Tropical Health Matters

By Emmanuel Fiagby in Accra, January 23, 2012, Voices for a Malaria-Free Future

The United Against Malaria (UAM) Partnership in Ghana being led by the Johns Hopkins University Center for Communication Program Voices for a Malaria-free Future project, the National Malaria Control Program and the Ghana Football Association held a special media event in Accra as a prelude to Ghana’s attempt to win the Africa Cup of Nations (AFCON) 2012 tournament currently taking place in Gabon and Equatorial Guinea. In the photo to the right we see Ghana’s NMCP Manager launching the UAM Malaria-Safe Playbook.

Held under the theme, “Partnership for Malaria Elimination – Winning the Africa Cup of Nations – AFCON 2012 and the fight to eliminate malaria,” the event brought together about 70 personalities representing 15 News papers, 6 Television stations/channels, 6 Radio stations, the National Sports Authority, the Ghana Football Association, the NMCP, WHO, USAID/PMI/CDC, Ministry of Information, Private Sector companies, academia and the Ghana Coalition of NGOs in Malaria.

In introducing the event, the Country Director of the Johns Hopkins University Voices Project Emmanuel Fiagbey reminded participants of the significance of tapping in to the enthusiasm and support for the national team the Black Stars to win the AFCON 2012 to promote greater advocacy for eliminating malaria from Ghana. “While football is the most popular sports in Ghana, malaria is the most popular killer, we need to employ the positive popularity of football to defeat the negative popularity of malaria,” he remarked.

In a statement to the event, Mr. Kwesi Nyantakyi, President of the Ghana Football Association reminded the audience and press members (seen in photo) that footballers are not immune to malaria. Malaria, he pointed out is a big threat to footballers and the practice of their profession. “Aside that we also think society has invested in us and we need to give back what society has invested in us. That is why we have decided to use the Ghana Football Association and football as a vehicle to disseminate information on malaria prevention and treatment,” he stated.

Presenting the key note address, Prof Fred Binka, a renowned Malariologist and Dean of the School of Public Health of the University of Ghana called on all stakeholders especially communities, civil society leaders and groups, NGOs, the media, local government agencies and development partners to ensure strict adherence to the use of ACTs in treating malaria. “The support of these groups will equally be crucial in lifting our education programs up two or more notches to encourage the use of LLINs by all Ghanaians in particular our children and pregnant women,” he emphasized.

With regards to funding challenges, Prof. Binka lamented the suspension of Global Fund Round 11 grants and opined that this could lead to loss of the gains so far made and malaria could be back with a heavy toll on especially children and pregnant women. He called for new partnerships from oil producing countries (OPEC) such as Saudi Arabia and new economic giants such as China to increase their resource support for malaria control and elimination in endemic countries.

Prof. Binka further stressed that the control and elimination of malaria will involve the contribution of every sector – from local government, education, employment and social welfare as well as private companies to the Ministry of Finance. “No sector can be excluded. Indeed we need a strong partnership with global initiatives, privately financed public sector projects, industry partnerships, local, regional and national partnerships led by civil society,” he accentuated.

In conclusion, Prof Binka hoped that the opportunity of the AFCON 2012, contest will energize several potential partners to accelerate their efforts to fight malaria by creating workplace malaria control policies and programs such as provision of treated bed nets and treatment services to their employees and dependants and adopting villages and whole districts within their catchment areas, working with them to reduce mosquito density and providing them with treatment and prevention services.

In launching a set of UAM branded malaria advocacy materials developed by the JHU/CCP/Voices project in partnership with the Ghana Football Association, Dr. Constance Bart-Plange, Manager of the National Malaria Control Program called on the Private Sector  companies to ensure the application of the Malaria-Safe Pillars of increased and continuing education, adherence to improved protection practices, greater visibility of efforts in order to attract added resources and promote effective advocacy. She charged the private companies in particular to endeavour to apply the 13 Winning Moves prescribed in the Winning Moves Chart, one of the materials launched. Other materials outdoored at the event included the 2012 edition of the GOAL Malaria Newspaper and the Malaria Safe Play Book – a Resource Guide for private companies.

