Category Archives: Case Management

Using the collaborative quality improvement approach to increase adherence to the test, treat, and track malaria case management framework: Experiences from 10 health facilities in Uganda

Thomson Ngabirano, Espilidon Tumukurate, Innocent Atukunda, Emily Katarikawe, Jimmy Opigo, Martin Muhire, Emily Goodwin, Sam Gudoi, Kassahun Belay, Peter Thomas, James Tibenderana have been working with the following partners in Uganda to improve malaria case management: Jhpiego, United States Agency for International Development’s (USAID) Malaria Action Program for Districts (MAPD) Project, Uganda National Malaria Control Program, Ministry of Health, University Research Co., the USAID ASSIST Project, Malaria Consortium, US President’s Malaria Initiative, and the US Centers for Disease Control and Prevention, Uganda. Their work, seen below, was presented at the 2018 Annual Meeting of the American Society of Tropical Medicine and Hygiene.

Malaria has a 19 percent parasite prevalence in Uganda and is a leading cause of morbidity and mortality in Uganda and in 2014 was responsible for:

  • 30-50 percent of outpatient visits
  • 15-20 percent of hospital admissions
  • 20 percent of inpatient deaths.[1]

In an effort to reduce its malaria burden, in 2016 the Ministry of Health in Uganda incorporated a number of World Health Organization recommendations into its National Malaria Policy Guidelines. The main elements in these guidelines implemented by health workers were:

  • testing all suspected malaria cases with malaria rapid diagnostic tests (mRDT) or microscopy before treatment
  • using artemisinin-based combination therapy (ACT) to treat only positive malaria cases
  • providing at least three doses of intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP).

However, a number of challenges for malaria service delivery were encountered during

implementation, including incomplete, inaccurate, and inconsistent malaria records and reports; health workers not adhering to the malaria test, treat, and track policy; and malaria causing high caseloads at outpatient and inpatient service points.

To overcome these issues, and in particular to improve adherence to the malaria test, treat and track policy and strengthen the quality of data collection and recording, USAID’s Malaria Action Program for Districts (MAPD) implemented a collaborative quality improvement approach (CQI).

A CQI approach was introduced to MAPD in November 2017 and implemented using both qualitative and quantitative methods. These included reviewing malaria indicators on the District Health Information System, identifying 10 high-volume facilities across MAPD’s five operational regions with poor malaria indicators (see Figure 1), holding entry meetings with the district health teams, conducting collaborative data reviews and problem analysis with health facility staff, and presenting the results of data reviews to health facility staff to identify inaccurate reporting and non-compliance with the test, treat and track policy. Interventions also included working with health facility staff to identify potential solutions and interventions, implementing agreed interventions and reviewing indicators, monitoring progress using documentation journals, holding learning sessions led by a CQI coach, agreeing on new actions.

Malaria data indicators reviewed include accuracy and completeness of cases in lab register and OPD, number of fever cases tested for malaria using mRDT or microscopy, number of malaria-negative cases treated with ACTs, number of malaria-positive cases treated with ACTs, and number of pregnant women receiving three or more doses of IPTp-SP.

In a sample of 300 cases from a June 2018 lab register, taken eight months after the CQI approach was introduced, all 300 (100 percent) were recorded in the respective OPD register. This represents a 108 percent increase from when an equivalent sample was first reviewed in November 2017. In a sample of 300 patients that were treated using ACTs in June 2018, all patients were tested for malaria using mRDTs or microscopy and no patients were treated that had tested negative. This represents an 89 percent decrease from November 2017 when 27 (nine percent) malaria-negative cases were incorrectly treated using ACTs.

Of the total 264 expectant mothers (who were 28 weeks pregnant and above) that attended ANC visits in July 2018, 142 (54 percent) received three or more doses of IPTp-SP. This is a marked increase on the 43 percent of pregnant women who received three or more doses in November 2017.

Feedback from discussions with health workers in facility meetings and regional learning sessions showed that health teams now accept that there is a need for accurate and complete data and understand the importance of adhering to the National Malaria Policy Guidelines. In conclusion … The CQI approach was found to promote accurate data collection and improve adherence to the malaria test, treat, and track policy among health workers at 10 health facilities in five regions of Uganda.

