited settings. Integrating referral for ATM services increases effectiveness of and public confidence in primary healthcare services at the grassroots.

7. (Upcoming on 21st July) The health impact of a program to integrate household water treatment, hand washing promotion, insecticide-treated bed nets, and pediatric play activities into pediatric HIV care in Mombasa, Kenya (MOAE0104 – Oral Abstract Session). N. Sugar, K. Schilling, S. Sivapalasingam, A. Ahmed, D. Ngui, R. Quick. (Project Sunshine, New York, United States, U.S. Centers for Disease Control and Prevention, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infections, CDC, Atlanta, United States, New York University, New York, United States, Bomu Hospital, Mombasa, Kenya).

Improving the Quality of Malaria Data in Burkina Faso

July 17th, 2014

Jhpiego and partners have been implementing USAID’s Improving Malaria Care (IMC) project in Burkina Faso for the past 9 months. In the paragraphs below, the team in Ouagadougou has reported their experiences in improving the quality of malaria data reported from the district level. Good quality data are needed to identify challenges and successes and make decisions for future malaria programming

DSCN5436 reviewing malaria treatment recordsIMC involves data collectors (Healthcare providers) directly in the data validation process. Previously, the malaria data validation was supported by the Global Funds and was done at the Regional level. The new approach proposed by IMC is to organize malaria data validation at district level where the healthcare providers who continuously collect data, can participate in the data validation meetings.

The pilot phase was conducted in the first 20 supported Health Districts in April (14th – 18th). In total, 520 healthcare providers attended the data validation meetings across 20 Health Districts. The most important lessons learnt are following:

  1. The involvement of the primary data collectors (Healthcare providers) in this activity reinforced their capacity to improve data quality;
  2. The correction of the mistakes made during these meeting have been integrated in the national database (BD_Malaria);
  3. This was another opportunity to explain the key indicators of malaria and how to control the data quality inside of the Health Facility;
  4. Based on the quantity of the mistakes noted during these data validation meetings in only 20 Health Districts (20 of 63 HD), we can affirm that these are some important data quality issues.

Dr Kam Semon, District Medical Officer of Banfora Health DistrictDr Kam Semon, District Medical Officer of Banfora Health District, after the Data validation workshop shared his views of the experience.

“Firstly, allow me to thank Jhpiego for his permanent assistance and innovation regarding healthcare management. I have appreciated the new approach developed by Jhpiego to ensure data quality. During this meeting I have noted that they are lot of mistakes in the data we used to plan and to make decision.

“I have noted that the Data manager at District level and healthcare providers (who collect routine data) have to work very closely to improve and ensure data quality. That means we have to more involve the Data Manager of District in the regular supervision visits. […] I promised you to use the new approach for all health data validation.

“I will discuss with my team, to include the data validation using that new approach in our quarterly health management meeting. I would like to thank Jhpiego once again. I also thank USAID for his financial support to the IMC project. “

Model World Health Organization at UNC Gillings School of Public Health

June 29th, 2014

UNC GillingsNeha Acharya, who is the Director of the American Mock World Health Organization conference, set to be held within UNC’s Gillings School of Public Health from October 3rd-5th, has shared the following announcement with us:

AMWHO is the nation’s very first simulation of the World Health Assembly, and seeks to educate undergraduate and graduate students on the proceedings of global health affairs. This conference will invite over 200 students from all across the nation, and is America’s very first model WHO event.

DSCN0367The American Mock World Health Organization (AMWHO) is an authentic simulation of the World Health Assembly, the sole decision-making body of the World Health Organization. Participants assume the role of a WHO ambassador, non-governmental organization member, or media representative, and form health related positions based upon their respective roles. Throughout the conference, participants will engage in debates and discussions about a thematic health topic, and work together to create a final working resolution to send to the World Health Organization in Geneva, Switzerland.

Modeled after the Ontario and Montreal World Health Organization conferences set in Canada, the primary focus of all three is to raise student awareness of pertinent health issues facing the world today, as well as to promote understanding of the many roles students can engage in through global health policy. The conference hopes to establish an environment similar to that of the World Health Organization’s Assembly, and educate future global health leaders in the proceedings of international health entities.

This simulation will be the United States’ first model-WHO conference, and is set to take place in Rosenau Hall within the University of North Carolina at Chapel Hill’s campus from October 3rd-5th, continuing in the years to come. Register at www.amwho2014.com? and purchase your $45 ticket! You can also follow plans and progress on twitter.

