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

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 everyfive 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

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

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 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.

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.

Colleagues from USAID’s Flagship Maternal and Child Survival Program are presenting poster 415 at the 68^th 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.

—–

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.

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.

Gbenga Jokodola tells his story of growing up to fight malaria in Nigeria. Gbenga has a MPH in Field Epidemiology from the University of Ibadan, and a BPharm from Ahmadu Bello University. He is currently working with Malaria Consortium as a Zonal Project Manager on the Seasonal Malaria Chemoprevention (SMC) Project, delivering preventive care to over 400,000 children between the ages of 3 – 59 months in Jigawa and Katsina States of Nigeria. He has worked on several malaria projects over the years sponsored by Unicef, the Global Fund, Catholic Relief Services and the Bill & Melinda Gates Foundation. As he narrates below, his early experiences with malaria were formative of his present focus in life.

Growing up in Zaria, northern Nigeria in the 70s and 80s was one of the best experience any child could ask for. I lived with my parents in two rented rooms in a compound on one of the streets in Sabon Gari Zaria – a community that had virtually all the tribes in Nigeria and of course, with all the love and communal living you can ever get from a true Nigerian community.

In such loving setting we enjoyed as children, I imagined that mosquito communities also lived around our pit latrine and backyard. I imagined that parent-mosquitoes trained their off-springs very well on how to bite and fly away tactfully, how to dodge the usual clap-like manner we use in killing mosquitoes, which homes to avoid visiting, and so on.

I was reputed to be a strong boy then, one of the few kids who were “strong”; I was a “tough” boy who rarely fell ill to malaria. Then, it was common to hear, “Gbenga is a strong boy”. I ate and slept in any room in our compound – with or without covering from mosquito and was hailed for doing so by my friends who often fall ill to malaria.

Life lesson as a Primary School pupil: There is no immunity against malaria

One day, the “malaria forces” (mosquitoes) taught me a life lesson: Indeed, there is no immunity against malaria.

My local Government primary school rotated school attendance between morning and afternoon every week. As an 8-year-old, while preparing for my afternoon school I suddenly felt very cold and sleepy at the same time and decided to lie down briefly on my senior brother’s 6-spring bed in our sitting room. Shortly after, I was shivering and sweating profusely under 3 of my mother’s wrappers.

Help was not immediately near as most people were out. My head was pounding like I was a piece of yam being pounded with a pestle in my mother’s mortar. My stomach was churning. All the while, I kept saying “I am a strong boy, I will not be sick”! I was in that state for over an hour. I began to wonder if I was strong after all and will not end up dying. I could no longer talk but my teeth were chattering.

Sweating profusely, yet I was cold! I was helpless. It was in this state that one of our neighbor’s daughters walked into our sitting room, wondering if there was any food to eat. Immediately she saw the “strong man” shivering under 3 wrappers, she raised an alarm. Her shout saved me as neighbors immediately rushed into our sitting room. Among them was a relation of the landlord, a beautiful “Aunty” Esther, who was visiting from the Ahmadu Bello University school of Nursing. As soon as she came over, she said: “this is malaria!”.

Aunty Esther immediately organized and rescued me that day; she saved the life of the “strong man”! She quickly sought iced-cold water and toweled my body with my father’s “untouchable” towel hanging on the door of the inner room. Ah, what a good feel it was! She then gave me a sweet syrup which I later found out to be Paracetamol syrup. After about 30 minutes, she returned with a plate of hot rice and stew, encouraging me to eat before treatment with anti-malarial medication. I struggled to eat the rice, angry that I had lost my ever-available appetite! I only took few spoons, amidst the encouragement I received from all present.

I was then given an injection by Aunty Nurse Esther, tucked back into the bed and told to prepare to sleep. She then said, “Gbenga, no school for you today, okay? You even need to get well before you resume school”. Everyone knew I loved school. I had to lose a precious school day (and three more days) to malaria! So, I simply focused on staying alive, wondering which “wicked” mosquito bit me. That was the day I dramatically lost my title of “strong man” to malaria, painfully realizing that I was not immune to malaria at all!

My treatment against malaria was continued with further jabs of the needle (twice a day) over the course of the next 3 days at the Dispensary/Primary Health Unit “Aunty” Esther directed my parents to. I got well and resumed school after the third day. Later, I researched and found out I was treated with a sedative, Chloroquine and Paracetamol.

