All posts by Bill Brieger

Joint Efforts to Improve Malaria Control in Three Refugee Camps in Kigoma, Tanzania

A team affiliated with the USAID-supported Boresha Afya health project in Tanzania prepared a presentation for the 68th Annual Meeting of the American Society of Tropical Medicine and Hygiene entitled, “Joint Efforts to Improve Malaria Control in Three Refugee Camps in Kigoma, Tanzania: Successes, Challenges and Lessons Learned,” as seen below. Team members included Shabani K. Muller, Juma Ng’akola, Zephani Nyakiha, Godfrey Smart, Tesha Goodluck, Jasmine Chadewa, Agnes Kosia, Zahra Mkomwa, Abdallah Lusasi, Dustana Bishanga, Rita Noronha, Lusekelo Njonge, Ally Mohamed, Gaudensia Tibajiuka, Chonge Kitojo, and Erik Reaves (Affiliations: USAID Boresha Afya Project -Path Tanzania; USAID Boresha Afya Project –Jhiego Tanzania; National Malaria Control Program, Regional Health Management Team-Kigoma. President’s Malaria Initiative/United States Agency for International Development)

Overview of USAID Boresha Afya Lake and Western Zones: USAID’s 5-year project was implemented in seven regions of Tanzania, including Kigoma. It supports the Government of Tanzania increasing access to high-quality, comprehensive, and integrated health services, with a focus on women and children. Its goal is to improve the quality of malaria case management, including malaria in pregnancy.

Malaria prevalence in Tanzania has decreased by half, from 14.8% in 2016 to 7.3% in 2017 (2015 and 2017 Tanzania Malaria Indicator Surveys). Malaria prevalence in Kigoma is 24% (above national prevalence). According to quarterly District Health Information System 2 data at facility level, about 50% of all malaria cases in Kigoma Region are from the three refugee camps.

Overview of Refugee Situation in Kigoma Region: The majority of refugees fleeing conflicts in Burundi and Democratic Republic of the Congo are hosted in Kigoma.
The three major refugee camps in Kigoma are Nyarugusu, Nduta, and Mtendeli.

Interventions to Improve Malaria Case Management included the following

  • Conducted on-the-job training and mentorship.
  • Conducted joint supportive supervision.
  • Discussed challenges and how to address them in refugee camp settings with other malaria partners.
  • Identified poor-performing indicators.
  • Collaborated with community providers.

Results of these interventions included the malaria lab reporting rate increased from 42% to 100%. This means that the rate of facilities reporting laboratory results in the District Heath Information System was very low. Clinical malaria diagnosis decreased from 4% to 0%. Nyarugusu’s malaria positivity rate decreased from 61% to 52%. Kigoma Region’s number of annual deaths due to malaria decreased from 359 in 2017 to 191 in 2018.

Results also showed an increased percentage of pregnant women who received the second dose of intermittent preventive treatment of malaria in pregnancy (IPTp2) from 26.7% in 2017 to 84.3% by June 2019. Increased IPTp3 coverage from 9.4% in 2017 to 13.2% in 2018.

Challenges and Mitigation are outlined in the attached table.

Several Lessons were Learned from the interventions. On-the-job and malaria mentorship training are important components in improving malaria case management in refugee camps. Supportive supervision is mainly based on gaps identification, and mentorship is focused on hands-on skill and capacity-building. Regular supportive supervision, when correctly using the MSDQI Tool, improves malaria service provision.

Working in collaboration with other stakeholders to implement vector control, social and behavior change communication, and other interventions is important in the fight against malaria in refugee camps.

This presentation was made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of the USAID Boresha Afya and do not necessarily reflect the views of USAID or the United States government.

Using Seasonal Malaria Chemoprevention (SMC) to Screen for Acute Malnutrition

Moumouni Bonkoungou, Ousmane Badolo, Youssouf Sawadogo, Stanislas Nebie, Thierry Ouedraogo, Yacouba Savadogo, William Brieger, Gladys Tetteh, and Blami Dao (affiliation PMI Improving Malaria Care Project; Jhpiego Baltimore; Johns Hopkins University; Ministry of Health, National Malaria Control Program) presented a poster entitled Using Seasonal Malaria Chemoprevention (SMC) to Screen for Acute Malnutrition at the 68th Annual Meeting of the American Society of Tropical Medicine and Hygiene. Their findings are outlined below.

