We cannot end malaria for good without addressing flaviviruses

April 30th, 2016

“End malaria for good”, the theme for the 2016 World Malaria Day, presents us with a double challenge.  We want to end malaria finally, or eliminate it between 2030 and 2040, but also, ending it will be good for saving lives and improving economies of endemic countries. The challenge arises when we consider whether we will have adequate resources to accomplish the task. As colleagues from the University of California in San Francisco observed, “Sustaining domestic and international funding as malaria burden decreases is a serious concern for most of the eliminating countries.”

One way to guarantee resources is through conserving what we have and only treating people for malaria when they actually have the disease and not some other febrile illness. The advent of malaria rapid diagnostic tests (mRDTs) that can be used at the primary care level, including within the community should have improved our ability to differentiate malaria from other causes of fever.  Unfortunately mRDTs do not always guide correct case management.  When a febrile patient tests negative, we may not have the ability to do further differential diagnosis. Some causes of fever do not have a direct cure. Therefore if malaria drugs are available through programs like the Global Fund, we are tempted to use them since many front line clinicians feel that, “We must do something for the patient.”

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Flaviviruses pose one challenge. Such choices not only waste scarce resources but may be harmful. A prime example is the recent outbreak of Yellow Fever in Angola. According to the World Health Organization, “The first, ‘acute’, phase usually causes fever, muscle pain with prominent backache, headache, shivers, loss of appetite, and nausea or vomiting,” making it easily confused with malaria. Treating most of these patients with malaria drugs may not cause harm, but 15% go on to develop severe disease including hemorrhaging and death. Proper use of mRDTs, follow-up observation of RDT-negative patients and provision of supportive care that treats dehydration, respiratory failure, and fever, can save lives.

Rapid diagnostic test kits are widely used in India for the diagnosis of dengue infection,  but do not feature in African clinics. Without Dengue RDTs, clinicians in Africa may assume that Dengue is a severe form of malaria and treat as malaria even without parasitological laboratory evidence. With suspected Dengue patients increased intake of oral fluids is recommended by WHO along with paracetamol (not aspirin) for fever and pains.

So far the global Zika Virus outbreak has spared Africa of its worst neurological and brain damaging effects. For the current epidemic the U.S. Centers for Disease Control and Prevention inform that, “The most common symptoms of Zika also resemble malaria and are fever, rash, joint pain, or conjunctivitis (red eyes). Other common symptoms include muscle pain and headache.”  for which CDC recommends palliative case management.

Like other flaviviruses Chikungunya “causes fever and severe joint pain. Other symptoms include muscle pain, headache, nausea, fatigue and rash,” according to WHO. WHO explains that, “Most patients recover fully, but in some cases joint pain may persist for several months, or even years.

It will be good to end malaria for good, but we must also have the means to detect and manage the other dangerous, life threatening febrile diseases that will be left behind. In the meantime we need to conduct proper differential diagnosis starting with mRDTs so that expensive malaria medicines will be used judiciously and correctly and other febrile illnesses will receive appropriate life-saving care.

World Health Worker Week – Improving Capacity to Defeat Malaria

April 4th, 2016

The Frontline Health Worker Alliance reminds us that, “Frontline health workers are the backbone of effective health systems – and are those directly providing services where they are most needed, especially in remote and rural areas.” These are the people who make delivery of essential malaria prevention and case management services possible. They further note that April 3-9, 2016 is World Health Worker Week and “is an opportunity to mobilize communities, partners, and policy makers in support of health workers in your community and around the world.”

Nigeria CDD performs RDT in Upenekang Community Ibeno LGA Akwa Ibom StateUnfortunately the very areas of the world that have the most malaria also have the greatest shortage of health workers as seen in Africa, South and Southeast Asia. In this situation skills and dedication of every single available frontline health worker are crucial for defeating malaria. This can only be achieved if they are up-to-date in the latest malaria programs.