[1] Reference: Uganda Bureau of Statistics (UBOS) and ICF International. Uganda Malaria Indicator Survey 2014-15. Kampala, Uganda and Rockville, Maryland, USA: UBOS and ICF International; 2015. Available at https://dhsprogram.com/pubs/pdf/mis21/mis21.pdf

MAPD is a project (running from 2016-2021), funded by the US President’s Malaria Initiative, USAID, UK aid, and the government of Uganda, which aims to improve the health status of the Ugandan population by reducing malaria-related morbidity and mortality among children and pregnant women. This poster was made possible by the support of the American and British People through the United States Agency for International Development and UK aid from the UK government. The contents of this poster are the sole responsibility of USAID Malaria Action Program for Districts and do not necessarily reflect the views of USAID or the United States Government and do not necessarily reflect the UK government’s official policies. For more information, please contact; 1. Dr Thomson Ngabirano, Malaria in Pregnancy Specialist Thomson.Ngabirano@Jhpiego.org 2. Dr Sam Siduda Gudoi, Chief of Party s.gudoi@malariaconsortium.org

Malaria Response Plan in Times of High Transmission: An Approach to Improving the Quality of Hospital Malaria Management

Ousmane Badolo, Stanislas Nebie, Youssouf Sawadogo, Thierry Ouedraogo, Moumouni Bonkoungou, Mathurin Dodo, Danielle Burke, William Brieger, and Gladys Tetteh of Jhpiego and the Improving Malaria Care Project (USAID) in Burkina Faso presented a poster on helping hospitals develop a malaria response plan. Their findings are shared below.

In Burkina Faso Malaria cases peak from June-September (rainy season), exceeding hospital capacity and causing high number of deaths, especially in children under 5 years of age. The Improving Malaria Care Project, funded by USAID/President’s Malaria Initiative, provided support to National Malaria Control Program to develop and implement malaria preparedness and response plans in all 11 regional hospitals

The Objectives of this effort aimed to describe development and implementation of malaria preparedness and response plan. From this the project planned to share lessons learned and challenges Malaria Preparedness and Response Plan Development and Implementation Process is seen in the attached chart.

In preparation of hospital staff for planning, the training reached Nurses and midwives were largest groups of trained providers at 52% and 30%, respectively. Providers were selected by hospital management team from pediatric maternity and emergency units.

Severe Malaria Cases Trend Regional Hospital in Burkina Faso is seen in the attached graph. In a second graph, Malaria Case Fatality Rate Trend at Regional Hospitals in Burkina Faso is shown. Even though there were more cases of severe malaria in 2017, Malaria case fatality rate decreased after implementing malaria response plan.

Challenges faced by the hospitals included Lack of funding for response plan activities, which were not included in the routine hospital work plan. Also there was a Lack of beds in some hospital rooms, especially in pediatric unit. Timing of clients coming to hospital posed a challenge as many do not come early and sometimes come when only complications start.

Lessons learned from the intervention include the fact that On-the-job training is opportunity to improve providers’ skills. Response plans must consider that providers’ refreshment, and securing blood and other commodities may improve severe malaria case management. Monthly data collection and analysis may highlight progress in malaria planning through case management and orient decision-making. Follow-up visits strengthened provider engagement on severe malaria case Management

In Conclusion, Response plans may provide a way to reduce malaria mortality. Each hospital should consider incorporating response plan into its annual work plan

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.

Improving Adherence to National Malaria Treatment Guidelines through a Low-Dose, High-Frequency Approach Targeting Village Malaria Workers in Selected Townships in Myanmar

Ni Ni Aye, May Aung Lin, Saw Lwin, Khin Than Win, Kyan Khaing, Nu Nu Khin, Kyaw Myint Tun who are colleagues from Jhpiego, PMI Defeat Malaria Project, University Research Co.,  Myanmar Nurses and Midwives Association; and the USAID/US President’s Malaria Initiative, Myanmar presented their experiences training village malaria workers on national malaria treatment guidelines at the 2018 Annual Meeting of the American Society of Tropical Medicine an Hygiene. Below are their findings.

The Trend of Malaria Cases and Deaths in Myanmar has been steadily decreasing. PMI Defeat Malaria Project (October 2016–September 2021) wants to ensure that this trend continues.

Project goals include reduce malaria burden, control artemisinin-resistant malaria in target area, and eliminate malaria in Myanmar. Specific Objectives are:

  • Achieve universal coverage of at-risk populations
  • Strengthen malaria surveillance system
  • Enhance provider technical capacity
  • Promote community and public and private-sector involvement in malaria control and elimination

Capacity Development Strategy for Village Malaria Workers (VMWs) focused on Two townships with low adherence to National Malaria Treatment Guidelines (NTGs): Palaw Township with 38 Village Malaria Workers (VMWs) and Gwa Township with 39 VMWs. The project used a Competency-based low-dose, high-frequency (LDHF) training approach. There were Three sessions, one day/month during June, July, and August 2017.

Post-training follow-up used a Clinical audit result review during supportive supervision and monitoring visits. Data quality assessment and verification was performed by field teams and monthly reports examined.