Malaria and malnutrition remain major public health burdens in Burkina Faso for children under five years of age. In 2017 the case fatality rate of malaria was 1.5 percent among children under five years of age and malaria was responsible for 35.9 percent of deaths in primary health facilities. Malnutrition was responsible for 4.6 percent of deaths in primary health facilities and 3.3 percent of deaths in hospitals in 2017.

What is IMC project? The US President’s Malaria Initiative (PMI) funded the Improving malaria Care (IMC) since 2013 to support National Malaria Control Program (NMCP). The goal is to improve quality of malaria prevention, diagnosis and treatment through 05 strategies.

Malnutrition was detected at the level of health facilities. The nutrition program did not have resources for active screening for malnutrition Since 2018, it has been decided on the couple with the SMC to recruit more children.

What is the strategy? In 2018, Burkina Faso Seasonal Malaria Chemoprevention (SMC) campaign integrated malnutrition screening in 12 health districts supported by IMC. During the SMC campaign, community health workers administer sulfadoxine-pyrimethamine + amodiaquine (SP+AQ).

They also screened for malnutrition using the Shakir sling to measure mid-upper arm circumference to detect for acute malnutrition. Children who are not severely malnourished receive the standard malaria preventative treatment by SP+AQ. Children diagnosed with severe malnutrition do not receive SP+AQ and are referred to health facilities for appropriate case management.

Moderate and severe malnutrition was documented in October 2019. In November, after the last round (October), 427 children with severe acute malnutrition have been reported by health facilities. 81.3 percent of severe acute malnutrition detected during SMC.

Challenges of SMC and malnutrition screening were documented as follows:

  • Inaccessibility of some areas
  • Reference of severe cases for management
  • Adequate home management of moderate cases
  • Proper care of referred children in health facilities
  • Follow-up of referrals
  • Search for those not followed-up

In Conclusion in the context of a limited resource country, SMC is a good strategy for the reduction of malaria cases as well as a great opportunity for the detection and management of malnutrition in children under five years of age. It is recommended to Couple the screening of malnutrition with other activities (immunization, distribution of bednets …). Raising parents’ awareness of the importance of managing cases is necessary as is Encouraging active case finding and community referral.

This poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID) under Cooperative Agreement No. AID-624-A-13-00010 and the President’s Malaria Initiative (PMI). The contents are the responsibility of the authors and do not necessarily reflect the views of USAID, PMI or the United States Government.

Retention of malaria knowledge and skills and adherence to National Malaria Treatment Guidelines by integrated community malaria volunteers

Retention of malaria knowledge and skills and adherence to National Malaria Treatment Guidelines by integrated community malaria volunteers in three States/Regions in Myanmar is the focus of a poster presentation by Ni Ni Aye, Aung Thi, Kyawt Mon Win, Thiha Myint Soe, May Oo Khin, Khant Maung Maung, and Saw Naung Naung at the 68th Annual Meeting of the American Society of Tropical Medicine and Hygiene. They are affiliated with Jhpiego Myanmar PMI Defeat Malaria Project, University Research Co. Myanmar PMI Defeat Malaria Project, and Myanmar National Malaria Control Program.

The PMI-supported Defeat Malaria Project aims to enhance technical and operational capacity of the National Malaria Control Program and providers at all levels of the health system in 3 States/Regions (S/R). In 2017, Myanmar introduced a new type of cadre, Integrated Community Malaria Volunteers (ICMV), as a foundation for integrated malaria control activities at village level.

Defeat Malaria is developing their capacity to ensure malaria case management according to National Treatment Guidelines (NTG). To date, Defeat Malaria has prepared 71 national and S/R level trainers to train and supervise 776 ICMVs caring for a population of nearly 600,000 people.

The study would like to explore the knowledge and technical skills retention of ICMVs working in these three States/Regions and how exactly they follow the national treatment guidelines.  NMCP’s Policy on ICMV notes that Malaria volunteers have been renamed as Integrated Community Malaria Volunteers (ICMV). Their Primary roles are malaria diagnosis, treatment, referral and IEC/BCC activities. They Refer and follow up when other diseases are suspected, including TB, HIV, leprosy, dengue and filariasis.

The Objective of the study was to explore the retention of malaria knowledge and skills of Integrated Community Malaria Volunteers after the training in Kayin and Rakhine States and Taninthary Region.  Also the study explored adherence to National Treatment Guidelines by the Integrated Community Malaria Volunteers in Kayin and Rakhine States and Taninthary Region.

This will be the secondary data analysis of “malaria knowledge and skills retention” using post training follow up tools and checklist during the supported supervision of NMCP conducted jointly with Defeat Malaria team in 2018 -2019 in three state and Region. The study population included 92 ICMVs.