Regular data Review Meetings in Mozambique, a Path to Improving Malaria Service Delivery

June 22nd, 2014

Health Alliance International (HAI) of the University of Washington, is collaborating with Centro de Investigação Operacional da Beira (CIOB) is based in Beira, Mozambique to improve the quality and use of routine monitoring and evaluation data from the health facility through to the district in Sofala Province. The aim is to strengthen the health system through data for decision making and improve quality and uptake of services. This effort is sponsored by a grant from the Doris Duke Charitable Foundation.

DSCN6314A key feature of the program is a regular data review meeting where representatives from health facilities in a district come together and each presents his/her standard Ministry of Health service indicators in a simple slide format.  After each presentation the speaker received feedback from the group, including members of the district health management team, on successes and challenges and is encouraged to make plans to improve both data quality and service uptake.

The data review meetings started with an overview of all HIV, reproductive, maternal and child health indicators. Separate review meetings for malaria service indicators have been recently introduced.

According to members of the district teams, the individual facility staff presenters have grown more skilled in formatting their data and presenting to an audience. Overall, participants in these meetings appear enthusiastic and interested in the results of their peers. Constructive critiques are the norm, and speakers express appreciation for suggestions on how they can improve their services and the resulting data.

IPTp preA sample chart from a health facility showing a quarterly review of intermittent preventive treatment for malaria in pregnancy (IPTp) is seen to the right.  After viewing this, meeting participants might ask the presenter what are the reasons for the drop-off in coverage. If for example, the problem of late antenatal care (ANC) attendance is mentioned, the group can ask the presenter to consider how to encourage women to attend earlier.

IPTp postIf the presenter then goes back and implements the suggestions, the second chart might reflect the results of improved service uptake. In this way the overall project hopes that close examination of their own data by service providers can strengthen service delivery and the health system.

We look forward to hearing more about this unique process so that it can be disseminated in other malaria endemic countries.

Tanzania Community Health Workers Blog on Malaria and Other Concerns

June 20th, 2014

The Connect Project of Ifakara Health Institute of Tanzania and Columbia Mailman School of Public Health with the support of the Doris Duke Charitable Foundation has trained community health workers known as Community Health Agents (CHAs), or the ancronym WAJA in Swhili, in three districts in Tanzania. The project has encouraged the CHAs to start blogging their experiences and challenges in promoting community health. Below are two examples of their work as it involved malaria.  More postings can be viewed on WordPress.

Net VoucherBoniface Madina Mwandishi, that CHA from Katindiuka Village, is particularly concerned about preventing malaria in pregnant women. When He talked to women in his service area he learned that the net voucher system that allows women to get insecticide treated nets at half the going price of TSH 2,500 (~$1.50) had problems.

First the vouchers were either late or not available in the nearby health facilities.  Many cannot afford to pay the full price. Thus most women are not using nets to protect themselves and their unborn children from malaria.

A village elder complained to Boniface that his wife was not able to obtain a net even until a month after their child was born. The elder stressed that had the vouchers and nets been available more women and children would have been protected from malaria. Boniface will follow up to report on the lapses in the voucher system.

motherCastor Mwinamile, the CHA from Mchombe Village, reports on problems with Malaria Rapid Diagnostic Tests (RDTs). He had called mothers together for health education, but they also used the opportunity to complain about the current stock-out of malaria RDTs in the village.

Mothers noted that without RDTs the actual disease of their sick child could not be determined easily. Maybe the child with fever had a urinary tract infection or maybe it was malaria. The CHA promised the mothers to inform the project quickly about the stock-out.

While CHAs are given basic phones to communicate with supervisors and among themselves, some do have smart phones and are able to post on the blog and share with their fellow CHAs who may not have a phone.

The feedback to the program and shared learning among the CHAs, enabled by the blog, demonstrate a unique learning and problem solving experience in community health. These two postings also show that the CHAs have made their communities aware of the benefits of malaria services, hence their demand for better access.

There are other postings about malaria on the Sauti ya Waja, so if your Swahili is adequate, we encourage you to also learn from the Community Health Agents of Tanzania.

Guinea Worm, Inching Toward Eradication

June 16th, 2014

Twenty-eight years ago efforts to eradicate guinea worm began in earnest. It was the UN Water Decade, and there was optimism that guinea worm could be the test case for success of the global effort to guarantee adequate and safe water for all.

gw_infographicAs can be seen in the CDC infographic, we have gone from 3.5 million cases to 148 during this time. As we reach toward the tail end of the worm, we find some challenges remain.

