Category Archives: Case Management

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

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.

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.

Guinea: The Challenge of Malaria Control in a Post-Ebola Context

The preliminary 2018 Demographic and Health Survey (DHS) data have been released for Guinea (Conakry). Since the last DHS in 2012, Guinea and its neighbors experienced the largest Ebola outbreak in history, an event that damaged already weak health systems.

The previous DHS showed very weak malaria indicators. Only 47% of households had at least one ITN, which averages to 0.8 ITNs per person (compared to the universal coverage of 2.0). Among vulnerable groups only 26% of children below the age of 5 years slept under an ITN, as did 28% of pregnant women. Very few, 18%, pregnant women got two doses of IPTp, and only 5% of febrile children received ACTs (testing was not reported then).

Not much has changed concerning ITN coverage as reported in 2018. Slight improvements are seen in IPTp (which now requires 3 or more doses) and malaria testing and treatment for children. Ironically none of the indicators has passed the original 2006 Roll Back Malaria target of 60%, let alone 80% for 2010 and not of course the drive for universal coverage.

DHS has released a preliminary report for 2018 and the malaria component is summarized in the charts posted here. The national coverage for ITNs is 44%, slightly lower than 2012, but the average per household member is slightly higher at 1.1. Again, these numbers do not mark significant progress. Looking at wealth and ITN ownership there is a slight benefit in terms of equity in net possession among those with lower income, but this must be seen in the overall context of very low basic coverage.

Having a net in the household and using it are different challenges as seen in the reports of sleeping under the net on the night prior to the survey among children under 5 years of age and pregnant women. The sad finding is that even in households that own a net, the coverage of these two groups remains very low. This is reflected in the low net per person ratio nationally (1.1).

One would almost wonder if malaria is a neglected disease in Guinea. The reality is that since 2003, Guinea has received around $172 million US dollars in malaria project funding from the Global Fund. Its most recent annual funding from the US President’s Malaria Initiative (PMI) is around $14 million.  Of that PMI funding 24% was designated for nets and related activities, while 52% was to be spent on medicines, diagnostics and pharmaceutical management. These investments include systems strengthening and capacity building in addition to commodities.

PMI provides the needed context: “Since the country was declared Ebola-free in in June of 2016, Guinea continues to make positive advances towards building a strong health system in line with the health recovery plan. The government continues to mobilize internal and external resources for rolling out the health system recovery plan, but much remains to be done if this plan is to yield the intended results.” Areas in particular need of strengthening within the National Malaria Control Program include coordination, health information systems, leadership, supervision and logistics.

Three years have passed since the last Ebola case in Guinea. Hopefully the country can stave off another outbreak and at the same time strengthen its health system. Guinea may not yet be targeted for malaria elimination, but until systems are strengthened, the resources going into malaria control will not be able to push malaria indicators toward saving more lives.