My parents later introduced “Sunday-Sunday Medicine” (one Sweetened pyrimethamine tablet weekly) against Malaria to our diet on Sundays. With this painful encounter with Malaria, I resolved to fight mosquitoes; I was determined to regain my “strong man” title. I made up my mind to be a community health worker, saving communities from diseases like malaria.

Fast-forward to Year 2007: My new twist in combating Malaria

By the year 2007, my personal malaria episodes had lessened with greater knowledge of the disease. In addition, the application of the preventive, diagnostic and treatment procedures reduced my malaria episodes to about 1 in 3 years. With each episode, I normally use laboratory test (microscopy) to confirm if severity is +, ++, or even +++. Thereafter, I get a prescription from a Physician on appropriate medication to use.

However, while practicing in Abuja, I encountered a tearful case of death from malaria, of an 8-year old beautiful daughter of a colleague. Three days prior to her death, a Community Pharmacist had dispensed anti-malarial medication to her, based on prescription tendered by the father from a Government hospital he had earlier taken her to. The news of her death brought back memories of how I would have died as

an 8-year old from this same Malaria. Yes, this same Malaria! That death of the 8-year old triggered a fresh resolve in me to step up my fight with mosquitoes and combat malaria squarely at community, state, National and global levels.

Still at War with Malaria in 2018

Now armed with post-graduate training in Public Health/Epidemiology and field-based experience, my Malaria diagnosis strategy has now changed. I now use Rapid Diagnostic Test Kits (RDT). If confirmed positive, I receive prescription on the most applicable Artemisinin-based combination Therapy (ACT) to use.

My malaria story continues and will only end when mosquitoes are defeated – when children and adults no longer fall ill nor die from mosquito bites that cause malaria.

You can follow Gbenga on Twitter.

After the World’s first attempt at eradicating the complicated disease malaria mainly through a single tool, a period of control set in where the aim was to reduce mortality through prompt and presumptive treatment of fevers with anti-malarials, particularly in young children. During this period in the 1980s and 1990s it was recognized that parasite-based diagnostic capabilities in the form of microscopy were limited, so in malaria endemic areas, it was worth providing inexpensive medicines like chloroquine (CQ) and sulfadoxine-pyrimethamine (SP) to febrile children in order to save lives. When the fevers did not resolve, other illnesses explored.

The difficulty arose in identifying cases that did not offer clinical clues that they might be malaria. Today countries approaching malaria elimination face challenges, such as seen in Zanzibar where, “outdoor transmission, a large asymptomatic parasite reservoir and imported infections, require novel tools and reoriented strategies to prevent a rebound effect and achieve elimination.”[i] Here we examine the challenge of asymptomatic malaria infections.

Background

By 1998 when the Roll Back Malaria partnership formed, there had been enough research done so that the malaria community had a better arsenal of interventions including insecticide-treated bed nets, artemisinin-based combination therapy (ACT) and intermittent preventive treatment with SP during pregnancy. The Abuja Declaration of 2000 set a target of 80% coverage of these interventions by the year 2010.

While ACTs overcame the challenges of parasite resistance that had developed for the single drugs, CQ and SP, it cost several times more than those medicines. The need for easy-to-use, inexpensive, point-of-care diagnostics was recognized so that not only would ACTs be targeted only to parasitologically confirmed malaria cases, but also in the process, overuse and misuse would not contribute to parasite resistance of these new drugs.[ii] Unfortunately, the development and dissemination of antigen-based rapid diagnostic tests (RDTs), lagged behind the availability of ACTs meaning that health workers unfortunately continued their business as usual with presumptive treatment using ACTs. 

The benefits of RDTs were generally two-fold. First, they could be used by front-line, auxiliary and community-based health workers. Secondly, they tended to identify more cases than microscopy. The big challenge was convincing health workers to use them and trust the results, because the era of presumptive treatment had given these staff a false sense of confidence in their own clinical diagnostic abilities.

Although reaching the 2010 coverage targets has remained illusive for most endemic countries, there has been enough progress for major reductions in incidence (despite a recent upsurge).[iii] As the proportion of actual malaria cases among febrile illness patients declines, concern has risen that transmission might continue among people with subclinical or asymptomatic malaria. Here we explore the extent of this problem and new directions in parasitological testing needed to ensure continued progress toward elimination in each endemic country.

