Malaria Matters

June 25, 2015

Congenital malaria: A neglected global health concern

Filed under: Congenital Malaria,Elimination,IPTp,Malaria in Pregnancy — Bill Brieger @ 7:30 am

Reena Sethi, DrPH Candidate in International Health, The Johns Hopkins Bloomberg School of Public Health and Senior Monitoring and Evaluation Adviser, Jhpiego shares with us the challenges of malaria acquired from the pregnant mother by their newborn child.

DSCN6805 mother of newborn in Malawi given LLINStrategies and recommendations to prevent the transmission of HIV from a mother to her child are known but less information is available on the epidemiology and management of malaria transmitted from pregnant women to their newborns. As presented in a review of congenital infections, one of the lesser known effects of malaria in pregnancy is the maternal-fetal transmission of infected erythrocytes that can result in poor perinatal outcomes. While clinical malaria in newborns is rare, most likely due to the transplacental transfer of maternal antibodies and the inhibitory effect of fetal hemoglobin on the development of malaria parasites, it is unclear what the true incidence of this condition is in Africa and Asia.

Recently published studies in Burkina Faso estimated the incidence of congenital malaria to be 2.1% and the prevalence of mother-to-child transmission of asymptomatic malaria to be 18.5% in one health center in Ouagadougou; in one hospital in Papua, Indonesia, congenital malaria was said to occur in 8 out of 1000 live births from 2005 to 2010; and in a study in one hospital in Madhya Pradesh, India, the incidence of congenital malaria was 29 out of 1000 live births. In a study involving six hospitals in Nigeria, the overall incidence of congenital malaria was found to be 5.1%. Transmission has been associated with both Plasmodium falciparum and Plasmodium vivax. The uncertainty and variation in estimates are likely related to the source of the tested blood (umbilical cord blood or infant peripheral blood), presentation of symptoms that are similar to neonatal sepsis, as well as the lack of capacity to conduct high quality diagnostic tests.

Since congenital malaria results from the transmission of parasites from the mother to the baby (presumably through placental transmission), prevention of malaria through the use of IPTp when appropriate reduces maternal parasitemia, most likely resulting in a lower rate of transmission of malaria to the newborn. In a study in Côte d’Ivoire, factors that protected mothers from placental malaria parasitaemia were the use of IPTp (SP) or ITNs during pregnancy and multigravidity. A study in Ibadan, Nigeria found that IPT-SP was effective in preventing maternal and placental malaria as well as improving pregnancy outcomes among parturient women. Researchers in Southern Ghana reported that placental malaria decreased after the implementation of IPTp.

However, in settings where IPTp is ineffective, the effect of alternative strategies, such as intermittent screening and testing in pregnancy (ISTp) on placental malaria should be examined. Little evidence is currently available on the efficacy of ISTp on maternal and newborn outcomes.

Further research also needs to be conducted in diverse settings to develop a standardized definition for congenital malaria and to understand the short and long-term consequences of this condition in order to establish guidelines for diagnosis and treatment. In pre-elimination contexts, where acquired malaria immunity may be reduced, further evidence is needed on the feasibility of screening all febrile babies and following newborns born to women with malaria during pregnancy and of other possible strategies to improve infant outcomes.

June 21, 2015

Equity, Inequities and Malaria

Filed under: Equity,Monitoring — Bill Brieger @ 7:31 am

The World Health Organization has just released a new report entitled, State of inequality: Reproductive, maternal, newborn and child health. Because of its effort to look across the board at low and middle income countries generally, it does not include more region specific indicators like malaria services. This led us to look at a few recent DHS/MIS  (Demographic & Health and Malaria Indicator Surveys) to see what we can learn about equity or its opposite for malaria.