For example, most malaria endemic countries in Africa have updated their malaria in pregnancy guidance to reflect the need to provide intermittent preventive treatment (IPTp) at every antenatal care visit after the 13th week of pregnancy with doses at a month interval. This means a pregnant woman may now receive 3 or more doses. What is still needed in many countries is full dissemination of this guidance to all frontline health staff so that they can implement this service correctly and fully.

DSCN3778As we move toward malaria elimination, more people will live in areas with unstable or epidemic transmission. The chances of developing severe malaria will increase. Updated skills on managing severe malaria that results in convulsions, chronic anemia and death are needed for these frontline staff.

Enhanced skills in surveillance are now needed as we move toward malaria elimination. Good diagnostic, record keeping and reporting skills are needed by frontline staff to help identify malaria transmission hotspots. Skills are also needed on treatment regimens that include transmission blocking medicines.

Vector control will remain an essential part of defeating malaria, but health workers will need to learn about new technologies as these become available. They will need skills for better targeting of complimentary interventions like larviciding. Continual efforts to manage routing distribution of long lasting insecticide-treated nets must ensure that health workers have the skills and resources to follow-up and promote actual use of the nets for their intended purpose.

Vaccines and other new technologies will become available for controlling malaria. Health worker capacity building will be needed to ensure each of these new additions to the malaria arsenal are implemented in the most effective manner.

From the foregoing we can see that there are many reasons why the malaria community should observe World Health Worker Week now and continue to build health worker capacity to defeat malaria throughout the year.

Year of the Monkey, Implications for Malaria

March 2nd, 2016

As human population expands and people move into once seemingly remote wilderness, there is greater contact between people and various animals and the greater chance for the spread of zoonotic disease. The West African Ebola outbreak is a case in point.[i] Now as the Lunar Year of the Monkey has begun, it is an important time to highlight the potential of shared disease between humans and their primate cousins.

 

image001The most widely known form of malaria that people acquire from monkeys occurs in Southeast Asia, Plasmodium knowlesi. The blame has been laid squarely on the shoulders of deforestation caused by human expansion into what was previously the primary domain of macaque monkeys. The discovery of the parasite is credited to Giuseppe Franchini in 1927[ii]. Published studies in English date back to the late 1930s.[iii],[iv] and for the next seven decades the primary focus of most research was on the effect on monkeys themselves as well as use of the parasite to model human disease.

 

African primates have been implicated in malaria transmission also. Researchers working in Gabon foundPlasmodium falciparum, the most common species of malaria in Africa in the greater spot-nosed monkey (Cercopithecus nictitans).[v] Today wild chimpanzees and gorillas throughout central Africa are endemically infected with parasites that are closely related to human P. vivax, with the implication that, “All extant human P. vivax parasites are derived from a single ancestor that escaped out of Africa.” [vi]

 

Duval and colleagues studied malaria in chimpanzees and gorillas in Cameroon. They found that, “One chimpanzeePlasmodium strain was genetically identical, on all three markers tested, to variant P. ovale type,” found in humans.[vii]Again in Cameroon, Duval and co-researchers identified samples of Plasmodium species in gorillas and chimpanzees that related to Plasmodium falciparum.[viii]

 

As long as the potential for zoonotic malaria transmission from primates to humans exists along with the potential for adaptation of such parasites to humans and subsequent transmission among humans, our goals of eliminating malaria as a human disease by 2030 are at risk.[ix] Ironically it is human activity that heightens this risk.

 

To date it does not appear that primate to human malaria transmission is occurring in Africa. Unlike the Plasmodium knowlesi situation Southeast Asia, “African apes harboring parasites do not seem to serve as a recurrent source of human malaria.” This is an important finding and potential reprieve for ongoing control and eradication measures in Africa.[x]

 

In a broader context Faust and Dobson explain that, “The diversity and distribution of primate malaria are an essential prerequisite to understanding the mechanisms and circumstances that allow Plasmodium to jump species barriers, both in the evolution of malaria parasites and current cases of spillover into humans,”[xi] implying it is not a matter of if humans and primates might share malaria disease in Africa, but when it will happen on the scale seen in Southeast Asia.