Understanding the Risk of Asymptomatic Malaria

Risk can relate to geographical, epidemiological, and socio-demographic factors as well as history of malaria interventions. Kenya has stratified the country by higher and lower malaria transmission areas. Even the higher areas are comparatively low compared to its higher transmission neighbors. Studying the prevalence of asymptomatic malaria in some of these higher transmission areas in the west of the country was seen as a way to better identify people at risk and learn about intervention effectiveness. An examination of apparently healthy children (no symptoms) revealed a Plasmodium falciparum malaria prevalence 36.0% (27.5%, 44.5%) by RDT and 22.3% (16.0%, 28.6%) by thick film microscopy.[iv] Living in a household with electricity was protective but the adjusted odds ratio of prevalence comparing households with and without indoor residual spray showed only borderline benefit. Unfortunately, in Zanzibar, asymptomatic malaria infection was not associated “with use of any vector control.”¹

A major challenge in detecting cases through routine health care systems is care seeking patterns of care seeking for fever. The 2018 World Malaria Report acknowledges that there are major equity challenges in care seeking wherein families with higher incomes, better education and living in urban areas are more likely to seek help for their febrile children that rural, poor and less educated families who would be more at risk. Care seeking without the signs of fever is more challenging. A dual strategy of enabling better service utilization as well as outreach to detect cases will be necessary to detect asymptomatic cases.³

In Burkina Faso, the prevalence of asymptomatic malaria infection in children under 5 years of age was estimated at 38.2% in 24 of its 70 health districts. Those at most risk for asymptomatic malaria infection included the following:[v]

• older children (48–59 vs < 6 months: OR: 6.79 [5.62, 8.22])
• children from very poor households (Richest vs poorest: OR: 0.85 [0.74–0.96])
• households located more than 5 km from a health facility (< 5 km vs ? 5 km: OR: 1.14 [1.04–1.25])
• localities with inadequate number of nurses (< 3 vs ? 3: 0.72 [0.62, 0.82]
• rural areas (OR: 1.67 [1.39–2.01])

Nine districts reported significantly higher risks (Batié, Boromo, Dano, Diébougou, Gaoua, Ouahigouya, Ouargaye, Sapouy and Toma. The researchers concluded that, “Such national spatial analysis should help to prioritize areas for increased malaria control activities.”

A study in Ghana found that, “children and pregnant women had higher prevalence of submicroscopic gametocytes (39.5% and 29.7%, respectively) compared to adults
(17.4%).”[vi]

An additional concern is emerging in terms of sharing of malaria parasite species between humans and primates, especially as urbanization and deforestation push these two populations into closer contact. For example Mapua and colleagues working in Central Africa Republic, “found the human malaria parasite P. ovale wallikeri in both asymptomatic humans and western lowland gorillas in Dzanga Sangha Protected Areas. Molecular analysis revealed that the genotype of the P. ovale wallikeri DNA found in a gorilla was genetically identical to that of a human isolate within the mt cytb and mt cox 1 genes, indicating potential human–ape transmission.”[vii] They noted similar sharing of parasites in the region between humans and chimpanzees.

Detecting and Responding to Asymptomatic Cases

WHO’s Framework for Malaria Elimination[viii] recognizes the important role of case detection and subsequent treatment as well as broader community level preventive responses around detected cases. In the context of elimination WHO notes that case detection “requires use of a diagnostic test to identify asymptomatic malaria infections.” WHO stresses that a case is a case, regardless of whether it is symptomatic or asymptomatic, as long as the diagnostic process confirms presence of malaria infection.

It is important to monitor Plasmodium parasitemia in areas where malaria transmission has declined and efforts to achieve malaria elimination are underway, such as Zambia, where 3,863 household members were tested.[ix] Only 2.6% were positive by either microscopy, RDT, or PCR. Of these, 48 (47%) had subpatent parasitemia, and 85% of those with subpatent parasitemia were asymptomatic. “Compared with individuals without parasitemia, individuals with subpatent parasitemia were significantly more likely to be aged 5–25 years.” The authors suggested that their findings pointed to the need for active or reactive case detection to identify asymptomatic individuals and thus better target individuals with subpatent parasitemia with appropriate malaria interventions.

