Category Archives: Case Management

Malaria News Today 2020-10-21: perspectives on falciparum, transfusion issues, drug effectiveness

Ironically, blood transfusion helps with severe malaria, but can be dangerous in mild cases. And with severe malaria delay in treatment is a major risk. Malaria parasites can be surprisingly diverse, even in one home. Health system performance, drug quality and patient adherence are key factors in the effectiveness of anti-malarials. Read more on each article or abstract in the links provided.

The impact of delayed treatment of uncomplicated P. falciparum malaria on progression to severe malaria

Mousa A et al. conducted a systematic review and a pooled multicentre individual-patient meta-analysis in PLoS Medicine. Despite the reported association of delay in receiving treatment for uncomplicated malaria (UM) with an increased risk of developing severe malaria (SM), access to treatment remains low in most high-burden areas. Researchers performed a pooled individual-participant meta-analysis with the aim to ascertain the correlation between treatment delay and presenting with SM using Ovid MEDLINE and Embas.

Findings revealed significantly higher risk of severe disease in children and adults who had longer delays from symptom onset to treatment-seeking; this relationship was noted to be the strongest for progression to severe malarial anaemia. Per estimates, nearly half of the severe anaemia cases in both children and adults could be averted if they presented within the first 24 hours of symptom onset.

Malaria parasites in Nigeria are genetically diverse: a danger but also a useful tool

Segun Isaac Oyedeji notes that his team’s research has already confirmed that in malaria-endemic countries such as Nigeria, infected individuals carry P. falciparum parasites that are genetically complex or diverse. What we didn’t know was how diverse the parasites are in the micro environment, such as within households and among children of the same family.

Oyedeji thought that knowing the population structure within households could help us understand more about the pattern and development of the disease. It could also inform development of appropriate guidelines and control measures. He found that even in the micro environment, P. falciparum parasites exhibit high genetic diversity. This finding was similar to results from larger communities in malaria endemic regions and has the same important implications. The implication is that a one-size fits all intervention or approach against the parasites may not be effective. There were children living under the same roof and infected by parasites that were genetically different.

New evidence to guide the practice of blood transfusions in children with severe malaria

The Barcelona Institute for Global Health (ISGlobal) described a new study that shows that transfusions could help increase survival, even at higher haemoglobin levels than those currently recommended. The results show that blood transfusion increased the survival of patients with severe disease.

In cases with complications, such as impaired consciousness or elevated lactate in blood, transfusion improved survival even in children whose levels of haemoglobin were higher the recommended threshold of 60g /l. For example, among patients with impaired consciousness, the authors observed improved survival upon transfusion with haemoglobin levels as high as 105 g / l. However, in the case of mild cases, transfusion was associated with an increase in mortality.

Global estimation of anti-malarial drug effectiveness for the treatment of uncomplicated Plasmodium falciparum malaria 1991–2019

Giulia Rathmes and colleagues note that anti-malarial drugs play a critical role in reducing malaria morbidity and mortality, but their role is mediated by their effectiveness. Effectiveness is defined as the probability that an anti-malarial drug will successfully treat an individual infected with malaria parasites under routine health care delivery system. Anti-malarial drug effectiveness (AmE) is influenced by drug resistance, drug quality, health system quality, and patient adherence to drug use; its influence on malaria burden varies through space and time. This study used data from 232 efficacy trials.

The global effectiveness of artemisinin-based drugs was 67.4% (IQR: 33.3–75.8), 70.1% (43.6–76.0) and 71.8% (46.9–76.4) for the 1991–2000, 2006–2010, and 2016–2019 periods, respectively. The use of artemisinin-based combination therapy (ACT) with a competent partner drug and having multiple ACT as first-line treatment choice sustained high levels of effectiveness. High levels of access to healthcare, human resource capacity, education, and proximity to cities were associated with increased effectiveness. Effectiveness of non-artemisinin-based drugs was much lower than that of artemisinin-based.

This study provides evidence that health system performance, drug quality and patient adherence influence the effectiveness of anti-malarials used in treating uncomplicated falciparum malaria. These results provide guidance to countries’ treatment practices and are critical inputs for malaria prevalence and incidence models used to estimate national level malaria burden.

Malaria News Today 2020-10-05: Concerns from Mali, Comoros, Ecuador, Southeast Asia and More

News and abstracts provide more on the surge of malaria in Mali. COVID-19 complicates malaria elimination in Southeast Asia. Peace Corps health care for volunteers in Comoros is questioned. Malaria risk in Ecuador is investigated. Risk maps are used/not used in three Sub-Saharan countries. The potential of microbiological control is considered. More information on each topic is available in the links provided.

Health workers raise alarm over surge in malaria cases, deaths in Mali

More details emerge on malaria in northern Mali. Medical workers in Mali raised an alarm over a surge in malaria cases which has seen at least 23 people killed by the disease in just the past one week. About 13,000 malaria cases were reported in the north by medical workers between September 21 and 27, representing an 88 percent increase in cases from the previous week. 59 people have died of malaria in the nation’s northern region since the beginning of the year, according to the ministry, which confirmed the deaths of the 23 people over the aforementioned September period.

Will COVID-19 hamper ASEAN’s fight to eliminate malaria?

Although progress elsewhere in the world has been slow, in the Asia-Pacific, deaths due to the mosquito-borne disease have dropped by 70% and cases have dropped by 22%. Within ASEAN, those figures—according to the Asia Pacific Leaders Malaria Alliance (APLMA)—are 92% and 67% respectively. The battle to eliminate malaria is continually evolving with different species of disease-carrying mosquitoes and parasites presenting new challenges. In 2008, a new strain of malaria that proved resistant to the anti-malarial drug artemisinin, nicknamed “super malaria”, emerged in Cambodia. It spread through the Greater Mekong region into Laos, Thailand and Vietnam and by 2017, it had developed resistance to another drug, piperaquine.