Initial and refresher ICMV trainings included a 5-day modular course for initial ICMV training as well as a 3 days focusing on malaria epidemiology, malaria diagnosis, treatment and referral. There was an IEC/ BCC component focusing on community-based prevention. Another component was a 2-day update on other diseases: TB, HIV, leprosy, dengue and filariasis including referral and follow up of suspected cases.

Another 3-day course for refresher ICMV training one year after initial training was provided. A 2-day session focusing on malaria diagnosis, treatment and referral, case studies and filling register was given. Finally, there was a 1-day update on other diseases.
Improved malaria knowledge among trained ICMVs in two regions (Gwa and Hlaningbwe) was demonstrated. There was reduced gap between pre- and post-test scores at initial vs. refresher training.

Initial training of ICMV and post training assessments of retention of malaria knowledge resulted in 892 ICMV from 14 townships being trained. 54% of ICMV had a passing score (?80%) in pre test for knowledge of malaria. More than 90% of ICMV had a passing score in post test for knowledge of malaria.

Additionally 92 ICMV were followed up after training to assess knowledge of malaria. 42 ICMV were assessed within 6 months after training, and 50 ICMV were assessed after 6 months of training.

Post training assessment of retention of malaria case management skills for ICMV 6 month after training found that 100% of ICMV achieved a passing score using a standardized skills check list during a simulation. Performance improved over the previous year’s 6-month post training assessment in RDT testing. 92% of ICMV told patients about blood testing and provided emotional support, and 100% of ICMV conducted RDT testing according to standardized checklist.

All ICMV disposed of used lancets immediately into safety box after use, and 95% of ICMV gave health education. 90% of ICMV recorded the test result in the main register. 100% of ICMV provide correct treatment according to NTG by using Job Aids. Only 30% of ICMV referred suspected other diseases (TB, leprosy, dengue) with negative RDT to the health centre.

Case management and adherence to NTG by ICMV during supervision period (Oct 2018 – September 2019) also reached 100%.

In conclusion, Supportive supervision, mentoring, and attention to language barriers lead to improved post-training retention of knowledge and skills. 1-6 months after ICMV training, retention of knowledge, skills, and decision making related to malaria case management are high in all 3 States/Regions. >6 months after completing training, knowledge retention and skills on malaria case management of ICMV are less in Rakhine and Tanintharyi Regions. Retention of knowledge and skills of ICMV who received lower scores due to language barriers were improved by mentoring during supervision in Kayin State.

After 6 months, a decline was noted in ICMVs’ communication skills for health education during RDT testing. Since most RDT tests are negative, they must use job aids to recall correct treatment for positive case but are still confused about use of primaquine even with job-aids. All ICMV adhered to NTG for positive cases and negative cases. They referred negative cases suspected of having other disease (TB, leprosy and dengue) to the health center.

Moving forward, tablets will be used to gather data during ICMV mentoring visits to facilitate data accuracy and sharing. Data will be uploaded to NMCP through Google. Project staff will continue to accompany NMCP on supportive supervision visits to ICMVs 1 – 6 months post training to model best practices and lend to sustainability of the approach.

This poster is made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the terms of its Cooperative Agreement No. AID-482-A-16-00003 and the USAID Defeat Malaria Project. The contents are the responsibility of the authors and do not necessarily reflect the views of USAID, PMI or the United States Government.

Prioritizing Facilities for Malaria Case Management Training In the Era of Limited Resources

Presenting at the 68th Annual Meeting of the American Society of Tropical Medicine and Hygiene are James Sarkodie, Amos Asiedu1 Eric LaFary, Richard Dogoli, Raphael Ntumy, Lolade Oseni, and Gladys Tetteh who are sharing experiences on “Prioritizing Facilities for Malaria Case Management Training In the Era of Limited Resources”. The authors are affiliated with the PMI Impact Malaria (IM) Project and Jhpiego Baltimore. Below are their findings.

Ghana has made significant recent improvements in malaria control, reducing malaria deaths by 70% (1565 in 2015 to 468 in 2018) with a corresponding decline in under-5 malaria case fatality rate (CFR) from 0.51% to 0.19%. However, significant geographical variations in malaria morbidity and mortality persist and to achieve greater impact, a one-size fits all training approach may no longer be the most effective option.

