Tropical Health Matters

The Sahel of West and Central Africa with its successive droughts is an area of nearly constant food insecurity and malnutrition.  Development partners, in trying to find more accurate ways to predict malnutrition and food insecurity have come to realize that the relationship between crop production on one hand and malnutrition on the other is complicated.

IRIN quotes USAID as saying “… the links between cereal production and malnutrition have been exaggerated, the complexities of regional market conditions inadequately conveyed, and the need for long-term structural solutions under-emphasized.” Furthermore, “While harvest outputs and malnutrition rates are linked, they are not inextricable.”  Ironically, food aid may not solve food problems.

IRIN commented on the structural factors of the chronic malnutrition problem by saying that, “This is because much of the malnutrition in the region is caused by other factors: poor water quality, low-quality health care, poor sanitation and poor feeding practices.”

According to IRIN the magnitude of the problem is huge. “A third of the population of Chad is chronically undernourished, regardless of the rains or size of the harvest. More than 50 percent of the population in Niger suffers from food insecurity, with 22 percent extremely food insecure, according to the World Bank in 2009.”

IRIN suggests that the solution to the problem requires addressing “the multi-dimensional aspects of malnutrition, including livelihoods, food production, social protection, health, water and disaster risk reduction; and on responses that focus on strengthening the incomes of poor households.”

Although malaria prevalence is low and seasonal in the Sahel, it is one of the health risks that contribute to chronic malnutrition in the Sahel. Bechir and colleagues researching the problem in Chad found …

“Thirty-four percent (CI 27-40) of nonpregnant women, 53% (CI 34-72) of pregnant women, and 27% (CI 23-32) of children were anemic. In subjects infected with Plasmodium, all women and 54% (CI 22-85) of children were anemic. Malnutrition was significantly associated with anemia in mothers and with selected intestinal parasites, anemia and age in their children.”

As an intervention, Tine et al. found in Senegal that “Combining IPTc and HMM can provide significant additional benefit in preventing clinical episodes of malaria as well as anaemia among children in Senegal.”

We must not forget the interrelatedness of health and development issues and their interventions. More inter-sectoral thinking and planning is needed.

Vida Ami Kukula from Dodowa Health Research Centre, Accra, Ghana, shares her poster presentation from the recently concluded American Society of Tropical Medicine and Hygiene Conference.

The influx of antimalarial drugs remains a great concern for health care providers and regulatory bodies. Monitoring the safety of antimalarial drugs at the community level possess a challenge to effective pharmacovigillance. Though, spontaneous reporting of events has been the easiest way of monitoring drug safety; these reports are not as expected. This method also has shortfall because only few patients report. Cohort event monitoring (CEM) is a more effective way of monitoring as visiting people in their homes is expensive.

The use of mobile phone calls to patients prescribed an antimalarial has not been adequately explored. This paper investigates how mobile phone calls can be used to monitor antimalarial safety in rural Dangme West District. CEM of patients with uncomplicated malaria prescribed an antimalarial from seventeen health providers were enrolled and followed by trained field workers.

A pre- treatment form was administered, patient information such as prior medications taken were recorded. Phone numbers of patients including home addresses was documented. Patients were informed and followed up by phone call or visited at home for patients without phones.

Follow ups were made from day three when they were expected to complete their antimalarial, however patients who experienced new events before day three were visited before their scheduled visit date. Post treatment form recorded new events patients experienced after taking the anti- malarial, and any other drug taken during the three days of the antimalarial treatment.

4165 patients were enrolled onto the study, 4144 cohorts were followed. 2630 (63.5%) were successfully interviewed on phone and 1514 (36.5%) by visits. Each call interview lasted an average of 4 minutes. It was observed that patients appreciated the calls made to check on their health.

In conclusion, mobile phone use increased access to cohort members followed up for drug safety monitoring. The use of mobile phones in future clinical monitoring activities is recommended. More studies should be conducted to confirm these findings.

Models represent reality but the closer they come to reality, they better they are at helping us plan.  A session at the American Society of Tropical Medicine and Hygiene yesterday addressed the modeling process for vector control.

VECNet is developing the capacity to take data from multiple sources to tailor vector populations and behavior to local situations. Such models need to consider vector bionomics/population variables, weather/climate/environment, and effectiveness of deployed vector control strategies.