For RNMCH malaria indicators and equity we can examine coverage of long lasting insecticide-treated nets for both pregnant women (abbreviated as “preg < LLIN” in the attached charts) and children below five years of age (child < LLIN), taking of at least two doses of intermittent preventive treatment by recently pregnant women (IPTp2), and finally receipt of artemisinin-based combination therapy for febrile children below five years of age (ACT child, or where ACT not specified AMD child for antimalarial drug).

Slide4The equity variables presented in these surveys include residence in a rural or urban area, education of the woman, and wealth quintile. Recent reports from Nigeria (DHS 2013), Malawi (MIS 2014), and Angola (MIS 2011) were examined.

The first issue one notices is that these countries have not achieved the Roll Back Malaria coverage target of 80% that was set for 2010, let along sustained it. One could argue that it is not important to talk about equity until a country Slide10demonstrates the health systems capacity to seriously scale up these interventions. On the other hand one could also argue that efforts toward achieving equity at any stage of a program are important as these point to future sustainability and achievement.

The three countries in question each present a very different picture when it comes to equity. Starting with women’s education it is important to note that in two of the countries the proportion women with  post secondary is too negligible to analyze separately. The underlying last of access to post-secondary education is an important equity issue in itself.

Slide7For Nigeria access to both IPTp and ACTs for children is skewed toward those with higher levels of education. Angola’s coverage is also better for more highly educated women. Malawian women with lower education have better IPTp2 coverage, but the other indicators are mixed.

Rural disparity compared to better urban access to malaria commodities is evident in Angola and Nigeria for all Slide2indicators, while Malawi is again mixed. Interestingly in Malawi children in rural areas (41%) show better use of ACTs than those in urban settings (23%).

Angola exhibits the starkest contrast among wealth quintiles with all indicators showing increased coverage as wealth increases. In Nigeria this is true for IPTp and ACTs, but for LLINs, there is a peak in the middle quintile. It is often said in Nigeria that wealthier people prefer screening their homes than sleeping under nets.

Slide9Many factors enter into the picture. Malawi which is poorer in terms of GDP that oil-rich Angola and Nigeria has achieved better overall coverage with less pronounced disparities. One should also consider the differences in physical size with implications for program logistics among the countries.

In its own report, WHO says, “Health inequality monitoring is an essential step towards achieving health equity. It has broad applications and can be conducted across diverse health topics. Applying the best practices in health inequality monitoring presents an opportunity to share the state of inequality with stakeholders, indicate areas in need of improvement and track progress over time.” With tools like DHS, MIS and even national health information systems, endemic countries should also monitor their malaria intervention coverage and bring stakeholders together to address equity gaps.

June 19, 2015

Increased Commodity Availability Improve Malaria Diagnosis among Children Under five in Sokoto State, Nigeria

Filed under: Diagnosis — Bill Brieger @ 10:59 am

Zainab Mohammed, Nosa Orobaton, and Mohammed A. Ibrahim from the Targeted States High ImpactTSHIP Project (TSHIP), USAID Nigeria and the JSI Research & Training Institute, Inc. are sharing their experiences in Sokoto State, Nigeria concerning the importance of primary care health workers practicing appropriate malaria diagnostics prior to prescribing malaria medicines.

Despite the national efforts to reduce indiscriminate use of antimalarial and to secure improvements in malaria diagnosis, presumptive treatment of malaria is still high in Sokoto State, Nigeria. Just 3% of children under five years with fever had a blood test for malaria (NDHS 2013). Therefore Zainab and colleagues set out to answer the question, “Does increased availability of diagnostic kits improve quality of malaria case management?” Their work was based on the following objectives

  1. To determine the effect of malaria Rapid Diagnostic Test (mRDT) kits availability in malaria case management among children U5 years in Sokoto State.
  2. To document the effect of multi-strategy approach in improving malaria case management among children under five in Sokoto State.