The training aimed to prioritize facilities for refresher malaria case management training by the US President’s Malaria Initiative-funded Impact Malaria Project in collaboration with Ghana Health Service through systematic evidence-based criteria informed by quantitative and qualitative data. The team gathered information using routine health management information system (HMIS) data from October 2017 to September 2018 including total malaria admissions, malaria deaths malaria case fatality rates were determined for all districts in respective regions.

Districts with high burden malaria mortality and morbidity were ranked using a Pareto chart. Districts with CFRs above the regional average were also identified.

Assessed qualitative data including facility referral patterns, access, and ownership (government, faith-based, private) to explain the observed findings.  Information used by Regional health management teams to prioritize districts and facilities for additional malaria case management training focusing on assessment, treatment and management of complications, effective monitoring and using quality improvement methods to identify change ideas to test to improve malaria case management. Figure 1 shows the Scheme of approach to prioritizing facilities for Intervention.

Analysis of Routine HMIS data for FY-2018 reveals 37 Districts accounted for 33.9% of all districts in the 5 IM Target Regions & 14.2% all Districts in Ghana. There were 183 Malaria Deaths. Fiudings also observed that 90.1% all Malaria deaths in 5 IM Target Regions, and 39.1% of all Malaria deaths in Ghana

A number of districts had child case fatality rates above the regional average. The Districts with under-5 malaria CFR above the regional average were Ashanti Region (AR) – 31%, , Brong Ahafo Region (BAR) – 28%, Eastern Region (ER) – 31% , Upper East Region(UER) – 15% and Upper West Region (UWR) – 27%. Figure 2 shows the Proportion of Malaria Admissions And Mortality Attributable to TOP 10 Facilities In Target Regions – FY-19

The result of selecting districts and facilities using Pareto Charts is seen in Figures 3 and 4. Figure 3 sows the  Distribution of Malaria Deaths in Districts in Ashanti Region, Ghana, FY-2018, and Figure 4 presents the Distribution of Malaria Deaths in Districts in Brong-Ahafo Region, Ghana, FY-2018.

In conclusion, using routine DHMIS2 data backed by qualitative information including access to health facilities, referral patterns and facility ownership, a rational replicable basis for the prioritization of districts and facilities for intervention can be created and facilities prioritized for training based on evidence.

Regional Health Management teams have adopted a rational approach for prioritizing health facilities for intervention with limited resources with the objective of achieving the best outcome.

Intensive Malaria Microscopy Training in Rwanda

Noella Umulisa, Veneranda Umubyeyi, Tharcisse Munyaneza, Ruzindana Emmanuel, Aline Uwimana, Stephen Mutwiwa, and Aimable Mbituyumuremyi presented “Assessment of Competence of Participants Before and After 6-day Intensive Malaria Microscopy Training in Rwanda” at the 68th Annual Meeting of the American Society of Tropical Medicines and Hygiene. (Affiliations: Maternal and Child Survival Program/Jhpiego, Malaria and Other Parasitic Diseases Division [Mal & OPDD], National Reference Laboratory, Rwanda Biomedical Centre [RBC]). Their findings are shared below.

WHO recommends prompt malaria diagnosis either by microscopy or malaria rapid diagnostic test (RDT) in all patients with suspected malaria before treatment is administered. Light Microscopy remains the mainstay of malaria diagnosis, allows the identification of different malaria-causing parasites (P. falciparum, P. vivax, P. malariae and P. ovale). It is estimated that a diagnostic test with 95% sensitivity and 95% specificity requiring minimal infrastructure would avert more than 100,000 deaths and about 400 million unnecessary treatments. Frequent delays occur since conventional microscopy methods are labour intensive, require skilled manpower and time

Sufficient training of laboratory staff is paramount for the correct microscopy diagnosis of malaria. In Rwanda, P. falciparum is by far the most common contributing 97-99% of the parasite population, followed by P. ovale with 0.5-2% and followed by P. malariae 0.5–1% as mono-infection.

Rwanda has 8 referral hospitals, 4 provincial hospitals, 36 district hospitals, 504 health centers, 818 health posts and 30,000 CHWs able to perform malaria diagnostics. Each of these health facilities has a laboratory able to perform malaria microscopy with at least 1 trained lab technician and 1 functioning microscope.

In May 2018, the Rwanda Biomedical Center and partners trained 1 lab technician per health center from 6 poor performing districts in malaria microscopy. The main objective was to evaluate the performance of laboratory technicians in detecting and quantifying malaria parasites from 75 health facilities within 6 districts in Rwanda. Information was collected at two points in time.