On the list of currently endemic countries one finds Chad. Chad was supposed to be in the pre-certification phase, but new cases appeared a few years ago.

Preliminary Guinea Worm Cases from 2011-13Sudan was the most highly endemic country until South Sudan gained independence and took the guinea worm cases with it. Recently a few cases have also appeared again in the Sudan itself seen in charts derived from CDC’s newsletter, Guinea Worm Wrap-Up.

Looking at the most recent data from early 2014, one can see that Mali is back to reporting no cases as have Ethiopia and Sudan for 2014. Caution is needed since transmission is more likely in the upcoming rainy season months than in the current dry period.

Preliminary Guinea Worm Cases from January to AprilWhat is common in these areas is either being in a state of conflict or bordering a conflict zone.  This makes efforts to detect cases and put interventions in place in a timely manner to prevent the next season’s transmission very difficult.

Unlike some other diseases, guinea worm has some relatively simple, epidemiologically appropriate and less expensive interventions like cloth water filters, abate/temephos for water source treatment and case containment.  Of course investments in improved water supplies will also solve the problem. But without easy access to the communities where transmission is occurring, the disease will persist at this incredibly low level.

Other disease elimination programs are equally affected by the problems of access and conflict, polio being a good example.  We know that malaria is also exacerbated in conflict situations, but in the locations where pre-elimination is near, like Swaziland, Botswana, South Africa and Namibia, the main concern is ensuring a strong health system to handle the additional surveillance tasks. Still we should not be complacent, because malaria is also endemic in these very sites where guinea worm stubbornly lingers.

Congenital Malaria, an Underappreciated Neonatal Problem

June 12th, 2014

The largest portion of infant deaths occurs in the neonatal period. During those first 28 days, the child is at risk from a variety of problems arising from delivery complications, infections and simply not being kept warm.

DSCN6373 smIn malaria endemic areas there is the small but important problem of malaria transferred from mother to child, or congenital malaria. The problem occurs with both Plasmodium vivax and falciparum.

Congenital malaria in the newborn is often hard to detect. There may be fever, but other signs and symptoms might include anaemia, jaundice, paleness, diarrhoea, vomiting, and general weakness.

Prevalence of congenital malaria in Ghana, for example, ranged from 2% by microscopy to 12% using polymerase chain reaction (PCR). In India microscopy revealed a prevalence of 3% with cases of both vivax and falciparum.

One would hope this problem could be avoided if prevention of malaria in pregnancy was practiced using insecticide treated nets, intermittent preventive treatment (IPTp) and prompt and appropriate case management, but studies still find placental and cord parasiteamia in countries where such interventions are supposed to be integrated into antenatal/prenatal care. In Colombia, “An association was found between congenital malaria and the diagnosis of malaria in the mother during the last trimester of pregnancy or during delivery, and the presence of placental infection.”

Countries are in the process of shifting to the relatively new WHO guidance on IPTp that encourages monthly doses of sulfadoxine-pyrimethamine from the beginning of the second trimester up until delivery. Countries are also trying to ensure universal coverage of ITNs so that women will be using nets prior to even becoming pregnant.

We still have trouble administering to take just two doses of IPTp, but if we want to prevent congenital malaria, we need to ensure that women are protected from malaria in their placentas and are free from parasites right up until they give birth and thereby prevent another cause of neonatal mortality.

New operational research projects in malaria elimination

May 30th, 2014

MESAKate Whitfield is sharing with us the following information about MESA‘s operational research …

New operational research projects in malaria elimination started in April 2014, after being selected for funding through MESA (the Malaria Eradication Scientific Alliance).

MESA grants awardedThe MESA operational research portfolio includes: proof-of-concept of novel vector control and diagnostic tools, use of mapping technologies for surveillance and tailored response, and mobile phone applications for hard to reach populations. Urban, rural and forest settings are addressed. The projects are summarised below

  • Mopping up and getting to zero: mapping residual malaria transmission for targeted response in urban Lusaka, Zambia.
  • Using voice]based technology to improve access to malaria care and treatment among high risk mobile population of forest goers in Cambodia.
  • Applying novel nucleic acid surveillance to malaria elimination in South Cotabato Province, Mindanao, The Philippines.
  • Efficacy and safety of high]dose ivermectin in reducing malaria transmission.

Akros landscapeinety-one proposals were submitted to the call and after a thorough review process with an independent Peer Review Panel, 4 were selected for funding. The Peer Review Panel was composed of 12 experts from all over the globe. You can find a schematic of the review process through this link.