DSCN3005aTheir methods included secondary data collection from the Sokoto State Health Management Information System (HMIS) from 2011 to 2014. No mRDTs were supplied to the State in 2011. In August 2012 – 108, 000 and 807, 850 kits were supplied by USAID/PMI through USAID/TSHIP with logistic support from USAID’s JSI/DELIVER to State Medical Store and distributed directly to HF. Service providers were trained on the job. Other activities included house-to-house education and counselling by community volunteers, radio phone in programs, face-to-face dialogue by ward development committees and radio jingles.

They found that although only 3% of health facilities (HF) provided malaria diagnostic services across the State, the percent of all facilities that provided the service had increased to 22% in August 2012 through 2015. The percent of children under five with fever symptoms and had confirmatory diagnostic tests for malaria was 19% and 20% in 2011 and 2012 respectively. By 2013, the coverage had tripled to 57% and had quadrupled to 84% in 2014. Overall, the percent of fever cases subjected to confirmatory diagnosis for malaria increased from 19% in 2011 to 84% in 2014.

In conclusion, the observed improvement in quality of malaria case management can be attributed to the availability of free mRDT at the HFs. Also contributing to the outcome were continuous training & mentoring of service providers and quality of awareness creation at community and HF level as well as through the media. Therefore, it is recommended that commodity logistics in support of supplying mRDT is strengthened to improve quality of malaria case management.

June 13, 2015

Moving toward Malaria Elimination in Botswana

elimination countriesThe just concluded 2015 Global Health Conference in Botswana, hosted by Boitekanelo College at Gaborone International Convention Centre on 11-12 June provided us a good opportunity to examine how Botswana is moving toward malaria elimination. Botswana is one of the four front line malaria elimination countries in the Southern African Development Community and offers lessons for other countries in the region. Combined with the 4 neighboring countries to the north, they are known collectively as the “Elimination Eight”.

The malaria elimination countries are characterised by low leves of transmission in focal areas of the country, often in seasonal or epidemic form. The pathway to malaria elimination requires that a country or defined areas in a country reach a slide positivity rates during peak malaria season of < 5%.

pathwayChihanga Simon et al. provide us a good outline of 60+ years of Botswana’s movements along the pathway beginning with indoor residual spraying (IRS) in the 1950s. Since then the country has expanded vector control to strengthened case management and surveillance. Particular recent milestones include –

  • 2009: Malaria elimination policy required all cases to be tested before treatment malaria elimination target set for 2015
  • 2010: Malaria Strategic Plan 2010–15 using recommendations from programme review of 2009; free LLINs
  • 2012: Case-based surveillance introduced

The national malaria elimination strategy includes the following:Map

  • Focus distribution LLIN & IRS in all transmission foci/high risk districts
  • Detect all malaria infections through appropriate diagnostic methods and provide effective treatment
  • Develop a robust information system for tracking of progress and decision making
  • Build capacity at all levels for malaria elimination

Botswana like other malaria endemic countries works with the Roll Back Malaria Partnership to compile an annual road map that identifies progress made and areas for improvement. The 2015 Road Map shows that –

  • 116,229 LLINs distributed during campaigns in order to maintain universal coverage in the 6 high risk districts
  • 200,721 IRS Operational Target structures sprayed
  • 2,183,238 RDTs distributed and 9,876 microscopes distributed
  • While M&E, Behavior Change, and Program Management Capacity activities are underway

Score cardFinally the African Leaders Malaria Alliance (ALMA) provides quarterly scorecards on each member. Botswana is making a major financial commitment to its malaria elimination commodity and policy needs. There is still need to sustain high levels of IRS coverage in designated areas.

Monitoring and evaluation is crucial to malaria elimination. Botswana has a detailed M&E plan that includes a geo-referenced surveillance system, GIS and malaria database training for 60 health care workers, traininf for at least 80% of health workers on Case Based Surveillance in 29 districts, and regular data analysis and feedback.

M&E activities also involve supervision visits for mapping of cases, foci and interventions, bi-annual malaria case management audits, enhanced diagnostics through PCR and LAMP as well as Knowledge, Attitudes, Behaviour, and Practice surveys.