In response, scientists and researchers focused their resources on areas where the new strain was present and were making headway towards eliminating it. COVID-19 could threaten that progress. “We have enough evidence from the Ebola epidemic to suggest how progress on malaria elimination could be derailed and we are seeing some clear warnings now,” APLMA/APMEN commented. Historically, malaria cases have risen in countries where healthcare is interrupted due to conflict, disaster and war.

Peace Corps faces questions over death of volunteer from Inverness

By Sheryl Gay Stolberg of the New York Times reported that the Peace Corps, which suspended all operations for the first time in its history as the novel coronavirus raced around the globe, is facing renewed questions about the quality of its medical care — in particular, after the death of a 24-year-old volunteer from undiagnosed malaria — as it prepares to send volunteers back into the field.

An investigation by the Peace Corps inspector general documented a string of problems with Heiderman’s care. Her doctor had “limited training in tropical medicine,” the investigation found, and failed to test for malaria, which would have revealed that Heiderman had been infected by the deadliest malaria parasite. The Peace Corps was also using outdated 2006 guidelines for malaria, which did not reflect the current standard of care.

Anopheline and human drivers of malaria risk in northern coastal Ecuador

Understanding local anopheline vector species and their bionomic traits, as well as related human factors, can help combat gaps in protection. In San José de Chamanga, Esmeraldas, at the Ecuadorian Pacific coast, anopheline mosquitoes were sampled by both human landing collections (HLCs) and indoor-resting aspirations (IAs) and identified using both morphological and molecular methods.

Among 222 anopheline specimens captured, based on molecular analysis. The exophagic feeding of anopheline vectors in San Jose de Chamanga, when analysed in conjunction with human behaviour, indicates a clear gap in protection even with high LLIN coverage. The lack of indoor-resting anophelines suggests that indoor residual spraying (IRS) may have limited effect. The presence of asymptomatic infections implies the presence of a human reservoir that may maintain transmission.

How useful are malaria risk maps at the country level?

This study examined the perceptions of decision-makers in Kenya, Malawi and the Democratic Republic of Congo. Declining malaria prevalence and pressure on external funding have increased the need for efficiency in malaria control in sub-Saharan Africa (SSA). Modelled Plasmodium falciparum parasite rate (PfPR) maps are increasingly becoming available and provide information on the epidemiological situation of countries. However, how these maps are understood or used for national malaria planning is rarely explored. In this study, the practices and perceptions of national decision-makers on the utility of malaria risk maps, showing prevalence of parasitaemia or incidence of illness, was investigated.

Three different types of maps were used to show malaria epidemiological strata: malaria prevalence using a PfPR modelled map (Kenya); malaria incidence using routine health system data (Malawi); and malaria prevalence using data from the most recent Demographic and Health Survey (DRC). In Kenya the map was used to target preventative interventions, including long-lasting insecticide-treated nets (LLINs) and intermittent preventive treatment in pregnancy (IPTp), whilst in Malawi and DRC the maps were used to target in-door residual spraying (IRS) and LLINs distributions in schools. Maps were also used for operational planning, supply quantification, financial justification and advocacy. Findings from the interviews suggested that decision-makers lacked trust in the modelled PfPR maps when based on only a few empirical data points (Malawi and DRC). Despite the availability of national level modelled PfPR maps in all three countries, they were only used in one country.

Infection of highly insecticide-resistant malaria vector Anopheles coluzzii with entomopathogenic bacteria

This study found that Chromobacterium violaceum reduces its survival, blood feeding propensity and fecundity of mosquitoes in Burkina Faso. The study was motivated by the concern that malaria eradication will not be achieved without the introduction of novel control tools. Microbiological control might be able to make a greater contribution to vector control in the future. The interactions between bacteria and mosquito make mosquito microbiota really promising from a disease control perspective.
Methods

To assess entomopathogenic effects of C. violaceum infection on mosquitoes, three different types of bioassays were performed in laboratory. These bioassays aimed to evaluate the impact of C. violaceum infection on mosquito survival, blood feeding and fecundity, respectively. During bioassays mosquitoes were infected through the well-established system of cotton ball soaked with 6% glucose containing C. violaceum.

The data showed important properties of Burkina Faso C. violaceum strains, which are highly virulent against insecticide-resistant An. coluzzii, and reduce both mosquito blood feeding and fecundity propensities. However, additional studies as the sequencing of C. violaceum genome and the potential toxins secreted will provide useful information render it a potential candidate for the biological control strategies of malaria and other disease vectors.

 

Malaria News Today 2020-09-15

Malaria Journal released three articles ranging from the relation between malaria and agricultural irrigation, artemisinin resistance on the Myanmar-China border, and efforts at costing malaria elimination interventions. PLoS Medicine examined the quality of malaria clinical management in children. Finally, Frontiers in Cellular and Infection Microbiology reported on a new drug against malaria and toxoplasmosis. Click on links to read more details.

Minimal tillage and intermittent flooding farming systems show a potential reduction in the proliferation of Anopheles mosquito larvae in a rice field in Malanville, Northern Benin

Irrigation systems have been identified as one of the factors promoting malaria disease around agricultural farms in sub-Saharan Africa. However, if improved water management strategy is adopted during rice cultivation, it may help to reduce malaria cases among human population living around rice fields.

A clear reduction of larva density was observed with both intermittent flooding systems applied to minimal tillage (MT?+?IF?+?NL) and intermittent flooding applied to deep tillage (DT?+?IF?+?AL), showing that intermittent flooding could reduce the abundance of malaria vector in rice fields. Recommending intermittent flooding technology for rice cultivation may not only be useful for water management but could also be an intentional strategy to control mosquitoes vector-borne diseases around rice farms.