In Month 1 there were a Pre-Test for Theoretical and practical evaluation, a Practical session, Slides preparation practice, and detection of parasite’s density and species. This was followed by the Post-Test, again a Theoretical and practical evaluation

In Month 4 Post training follow up was conducted with 35 randomly selected trained lab technicians after 4 months. Observation of technicians’ Conduct visual inspection and maneuvers used in routine malaria diagnosis was done. Their ability to Detect parasites on a standardized pre-validated slide panel of five slides was determined. during this 4 Months Post-Training Species Detection Performance, P. Falciparum was identified correctly more often than P. ovale or P. malariae.

The attached charts show the results of training. During the training 75 technicians from 75 health centers in 6 districts were trained from May 28th–June 18th, 2018. 53% of the trained lab technicians were female and 47% male.

Correct Parasite Density was slightly higher just after training. Classic training improved the performance of lab technicians in parasite’s density from 53% to 87% immediately after training.

After 4 months of training, P. falciparum and P. ovalae were correctly detected by 93% and 79% of lab technicians, respectively. Also, after 4 months of training, P. malariae was detected only by 68% of evaluated lab technicians. Training: Sensitivity (99%) and specificity (85%) remain high. Performance of lab technicians assessed using standardized pre-validated slide panel as gold standard after >4 months

Trainings of lab technicians improves performance on malaria parasites density and species detection. P. falciparum is the most well detected species followed by P. ovale . The detection rate for P. malariae was the lowest, this can be explained by the fact is not often seen in Rwanda. Participants had high sensitivity and specificity in the detection of malaria parasites.

Continuous capacity building for lab staff is needed to ensure accurate malaria laboratory diagnosis for appropriate treatment. Malaria microscopy diagnosis quality control/assurance activities from central and district level to health center level should be strengthen for continuous capacity building of lab technicians

Acknowledgements: This poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of the Maternal and Child Survival Program and do not necessarily reflect the views of USAID or the United States Government.

Evaluation of the Contribution of Community Health Workers (CHWs) in improving Health Facility Attendance

The following colleagues addressed the role of Community Health Workers in promoting antenatal care in Chad: Naibei Mbaïbardoum, Ali Soumaine Baggar, Djimodoum Moyreou, Mamadjibeye Joseline, Noella Umulisa, Elana Dhuse, and Kodjo Morgah.  (Affiliation: Improving the Quality of Malaria Control Services in Chad and Cameroon program/Jhpiego, and the Provincial Health Delegation of the Logone Oriental Region, Chad). Their work entitled “Evaluation of the Contribution of Community Health Workers (CHWs) in improving Health Facility Attendance, particularly for timely ANC attendance and IPTp services, in six districts in the Provincial Health Delegation of the Logone Oriental Region in Chad” was a poster presentation at the 68th Annual meeting of the American Society of Tropical Medicine and Hygiene.

Malaria in Chad

Malaria in pregnancy causes up to 10,000 maternal deaths each year and contributes to high rates of maternal morbidity especially in first-time mothers Malaria is a leading cause of morbidity and mortality in Chad with ~2.2 million cases of malaria occur every year in Chad. In 2017, Chad national data revealed that malaria represented 36% of outpatient consultations and 30.8% hospitalization cases. Incidence of malaria in the Logone Oriental is 122/1000.

Malaria related death rate among pregnant women decreased from 11.1% in 2013 to 4.3% in 2017. In 2017, the coverage for the first dose of intermittent preventive treatment (IPTp1) was 81%, while IPTp3 and IPTp4 were only 29% and 9%, respectively .

Community Health Strategy in Chad

Chad introduced community health interventions in 2014. Malaria community interventions consist of promoting malaria prevention and raising awareness. Jhpiego introduced the CHW reference sheet as a tool that links the community with health facilities. Jhpiego trained CHWs and their supervisors on how to use the forms in referral and counter-referral within the community.

The “Improving the Quality of Malaria Control Services in Chad and Cameroon” project, implemented by Jhpiego, has trained, equipped and supported 109 community health workers in the Logone Oriental region To improve health facility attendance by the population, starting in April 2017, 77 of the 88 trained CHWs referred suspected cases of malaria and pregnant women for ANC/IPTp services using referral and counter-referral forms.

The objective of the evaluation is to assess the contribution of the CHWs in the improvement of health facility attendance particularly for timely ANC and IPTp services, using community-based referrals.