Modelers encourage us to think beyond existing malaria control strategies and consider a varierty of mosquitoe behaviors beyond direct feeding on humans and immediate resting thereafter. Such understandings can lead us to ask whether new interventions could be directed at other vector bevahiors such as …

• laying eggs (oviposition)
• feeding on sugars
• seeking hosts
• mating
• resting generally

In short, we were challenged to look at aspects of vector biology that have been ignored or unknown in the past.

The MAP project out of Oxford is also beginning detailed mapping of vectors by region and utlimately my country.  Globally there are 41 dominant vector species, so the work ahead is immense, but some mapping has started with three in a program called Risk Mapper.

The session also included product impact estimation. This should help program planners decide on hypothetical outcomes of investments in different existing interventions and even consider possible outcomes were new interventions developed to address the other aspects of mosquito behavior outlined above – e.g. traps, repellents.

The modeling process requires a lot of data that needs to be updated as control interventions proceed. Such data requires a strong corps of entomologists and health information systems staff that many countries lack.  Hopefully modeling efforts will also include these elements of human resource development.

Is malaria treatment affordable in a rural district of Ghana? – a poster presentation at the American Society of Tropical Medicine and Hygiene annual meeting.

Alexander A. Nartey, Patricia Akweongo, Christine Clerk, Elizabeth Awini, Jonas Akpakli, Margaret Gyapong: Dodowa Health Research Centre, Accra, Ghana

Although Ghana has instituted a national health insurance scheme (NHIS) as a measure to lessen the burden of health care cost to households, majority of people continue to pay cash directly to seek care, a study has revealed.

The study which was conducted in  Dangme West District from October 2009 to August 2011 under the INDEPTH Effectiveness and Safety Studies of Antimalarials in Africa (INESS) platform was to assess household cost in treating fevers and the socio-economic burden of fever/malaria to households in the district. Malaria ranks first on the top ten list of most important diseases within the district.

The study showed that 78.9 per cent of the 511 people interviewed from pre-selected households paid out of their own pockets for the treatment of fever while the remaining 21.1 per cent used their health insurance. The majority of the people had health insurance cover but paid directly for care because they claimed it took too long for them to be attended to at the hospital if they presented their health insurance card. Additionally, some of the respondents paid out of their pockets because they preferred the private clinics where they received prompt care for their fevers.

The study also showed that 79.5 per cent of the respondents sought care outside home by visiting a drug store or health facility. An average of ¢5.00 ($3.3 USD) was spent before seeking care at the health facility and direct average cost per visit to health facility was ¢11.5 ($7.8 USD).

The average number of days lost due to malaria was six days while reduction of productivity due to malaria accounted for 28 per cent. About 1.6 per cent of the patients borrowed money to access health care.

It is evident that a household spends substantial amount on drugs, transport and food for an episode of fever within the district. Out-of-pocket payment is very high and places a high burden on household income. A household may spend an average of 12 working days of the daily minimum wage for the treatment of a fever episode.

The study, therefore, recommended that there is the need to investigate why individuals who are insured with the NHIS have to pay to get prompt treatment at NHIS accredited health facilities. Additionally, home based management of fever should be rolled out in rural communities to help reduce household burden of treating fevers.

We recently suggested that malaria elimination efforts learn from guidelines and manuals developed for the elimination of lymphatic filariasis. Today at the American Society for Tropical Medicine and Hygiene meeting, a presentation from the South Africa National Department of Health and its partners outlined how they are “Strengthening Malaria Information Systems in South Africa: Moving Towards Elimination.”

The presentation stressed that, “locally transmitted malaria cases have declined by 92% and malaria deaths have declined by 82% in 2010 as compared to 2000.” This serious drop in malaria cases is spurring the need recognize the transition from control strategies to efforts appropriate to the pre-elimination phase.