No evidence of amplified Plasmodium falciparum plasmepsin II gene copy number in an area with artemisinin-resistant malaria along the China–Myanmar border

The emergence and spread of artemisinin resistance in Plasmodium falciparum poses a threat to malaria eradication, including China’s plan to eliminate malaria by 2020. Piperaquine (PPQ) resistance has emerged in Cambodia, compromising an important partner drug that is widely used in China in the form of dihydroartemisinin (DHA)-PPQ. Several mutations in a P. falciparum gene encoding a kelch protein on chromosome 13 (k13) are associated with artemisinin resistance and have arisen spread in the Great Mekong subregion, including the China–Myanmar border. Multiple copies of the plasmepsin II/III (pm2/3) genes, located on chromosome 14, have been shown to be associated with PPQ resistance.

DHA-PPQ for uncomplicated P. falciparum infection still showed efficacy in an area with artemisinin-resistant malaria along the China–Myanmar border. There was no evidence to show PPQ resistance by clinical study and molecular markers survey. Continued monitoring of the parasite population using molecular markers will be important to track emergence and spread of resistance in this region.

Costing malaria interventions from pilots to elimination programmes

Malaria programmes in countries with low transmission levels require evidence to optimize deployment of current and new tools to reach elimination with limited resources. Recent pilots of elimination strategies in Ethiopia, Senegal, and Zambia produced evidence of their epidemiological impacts and costs. There is a need to generalize these findings to different epidemiological and health systems contexts. Drawing on experience of implementing partners, operational documents and costing studies from these pilots, reference scenarios were defined for rapid reporting (RR), reactive case detection (RACD), mass drug administration (MDA), and in-door residual spraying (IRS). These generalized interventions from their trial implementation to one typical of programmatic delivery. In doing so, resource use due to interventions was isolated from research activities and was related to the pilot setting. Costing models developed around this reference implementation, standardized the scope of resources costed, the valuation of resource use, and the setting in which interventions were evaluated. Sensitivity analyses were used to inform generalizability of the estimates and model assumptions.

Populated with local prices and resource use from the pilots, the models yielded an average annual economic cost per capita of $0.18 for RR, $0.75 for RACD, $4.28 for MDA (two rounds), and $1.79 for IRS (one round, 50% households). Intervention design and resource use at service delivery were key drivers of variation in costs of RR, MDA, and RACD. Scale was the most important parameter for IRS. Overall price level was a minor contributor, except for MDA where drugs accounted for 70% of the cost. The analyses showed that at implementation scales comparable to health facility catchment area, systematic correlations between model inputs characterizing implementation and setting produce large gradients in costs. Prospective costing models are powerful tools to explore resource and cost implications of policy alternatives. By formalizing translation of operational data into an estimate of intervention cost, these models provide the methodological infrastructure to strengthen capacity gap for economic evaluation in endemic countries. The value of this approach for decision-making is enhanced when primary cost data collection is designed to enable analysis of the efficiency of operational inputs in relation to features of the trial or the setting, thus facilitating transferability.

Quality of clinical management of children diagnosed with malaria: A cross-sectional assessment in 9 sub-Saharan African countries between 2007–2018

Appropriate clinical management of malaria in children is critical for preventing progression to severe disease and for reducing the continued high burden of malaria mortality. This study aimed to assess the quality of care provided to children under 5 diagnosed with malaria across 9 sub-Saharan African countries. We used data from the Service Provision Assessment (SPA) survey. SPAs are nationally representative facility surveys capturing quality of sick-child care, facility readiness, and provider and patient characteristics across 9 countries, including Uganda (2007), Rwanda (2007), Namibia (2009), Kenya (2010), Malawi (2013), Senegal (2013–2017), Ethiopia (2014), Tanzania (2015), and Democratic Republic of the Congo (2018).

In this study, we found that a majority of children diagnosed with malaria across the 9 surveyed sub-Saharan African countries did not receive recommended care. Clinical management is positively correlated with the stocking of essential commodities and is somewhat improved in more recent years, but important quality gaps remain in the countries studied. Continued reductions in malaria mortality will require a bigger push toward quality improvements in clinical care. Despite increases in the distribution of malaria tests and effective antimalarial medications, significant gaps in the quality of care for pediatric malaria are present in these 9 countries. Further improvements in quality of malaria care may require a better understanding of remaining barriers and facilitators to appropriate management.

Novel drug could be a powerful weapon in the fight against malaria and toxoplasmosis

Princeton researchers are making key contributions toward developing a promising new treatment for the widespread and devastating diseases toxoplasmosis and malaria.
The Princeton scientists specialize in preparing the drug compound into a medicine that is both safe and effective for humans and able to reach its intended sites of action in the body in sufficient doses. An international team of scientists found the new drug—designated JAG21—to be highly effective against parasites in cell-based studies in the lab. After the discovery, team representatives contacted Princeton’s Robert Prud’homme for help in translating the JAG21 compound into a deliverable medication. Prud’homme is a co-author of a study, published in June 2020 in Frontiers in Cellular and Infection Microbiology, that describes the compound and its excellent preliminary results in mice.

Malaria News Today 2020-09-12/13 Weekend

Recent news over this weekend included efforts at school and peer education on bednets in Ethiopia, gender inequality effects of COVID-19 and pandemics, a reduction in severe malaria in Rwanda and increased use of home based case management, and the altering of scientific reports by political appointees. Links in these summaries take one to the full story.