The Evaluation/Study question was “What is the contribution of CHWs in increasing community access to preventative care treatment for malaria, especially among pregnant women and children under five?” From Feb-Mar 2019, Jhpiego conducted a records review of the following  tools:

  • Facility Reporting forms
  • Referral forms and counter-referral forms
  • Registers of ANC and other consultation visits
  • CHW supervision reports conducted by supervisors in health centers

The referrals of 72 CHWs in six districts In Logone Oriental region were reviewed for the period of Jan-Dec 2018. There were 72 CHWs.

Cases referred to health centers. In total, 1153 persons were referred by the CHW. 59.9% (691/1153) of those referrals arrived at the health centers. Pregnant women referred for ANC/IPTp services were the group who reached health centers at the highest rate, followed by children under 5.

Conclusions and Recommendations

Findings of this evaluation show that CHWs could play a significant role in improving health facility attendance, increasing ANC/IPTp compliance at health centers in six districts in the Logone Oriental region. So far, this finding has made the following possible:

  • Review the mapping of CHWs to redefine the population to be covered
  • Update all CHW tools (registers, supervision grids, report cards)
  • Make orientation maps for the pregnant woman

One of the major challenges to scaling up the use of CHWs in strengthening linkages between community-level interventions and facility services is the size and geographical scope of the population covered by CHWs. CHW registers and reference sheets are not consistently completed as required, and supervisors do not always check on this

Re-mapping of CHWs is needed following national norms to include Number of villages, households, pregnant women to be covered by CHWs. An Increase the number of CHWs is also required with a focus on recruiting female CHWs to improve communication among women that encourages ANC attendance. The health services should strengthen existing supportive supervision system from health centers to CHWs to ensure that registers and reference sheets are consistently completed, leading to better delivery of services.

This work was supported by the had Ministry of Health, ExxonMobil Foundation, Esso and Jhpiego.

The Effect of Optimized Supportive Supervision on Improved Quality of Malaria Services in Liberia

Colleagues from USAID’s Flagship Maternal and Child Survival Program are presenting poster 415 at the 68th Annual Meeting of the American Society of Tropical Medicine and Hygiene. They include Lauretta N. Se, MPH; George Toe Jr., MPH; Anne Fiedler, MPH;  Thomas Hallie; Mantue Reeves, MSc; Birhanu Getahun, MD, MPH; Lolade Oseni, MD, MPH; Gladys Tetteh, MD, MPH. They have shared key points from their presentation below.

Background

Malaria prevalence in children <5 years is 45% (LMIS, 2016), with regional variations with the highest in South-Eastern regions of the country (69%). Malaria accounts for about 42 % of all clinical consultations (2013 Liberia health facility survey).

The U.S. President’s Malaria Initiative (PMI) has been committed to supporting the MOH strategy since 2008 when it began working in three out of fifteen malaria-affected counties. PMI prioritizes support to CHTs in their responsibility of directly managing the local health systems and providing oversight for efficient malaria service delivery.

In 2017 and 2018 PMI through the MCSP/EMS project expanded support to 11 counties (5 phase 1 and 6 phase II) in Liberia, focusing on malaria case management and malaria in pregnancy interventions. To improve the quality of malaria services in Liberia, MCSP/EMS in collaboration with CHT implemented optimized supportive supervision of health workers.

Methodology

At the beginning of each phase (2017 and 2018), MCSP/EMS conducted an organizational capacity assessment of the CHTs/DHTs. One key gap identified was the inconsistent and low quality of the supportive supervision of health facilities by ALL levels of the health system. Expected supervision schedules are:

  • National level (25% of HFs , semi-annually)
  • County level (75% of HFs , quarterly)
  • District level (100% of HFs, monthly)

MCSP/EMS worked with Ministry of Health supervisors to employ  an optimized supportive supervision program for facility health workers using the updated Joint Integrated Supportive Supervision Tool. The tool has five malaria standards:

  1. Screening (with 5 verification criteria)
  2. Diagnosis (with 3 verification criteria)
  3. Management and Treatment (with 4 verification criteria)
  4. Health Education (with 2 verification criteria)
  5. Malaria in Pregnancy (with 6 verification criteria)

The assessment team provided prior information to the facility staff about the supervision visit during the entry meetings. The supervision team consisted of  county, district health team supervisors and MCSP/EMS staff. During the supervision the  assessment of malaria standards was done using direct observation, record reviews, and simulation,  after which each standard was scored.

JISS: Process and Benefits

The ultimate goal of supportive supervision is to improve the quality of health services provided at the health facility. During each supervision visit, supervisors:

  • Provided on-the-job training, mentoring and coaching on identified gaps
  • Reinforced the review of data and its use for program improvement
  • Developed an action plan from gaps identified and discussed remedial actions through follow-up
  • Initiated subsequent supervision visits based on previous action plans

The Improved Performance on Joint Integrated Supportive Supervision (JISS) and Malaria Standards Assessment at 117 health facilities in the 5 Phase 1 Counties is seen in the attached charts.