The project also Conducted refresher training using LDHF approach for at least two doses followed by on-the-job training and regular supervision and monitoring. They Formulated culturally appropriate materials for areas like Palaw Township where different languages are spoken. A Job Aid on Benefits of Adherence to Antimalarial Drug was developed.

VMW Rapid Diagnostic Testing was observed by Month. There was an Improvement in VMW Knowledge Assessment Scores with a positive Post-training Assessment Knowledge of Malaria.

Post-training Assessment for RDT Competency also took place. 85-90% of VMWs Told clients about blood testing and provided emotional support. 70-80% of VMWs Conducted RDT testing according to standards. 95-98% of VMWs Performed hand hygiene before and after rapid diagnostic test. 80-90% of VMWs Disposed used lancet immediately into safety box after use. 85-90% of VMWs Gave health education. Finally 80-90% Disposed of contaminated items appropriately and recorded test in malaria register, and 80% Used job aids/manual and provided correct treatment according to National Training Guidelines (NTGs).

In Conclusion, Improvement was seen in adherence to NTGs assessed as percent of uncomplicated malaria cases that received correct antimalarial treatment. VMWs Adhered to NTGs. In Gwa thus Increased from 72% to 100% and remained high. In Palaw this Stayed at 91% – 92% after training period. Therefore, the LDHF approach was appropriate for VMW capacity-building on protocol adherence in Gwa Township where there was no language barrier.

Next Steps include Conducting refresher training using LDHF approach for at least two doses followed by on-the-job training and regular supervision and monitoring. The project will Formulate culturally appropriate materials for areas like Palaw Township where different languages are spoken.

Improving Malaria Care Project Contribution in Transforming Malaria Control for Vulnerable Populations in Burkina Faso

Mathurin Dodo, Ousmane Badolo, Stanislas Nebie, Youssouf Sawadogo, Thierry Ouedraogo, Moumouni Bonkoungou, Youssouf Zongo, Maria Gouem, Danielle Burke, Gladys Tetteh, Lolade Oseni, Linda Fogarty, and William Brieger of Jhpiego and the USAID Improving malaria Care Project in Burkina Faso shared the status of malaria control efforts at the 2018 Annual Meeting of the American Society of Tropical Medicine and Hygiene. The focus on vulnerable populations is shared below.

Burkina Faso in 2010-2012 experienced poor capacity in malaria prevention and control, Malaria fatality rate was high:

  • Pregnant women: 0.71% in 2010 and 0.66% in 2012
  • Children under 5: 2.8% in 2010 and 2.7% in 2012

Improving Malaria Care (IMC) Project funded by USAID/President’s Malaria Initiative, began in 2013. IMC supports National Malaria Control Program to improve prevention and case

Management. IMC’s Strategies include the following:

  • Update national malaria prevention and case management guidelines
  • Strengthen health care provider capacity
  • Align malaria training package with revised guidelines
  • Strengthen national malaria health management information system (HMIS)

IMC together with the National Malaria Control Program has been strengthening Health Care Provider Capacity. 54 health districts have been covered by IMC direct support where 1819 providers were trained. Training reached 185 trainers/supervisors on revised training Modules who then trained 1,819 health care providers from 1,349 health facilities in 54 districts on new guidelines

After training 58 supervisors rolled out quality improvement (QI) systems. They oriented 897 providers from referral hospitals on new severe case management guidelines. Formative Supervision, Performance and Quality Improvement efforts were based on an improved malaria supervision guide and tools. Post-training supervision reached each provider. Specifically, malaria supervisions occurred twice a year.

The quality improvement approach, SBM-R® (Standards-Based Management and Recognition) approach, was implemented in 6 regions, 28 districts. Organized data review and validation workshop in 67 districts were another aspect of quality improvement. To sustain quality improvement, IMC conducted 2-day quality assessments and guided developed DQI implementation plans.

Social Behavior Change Communication was a central component of IMC. IMC conducted 13 regional advocacy workshops on malaria issues. The project developed and broadcast 2 malaria spots through 27 media, revised 5 diagnostic and case management job aids, distributed 7,440 job aids to health facilities, and reached 792,660 people through community activities and sensitization sessions

IMC Strengthened National Malaria HMIS. This included training 1,300 (72%) health workers to enter data into monthly reporting forms. Also trained were 326 data managers on HMIS and data use for decisionmakers. The malaria data collection system was integrated into national HMIS using DHIS2. To facilitate this the national HMIS manual was revised and distributed.  Data Quality was improved through malaria data review and validation at district levelUltimately these interventions resulted in Improved Malaria Services. More confirmed simple malaria cases received artemisinin-based combination therapy (65% in 2013 to 90% in 2017). More women received three doses of IPTp3 (14% in 2014 to 51% in June 2018). More suspected cases tested for malaria (65% in 2013 to 96% 2017). More women received insecticide-treated nets at antenatal care. There was Better accuracy in reporting of malaria key indicators.