Malaria elimination activities are not simple. Just because cases drop, our job is easier. Botswana, like its neighbors in the ‘Elimination Eight’ is putting in place the interventions and resources needed to see malaria really come to an end in the country. Keep up the good work!

May 23, 2015

Verifying Malaria Medicines on Your Mobile

Filed under: Drug Quality,Private Sector,Treatment — Bill Brieger @ 6:00 pm

On their website Sproxil says that, “Sproxil actively supports Nigeria’s National Agency for Food and Drug Administration and Control (NAFDAC) in the fight against counterfeiting by pioneering Nigeria’s first Mobile Authentication Service.” They note further that …

“On February 2, 2010, NAFDAC launched the NAFDAC MAS, putting the power of product verification right in the hands of the consumer. MAS is powered by Sproxil’s award-winning cloud-based Mobile Product Authentication™ technology, and remains the world’s largest nation-wide implementation of consumer-facing SMS anti-counterfeiting technology in the world.”

Below are two malaria medicine packets recently purchased. After scratching the small label (see it circled, we got the SMS messages as posted.  The NAFDAC registration number alone is not enough to ascertain the validity. This is a smart procedure, even without a smart phone. Of course one still needs to read the expiry dates!

P-Alaxin front scratch off1. OK Genuine P-Alaxin Tablet. Your PIN:949769012921 NRN:04-9495 Problem? Call 08039012929 NAFDAC & Bliss Care Sproxil SMS

Lonart DS back PIN2. OK Original Lonart DS tabs NRN:04-9927 Use mosquito nets to help avoid malaria Problem? Call 08039012929 NAFDAC & GREENLIFE CARE Sproxil Solution

May 6, 2015

Lessons Learned from a Supervisory Visit to a Medicine Shop

Filed under: Private Sector,Treatment — Bill Brieger @ 1:16 pm

DSCN2943In this posting Hajara Moses John of the Bauchi State Agency for the Control of HIV/AIDS, TBL and Malaria [BACATMA] shares lessons learned in supervising medicine sellers.

Our team had planned supervisory visit last week to patent medicine vendors (PMVs) where shop owners have been taught the correct management of childhood illnesses. Our experience one particular shop pulled together so many lessons about training and supervision, and we are sharing this here. In the first shop we visited that day we found a boy aged 12 behind the counter. I took on the role of a mystery client, and mentioned some symptoms to the boy. “My 5-year old son is at home with catarrh. His nose is really running and his breathing is fast. What do you recommend I give him?”

The boy mentioned a local brand of antihistamine. I asked if there was anything else we should do, and the boy said that should work fine.

Next I said my two-year old daughter was also unwell. She was having fever, shivers with aches and pains. Did he have any suggestions for her? His prompt answer was “Ampiclox.”

I then asked him where the owner of the shop was. He said, “Oh my father has traveled.” I asked what class the boy was in school, to which he said the first class of junior secondary school.

Word of our visit must have spread in the area, because then a woman rushed in who it turned out to be the boy’s mother and asked how she could help us.

We explained that we were from the Ministry and were going around to help medicine shop owners improve the quality of their services. The mother happily reported that she had received training “in malaria and those other small small diseases of pickin,” from the Minsirty fo health and again from a NGO.

I went back to case of the child with a respiratory infection and pointed out the breath counting beads on the table. She said it was her husband who had done the training where the beads were explained but never taught her how to use them. We then spent some time explaining to the mother and her son about the beads and demonstrated how to use them, and also explained about management of fever.

Finally I asked the mother why she was not in the shop since her husband had traveled. She said she was in the kitchen preparing lunch for the children, and as the oldest, the 12-year old was assumed capable of running the shop. We encouraged her to discuss as a family how they could share what they have learned about managing child illness and always ensure that a competent person is available in the shop.