Lessons and Conclusions

Training of district and county supervisors in the updated JISS tool improved the quality of supervision and data. Provision of updated MIP and case management guidelines to  both facility staff and supervisors, coupled with training,  improved adherence to standards Action plans developed during supervision visits helped facilities track their own progress and  instill sustained ownership of data and solutions Providing the county and district supervisors the opportunity to lead the supportive supervision planning and execution promoted leadership and ownership among these leaders.

The optimized supportive supervision and mentoring visits fostered health worker adherence to malaria protocols thereby contributing to measurable improvements in meeting and sustaining malaria standards and compliance. MCSP is sharing the lessons learned in fostering quality improvement from targeted supportive supervision of health care workers to scale up and improve the quality of malaria services delivery in Liberia.

Challenges and Recommendations

Most of the county and districts supervisors who were part of the JISS team had not been trained on the revised JISS tools in the EMS supported counties before the start of the project. Supportive supervision is greatly hampered by inadequate and untimely budgetary allocations by the Government of Liberia to the counties, which results in infrequent supervisory visits to the facilities and affects the quality
of services.

Empowerment of DHT and CHT supervisors: To implement optimized and effective supportive supervision to health facilities, DHTs/CHTs need to be equipped with updated tools,  provided mentoring and coaching skills, and timely provision of financial and logistical support. There is need for regular targeted and timely mentoring and coaching of  facility staff to improve adherence standards.

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This poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID) under Cooperative Agreement No. AID-624-A-13-00010 and the President’s Malaria Initiative (PMI).
The contents are the responsibility of the authors and do not necessarily reflect the views of USAID, PMI or the United States Government.

What to Observe on October 12th? Malaria’s Arrival in the Americas

Controversy exists about what historical event should be observed in the USA on 12th October. Ernest Faust explained many years ago that, “there is neither direct nor indirect evidence that the malaria parasites existed on this continent prior to the advent of the European conquerors,” while at the same time in the 16th through 18th Centuries, malaria was common in England, Spain, France, Portugal and other European nations that arrived in the “New World.” Initially, with the first voyage of Columbus the European explorers and settlers brought the disease, primarily Plasmodium vivax, while the slave trade brought P. falciparum.

National Geographic in its May 2007 issue provided the story “Jamestown, The Real Story.” This article reported that, “Colonists carried the plasmodium parasite to Virginia in their blood. Mosquitoes along the Chesapeake were ‘infected’ by the settlers and spread the parasite to other humans.” Thus malaria became one of many imported diseases that decimated the indigenous population. The spread of P. vivax in Jamestown was not surprising since the settlement was “located on marshy ground where mosquitoes flourished during the summer.”

Recent research has shown that the “Analysis of genetic material extracted showed that the American P. falciparum parasite is a close cousin of its African counterpart.” This research has documented two genetic groups in Latin America, related to two distinct slave routes run by the Spanish empire in the North, West Indies, Mexico and Colombia and the Portuguese empire to Brazil. Indigenous and remote rural populations of Bolivia, Colombia, Ecuador, Peru, Venezuela and Brazil remain at risk today.

In the South American continent the  native American population might have brought Melanesian strains of P. vivax before the Europeans arrived, but colonizers brought new strains from both Europe and Africa, as well as P. falciparum. Clearly, human migration has played an important role in malaria parasite dissemination through the Americas.

But back to the North American Continent where the USA is observing the historical implications of 12th October, Mark Blackmore reminds us that, “Anthropological and archeological data provide no indication of mosquito-borne diseases among the indigenous people of North America prior to contact with Europeans and Africans beginning in the fifteenth century” (Wing Beats Volume 25 Winter 2015). The spread of malaria by European colonizers is certainly not something to celebrate today.

Biology and Malaria Eradication: Are there Barriers?

During a press conference prior to the release of the executive summary of 3-year study of trends and future projections for the factors and determinants that underpin malaria by its Strategic Advisory Group on Malaria Eradication (SAGme), WHO outlined some hopeful signs emanating from the SAGme including

  1. Lack of biological barriers to malaria eradication
  2. Recognition of the massive social and economic benefits that would provide a return on investment in eradication, and
  3. Megatrends in the areas of factors such as land use, climate, migration, urbanization that could inhibit malaria transmission

Concerning the first point, the executive summary notes that, “We did not identify biological or environmental barriers to malaria eradication. In addition, our review of models accounting for a variety of global trends in the human and biophysical environment over the next three decades suggest that the world of the future will have much less malaria to contend with.”