Effectiveness of peer-learning assisted primary school students educating the rural community on insecticide-treated nets utilization in Jimma-zone Ethiopia

Abstract: Making insecticide-treated nets (ITNs) utilization a social norm would support the global goal of malaria eradication and Ethiopian national aim of its elimination by 2030. Jimma zone is one of the endemic settings in Ethiopia. This study aimed to report effects of malaria education, delivered by students, on community behaviours; particularly ITNs. The intervention engaged students from primary schools in participatory peer education within small groups, followed by exposing parents with malaria messages aimed at influencing perceptions and practices.

Over the intervention periods, the findings showed significant improvement in exposure to and content intensity of malaria messages delivered by students. Socio-demography, access, exposures to messages, and parental perception that students were good reminders predicted ITN utilization over the intervention periods with some changing patterns. Exposing the community to malaria education through students effectively supports behaviour change, particularly ITN usage, to be more positive towards desired malaria control practices. A school-based strategy is recommended to the national effort to combat malaria.

Melinda Gates calls on Leaders to Ensure that Women, Girls are Not Left Behind in the Global Response to COVID-19

Melinda Gates has launched a paper exploring how the COVID-19 pandemic has exploited pre-existing inequalities and drastically impacted women’s lives and livelihoods. In the paper, titled “The Pandemic’s Toll on Women and Girls,” Melinda makes the case that to recover fully from this pandemic, leaders must respond to the ways that it is affecting men and women differently. She puts forward a set of specific, practical policy recommendations that governments should consider in their pandemic response—to improve health systems for women and girls, design more inclusive economic policies, gather better data, and prioritize women’s leadership.Writing in the paper, Melinda describes how previous disease outbreaks, including AIDS and Ebola, tend to exploit existing forces of inequality, particularly around gender, systemic racism, and poverty.
Melinda concludes, “This is how we can emerge from the pandemic in all of its dimensions: by recognizing that women are not just victims of a broken world; they can be architects of a better one.

Severe malaria drops by 38% in Rwanda

In its annual Malaria and Neglected Tropical Diseases Report, the Ministry of Health says that the national malaria incidence reduced from 401 cases per 1,000-person in 2017-2018 fiscal year to 200 cases per 1,000-person in 2019-2020. According to the report, 4,358 cases of severe malaria (representing a 38 per cent reduction) were reported at the health facility level compared to 7,054 in 2018-2019. The decrease in malaria deaths is attributed to home based management interventions, the free treatment of malaria for Ubudehe Categories I and II and the quality of care at health facility level.

There has also been a steady increase of proportion of children under 5 and above plus adults who are seeking care from 13 per cent to 58 per cent in 2015-2016 and 2019-2020 respectively. “This indicates that interventions such home based treatment of children and adults that contributed to early diagnosis and treatment have been successful in decreasing the number of severe cases and consequently the number of malaria deaths,” the report indicates.

Political appointees sought to alter CDC scientific reports so they don’t contradict or undermine the president

Caputo (a US presidential appointee) and his communications staff have worked to delay CDC reports that contradict President Donald Trump’s rhetoric. One publication was held back for about a month, according to Politico, for recommending against the use of hydroxychloroquine, a malaria drug touted by the White House as a potential cure for COVID-19.

The reports, written by career scientists, are known as the Morbidity and Mortality Weekly Reports, and according to Politico, are used to “inform doctors, researchers, and the general public about how Covid-19 is spreading and who is at risk.” Jennifer Kates, of the Kaiser Family Foundation’s global health work, who has relied on past reports, told Political they are “the go-to place for the public health community to get information that’s scientifically vetted.” Alexander (a presidential appointee), in this missive, said any future reports related to the coronavirus “must be read by someone outside of CDC like myself.”

COVID19 Challenges for African Researchers

Not surprisingly COVID-19 related travel restrictions and bans now occur throughout the world, and for African researchers, this means inability to travel for research related collaborations, planning meetings and conferences. Thus, it becomes necessary to ask, “What can we do here at home,” especially considering increasing restrictions on local movement and gatherings.

In the very short time since COVID-19 was finally and officially recognized in China, many research articles have been published. Although these obviously focus on China, they raise possible research questions that need to be addressed in Africa, especially those countries still at the early stages of the epidemic.

Obviously, studies on the clinical management are needed, and one group of Chinese researchers are examining “biological products have broadly applied in the prevention and treatment of severe epidemic diseases, they are promising in blocking novel coronavirus infection,” especially based on reports from previous coronavirus experiences like SARS and MERS.[1] Other studies have examined the role of managing blood glucose levels[2], anticoagulant treatment[3] and the potential of antiviral treatment,[4] among others. What aspects of clinical management will become important to African patients’ survival?

In the process of requesting adequate diagnostic, monitoring and treatment supplies and equipment generally for the country, the tertiary and research hospitals need to ensure they have made requests for the equipment and supplies that are needed not just to provide life-saving treatment, but also to test appropriate approaches in the local setting. Each setting is different and must be studied because already there are anecdotal reports of younger age groups being affected by severe disease in the USA compared to earlier reports from China.

Taking a lesson from the Ebola epidemic in West Africa, there is need to study how COVID-19 will affect the delivery of health care, especially malaria services. Patrick Walker and colleagues[5] modeled the effects of health systems disruption on malaria including challenges in receiving based treatment when clinics were overwhelmed, seen as possible sources of disease and finally shut down as health workers themselves died. Outreach services like insecticide-treated net distribution were also stopped, and the efforts of community health workers were curtailed. To what extent is that happening with COVID-19?

Until there are proven drugs and vaccines, it is extremely important to learn about local epidemiology[6] in order to develop appropriate strategies to prevent the spread of COVID-19. This effort should involve researchers from many disciplines such as public health specialists, anthropologists, sociologists, educationists, and psychologists.

While the medical research mentioned above is carried out in hospitals and clinics, people conducting social and epidemiological studies ideally should be in the community where we can observe people washing their hands or not, gathering in groups or not, and finding out why they do these things. We need formative research to help develop health education, and at the same time ensure social and educational scientists can gather information to evaluate whether the health education as appropriate and worked.