Training of PMVs is not a simple matter. The person trained may not always be in the shop nor share what he/she learned with other salespeople. Supervision is necessary in order to reinforce what was learned during training and provides an opportunity to teach others on-the-job. PMVs provide a large portion of the services in many African communities, and we must ensure that they can focus on quality.

April 27, 2015

Invest in Using Preventive Services: an Update from the 2014-15 Uganda Malaria Information Survey

Filed under: IPTp,ITNs,Monitoring — Bill Brieger @ 7:22 pm

MIS Uganda 2014-15The Demographic and Health Survey people have just released the preliminary MIS results for Uganda. From the viewpoint to the Millennium Development Goals (MDGs), there are cautiously positive signs.

Insecticide treated bednet ownership by households has reached 90%. Equity appears to have been achieved with the households in the lowest, second and third wealth quintiles registering 92%, 94% and 93% ownership. The highest and next highest quintiles had 85% and 88% ownership respectively. Those in the higher wealth quintiles often have better quality housing that of itself offers preventive benefits.

An interesting number is that over 86% of households obtained their nets through campaigns. It appears that the catch up phase of net distribution is repeating itself and the more sustainable keep up phase where nets are provided through routine services has not taken effect.

Household ownership of at least one net translates into use by only 69% of residents generally, and still only 74% in homes that actually own a net. Net use by ‘vulnerable groups’ was a bit better: 74% for children below five years of age and 75& for pregnant women. Thus we can see that household ownership does not guarantee that we meet the 2010 target of 80% coverage/use.

We have moved from recommending two doses of sulfadoxine-pyrimethamine as intermittent preventive treatment for malaria in pregnancy to three or more. The MIS does not report on increased doses but even for two contacts, only 25% of recently pregnant women in Uganda were covered.

The results show that malaria prevention is still an elusive goal. Thirty per cent of children given malaria rapid diagnostic tests during the survey had malaria parasite antigens. We must invest more in ensuring that preventive interventions are routinely available and are actually used before our attention is diverted from the MDGs to the SDGs.

April 25, 2015

Huambo: Thinking ahead toward investing in malaria elimination

Filed under: Elimination,Invest in Malaria Control — Bill Brieger @ 4:47 pm

wmd2015logoEight members of the Southern African Development Community are strategizing toward the pre-elimination phase of malaria.  The four frontline states are Namibia, South Africa, Swaziland and Botswana.  The second tier includes Angola, Zambia, Zimbabwe and Mozambique.

Huambo circled Pf_mean_2010_AGOMalaria prevalence varies by province in Angola with greater burden in the north (see map on right). Huambo in the central highlands is the second most populous province at 2 million and in some of the 11 municipalities malaria transmission is low.  This has led provincial health authorities to strategize how to invest in pre-elimination efforts where appropriate while maintaining full prevention interventions where needed.

An analysis of routine health information system (HIS) data is a first step. Rapid Diagnostic tests are part of the basic protocol for case management in all health centers. Data for 2014 was summarized by municipality. Test positivity rates for each municipality are shown in the map to the left. These range from a low of 2% in Katchiungo in the east to 54% Bailundo in the north.

Huambo Municipalities Malaria Test PositivityMore detailed geospatial analysis will be needed looking at variations within municipalities by health center catchment area, but a broad picture emerges that three municipalities in the northern part of the province have higher RDT positivity rates, and require sustained interventions like long lasting insecticide-treated nets and intermittent preventive treatment for pregnant women.

Reactive case detection such as being practiced in Swaziland might be considered in the remaining 8 municipalities after some initial pilot testing. Community based surveys using RDTs and more precise tests like polymerase chain reaction (PCR) could also be tried in order to supplement current HIS data and provide better targeting of interventions.

Hopefully government and partners will invest in helping Huambo test these processes. Huambo could then provide a good model for approaching malaria elimination for the rest if the country and the region.