The group did agree that, “using current tools, we will still have 11 million cases of malaria in Africa in 2050.” So one wonders whether there are biological barriers or not.

Interestingly the group did identify, “Potential biological threats to malaria eradication include development of insecticide and antimalarial drug resistance, vector population dynamics and altered vector behaviour. For example, Anopheles vectors might adapt to breeding in polluted water, and mosquito vector species newly introduced to Africa, such as Anopheles stephensi, could spread more widely into urban settings.”

This discussion harkens back to an important conceptual article by Bruce Aylward and colleagues that raised the question in the American Journal of Public Health, “When Is a Disease Eradicable?” They outlined three important criteria that had been proposed at two international conferences in 1997 and 1998.

  1. biological and technical feasibility
  2. costs and benefits, and
  3. societal and political considerations

Their further expansion on the biological issues using smallpox as an example is instructive. They noted that not only are humans essential for the life cycle of the organism, but that there was no other reservoir for the causative virus, and the virus could not amplify in the environment. In short, there were no vectors, as in the case of malaria. The relatively recent documentation of transmission of malaria between humans and other primates of different plasmodium species is another biological concern. At this point, Malaysia, for example, is reporting more cases of Plasmodium knowlesi in humans that either P vivax or P falciparum.

Another biological issue identified by Aylward and colleagues was the fact that smallpox had one effective and proven intervention, the vaccine. Application of the vaccine could be targeted using photograph disease recognition cards as the signs were quite specific to the disease. Malaria has several effective interventions, but most strategies emphasize the importance of using a combination of these, and implementation is met with a number of management and logistical challenges. The signs and symptoms of malaria are confused with a number of febrile illnesses.

Finally, two other issues raised concern. Insecticide resistance was recognized in the first malaria eradication effort, and is raising its head again, as pointed out by SAGme. Comparing smallpox and yaws, the challenge of latent or sub-clinical/asymptomatic infection was mentioned. Malaria too, is beleaguered with this problem.

Clearly, we must not lose momentum in the marathon (not a race) to eliminate malaria, but we must, as WHO stressed at the press conference, increase our research and development efforts to strengthen existing tools and develop new once to address the biological and logistical challenges.

Doubling a Cholera Response: Applying a single-dose OCV strategy to outbreak control in South Sudan

As part of the course on Social and Behavioral Foundations in Primary Health Care, Rebecca Huebsch posted in the class blog. We have shared these thoughts below.

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91,000 people die from cholera every year. Cholera is a burden which is carried by some of the poorest and most vulnerable people in the world. This disease, which puts about 1.4 billion people at risk annually, is most predominant in low-income nations. One of these nations is South Sudan. Since its independence in 2011, South Sudan has been plagued by ongoing conflict, displacements, poverty, and disease outbreaks. In South Sudan’s most recent cholera outbreak, there were already 20,000 cases before the outbreak could be brought under control.download

Controlling a cholera outbreak requires a combination of approaches; water and sanitation, hygiene promotion, case management, and reactive vaccination campaigns. The oral cholera vaccine (OCV) revolutionized cholera responses and made it possible protect people from this dangerous disease. OCV campaigns are still incredibly resource intense and traditionally target each person with 2-doses of the vaccine. In places like South Sudan, even reaching these people once is difficult, finding them a second time requires a great deal of motivation, resources, and creativity. In the rainy season, large swaths of South Sudan are flooded and become swamps. This is also the time of year that people are most at risk of cholera. A vaccination campaign requires vaccination teams to literally walk through the swamps for hours, or even days, to reach the affected areas.

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Fortunately, a more streamlined approach is possible, and has even been tested in emergency cholera responses in South Sudan. There is a growing body of evidence that supports a single-dose strategy for OCV campaigns. In settings where cholera is endemic, like South Sudan, a single dose of OCV can be as effective as 2 doses for controlling an outbreak. Adopting this strategy would allow the same amount of vaccine to protect double the amount of people. It would also save on the logistical costs of trying to reach each person twice. While a second dose of cholera vaccine makes sense for routine immunization programs because it provides prolonged coverage, it is costly and limiting to an emergency response. In a cholera outbreak, the State Ministries of Health may look to a single-dose strategy to more efficiently control the outbreak and protect their people.