Likewise, research is needed on health systems[7] and must involve political scientists, economists, public administrators, and of course public health specialists, also. A great danger exists for people who cannot keep a social distance from themselves such as those incarcerated in prison and living in camps for refugees and internally displaced people,[8] a common problem throughout the continent. They too need to get into the organizations and systems that provide care and learn what the policy makers and decision makers are thinking.

As Bronwyn Bruton has observed,[9] “Some 40 percent of Africans live in water-stressed environments in which obtaining access to clean water—let alone soap—is an insurmountable daily hurdle, and for those populations, even simple measures to prevent the spread of the virus, such as frequent handwashing, will be out of reach.” In addition he asks difficult questions about what happens to children who are home and cannot go to school, the vast numbers of people in the informal economy who cannot rely on a salary, if they stay home, and the many people in conflict zones. These are questions that urgently need to be studied in Africa.

Answers to our COVID-19 research questions are needed urgently, probably much sooner than funding can be found to support such research.  The question for our African research colleagues is what can be done now with resources at hand in an environment where movement is restricted? We will definitely need speedy responses from our Institutional Ethics Review Boards and be creative in our use of research methods.

Roxana Elliott[10] reports that data collection in the diverse African region “is difficult, especially when measuring statistics such as mobile penetration, which require face-to-face data collection in order to include those who cannot be reached via mobile. Language barriers, lack of infrastructure, and the sheer number of people throughout Sub-Saharan Africa make collecting face-to-face data nearly impossible due to cost and time constraints, especially in rural areas.” She, therefore, suggests that mobile-based surveying methodologies can alleviate these issues. She also recommends a country-by-country approach, and hence we see that in 2017 an estimate of 32% of the population had a smartphone 48% a basic phone, and 20% no phone.

How can social and health researchers design studies using this mobile resource to answer vital COVID-19 questions in the nearest future? If our students are now at home, can they, for example, be contacted to observe, at a safe distance, the human health related actions in their communities? Can they interview family members to learn why people practice prevention or not? Can they relate family experiences seeking health services for suspected respiratory illness?  Can they report on the water supply situation in the rural and urban areas where they are staying?

There are the questions which African colleagues can debate at a proper social distance (via phone, zoom, Skype, WhatsApp, and others), and come up with creative ways to find answers to prevent a worsening epidemic in Africa.

References

[1] Yan CX, Li J, Shen X, Luo L, Li Y, Li MY. [Biological Product Development Strategies for Prevention and Treatment of Coronavirus Disease 2019. Article in Chinese] Sichuan Da Xue Xue Bao Yi Xue Ban. 2020 Mar;51(2):139-145. doi: 10.12182/20200360506. (English abstract in PubMed).

[2] Ma WX, Ran XW. [The Management of Blood Glucose Should be Emphasized in the Treatment of COVID-19. Article in Chinese]. Sichuan Da Xue Xue Bao Yi Xue Ban. 2020 Mar;51(2):146-150. doi: 10.12182/20200360606.

[3] Tang N, Bai H, Chen X, Gong J, Li D, Sun Z.Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy. J Thromb Haemost. 2020 Mar 27. doi: 10.1111/jth.14817. [Epub ahead of print]

[4] Wu J, Li W, Shi X, Chen Z, Jiang B, Liu J, Wang D, Liu C, Meng Y, Cui L, Yu J, Cao H, Li L. Early antiviral treatment contributes to alleviate the severity and improve the prognosis of patients with novel coronavirus disease (COVID-19).J Intern Med. 2020 Mar 27. doi: 10.1111/joim.13063. [Epub ahead of print]

[5] Patrick G T Walker, Michael T White, Jamie T Griffin, Alison Reynolds, Neil M Ferguson, Azra C Ghani. Malaria morbidity and mortality in Ebola-affected countries caused by decreased health-care capacity, and the potential effect of mitigation strategies: a modelling analysis. www.thelancet.com/infection Published online April 24, 2015 http://dx.doi.org/10.1016/S1473-3099(15)70124-6

[6] Luan RS, Wang X, Sun X, Chen XS, Zhou T, Liu QH, Lü X, Wu XP, Gu DQ, Tang MS, Cui HJ, Shan XF, Ouyang J, Zhang B, Zhang W, Sichuan University Covid-ERG.[Epidemiology, Treatment, and Epidemic Prevention and Control of the Coronavirus Disease 2019: a Review. Article in Chinese]. Sichuan Da Xue Xue Bao Yi Xue Ban. 2020 Mar;51(2):131-138. doi: 10.12182/20200360505.

[7] Philip Obaji, Kim Hjelmgaard and Chris Erasmus Coronavirus infections in Africa are rapidly rising. Its weak health systems may buckle. USA Today. Updated 27 March 2020, Accessed 29 March 2020. https://www.usatoday.com/story/news/world/2020/03/27/coronavirus-africa-preparedness-rising-covid-19-infections/5076620002/

[8] Nick Turse. In West African Coronavirus Hotspot, War Has Left 700,000 Homeless and Exposed. The Intercept. March 26 2020, 5:33 p.m. https://theintercept.com/2020/03/26/burkina-faso-africa-coronavirus/

[9] Bronwyn Bruton. What does the coronavirus mean for Africa?. Atlantic Council. Tue, Mar 24, 2020. https://atlanticcouncil.org/blogs/africasource/what-does-the-coronavirus-mean-for-africa/

[10] Roxana Elliott. Mobile Phone Penetration Throughout Sub-Saharan Africa. GeoPoll (In Market Research, Tech & Innovation). Posted July 8, 2019 https://www.geopoll.com/blog/mobile-phone-penetration-africa/

Improving the Quality of Malaria Case Management and Malaria Prevention During Pregnancy in Public Health Facilities in Burkina Faso

Thierry D. A. Ouedraogo, Ousmane Badolo, Mathurin Dodo, Bonkoungou Moumouni, Youssouf Sawadogo, Dao Blami, and Stanislas Nébié presented a poster entitled “Improving the Quality of Malaria Case Management and Malaria Prevention During Pregnancy in Public Health Facilities in Burkina Faso” at the 68th Annual Meeting of the American Society of Tropical Medicine and Hygiene. Their findings are shared below.