April 23, 2015

Burkina Faso: Defeating Malaria by Investing in Expanding Intermittent Preventive Treatment in Pregnancy

Filed under: IPTp,Malaria in Pregnancy — Bill Brieger @ 9:10 am

WMD15_6b_Facebook_FinalIn Burkina Faso, Antenatal Care (ANC) is a national platform for malaria in pregnancy prevention and control. The 2010 Demographic and Health Survey showed a good initial ANC registration rate (95%), but over 56% of pregnant women in rural areas do not register until their second or third trimester. Thus they may have missed the full regimen of ANC services including Long Lasting Insecticide-treated nets and intermittent preventive treatment of malaria in pregnancy (IPTp).

In 2010 only 10.6% of pregnant women nationally and 8.4% in rural areas received two doses of IPTp. Now WHO recommends more doses. This had improved by the time the 2014 Malaria Information Survey was completed to 68% for one dose, 48% for two and 22% for three doses.

Jhpiego’s USAID-supported Improving Malaria Care (IMC) project in Burkina Faso has been providing technical assistance and training to health districts and their ANC staff on implementing updated (2012) WHO IPTp guidelines. The recommended provision of IPTp at every ANC visit from the 13th week of pregnancy onward leads to the possibility of 3 or more doses per woman. The new guidance was incorporated into the update of Burkina Faso’s malaria strategy and has been disseminated since September 2014.

CoverageAnnual data from the Health Management and information System for 2014 from three districts (Batie, Po and Ouargaye) and 61 health clinics where IMC has been working were collected and summarized. A total of 26,909 women registered for ANC our of the estimated 35,420 in the Three districts.

The chart at the left shows coverage of ANC visits and IPTp provision based on the estimated 2014 population of pregnant women in the districts. Eleven (17.7%) clinics had not started the updated IPTp guidance. The Ministry of Health also experienced stock-outs of sulfadoxine-pyrimethamine.

Being new IPTp3+ poses challenges and needs greater investment. The IMC project in collaboration with the National Malaria Control Program is examining ways to invest in stronger antenatal malaria prevention including capacity building for ANC staff and provision of IPTp by the existing network of volunteer community health workers.

April 22, 2015

World Malaria Day 2015 Blog Postings Help #DefeatMalaria

wmd2015logoA special World Malaria Day 2015 Blog has been established. So far nine postings are available at http://www.worldmalariaday.org/blog. Please read and share with colleagues.

1. “Investing in integrated health services to defeat malaria”BY ELAINE ROMAN, MCSP Malaria Team Lead.

2. “Fake antimalarials: how big is the problem?”

BY DÉBORA MIRANDA, Technical Communications Officer, ACT Consortium (UK).

3. “Why antimalarial medicines matter”WMD15_7_Facebook_Final

BY PROFESSOR PAUL NEWTON AND ANDREA STEWART, Worldwide Antimalarial Resistance Network and Laos Oxford University Mahosot Hospital Wellcome Trust Research Unit.

4. “Malaria as an entry point for addressing other conditions”

BY HELEN COUNIHAN, Senior Public Health Specialist, Community Health Systems.

5. “Bridging the Care-Seeking Gap with ProAct”

BY MATT McLAUGHLIN, Program Manager of Peace Corps Stomping Out Malaria in Africa initiative.

WMD15_6a_Facebook_Final6. “Defeating Malaria in Pregnancy”

BY CATHERINE NDUNGU, ELAINE ROMAN AND AUGUSTINE NGINDU, Jhpiego.

7. “Intermittent Preventive Treatment, a Key Tool to Prevent and Control Malaria in Pregnancy”

BY CLARA MENÉNDEZ, Director of ISGlobal’s Maternal Child and Reproductive Health Initiative.

8. “Widespread artemisinin resistance could wipe out a decade of malaria investment”

BY TIM FRANCE, Asia Pacific Leaders Malaria Alliance.

9. “The long walk to a malaria-free world”

BY DAVID REDDY, CEO Medicines for Malaria Venture.

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