WHO explains that active case detection (ACD) takes place in areas of limited or under-utilization of health care services.⁴ It may start with initial screening for symptoms, followed by appropriate parasitological laboratory confirmation. In low-transmission settings or as part of a focus investigation, “ACD may consist of testing of a defined population group without prior symptom screening (population-wide or mass testing) in order to identify asymptomatic infections.” Elimination cannot be achieved until even asymptomatic infections have stopped. The challenge is the expense of community-wide screening.

Reactive Case Detection (RCD), according to WHO, takes place in settings low transmission intensity where the few “occurring malaria cases are highly aggregated.”⁴ When a case is identified, usually through identification of an actual infected patient at a local clinic, the community where the patient comes from is visited and a “net is cast around the index case” where household members and neighbors within a selected radius are tested. In this process asymptomatic cases are also identified.

Our existing diagnostic tools may be inadequate. McCreesh and colleagues reported on subpatent malaria in Namibia that, “fever history and standard RDTs are not useful to address this burden. Achievement of malaria elimination may require active case detection using more sensitive point-of-care diagnostics or presumptive treatment and targeted to high-risk groups.” This includes loop-mediated isothermal amplification (LAMP) using dried blood spots, which they tested.[x] Likewise from experience in a Zambian study, Kobayashi and co-researchers suggest, “more sensitive diagnostic tests or focal drug administration may be necessary to target individuals with subpatent parasitemia to achieve malaria elimination.”[xi]

Responses to detecting asymptomatic cases start at the individual level with prompt treatment of those found through RCD to be infected. Then focused preventive interventions such as distribution of insecticide treated bednets can be provided to those in the cluster or village. Follow-up would be needed for such ‘hot spots.’ 

On a broader basis we have Seasonal Malaria Chemoprevention (SMC) as practiced in Sahelian countries where during the peak transmission (rainy) season intermittent preventive treatment is given to children monthly by community health workers and volunteers. Of course, many of these children would be asymptomatic carriers and SMC could benefit the reduction of parasites in circulation. At present SMC focuses on pre-school aged children, but Thera and co-researchers stress the importance of reaching school aged children who are also often asymptomatic carriers.[xii]

Another intervention being tested for mass drug administration (MDA) use providing the community with ivermectin, a drug that has been highly effective in controlling filarial diseases and also found to kill mosquitoes who take a blood meal from a person who has recently taken it.[xiii] This strategy is still being tested, but again MDA means all community members, especially those with asymptomatic infection, would be reached.

A major question requires further research. To what extent do asymptomatic, submicroscopic and subpatent parasitemia contribute to continued malaria transmission? Another question is how can we address malaria infection in other primates? We know that scientists recommend targeting of malaria elimination interventions based on mapping of these infections.⁵ We therefore need to study the actual transmission potential of this phenomenon.

---

[i] Björkman A, Shakely D, Ali AS, Morris U, Mkali H, Abbas AK, Al-Mafazy A-W, Haji KA, Mcha J, Omar R, Cook J, Elfving K, Petzold M, Sachs MC, Aydin-Schmidt B, Drakeley V, Msellem M and Mårtensson A. From high to low malaria transmission in Zanzibar—challenges and opportunities to achieve elimination. BMC Medicine (2019) 17:14, https://doi.org/10.1186/s12916-018-1243-z

[ii] Global Malaria Programme. Universal access to malaria diagnostic testing – An operational manual. World Health Organization. November 2011 (rev. February 2013). https://www.who.int/malaria/publications/atoz/9789241502092/en/

[iii] Global Malaria Programme. World malaria report 2018. World Health Organization. 19 November 2018. https://www.who.int/malaria/publications/world-malaria-report-2018/en/

[iv] Peprah S, Tenge C, Genga IO, Mumia M, Were PA, Kuremu RT, Wekes WN,  Sumba PO, Kinyera T, Otim T, Legason ID, Biddle J, Reynolds SJ, Talisuna AO, Biggar1 RJ, Bhatia K, Goedert JJ, Pfeiffer RM, Mbulaiteye SM. A Cross-Sectional Population Study of Geographic, Age-Specific, and Household Risk Factors for Asymptomatic Plasmodium falciparum Malaria Infection in Western Kenya. The American Journal of Tropical Medicine and Hygiene, Volume 100, Issue 1, Jan 2019, p.54-65. DOI: https://doi.org/10.4269/ajtmh.18-0481.