In her concluding remarks, the Ag. Director General of the Ghana Health Service, Dr. Gloria Quansah Asare who chaired the event called on all malaria program managers, specialists and activists to remain ever committed and creative in the presentation of malaria information to the public as demonstrated by the Voices UAM Partnership. “The more efforts we put in the development and presentation of our health messages to our audiences the more successful we would be in making such messages acceptable and easy to adopt by our clientele, she emphasized.

About United Against Malaria: Founded in the lead–up to the 2010 FIFA World Cup South Africa, United Against Malaria is an alliance of football teams and heroes, celebrities, health and advocacy organizations, governments and corporations who have united together to end malaria deaths by 2015. We have the tools and the momentum. United, we can beat malaria.

Malaria incidence and prevalence has been dropping quickly in Rwanda, below 2% in children under 5 years old. Malaria in Pregnancy (MIP) is still a risk some and may be more severe as the disease becomes rare and immunity reduces. The US President’s Malaria Initiative is supporting a prevalence study of MIP through its Maternal and Child Health Integrated Program (MCHIP) and the National Malaria Control Program (NMCP) so that appropriate data will become available to design appropriate MIP interventions as the country moves towards malaria elimination.

The study focuses on pregnant women during their first visit to focused antenatal care (FANC) for their current pregnancy. Four FANC visits promote maternal and newborn health through 1) Early detection and treatment, 2) Prevention of complications and disease, 3) Birth preparedness and 4) Health promotion.

The study of over 4000 women is at the half way mark. Supervisory visits determine if data such as RDT, Microscopy and PCR tests, are being gathered correctly.

Pictured here are Alice and Donatien who are nurses based at Gakoma Health center in Gisagara District and were trained for the the MIP prevalence study. They are seen here taking blood samples for the study. They have integrated the study procedures into the routine FANC they provide. This makes it easier for the client as well as the nurses who also extract study data on age, parity, hemoglobin, bednet ownership and fever history which is normally collected as part of FANC.

Since data collection began in late December, Alice and Donatien have enrolled about half of their target number of clients.  When the results from all 38 health centers across the country are compiled in April, the National Malaria Control Program will have valuable information to plan how best to protect pregnant women as the country moves closer to malaria elimination.

Agente Santé Maternelle (ASM) are one of four types of Rwandan Community Health Workers (CHWs) which include community case management and social mobilization workers who are selected by their own villagers and serve as volunteers.

ASM identify, follow, educate and refer pregnant women in their villages to the nearest health center. During the USAID ACCESS Project in Rwanda, Jhpiego assisted the Ministry of Health to adapt UNICEF training materials for ASMs. MCHIP is continuing the work and focuses on training and kitting ASMs in five Districts.

Alphonsine, an ASM from Karubondo village near Gikondo Health Center keeps a record book of pregnant women she is following. Her village has 179 households, 696 residents and 124 women of reproductive age (WRA).

The program ensures that ASM have manageable case loads. Since her training by MCHIP in August 2011, Alphonsine has seen 17 clients and now is following 9 pregnant women.

Health education materials such as a flipchart for the ASMs include emphasis on bednet use and prompt treatment of fevers. AMS also have a carry bag, boots, umbrella, thermometer, and a torch.

Some women are reluctant to reveal their pregnancies because of social issues like being a widow or a teenager. The AMS must work hard to gain trust so women confide in her. Volunteer work as ASM must fit in with her hard work as a farmer.

ASMs encourage women to attend Antenatal Care at nearest clinic. There they will reveive free bednets. The ASM then educates the women on proper and regular net use. The ASM also refers women with danger signs in pregnancy to ANC. Such signs may be high temperature for which proper testing and treatment is needed if they have malaria.

Rwanda is closing in on malaria elimination. The various kinds of CHWs play an important role in prevention, case detection and assurance of appropriate treatment. Community vigilance is a crucial component of eliminating the disease.

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.