Currently malaria is endemic in only 3 provinces, Kwazulu Natal, Mpumalanga and Limpopo, with over 90% of cases in the latter. Thyere is a lack of standardized malaria information across these three provinces, absence of timely notification and lack of information that could aid targeting of interventions.  The national program is addressing this by identifying seven key components of an information tracking system that focuses on –

1. Rapid Diagnostic Tests
2. Geographic Information System
3. Parasitology
4. Entomology
5. Indoor Residual Spraying
6. Case Investigation
7. Notification

The three provinces have some but none has all of these embedded in a comprehensive and systematic information system that does more than track epidemics.  In addition there is emphasis on ensuring adequate human resources to undertake these tasks.

South Africa recognizes that political and financial commitment is needed in the country. There is a realistic expectation that the country cannot depend on donors to sustain their malaria information system.  Hopefully these efforts will also be adopted by the other front line malaria elimination target countries in Southern Africa.

Sessions at the current American Society of Tropical Medicine and Hygiene in Philadelphia have focused on progress in the global elimination of lymphatic filariasis (LF). Filariasis and malaria have some elements in common, such as some mosquito vectors, and possibly malaria elimination efforts could learn from LF elimination.

The duration of a typical filariasis elimination program might span around 10 years, much shorter than expected for malaria, where Roll Back Malaria has already been working hard for 13 years. Even with this difference LF elimination has important surveillance tools needed for the end game that can be adapted for malaria. As the figure here shows, the first step is mapping which can take at least a year.

Then there are at least five annual mass drug administrations (MDA) with ivermectin or DEC and albendazole.  Monitoring goes along with distribution, and as pointed out at a panel presentation at ASTMH, determines whether the program can enter Step 3 (three rounds of annual surveillance) or complete a few more MDA rounds.  Eventually the project site is certified as having eliminated filariasis.

An ASTMH symposium highlighted the challenges: “The decision to implement a mass drug administration (MDA) program for LF is based on convenience sampling to demonstrate that the prevalence of infection is greater than 1% in a selected district or implementation unit. Making the decision to stop MDA has been a challenge for countries,” when prevalence drops below 1%.

Fortunately those involved in LF have tools and guidelines to focus their efforts. These guide initial mapping and choice of diagnostic tools, ongoing program monitoring and endline Transmission Assessment Surveys (TAS)  The purpose of the guidelines is …

“Effective monitoring, epidemiological assessment and evaluation are necessary to achieve the aim of interrupting LF transmission. Th is manual is designed to ensure that national elimination programmes have available the best information on methodologies and procedures for (i) monitoring MDA, (ii) appropriately assessing when infection has been reduced to levels where transmission is likely no longer sustainable, (iii) implementing adequate surveillance aft er MDA has ceased to determine whether recrudescence has occurred, and (iv) preparing for verifi cation of the absence of transmission.”

The guideline manual provides general guidance to national programmes but reminds program managers that each program is unique and may require further technical guidance.

Several countries, especially in the Asia-Pacific Region and Southern Africa are working toward malaria elimination. Such tools adapted to malaria program needs are required. One of the challenges for the TAS is that while countries have received donations of medicines to eliminate LF, they have found it harder to find or allocate funds to do the necessary surveillance to know when to stop interventions and verify elimination. This also rings true for malaria – donors and governments should not stop funding malaria elimination until certification has been achieved.

Jhpiego presented its recent experiences in building iCCM onto an existing malaria program in Akwa Ibom State, Nigeria, during the American Society of Tropical Medicine and Hygiene meeting today.

Establishing Integrated Community Management of Malaria, Pneumonia and Diarrhea in Two Selected Local Government Areas, Akwa Ibom State, Nigeria

William Brieger, Bright Orji, Emmanuel Otolorin, Eno Ndekhedehe, Jones Nwadike

Many intervention studies have demonstrated that local volunteers practicing integrated Community Case Management (iCCM) can increase access to appropriate lifesaving interventions. These interventions are important for giving us confidence in community capacity, but key management questions remain on how to establish, manage and expand iCCM efforts in order to reach Roll Back malaria Targets and Millennium development Goals.

The Nigeria MIS 2010 revealed inappropriate treatment andpPoor community response to malaria interventions. Among children (less than 5 years) with fever 2 weeks preceding the survey, only 26% took any antimalarial and only 3.2% took an ACT. Malaria treatment was largely by presumptive diagnosis.

A initial management decision for iCCM is what combination of interventions will comprise a start-up package. Nigeria’s Malaria Plus Package includes 19 potential health interventions at the community level, but clearly a program could not afford, let along manage the simultaneous implementation of all 19.