Improved services led to decreased national malaria fatality rate. In the General population there was a decrease in malaria deaths of 34% and a decrease in overall fatality rate by 47%. Among pregnant women there was a decrease in malaria deaths by 91% and a decrease in malaria fatality rate by 93%. For Children under 5 years of age, there was a decrease in malaria deaths by 34% and a decrease in fatality rate 48%

In conclusion the IMC Project Contributed to Lives Saved in Burkina Faso. IMC supported health delivery sites in Burkina Faso (Jan 2014 -Sep 2017). As a result the health system was able to Distribute 33,566,671 courses of artemisinin-based combination therapy. IMC provided 2,175,648 pregnant women with intermittent preventive treatment 2nd dose and distributed 1,146,185 nets to pregnant women during antenatal care visit. These interventions averted estimated 150,390 malaria deaths and 12,866,271 DALYs (Disability-Adjusted Life Years calculated using PSI Impact calculator. 1 DALY=1 lost year of “healthy” life.)

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.

One SMS Saves Lives in Madagascar

Haja Andriamiharisoa, Eliane Razafimandimby, Jean Pierre Rakotovao, Jean Eugene Injerona, Zo Harifetra, Lalanirina H. Ravony, Rado Randriamboavonjy, Jocelyn Razafindrakoto, and Laurent Kapesa have been working with the USAID Maternal and Child Survival Program. At the 2018 Annual Meeting of the American Society of Tropical Medicine and Hygiene they presented their experiences on “Improving Procurement and Redeployment of Malaria Commodities Using SMS and Web Mapping at a District Level in Madagascar,” and are also sharing via this posting.

Malaria is a public health problem in Madagascar. In 2016, the frequency of diseases at health center level, places malaria at the 4th cause of hospital morbidity and mortality. Out of about 30 thirty diseases, malaria accounts for 5.6% of all cases.

Health facilities often experience commodity stock-outs of products used for malaria prevention and case management. The existing logistics reporting system does not allow for macro or micro views of the monthly stock situation at the health facility level, which inhibits rapid decision-making.

On January 2018, implementation of a fast data collection system and easy-to-use data visualization began. The tool was based on the use of SMS and web mapping to map the level of monthly keys stock of commodities. The data are sent by providers at facility level via structured SMS and are published by a web server by a web mapping process. Note that sending a monthly SMS costs 9 US cents per facility. Providers at 773 health facilities in 16 regions of Madagascar sent monthly SMS (each message cost $0.09) with ART, ACT, and ITN stock levels.

  • Sample message: “Please send the quantity in stock at the end of month in: ART, ACT, ITN.”
  • Structure like: “palu csbcode year month ART ACT ITN. Thank you.”
  • Sample of answer received: “palu 520241031 D A 200 25 0”

Thus was created an easy-to-use tool from data received. It was free to use, and no password was needed. The SMS is simple and short (of 40 forty characters, composed of:

  • “palu” diminutive of malaria so that the system is ready for data collection from other cases
  • the health facility code : 520241031
  • year : here D : as project has implemented sms data collecting system since 2015 = A
  • month : here A that means January
  • stock of Injectable Artesunate (ART) : 200
  • stock of tablet for Artemisininbased combination therapy (ACT) : 25
  • stock of Insecticide Treated Nets (ITN) : 0

Providers send SMS after completing the Monthly Activity Report. (CSB = Centre de Santé de Base, or basic health center). The received data are then displayed as web mapping on a Google map background, embedded on a web page. From this screen shot, The page displays a map of stock outs for the selected month, and monthly charts of the stock status of the three commodities. Accessing this website, is open, without restriction.

From the end of January to the end of June 2018, a hundred health facilities sent SMS each month. The data we received shows that on average:

  • 75% Average stock-out of ITN
  • 53% Average stock-out of ART
  • 9% Average stock-out of ACT

The attached three-map picture provides a broad view from three screenshots of the system, showing the evolution of stock-outs at a facility level

  • Each point represents health facilities:
  • When the dot is green, this means that the 03 commodities are available in stock
  • When in brown, at least one of the 03 elements is unavailable
  • At first sight, there are more stockouts than stock availability and a tendency of the reduction of green points over the months
  • Appropriate decision-making would change the points of the map of the following months to green

After this broad view of the country’s overall situation and given the large number of facilities with out of stock, an emergency supply for all districts was done for some medicine since February 2018. Based on maps and stats, we could improve our interventions at a CSB level through rapid and adequate decision-making as in the supply of ITN and ART.

