Posts or Comments 31 January 2023

Monthly Archive for "October 2022"



Antenatal Care (ANC) &IPTp Bill Brieger | 31 Oct 2022

Comparative analysis of facility and community distribution of intermittent preventive treatment of malaria in pregnancy

Charity Anoke, Bright Orji, Emily Bryce, Elizabeth Oliveras, Joseph Enne, Elizabeth Njoku, Lawrence Nwankwo, Emmanuel Ugwa, Bartholomew Odio, Herbert Onuoha, Christina Maly, Emmanuel Otolorin, Elaine Roman, and Oniyire Adetiloye are presenting a poster for the TiPToP project at the American Society of Tropical Medicine and Hygiene’s Annual Meeting in Seattle. Below is the evidence from maternity record booklets in Ohaukwu, Ebonyi State Nigeria.

Nigeria has the highest malaria burden globally, contributing to 31.9% of global malaria deaths, and is one of the two countries with the greatest burden of malaria during pregnancy. According to the 2018 Nigeria Demographic and Health Survey (DHS), even though up to 57% of pregnant women attend ANC four or more times, only 17% received three or more doses of IPTp as recommended by the WHO.

Nigeria supported this demonstration project of CHWs in delivering intermittent preventive treatment of malaria in pregnancy (IPTp) at the community-level, complementing IPTp at antenatal care (ANC) in three districts. Data were extracted from 735 maternity record booklets (MRB) at 25 public health facilities in Ohaukwu for women presenting for ANC between April and September of 2019. The MRB allowed for the longitudinal analysis of client-level data that is not available from routine data sources.

Sixty percent of women received IPTp doses only in the community, while 28% received IPTp only at ANC and 12% received IPTp in both locations. One-way ANOVA and post-hoc Tukey tests were used to examine the difference in mean number of ANC visits and number of IPTp doses between the three groups. The mean number of ANC visits was significantly higher in the group of women receiving IPTp at both locations compared to those only receiving IPTp in the community (0.89 ± 0.18 visits, p<0.01) and those only receiving IPTp during ANC (0.61 ± 0.20 visits, p<0.01).

There was no statistically significant difference in the mean number of ANC visits between the groups receiving IPTp only in one location (0.29 ± 0.13 visits, p=0.077). The difference in number of doses was statistically significant across all groups, whereby women in the facility-only group received the fewest IPTp doses. Receipt of IPTp in both locations was associated with both greater numbers of ANC visits and IPTp doses. Only receiving IPTp in the community was not associated with a decrease in ANC attendance.

These data suggest complementing ANC-based IPTp distribution with community-based distribution is beneficial.

Children &Mortality &Seasonal Malaria Chemoprevention Bill Brieger | 31 Oct 2022

Contribution of Seasonal Malaria Chemoprevention (SMC) to the Reduction of Malaria Burden in Children Under 5 Years of Age in the Sud-Ouest Region, Burkina Faso

Moumouni Bonkoungou, Ousmane Badolo, Mathurin Bonzi, Youssouf Sawadogo, Andre Kone, Thierry Ouedraogo, Gauthier Tougri, Mathurin Dodo, Edward Kenyi, Gladys Tetteh, and William Brieger working with the US PMI Impact Malaria project implemented Seasonal Malaria Chemoprevention (SMC) in collaboration with the National Malaria Control Program (NMCP) of Burkina Faso in 3 regions. Their findings are seen below and are presented at the Annual Meeting of the American Society of Tropical Medicine and Hygiene in Seattle.

According to health statistics for 2020, in Burkina Faso, malaria accounts for 40% of medical consultations and 27% of deaths. Children under 5 years of age account for 72% of malaria deaths. 

In 2021, the SMC consists of the administration of three days of monthly treatments of amodiaquine plus sulfadoxine-pyrimethamine to all eligible children (3-59 months of age) during the high malaria transmission season (June to October). The objective is to maintain therapeutic concentrations of these antimalarials during the period of high transmission. 

In 2021, 19 of 70 health districts (27%) were supported by the project to implement SMC with more than 838,000 children under 5 years treated, including 180,000 from the Sud-Ouest region (Dano, Batie, Kampti, Gaoua, and Diebougou health districts). In this region of high rainfall, the number of severe malaria cases in children under 5 years decreased from 17,760 in 2017 (before SMC) to 14,609 in 2021 with SMC after 4 years of SMC implementation, i.e., a reduction of 17%. 

The number of malaria deaths also decreased from 133 in 2017 (before SMC) to 118 in 2021, a reduction of 11%. Kampti health district recorded the highest reduction of deaths of 78% [33 to 7 deaths] between 2017 and 2021 and Dano district had a reduction in severe malaria cases by 28% between 2017 and 2021. 

The main challenges with SMC include a delay in referral of fever cases by community distributors to health facilities during the campaign, management of vomiting during the 2nd or 3rd dose, and failure to retain the treatment cards by the parents. Seasonal Malaria Chemoprevention is a proven intervention and appears to be an important

component of the malaria prevention strategy in Burkina Faso but consideration should be given to address ongoing implementation challenges.