[v] Ouédraogo M, Samadoulougou S, Rouamba T, Hien H, Sawadogo JEM Tinto H, Alegana VA, Speybroeck N and Kirakoya?Samadoulougou F. Spatial distribution and determinants of asymptomatic malaria risk among children under 5 years in 24 districts in Burkina Faso. Malaria Journal 2018; 17:460 https://doi.org/10.1186/s12936-018-2606-9

[vi] Lamptey H, Ofori MF, Kusi KA, Adu B, Owusu-Yeboa E, Kyei-Baafour E, Arku AT, Bosomprah S, Alifrangis M, Quakyi IA. The prevalence of submicroscopic Plasmodium falciparum gametocyte carriage and multiplicity of infection in children, pregnant women and adults in a low malaria transmission area in Southern Ghana. Malar J. 2018 Sep 17;17(1):331. doi: 10.1186/s12936-018-2479-y.

[vii] Mapua MI, Hans-Peter Fuehrer HP, Petrželková KJ, Todd A, Noedl H, Qablan MA, and Modrý D. Plasmodium ovale wallikeri in Western Lowland Gorillas and Humans Central African Republic. Emerging Infectious Disease journal. Volume 24, Number 8—August 2018. https://wwwnc.cdc.gov/eid/article/24/8/18-0010_article

[viii] Global Malaria Programme. A framework for malaria elimination. ISBN 978-92-4-151198-8. World Health Organization 2017, http://www.who.int/malaria/publications/atoz/9789241511988/en/

[ix] Kobayashi T, Kanyangarara M, Laban NM, Phiri M, Hamapumbu H, Searle KM, Stevenson JC, Thuma PE, Moss WJ and the Southern Africa International Centers of Excellence for Malaria Research. Characteristics of Subpatent Malaria in a Pre-Elimination Setting in Southern Zambia. The American Journal of Tropical Medicine and Hygiene, 10 December 2018, DOI: https://doi.org/10.4269/ajtmh.18-0399

[x] McCreesh P, Mumbengegwi D, Roberts K, Tambo M, Smith J, Whittemore B, Kelly G, Moe C, Murphy M, Chisenga M, Greenhouse B, Ntuku H, Kleinschmidt I, Sturrock H, Uusiku P, Gosling R, Bennett A, Hsiang MS. Subpatent malaria in a low transmission African setting: a cross-sectional study using rapid diagnostic testing (RDT) and loop-mediated isothermal amplification (LAMP) from Zambezi region, Namibia. Malar J. 2018 Dec 19;17(1):480. doi: 10.1186/s12936-018-2626-5.

[xi] Kobayashi T, Kanyangarara M, Laban NM, Phiri M, Hamapumbu H, Searle KM, Stevenson JC, Thuma PE, Moss WJ, For The Southern Africa International Centers Of Excellence For Malaria Research.Characteristics of Subpatent Malaria in a Pre-Elimination Setting in Southern Zambia. Am J Trop Med Hyg. 2018 Dec 10. doi: 10.4269/ajtmh.18-0399. [Epub ahead of print]

[xii] Thera MA, Konea AK, Tangaraa B, Diarraa E, Niarea A, Dembeleb A, Sissokoa MS, Doumboa OK. School-aged children based seasonal malaria chemoprevention using artesunate-amodiaquine in Mali. Parasite Epidemiology and Control 3 (2018) 96–105. https://doi.org/10.1016/j.parepi.2018.02.001

[xiii] Smit MR, Ochomo EO, Aljayyoussi G, Kwambai TK, Abong’o BO, Chen T, Bousema T, Slater HC, Waterhouse D, Bayoh NM, Gimnig JE, Samuels AM, Desai MR, Phillips-Howard PA, Kariuki SK, Wang D, Ward SA, ter Kuile FO. Safety and mosquitocidal efficacy of high-dose ivermectin when co-administered with dihydroartemisinin-piperaquine. www.thelancet.com/infection Published online March 27, 2018 http://dx.doi.org/10.1016/S1473-3099(18)30163-4