Background: In 2017, malaria was the leading cause of medical consultation (43.34%), of hospitalization (44.05%) and of death (16.13%) in Burkina Faso. The disease mostly kills children under five years and pregnant women. One objective of the National Malaria Control Program (NMCP) is to contribute to improving the health of the population by reducing malaria mortality rate by at least 40% compared to 2015 in Burkina Faso by the end of 2020.

In order to achieve that, the NMCP revised the malaria treatment guidelines in 2014 to take into account WHO guidelines on malaria case management and conducted training in primary health care facilities. NMCP implemented a one-day orientation training in district and regional hospitals since 2015, with the support of the PMI Improving Malaria Care Project.

Health Care Providers Training: The training of health care providers was carried out in several 5-days sessions at health districts level. It was aimed at strengthening their skills in the prevention and management of malaria cases in Primary health centers (CSPSs) according to the revised guidelines. 1,819 providers (633 females, 1,186 males) have been trained on the updated malaria prevention and control guidelines in 53 districts during this period.

The training covered the definition and epidemiology of malaria, malaria drug prevention, biological diagnosis of malaria, of uncomplicated malaria cases management, severe malaria case management, healing assessment and health education, monitoring and evaluation. Clinical learning sessions on uncomplicated and severe malaria case management have allowed providers to practice treatment themselves.

The goal of the project was To assess the diagnosis and case management of uncomplicated and severe malaria according malaria guideline in the various health facilities in Burkina Faso in 2017. A cross-sectional study was conducted in 2017 to assess the quality of malaria treatment and prevention during pregnancy in public health facilities.

Submission of protocol Ethics Committee included Information of the surveyed structures and Information to respondents & verbal agreement. The team also worked to provide Quality assurance, Investigator training, Supervision of data collection and Development of guidelines for data collection.

Data processing began with Data review. Data entry used Epi Info input 7.2.2.6. The Data collection period ran from 17-30 September 2018. The assessment focused on the malaria diagnosis and treatment. A comparative analysis of 2015 and 2017 data was done to understand trends.

Challenges included The lack of regional and district regular supervision and
The treatment of presumptive cases without confirmation. The non-application of the treatment protocol for severe malaria occurred in some case and as were variations in doses and duration of treatment. There was some stock-out of drugs for the treatment of uncomplicated and severe malaria.

Overall there was an increase in correct procedures, and IMC project has strongly contributed to this success by training health care providers since 2015, by regularly monitoring the implementation of malaria control guidelines during supervision, and by ensuring the availability of supplies at all levels

Recommendations include Ensuring the effective implementation of national guidelines for malaria management according to levels of care and the availability of supplies for the diagnosis, treatment and prevention of malaria during pregnancy at all levels.

In Conclusion, The results of the evaluation show that all health centres surveyed (50/50) have the capacity to diagnose (confirm cases) and treat malaria cases. At the end of the study, the results indicate that progress has been made in the diagnosis and treatment of malaria from 2015 to 2017.

*Affiliation: PMI Improving Malaria Care Project; Jhpiego Burkina Faso. 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.

Use of Malaria Service and Data Quality Improvement in Mwanza Tanzania

Emmanuel Lesilwa, Goodluck Tesha, Jasmine Chadewa, Agnes Kosia, Zahra Mkomwa, Bayoum Awadhi, Gaudiosa Tibaijuka, Rita Noronha, Dunstan Bishanga, Lusekelo Njonge, Frank Chacky, Abdallah Lusasi, Ally Mohamed, Chonge Kitojo, and Erik Reaves presented a poster entitled “Use of Malaria Service and Data Quality Improvement (MSDQI) Tool in Cascaded Supervision Approach Improved Quality of Malaria Services – Experience from Mwanza, Tanzania” at the 68th Annual Meeting of the American Society of Tropical Medicine and Hygiene. Their findings are shared below.

Inadequate quality of malaria service and data has been one of the problems in Mwanza region due to high malaria prevalence, inadequate knowledge of supervisors and standardized supervision tool. In 2017, NMCP and stakeholders developed malaria services and data quality improvement (MSDQI) tool to guide supervisors. The tool comprises of seven modules addressing performance of Malaria Case Management with indicators weighted against a standard score. Any facility scoring below 50% of the overall score is deemed poorly performing, 50%-75% moderate and above 75% good performance.

What is Malaria Service and Data Quality Improvement (MSDQI)? It is a checklist to guide supportive supervision teams in evaluating the quality of malaria services at the health facility level. MSDQI helps with the:-

  • Monitoring and evaluation
  • Facility-based malaria performance indicators
  • Provision of timely, accurate information and data for decision-making at district, regional, and national levels

In the attached graphs we present the Number of malaria test among OPD cases and the Number of malaria test among OPD cases which increased from 527,734 in 2016 to 1,241,990 in 2018 in Mwanza region. This resulted to the decrease of patients treated without malaria confirmatory test.

After intervention with MSDQI, there was a Decline in proportion of malaria cases clinically diagnosed and treated in Mwanza Regions reduced from 6.5% cases in 2016 to 0.1% cases in 2018

Good progress in IPTp2 and IPTp3 Coverage in Mwanza region was also documented. IPTp2 increased from 37.6% in 2016 to 72.3%, while PITp3 increased from 1.2% in 2016 to 48.5% in 2018.