Conflict &ITNs Bill Brieger | 30 Oct 2022

Insecticide Treated Mosquito Nets in Conflict-Affected Fragile States

Marwa Ramadan of the Alexandria Faculty of Medicine, Alexandria, Egypt and William Brieger of the Johns Hopkins Bloomberg School of Public Health are presenting this information at the Annual Meeting of the American Society of Tropical Medicine and Hygiene in Seattle.

Studies have highlighted the potential impact of conflict and displacement on malaria prevention and mitigation efforts, but few investigated the effect of subnational conflict intensity on access and utilization of mosquito nets in fragile countries.

This study bridges the gap by applying a conflict intensity lens to the analysis of access and utilization of Insecticide Treated Nets (ITN) in two conflict-affected fragile states (Nigeria and Democratic Republic of Congo (DRC)), where at least 45 % of global malaria deaths occur.

We used the Demographic health survey (DHS) and the Uppsala Conflict Data Program for information on access and utilization of nets and conflict events respectively. Access was defined as the percentage of population with at least one ITN per 2 household members, while utilization was defined as the percentage of population who slept under an ITN the night before the survey in households with at least 1 ITN.

To define conflict intensity, we linked household clusters to conflict events within a 50 km distance using ArcGIS. Conflict intensity was then categorized into medium or high intensity conflict and no or low intensity conflict using a cut-off of 2 or more deaths per 100, 000 population per cluster. Access and utilization of ITNs was compared by conflict intensity at the household cluster level.

Analysis of data from 281,689 individuals living in 58,183 households revealed that 42.8% (CI: 42.3 – 43.3%) and 39.9% (CI: 39.5 – 40.1%) of members living in neighborhoods with medium and high intensity conflict in DRC and Nigeria respectively had access to ITNS compared to 47.9% (CI: 47.6 – 48.1%) and 51.0% (CI: 50.8 – 51.2%) in no or low intensity conflict.

Similarly, 65.1% (CI: 64.3 – 65.9%) and 62.8% (CI: 62.3 – 63.3%) of those living in medium or high intensity conflict in DRC and Nigeria respectively utilized ITNS compared to 69.2 % (CI: 68.8 %-69.6 %) and 65.7% (CI: 65.4-66.0%) in no or low intensity conflict.

National malaria control programs must consider that access and utilization of ITNS are statistically significantly lower in neighborhoods with medium or high intensity conflict and target supporting interventions accordingly.

Children &COVID-19 &Diagnosis &IPTp &ITNs &Malaria in Pregnancy &Treatment Bill Brieger | 06 Oct 2022

2021 DHS and MIS Findings from Six Malaria Endemic Countries

The Demographic and Health Survey Program has released final and summary reports for both DHS and Malaria Indicator Surveys (MIS) for 2021 from several malaria endemic African countries. Below is a brief summary of some of the findings from Madagascar, Nigeria, Burkina Faso, Mali, Côte d’Ivoire, and Senegal. Click the link on each country to download a copy for yourself.

The proportion of the population who slept under an insecticide treated bednet the night before the survey varied. In Madagascar it was 49%, While in Nigeria it was 59%. Mali achieved the highest coverage at 73%, while Burkina Faso had the lowest previous night coverage at 41%.

Senegal showed a worrying decrease from 63% in 2016 to 46% in 2021. Côte d’Ivoire did not report total household use, but indicated that 72% of homes had at least one net, with 58% of children below 5 years of age and 64% of pregnant women sleeping under them.

At least three doses of sulfadoxine-pyremethamine is recommended for Intermittent preventive treatment of malaria in pregnant women. The national average was 38% for at least 3 doses in Senegal, although ironically 92% had been reached with the first dose. In Mali only 35% received at least a third dose. Burkina Faso started out with 92% for the first dose, but reached 57% with three or more. Côte d’Ivoire started with 80% receiving their first dose and concluded with only 35% receiving a third. Both Madagascar and Nigeria had the lowest 3-dose coverage at 31%.

Malaria testing and treatment using rapid diagnostic tests and artemisinin-based combination therapy (ACT) was reported. Nigeria demonstrates the challenges of following guidelines. Although 63% of children under 5 years of age were reported to have had a fever in the two weeks preceding the survey, only 24% of those received a diagnostic test. The summary results report that 74% of those with fever “who took any anti-malaria medicine” used the recommended ACT. The implication is that many received medicine without confirmatory testing such that some may have gotten ACT who needed another medicine and some who actually had malaria may have missed the correct treatment.

A similar low level of testing was seen in Senegal (22%), Mali (23%), and Madagascar (20%). Côte d’Ivoire reported 38% of febrile children having been tested. Burkina Faso performed better for testing with 65%.

These brief findings indicate that implementation of Malaria interventions are far from ideal. We know that some of the blame can be placed on health service disruptions due to demands of COVID-19 activities by health ministries and partners. Still, with 8 years remaining until 2030, Reinvigorated efforts are needed in all endemic countries if these six examples are indicative of the challenges we face.