In conclusion, the use of SMS data collection to map stock-outs online can quickly improve input supply through simple spatial analysis. Sending SMSs to alert district-level officials about overstock in facilities at the same district level can solve many stock-out issues. All districts were restocked using this SMS and Web mapping system, but routing to the CSBs remains a challenge. Punctual stock-out reporting could significantly reduce the morbidity and mortality caused by malaria.

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

Performance of Community Health Workers in Providing Integrated Community Case Management (iCCM) Services in Eight Districts of Rwanda

During the first poster session at the 2018 Annual Meeting fo the American Society of Tropical Medicine and Hygiene, Noella Umulisa, Aline Uwimana, Cathy Mugeni, Beata Mukarugwiro, Stephen Mutwiwa, and Aimable Mbituyumuremyi of the Maternal and Child Survival Project (USAID)/Jhpiego and the Ministry of Health, Rwanda, presented findings from a review of community health workers in malaria case management. Their findings follow:

Rwanda has achieved near universal coverage of long-lasting insecticide nets, artemisinin-based combination therapy (ACT) and diagnosis, and targeted indoor residual spraying. Even so, there was an unprecedented increase in malaria cases from 2012-2017 despite optimal coverage of preventive and curative key interventions. The increase was caused by higher temperature, more rainfall, and increased resistance to insecticides.

With more cases, the need for community case management (CCM) is crucial. Rwanda therefore trains, equips and supports community health providers to deliver high- impact treatment interventions and aims to supplement facility-based case management. Rwanda introduced integrated CCM 2008. Trained community health workers (CHWs) provide iCCM based on empirical diagnosis and treatment of pneumonia, diarrhea, and malaria. They also conduct malnutrition surveillance, comprehensive reporting and referral services.

Given the changing status of malaria in the country, it was necessary to evaluate the performance of the CHWs. The evaluation aimed 1) to evaluate CHW performance in managing malaria, pneumonia and diarrhea in 8 districts of Rwanda based on national guidelines, and 2) to identify areas to reinforce and empower community health interventions. Using proximity (near/far) to hospitals and health centers, CHWs who had a minimum of 3 months experience using malaria rapid diagnostic tests (RDTs) were selected for interview. Slightly over half of CHWs were Males (56.2%). Most were over 40 years of age and nearly one-third were 50 years and older. Only 2% were between 25-29 years old.

Based on National Guidelines, CHWs were judged to have provided “adequate” treatment more frequently than “correct” treatment. Overall, 90% of cases were adequately treated; only 70% correctly treated. Among the three main conditions, malaria was most often adequately and correctly treated. Incorrect treatment was due to lack of adherence to guidelines. For malaria incorrect treatment often meant using the wrong does for age packet for treatment when the correct packet was not in stock.

In conclusion, CHWs correctly treat 70% of children for all IMCI pathologies according to national guidelines. Malaria was the most seen/treated pathology; cases increased during study period. Overall, cases more often treated adequately than correctly. CHWs use complex tools thus lack adequate time to follow all steps correctly when providing services.

The study team recommends the need to strengthen iCCM commodities supply chain, especially at community level through supervision and mentorship conducted at health centers, district hospitals and central level. Also it is necessary to revise and simplify iCCM tools used by CHWs to decrease burden and improve quality of services.

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

Malaria Featured in Jhpiego Sessions at ASTMH 2018

Below is a list of Jhpiego Sessions at this week’s American Society of Tropical Medicine Annual Meeting in New Orleans (28 October-1 November). Please attend if you are at the conference:

Poster Session A, Monday, October 29 (Posters in Marriott Grand Ballroom – 3rd Floor )

  • Poster Number 098: Performance of community health workers in providing integrated community case management services (iCCM) in 8 districts of Rwanda
  • Poster 380: Contribution of quarterly malaria data review and validation to data quality and malaria services Improvement
  • Poster LB-5117: Community based health workers can enhance coverage of intermittent preventive treatment of malaria in pregnancy and promote antenatal attendance

Poster Session B, Tuesday 30 October

  • Poster 1088: Assessing organizational capacity to deliver quality malaria services in rural Liberia
  • Poster 1092: Contribution of IMC project in transforming the face of malaria control for vulnerable populations in Burkina Faso
  • Poster 1093: Malaria response plan in times of high transmission: An approach to improving the quality of hospital malaria management
  • Poster 1111: Setting the stage to introduce a ground breaking approach to prevent malaria in pregnancy in Sub-Saharan Africa: baseline-readiness assessment findings from Democratic Republic of Congo, Mozambique, Madagascar, and Nigeria
  • Poster 1337: Institutionalizing infection prevention and control practices in health facilities in Liberia following the Ebola epidemic