There was Increased coverage of LLINs in pregnant women and infants.
Increased coverage of LLINs in Pregnant women went from 4.9% 2016 to 75.6% in 2018. Likewise that for Infants increased from 2.9% 2016 to 65% in 2018.

Several Lessons were Learned. Cascaded supervision approaches contribute to improved quality of malaria service provision and hence improved malaria indicators. The Way forward is to Continue using cascaded supervisors to improve quality of data and malaria services through MSDQI

*Affiliation: : USAID Boresha Afya Lake and Western Zone – PATH; USAID Boresha Afya Lake and Western Zone –Jhpiego; National Malaria Control Programme-Tanzania Ministry of Health, Community Development, Gender, Elderly and Children, Tanzania; US President’s Malaria Initiative-United States Agency for International Development

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

Systematic Approach to the Review of Malaria Management Guidelines Ghana, 2019

Mildred Komey Akosua,* James Sarkodie, Kezia Malm1 Raphael Ntumy, and Gladys Tetteh presented a poster entitled “Systematic Approach to the Review of Malaria Management Guidelines Ghana, 2019” at the 68th Annual Meeting of the American Society for Tropical Medicine and Hygiene.

The primary objective of the Ghana NMCP is to reduce morbidity & mortality due to malaria through effective strategies. Implementation of these effective malaria control strategies depends largely on the availability of up-to-date, evidence-based, and standardized reference materials to guide and improve practice. Guidelines for the management of malaria in Ghana, including the anti-malaria drug policy (ADP), guidelines for case management of malaria (CM) and guidelines for malaria in pregnancy (MiP) were last updated in 2014. The 2014 review took over six months and left behind no documented methodology to guide subsequent reviews.

The World Health Organization recommends a comprehensive review every five years. In order to make the 2019 review process concise, efficient and reproducible, the NMCP with support from the PMI Impact Malaria project outlined a methodical approach to the review.

The process established an oversight review committee; identified all stakeholders relevant to update the ADP and guidelines; prepared a reference package of technical resources and research findings; nominated experts and allocated them to topic-specific technical working groups (TWGs). (Fig 1)

Then, a series of TWG consultative meetings were held with clearly defined processes and outputs, and independent external experts and potential end users of the guidelines ratified the draft guidelines. (Fig 2 and Fig 3)

A final phase included development of training content, training manuals, and development of key job-aids. (Fig 4 and Fig 5) Costs for the review process were identified and funding obtained.

All components of the 2019 process were enhancements to the unrecorded 2014 review. The process resulted in a documented and costed methodological approach, an up-to-date ADP, MiP and CM guidelines, training curriculum, training manuals, and job aids; all developed in a timely and efficient manner over a three-month period.

It also resulted in an approach for achieving minor policy and guideline updates between comprehensive five-year reviews. Using a systematic well-defined comprehensive approach with clear expectations for inputs, process, outputs, roles, timelines, costs, and sequelae actions, results in up-to-date widely accepted policies and guidelines whose implementation can be easily operationalized, with mechanisms for minor guideline updates between comprehensive five-year reviews.

*Author affiliations: Ghana National Malaria Control Programme, PMI Impact Malaria Project, Jhpiego

TWITTER.COM/IMPACT_MALARIA; IMPACTMALARIA.ORG

Malaria Case Management Practice and Elimination Readiness in Five Elimination Districts of Madagascar, 2018

Anjoli Anand,* Favero Rachel, Catherine Dentinger, A. Ralaivaomisa, S. Ramamonjisoa, Elaine Razafimandimby, Jocelyn Razafindrakoto, Katherine Wolf, Laura C. Steinhardt, Julie Thwing, Bryan K. Kapella, M. Rabary, Sedera Mioramalala, Jean Pierre Rakotovao presented a poster on “Malaria Case Management Practice and Elimination Readiness in Five Elimination Districts of Madagascar, 2018” at the 68th Annual Meeting of the American Society of Tropical Medicine and Hygiene. Their findings are shared below.

Madagascar’s Malaria National Strategic Plan 2018-2022 calls for progressive malaria elimination beginning in low-incidence districts (< 1 case/1000). Although an elimination plan has not yet been developed, optimizing access to prompt diagnosis and quality treatment will be its foundation, along with improving outbreak detection and response, and developing an elimination plan.

There was need to understand current practices in preparation for elimination such as estimating current implementation readiness, documenting current diagnosis and treatment practices (case management), Assessing the use of data to inform decision-making and determining the availability of commodities, training and supervision. To assess this readiness and inform planning, we surveyed health facilities (HFs) and communities.

In September 2018, we randomly selected 35 HFs in 5 of the 8 districts identified for elimination, surveyed 41 HWs and 34 community health volunteers (CHVs), and observed 300 clinical encounters between HWs and patients of all ages. Quantitative and qualitative tools were used to collect data. There were a health facility checklist, an interview guide for health facility providers, a clinical observation guide, a community health volunteer CHV) interview guide, and a stakeholder interview guide.

To evaluate elimination readiness, a composite score was assigned to each HF catchment area that incorporates all survey responses based on commodity availability, malaria CM practices, data management, and supervision practices.

In preliminary results, 8 of 34 (24%) CHVs reported that they do not manage children under 5 years (CU5) with fever at the community level. Of 26 CHVs who care for CU5, 18 (69%) identified history of fever as a criterion for suspected malaria, 20 (77%) reported using a malaria rapid diagnostic test (RDT) when evaluating patients reporting fever, and 15 (58%) reported giving antimalarials for a positive RDT. Among treating CHVs, 13 (30%) reported having RDTs, and 11 (42%) reported having antimalarials currently available. A

Among facility-based HWs, 83% identified history of fever as a criterion for a suspected case. Of 120 patients with reported or recorded fever, 56 (47%) were tested with an RDT. Five RDTs were positive; a first-line antimalarial was prescribed to 4 of those patients. This evaluation is a baseline for CM performance as Madagascar establishes elimination targets. In the evaluated districts, CM could be improved by strategies to increase testing at CHV and HF levels and address availability of commodity stocks in the community.