 

[i] Pigott DM, Golding N, Mylne A, Huang Z, Henry AJ, Weiss DJ, Brady OJ, Kraemer MUG, Smith DL, Moyes CL, Bhatt S, Gething PW, Horby PW, Bogoch II, Brownstein JS, Mekaru SR, Tatem AJ, Khan K, Hay SI. Mapping the zoonotic niche of Ebola virus disease in Africa. eLife 2014;10.7554/eLife.04395. http://dx.doi.org/10.7554/eLife.04395

[ii] Franchini G (1927) Su di un plasmodio pigmentato di una scimmia (On a pigmented plasmodium of a monkey). Arch Ital Sci Med Colon 8:187–90. http://www.cabdirect.org/abstracts/19272901681.html

[iii] Coggeshall LT and Kumm HW. Effect of repeated superinfection upon the potency of immune serum of monkeys harboring chronic infections of Plasmodium knowlesi. J Exp Med. 1938 Jun 30; 68(1): 17–27. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2133656/

[iv] Eaton MD, Coggeshall LT. Complement fixation in human malaria with an antigen prepared from the monkey parasitePlasmodium knowlesi. J Exp Med. 1939 Feb 28;69(3):379-98. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2133745/

[v] F.Prugnolle, B.Ollomo, P.Durand, E.Yalcindag, C.Arnathau, E.Elguero, A.Berry, X.Pourrut, J-P.Gonzalez, D.Nkoghe, J.Akiana, D.Verrier, E.Leroy, F.J.Ayala and F.Renaud. African monkeys are infected by Plasmodium falciparum nonhuman primate-specific strains. PNAS, 4 July 2011

[vi] Liu W, Li Y, Shaw KS, et al. African origin of the malaria parasite Plasmodium vivax. Nature Communications. 2014; 5:3346, DOI: 10.1038/ncomms4346, www.nature.com/naturecommunications

[vii] Duval L, Nerrienet E, Rousset D, Sadeuh Mba SA, Houze S, et al. (2009) Chimpanzee Malaria Parasites Related to Plasmodium ovale in Africa. PLoS ONE 4(5): e5520. doi:10.1371/journal.pone.0005520

[viii] Duval L, Fourment M, Nerrienet E, Rousset D, Sadeuh SA, Goodman SM, Andriaholinirina NV, Randrianarivelojosia M, Paul RE, Robert V, Ayalak FJ, Ariey F. African apes as reservoirs of Plasmodium falciparum and the origin and diversification of the Laverania subgenus. PNAS 2010; 107(23): www.pnas.org/cgi/doi/10.1073/pnas.1005435107

[ix] Ouma C. How can we defeat malaria by 2030? World Economic Forum. Friday 11 September 2015. https://www.weforum.org/agenda/2015/09/how-can-we-defeat-malaria-by-2030/ (accessed 2016-02-20)

[x] Sundararaman SA, Liu W, Keele BF, Learn GH, Bittinger K, Mouacha F, Ahuka-Mundeke S, Manske M, Sherrill-Mix S, Li Y, Malenke JA, Delaporte E, Laurent C, Mpoudi Ngole E, Kwiatkowski DP, Shaw GM, Rayner JC, Peeters M, Sharp PM, Bushman FD, Hahn BH. Plasmodium falciparum-like parasites infecting wild apes in southern Cameroon do not represent a recurrent source of human malaria. Proc Natl Acad Sci USA. 2013; 110(17): 7020-5. doi: 10.1073/pnas.1305201110.

[xi] Faust C and Dobson AP. Primate malarias: Diversity, distribution and insights for

zoonotic Plasmodium. One Health 2015 1:66–75. http://dx.doi.org/10.1016/j.onehlt.2015.10.001

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.

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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.

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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.