Scientific Session 87, Tuesday, 1:45 – 3:30 p.m. Marriott – La Galerie 1 & 2 – 2nd Floor: Improving procurement and redeployment of district level malaria commodities using SMS and web mapping in Madagascar

Poster Session C, Wednesday 31 October

  • Poster 1816: Experiences and perceptions of care seeking for febrile illness among caregivers and providers in 8 districts of Madagascar
  • Poster 1818: Improving adherence to national malaria treatment guidelines by village health workers in selected townships through a low-dose, high-frequency training approach
  • Poster 1819: Improving malaria case management through national roll-out of Malaria Service and Data Quality Improvement (MSDQI): A Case study from Tanzania
  • Poster 1820: Collaborative quality improvement framework to support data quality improvement, experience from 10 collaborative facilities in Uganda
  • Poster 1821: Using malaria death audits to improve malaria case management and prevent future malaria related preventable deaths
  • Poster 1833: Multiple approaches for malaria case management in the struggle to reach pre-elimination of malaria.

Scientific Session 182, Thursday, November 1, 10:15 am – 12:00 p.m. Marriott – Balcony I,J,K – 3rd Floor: Seasonal malaria chemoprevention, an effective intervention for reducing malaria morbidity and mortality

Establishing Mobile Outreach Teams (MOTs) for strengthening Active Case Detection with Mobile Populations in Vietnam 2016-2020

Mobile migrant populations present a special challenge for malaria control and elimination efforts. Nguyen Ha Nam and colleagues* (Nguyen Xuan Thang, Gary Dahl, James O’Donnell, Vashti Irani, Sara Canavati, Jack Richards, Ngo Duc Thang, and Tran Thanh Duong) presented their study of this group at the recent Malaria World Congress. They are also sharing what they learned below.

Mobile Migrant Populations (MMPs) are a key population for containing the spread of malaria in the border areas between Cambodia and Vietnam. The number of imported cases in Viet Nam in 2017. 12,5% of such cases caught in Binh Phuoc and Dak Nong provinces and all of them came from Cambodia. The provinces bordering Cambodia and Vietnam have been had the highest malaria transmission intensity. This borders are frequented by MMPs who have proven difficult to target for surveillance and malaria control activities.

Mobile Outreach Teams (MOTs) provide a potential approach to target malaria elimination activities for MMPs who may not be strongly supported by the regular village-based and clinic-based health services. This work describes the implementation of MOTs in Binh Phuoc and Dak Nong Provinces, which are high-risk regions along the Viet Nam-Cambodia border. These activities were conducted as part of the Regional Artemisinin-resistance Initiative (RAI) in 2017. Each MOT was comprised of 2 Commune Health Staff and 1 Village Health Worker (VHW) from the village nearest to the outreach area.

In the first phase of the pilot, 3 communes of 2 districts in Binh Phuoc and 2 communes of 1 district in Dak Nong with highest malaria cases reported from NIMPE are selected as targeted areas. The Objectives were to …

  • Design/tailor Mobile Outreach Information Education and Communication/Behaviour change communication (BCC/ IEC) Toolkit
  • Intensify case detection and quality management by increasing the coverage of diagnostics and treatment for hard to reach populations
  • Strengthen outreach to high-risk and under-served populations through MOT scouting activities to locate unreached Mobile Communities and map their locations
  • Link MMPs with health facilities and Village Health Workers

All MOT members were provided with smartphones and were trained on how to use the EpiCollect5 app to track malaria cases, record mapping information and upload real-time reports of these malaria cases. MOTs conducted 5-day outreach activities every month. These activities began with scouting out locations of the MMP communities.

Once located, the MOTs geo-tagged the location of the community, conducted a short epidemiological survey on the community and screened for malaria using Rapid Diagnostic Tests and blood smear microscopy. Active malaria cases were provided with treatment according to the National guidelines, and Long Lasting Insecticidal Nets were distributed based on results of diagnosis and the survey.

This action has led to increased diagnosis and treatment of hard to reach MMPs with increased access by those communities to malaria services. Improved understanding and increased use of malaria prevention practices hard to reach MMP communities/households. Mapped of previously unreached MMP Communities and unofficial border crossing points with malaria transmission hotspots and highly frequented crossing identified. The number of MMPs were monitored by MOTs were 2,699 accounting for 5.18% of the population in the project sites (2,699/52,095).