*Affiliations: Epidemic Intelligence Service, Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, United States; Maternal Child Survival Program, Washington, DC, United States; US President’s Malaria Initiative; US Centers for Disease Control and Prevention, Antananarivo, Madagascar; Maternal Child Survival Program, Madagascar, Antananarivo, Madagascar; Maternal Child Survival Program, Antananarivo, Madagascar; US President’s Malaria Initiative, Antananarivo, Madagascar; Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, United States; National Malaria Control Program, Antananarivo, Madagascar

Efficacy of artemether-lumefantrine for the treatment of uncomplicated Plasmodium falciparum infection in Rwanda, 2018

The Efficacy of artemether-lumefantrine for the treatment of uncomplicated Plasmodium falciparum infection in Rwanda, 2018 was investigated by Aline Uwimana, Noella Umulisa, Eric S. Halsey, Meera Venkatesan, Tharcisse Munyaneza, Rafiki Madjid Habimana, Ryan Sandford, Leah Moriarty, Emily Piercefield, Zhiyong Zhou, Samaly Souza, Naomi Lucchi, Daniel Ngamije, Jean-Louis N Mangala, William Brieger, Venkatachalam Udhayakumar, Aimable Mbituyumuremyi.* The results were presented at the 68th Annual Meeting of the American Society of Tropical Medicine and Hygiene and are seen below.

Background: In Rwanda, there were 4,195,013 confirmed malaria cases and 341 malaria-related deaths in 2018[1]. Regular monitoring of artemisinin-based combination therapy efficacy is important to assess drug efficacy and for timely detection of the emergence of antimalarial drug resistance. In Rwanda, national policy is to routinely monitor the first-line antimalarial per World Health Organization (WHO) guidelines[2] The most recent therapeutic efficacy results in Rwanda showed an efficacy of the first-line antimalarial, artemether-lumefantrine (AL), of >97% in Masaka and Ruhuha in a study conducted from 2013 to 2015[3]

Methods: This was an Efficacy trial based on the standard WHO in vivo protocol[2]. Three sites (see map) were selected in Rwanda. Artemether-lumefantrine (AL) was given twice daily; each dose given under observation for 3 days. Participants were treated with AL and followed for 28 days from March 2018 to December 2018.

PCR correction, differentiating recrudescence from reinfection in late treatment failure samples, was performed using genotyping of seven neutral microsatellites. Microsatellite data were analyzed using a previously published algorithm that assigns each late treatment failure a posterior probability of recrudescence[4]

  • Primary Endpoint: 28-day PCR-corrected efficacy
  • Secondary Endpoints: 28-day uncorrected efficacy, day 3 parasitemia

PCR-corrected and uncorrected efficacies are seen to the left.  Kaplan Meier Curves are presented. Uncorrected (top) and PCR-corrected (bottom) survival functions for time until failure for a 2018 therapeutic efficacy study using artemether-lumefantrine in three Rwandan study sites; ACPR: adequate clinical and parasitological response. Day 3 Parasitemia was identified. Two sites, Masaka and Rukara, had > 10% of subjects with parasites detectable on day 3, a WHO criteria for suspected artemisinin resistance.

With PCR-corrected efficacies greater than the 90% cut-off recommended by WHO, AL remains an effective antimalarial to treat uncomplicated P. falciparum in Rwanda
More than 10% of subjects had day 3 parasitemia at two sites; the relationship with this finding and k13 mutations observed in this study was presented in ASTMH poster LB-5295 (Friday, November 22, 2019).

Periodic antimalarial efficacy monitoring in Rwanda should be maintained, and future studies should incorporate additional methods to assess parasite clearance times and presence of molecular markers of resistance. WHO algorithm indicating that, for this study, even with suspected artemisinin resistance in Rwanda, no change in ACT treatment policy is warranted at this time.

References

  1. Rwanda Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Center, HMIS data, 2018.
  2. WHO, Methods for Surveillance of Antimalarial Drug Efficacy, 2009.
  3. Uwimana A, Efficacy of artemether–lumefantrine versus dihydroartemisinin–piperaquine for the treatment of uncomplicated malaria among children in Rwanda: an open-label, randomized controlled trial, Trans R Soc Trop Med Hyg; doi:10.1093/trstmh/trz009; 2019.
  4. Plucinski MM, Morton L, Bushman M, Dimbu PR, Udhayakumar V. Robust algorithm for systematic classification of malaria late treatment failures as recrudescence or reinfection using microsatellite genotyping. Antimicrob Agents Chemother;59:6096–100; 2015.

Contact Information: Aline Uwimana, MD: aline.uwimana@rbc.gov.rw and Eric Halsey, MD: ycw8@cdc.gov

*Affiliations: Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Centre, Kigali, Rwanda; Maternal and Child Survival Program/JHPIEGO, Baltimore MD, USA; The US President’s Malaria Initiative, Atlanta, Georgia, USA; Malaria Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA; US President’s Malaria Initiative, Washington DC, USA; National Reference Laboratory, Rwanda Biomedical Centre, Kigali, Rwanda; US Peace Corps, Kigali, Rwanda; US President’s Malaria Initiative, Kigali, Rwanda; WHO Rwanda Office, Malaria and Neglected Tropical Diseases Programs, Kigali, Rwanda; The Johns Hopkins University, Bloomberg School of Public Health, Department of International Health, Baltimore, MD, USA