MESA (the Malaria Eradication Scientific Alliance) follows-up on the mal ERA agenda and provides a dedicated platform for the community in order to accelerate the translation of the science of malaria eradication for impact.

Women’s Education and Bed Net Use in Nigeria

May 26th, 2014

Concern about women’s and girl’s education in Nigeria and worldwide has peaked with the abduction of around 300 female secondary school school students in northeastern Nigeria. Normally we see many positive benefits of women’s education in various health indicators, but it appears that bednet use does not follow that trend neatly.

Use of nets all womenAnalysis of bednet use in the Nigeria Malaria Indicator Survey (MIS) of 2010 found that ironically net use of all kinds, including ordinary nets, insecticide treated nets and long lasting insecticide-treated nets actually decreased as educational level of women increased.

Interestingly the same picture is painted for levels of wealth with 41% in the lowest quintile using any kind of net the night before the survey versus 16% for the highest quintile. Also of note, 19% of urban women reported using any kind of net versus 34% in the rural areas.

In contrast the 2010 Nigerian MIS found that only 22% of women without education had received any antenatal care (ANC) during a recent pregnancy compared to 89% with greater than secondary education. Getting at least two doses of intermittent preventive treatment (IPTp) during ANC was only 7% for those without formal education, but 24% for those with higher than secondary education. Why does bednet use show a reverse trend here?

One factor may be the delivery mechanism. ANC and IPTp require utilization of a service with all the economic and intra-family dynamics that this implies.  Nets have so far been mainly provided during outreach campaigns.  Is there an element of equity going on here with an effort to reach the less educated and poorer segment of society with nets?

Also educated people and those with relatively greater wealth may have better housing conditions that are less likely to encourage mosquito entry. Such families may perceive that they have less need for nets if they actually have ceilings and windows with netting.

Just by way of comparison, a similar picture of net use was was seen in the Malawi MIS of 2012. That survey only recorded three levels of education and the contrast between highest and lowest use was only about 10% points compared to 25% difference in Nigeria.

Colleagues have recently documented gaps in net access and use across many countries. We need to ensure not only that nets reach a house, but that adequate numbers of nets are available for universal coverage (UC = at least one for every two residents – though this adequacy calculation depends on cultural sleeping patterns).

Malaria control efforts since 2009 have been aiming at UC, but various surveys have shown this goal to be elusive, let alone sustainable, since nets need to be replaced every 2-3 years.  It is encouraging if some element of equity might underlie net distribution, but we still need to learn more about why people get and use nets or alternatives to ensure that all women and other household members are truly protected from malaria.

Satellite Mapping, an important step toward malaria control and elimination in Nigeria

May 23rd, 2014

Omede Ogu of Nigeria’s Federal Ministry of Health reports on efforts to undertake mapping of malaria in the country as a basis for better planning of control and eventual elimination efforts.

surface water 1The National Malaria Elimination Program (NMEP) has been meeting with the team from the National Space Research and Development Agency (NASRDA). Progress on pilot malaria mapping in Niger State is being reviewed, though the study is yet to be concluded. NMEP is also looking at opportunities that exist to expand their initial mapping to cover the whole of the country. Discussions are underway on next steps and development of a road map or a framework for the study going forward.

NASRDA explained that the current mapping effort was aimed is to use satellite-based technology to map surface water for Malaria Control in North-central Nigeria with Niger State as a Pilot study. They noted that data in inaccessible locations such as the marshy areas, thick forests, rugged terrain etc. were previously unavailable for relevant environmental policy and decision making in the region and Nigeria.

In addition is will be possible to do infrastructural mapping and inventory of health care facilities, in order to identify and assess the state of health care facilities, how accessible and future areas of need provision of these facilities in the country.

So far NASRDA has identified settlements, and locations of hospitals and health centres throughout Niger State using Global Positioning System (GPS). They have also identified water bodies and wetlands locations throughout the state.

Finally they are developing a map of Surface Water and wetlands in the state showing these in relation to locations of settlements, hospitals and health centres. NMEP is planning to link with colleagues doing similar mapping in Kenya.

NMEP plans to have the final report of the study ready by October for dissemination. Major partners with funding lines in their 2014 work plans for this study are the National Primary Health Care Development Agency (NPHCDA) and NASRDA. Additional funding and support is being sought.

Kenya already is using its mapping to focus appropriate malaria interventions. All countries will benefit in better mapping for targeting their malaria control and elimination efforts.