These screened MMPs were almost located along the border among project communes in Bu Gia Map National Forest where have a lot of unofficial border crossers, timber camp communities, and other revolving communities. 1,977 targeted people were tested for malaria. This number was achieved 73.25% of mobile migrant people (1,977/2,699). This work highlights how MOTs can target the previously unreached populations of MMPs to strengthen malaria surveillance and active case responses to reduce malaria transmission in Viet Nam.

A system of real-time data collection of malaria cases from VHWs and MOTs using mobile phone uploads was established. Border screening and tracking hard to reach communities is a useful approach to implement to identify imported cases; however, it is labor-intensive, and misses subjects crossing at unofficial borders due to limited working time of MOTs (5 days a month).

Positive cases in Binh Phuoc province are maintained for keeping track after receiving treatment due to no confirmed cases detected in targeted communes in Dak Ngo province, though these communes mainly have numerous transient timber camps moving in deep forests, and highly mobile border-crossers moving between regions and countries frequently. Future work will combine routine support from District health staff and expand the role of VHWs with motorbike provision for each MOT in order to not only to improve their quality outreach activities but also develop stronger Active Case Detection in the next phase of the project.

*Team members represent the National Institute of Malariology, Parasitology and Entomology, Hanoi, Viet Nam; Health Poverty Action, London, UK; and the Burnet Institute, Melbourne, Australia.

References

  • Kheang ST, Lin MA, et al. Malaria Case Detection Among Mobile Populations and Migrant Workers in Myanmar: Comparison of 3 Service Delivery Approaches. 2018
  • Shannon Takala-Harrison,a Christopher G. Jacob, et al. Independent Emergence of Artemisinin Resistance Mutations Among Plasmodium falciparum in Southeast Asia. 2014.
  • Imwong M, Hien TT, et al. Spread of a single multidrug resistant malaria parasite lineage (PfPailin) to Vietnam. 2017.
  • Richard J Maude,corresponding author Chea Nguon, et al. Spatial and temporal epidemiology of clinical malaria in Cambodia 2004–2013. 2014.
  • Imwong M, Nguyen TN, et al.The epidemiology of subclinical malaria infections in South-East Asia: findings from cross-sectional surveys in Thailand–Myanmar border areas, Cambodia, and Vietnam. 2015.
  • Hannah Edwards, Sara E. Canavati, et al. Novel Cross-Border Approaches to Optimise Identification of Asymptomatic and Artemisinin-Resistant Plasmodium Infection in Mobile Populations Crossing Cambodian Borders. 2015.

Burkina Faso Celebrated World Malaria Day with Pledges to Defeat Malaria

Burkina Faso celebrated World Malaria Day with pledges to Defeat Malaria on 25th April 2018. Dr Ousman Badolo. Technical Director of Jhpiego’s USAID/PMI Supported Improving Malaria Care (IMC) Project describes below the event in the village of Kamboinsin, not far from the capital, Ouagadougou. Ibrahim Sawadogo from IMC provided the photographs.

The day started with a proclamation of malaria day from Burkina Faso’s President, Roch Marc Christian Kaboré, to his assembled cabinet and the press. The president recognized that malaria is still a major public health issue in the country, and while deaths are decreasing, the incidence of malaria is not. The President called for a greater commitment of resources by all partners to insure that malaria can be defeated in Burkina Faso by 2030.

Kamboinsin village in Sig-Noghin Health District was the site of further observances organized by the National Malaria Control Program, later that afternoon. This district was chosen because of having among the highest incidence rates for malaria in the region. Many partners set up booths to share their work in malaria with partners and citizens of the district. Included were three research centers (Centre Muraz, CNRFP and IRD), and three USAID programs supported by the President’s Malaria Initiative in Burkina Faso (Procurement and Supply Management [PSM], IMC and VectorLink), among others.

During the program both the Minister for Health and the US Ambassador spoke. The Minister highlighted the main strategies that Burkina Faso is employing to reduce and eliminate malaria including regular use of insecticide treated nets (ITN), seasonal malaria chemoprevention, Intermittent Preventive Treatment in Pregnancy (IPTp), Prompt and Appropriate Case Management and other Vector Control Strategies.

The US Ambassador shared a real-life story of a pregnant woman who during her current pregnancy decided to register early for Antenatal Care (ANC) as encouraged by the IMC project. She was able to get several doses of IPTp as required as well as obtain an ITN on her first visit, unlike in her previous pregnancies.

Entertainment was provided by the comedian Hypolythe Wangrawa (alias M’ba Bouanga) who presented a sketch involving his ‘son’ who was not encouraging his wife to attend ANC and receive malaria prevention services. M’ba Bouanga chastised the son and an actor playing a midwife explained to the family the value of attending ANC and preventing malaria. Singers Maria Bissongo, Miss Oueora and Aicha Junior provided the audience with a song that embodied a variety of malaria prevention and care messages.