Jhpiego had successfully piloted community directed interventions (CDI) for  malaria in pregnancy (MIP) control interventions. Further formative research in two selected Local Government Areas showed poor access to malaria treatment for all age groups due to distance from health facility, poverty, financial constraints, and perceptions of health services quality. Therefore, iCCM was added to CDI for MIP prevention to improve treatment access and coverage for all age groups.

Teamwork was a necessary part of the process to guarantee sustainability. This included Local Government Health departments, Technical Assistance from Jhpiego (affiliate of Johns Hopkins University), World Bank Booster Project in State Ministry of Health Malaria Unit, a core Training and Supervisory team from the Ministry and iCCM/Malaria Plus Package Guidelines from National Malaria Control Program.

Stakeholder Challenges posed management problems including State Program Manager’s skepticism that community members can perform RDTs correctly, Health facility workers’ poor acceptance of RDTs as opposed to using their clinical judgment, and provider’s reluctance to trust communities with antibiotics.

Health Facility Management Challenges were numerous including procurement problems as needed medicines come from different funding sources. There was difficulty in sourcing RDTs that come with ready and easy to use components.

Procurement and supplies of AMFm drugs were delayed due to cumbersome, delayed drug registration processes. Sharps and waste disposal for RDTs needed attention. Finally there were multiple statistics tracking registers, as no one register captures all the indicators – a burden M&E personnel.

Community Challenges started with the belief that ‘blood of someone alive cannot be buried’ such that disposing of RDT cassette by burial would mean burying the person alive. Community members perceived that person has malaria even if RDT is negative. Cpommunity volunteers requested for incentives and motivation as new tasks included.

Addressing Stakeholder Challenges we held Stakeholders consensus meetings helped address reluctance by the health ministry to allow RDT use at the community level. Consensus meetings created an opportunity for programs to integrate as IMCI, RH and Malaria departments trained providers

Solving health facility management Challenges required that We work with other malaria partners to identify reliable sources of RDTs and drugs. Linking with a local pharmaceutical company already registered with AMFm helped fast tract supplies of ACTS.

Community Dialogue was essential to overcome village concerns. Through dialogue the community agreed on incineration as an acceptable method of RDT disposal. Engaged communities accepted that only positive RDT-results need ACTs. Volunteers’ demands for incentives challenged by leaders who reminded the volunteers that they were accountable to their neighbors, friends and relatives in the village. Community self-monitoring was undertaken and two volunteers who did not deliver their ACTs were fined one-goat each by the community for failing to provide services.

Lessons Learned were foremost the need for consensus building among partners on roles and extent of services to be provided by volunteers. Continual community education and dialogue prior to the initial start-up iCCM provision and throughout is required. Without attention to these start-up processes we cannot expect to reach our endpoint coverage indicators and develop a scalable and sustainable program.

Improving Quality Performance among Community Health Workers Providing Integrated Community Management of Febrile Illnesses in Nigeria

A Poster Presentation at the 60th ASTMH meeting by Bright C. Orji, William R. Brieger, Emmanuel O. Otolorin, Jones Nwadike, Enobong Ndekhedehe, Olugbenga Ishola, Godfrey Akro, Nancy Ali

Efforts to improve access to quality case management of febrile illness include the engagement of Community Health Workers (CHWs) to use Rapid Diagnostic Tests (RDTs), dispense ACTs and manage pneumonia and diarrhea. Use of CHWs reduces challenges like a weak public sector, human resource constraints, and variable quality of the private sector.

Studies have suggested that CHWs are able to perform case management services in a training setting, but not much has been done to measure quality performance among CHWs in the field. Jhpiego and the Akwa Ibom State, Nigeria health authorities trained CHWs and developed simple quality performance standards (one-page tool) for CHWs providing community services in Akwa Ibom State, Nigeria.

All 131 trained CHWs in two local government areas providing malaria, pneumonia and diarrhea case management were assessed using the standards. The tool has 37 performance criteria (PC) to measure CHW knowledge, skills and competence in 3 sections:

• History taking and Examination
• Conducting RDTs for Malaria and
• Illness Management

Trained assessors observed CHWs providing services. Each correctly performed criterion was scored 1 point. Three rounds of assessments were conducted at an interval of two months from May-November, 2011.