A highlight of the occasion was recognition of high performing health districts in the country. They were judged on criteria including good management of malaria commodity stocks, reduced case fatality rates, use of diagnostic tests to confirm malaria before treatment and coverage of at least three doses of IPTp. Four districts were given awards, Titao, Thyou, Boussouma and Batie, while Charles de Gaul Pediatric Hospital was also recognized.

One can watch a video of the proclamation by the President on the National Facebook page. More details of the events are found in the following media: Lefaso.net and Paalga Observer.

World Malaria Day in Burkina Faso demonstrated the political will and commitment to “defeat malaria.” More and more national resources will be needed to reach the endline in 2030.

On World Malaria Day the realities of resurgence should energize the call to ‘Beat Malaria’

Dr Pedro Alonso who directed the World Health Organization’s Global Malaria Program, has had several opportunities in the past two weeks to remind the global community that complacency on malaria control and elimination must not take hold as there are still over 400,000 deaths globally from malaria each year. At the Seventh Multilateral Initiative for Malaria Conference (MIM) in Dakar, Dr Alonso drew attention to the challenges revealed in the most recent World Malaria Report (WMR). While there have been decreases in deaths, there are places where the number of actual cases is increasing.

Around twenty years ago the course of malaria changed with the holding of the first MIM, also in Dakar and the establishment of the Roll Bank Malaria (RBM) Partnership. These were followed in short order by the Abuja Declaration that set targets for 2010 and embodied political in endemic countries, as well as major funding mechanisms such as the Global Fund to fight AIDS, TB and Malaria. This spurred what has been termed a ‘Golden Decade’ of increasing investment and intervention coverage, leading to decreasing malaria morbidity and mortality. The Millennium Development Goals provided additional impetus to reduce the toll of malaria by 2015.

On Facebook Live yesterday Dr Alonso talked about that ‘Golden Decade.’ There was a 60% decrease in mortality and a 40% decreases in malaria cases. But progress slowing down and we may be stalled at a crossroads. He noted that history show unless accelerate efforts, malaria will come back with a vengeance. Not only is renewed political leadership and funding, particularly from affected countries needed, but we also need new tools. Dr Alonso explained that the existing tools allowed 7m deaths be diverted in that golden decade, but these tools are not perfect. We are reaching limits on these tools such that we need R&D for tools to enable quantum leap forward. Even old tools like nets are threatened by insecticide resistance, and research on alternative safe insecticides is crucial.

Dr Alonso at MIM pointed to the worrying fact that investment in malaria overall peaked in 2013. Investment by endemic countries themselves has remained stable throughout and never gone reached $1 billion despite advocacy and leadership groups like the Africa Leaders Malaria Alliance. The 2017 WMR shows that while 16 countries achieved a greater that 20% reduction in malaria cases, 25 saw a greater that 20% increase in cases. The outnumbering of decreasing countries by increasing was 4 to 8 in Africa, the region with the highest burden of the disease. Overall 24 African countries saw increases in cases between 2015 and 2016 versus 5 that saw a decrease. A review of the Demographic and Health and the Malaria Information Surveys in recent years show that most countries continue to have difficulty coming close to the Abuja 2010 targets for Insecticide treated net (ITN) use, prompt and appropriate malaria case management and intermittent preventive treatment of malaria in pregnancy (IPTp).

The coverage gap is real. The WMR shows that while there have been small but steady increase in 3 doses of IPTp, coverage of the first dose has leveled off. Also while ownership of a net by households has increased, less than half of households have at least one net for every two residents.

In contrast a new form of IPT – seasonal malaria chemoprevention (SMC) for children in the Sahel countries has taken off with over 90% of children receiving at least one of the monthly doses during the high transmission season. Community case management is taking off as is increased use of rapid diagnostic testing. Increased access to care may explain how in spite of increased cases, deaths can be reduced. This situation could change rapidly if drug resistance spreads.

While some international partners are stepping up, we are far short of the investment needed. The Gates Foundation is pledging more for research and development to address the need for new tools as mentioned by Dr Alonso. A big challenge is adequate funding to sustain the implementation of both existing tools and the new ones when they come online. Even in the context of a malaria elimination framework, WHO stresses the need to maintain appropriate levels of intervention with case management, ITNs and other measures regardless of the stage of elimination at which a country or sub-strata of a country is focused.

Twenty years after the formation of RBM and 70 years after the foundation of WHO, the children, families and communities of endemic countries are certainly ready to beat malaria. The question is whether the national and global partners are equally ready.