At the end of each round assessors provided feedback and refresher training for CHWs during their monthly meetings. During Round 1 CHWs achieved an average of 19 (52.2%) PC. This rose to 25 (67.5%) PC at Round 2 and 28 (75.6%).
PC that needed most improvement included checking signs and symptoms to distinguish among the illnesses. CHWs also needed reinforcement on checking RDT expiry date, entering results on records, safe disposing of sharps, and counseling on preventive measures.

In conclusion feedback after Rounds 1 and 2 helped CHWs improve their performance. Additional quarterly assessments and feedback sessions are planned. CHW supervisors can use this tool to enhance the quality of services provided by the CHWs and improve CHW training.

The ASTMH 60th annual meeting today featured a panel on integrated community case management (iCCM). The variety of experiences was notable. Some used volunteer CHWs, while had ones receiving a very minimal pay package. In some cases RDTs were used, while in others not. In some places national policy allowed CHWs to give antibiotics, though not in others.

A multi-country study sponsored by the Tropical Disease Research Program trained CHWs in using RDTs for malaria and recognizing high respiration rates for pneumonia. The intervention group had lower than 5% rate of inappropriate ACT provision compared to around 20% for the control CHWs. While incorrect antibiotics use was better in the intervention group, it was still 40%. This must be addressed to avoid problems like antibiotic resistance.

In Cameroon training CHWs had a very positive effect on access to malaria and diarrhea case management. Access through CHWs was especially higher among the poorest segment of the population.

A quality of care study in Malawi among community based health surveillance assistants (HSAs) found that a simplified IMCI algorithm found improvements in assessment, classification and treatment skills performance for malaria, pneumonia and diarrhea. Community satisfaction was also greater with the IMCI-trained HSAs.

While intervention studies showed improved skills of and access to CHWs for iCCM, management problems like stock-out were also documented. An MCHIP analysis of iCCM logistics issues found that variations in access may be due to whether a country practices cost recovery or has a uniform national supply and logistics system. Fortunately, even if CHWs raise the issue of material incentives, they do value the knowledge they gain, and the recognition they receive from the community.

Thirty-three years after Alma Ata we working hard to understand the basic processes and functions of CHWs. Clearly one size will not fit all, but common goal can be improving access to quality care for all.

The American Society of Tropical Medicine and Hygiene’s 60th annual meeting began today in Philadelphia with a keynote talk by Jeffrey Sachs, Director of the Earth Institute at Columbia University. The talk echoed Sachs’ recent online writings about the uncertainties in Global Fund support from major donors, especially the United States. But first the good news.

Sachs reminded the audience that this year marks ten years of Global Fund existence.  In that time, he explained, many new malaria technologies have become available ranging from an alphabet soup of ACTs, RDTs, LLINs, IPT, SMS and more.  This period has also seen a major increase in global malaria financial support (World Bank, Global Fund, PMI, etc.,) from $0.2 billion in 2004 to $1.8 in 2010.

Sachs cautioned that figures in the millions and billions were not the usual grist of macroeconomists who prefer to consider the movement of trillions of dollar or more. And yet, he noted that even with this scale up over the years, millions of malaria deaths have been averted.

Then came the challenges. Global Fund support has been mostly used for commodities, as ‘acronymed’ above. What is needed are string primary health care systems, including community health workers, to deliver these interventions.  Sachs stressed that such commodities should be free to poor people, and that social marketing strategies were actually a death sentence to poor people who could not protect their families without free and equitable access to these services.

Finally, the bad news. Sachs called our current situation with Global Fund a crisis in development assistance.  He described the crisis in terms of …

• Unprecedented attaches on development assistance by Republican candidates for the US Presidency
• Lack of current White House Leadership
• Cancellation of Global Fund Round 11

Sachs wondered whether the Millennium Development Goals can now be achieved. He concluded that gains against the diseases are all at risk, and that we are on the edge of collapse after ten years of work.Clearly much of the research and programs discussed at this weeks meetings will be threatened by expected cuts in development assistance, but more importantly, lives that the rearch and programs could benefit are at greater risk.