Category Archives: Children

Improving Malaria through National Rollout of Malaria Service and Data Quality Improvement: A Case Study from Tanzania

Case Management, Children, Health Workers, IPTp, Malaria in Pregnancy, Quality of Services

Jasmine Chadewa, Chonge Kitojo, Goodluck Tesha, Naomi Kaspar, Lusekelo Njoge, Zahra Mkomwa, Dunstan Bishanga, George Greer, Abdallah Lusasi, and Sigsbert Mkude of the USAID Boresha Afya Project, the US President’s Malaria Initiative, the National Malaria Control Program, and the Community Development, Gender, Elderly and Children (Tanzanian Ministry of Health) shared how malaria data quality could be improved at the 2018 Annual Meeting of the American Society of Tropical Medicine and Hygiene. Below are their findings.

Tanzania has a high malaria burden (see Figure 1) and is facing an increased demand for health services. The Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC) developed the Malaria Service and Data Quality Improvement (MSDQI) checklist to guide supportive supervision teams in evaluating the quality of malaria case management (MCM) services at facility level. MSDQI helps with the collection, monitoring, and evaluation of facility-based malaria performance indicators at all levels of service delivery that provide timely, accurate information and data for decision-making at district, regional, and national levels.

USAID Boresha Afya conducted MSDQI assessments in 1,222 health facilities in the Lake and Western zones in outpatient departments (OPDs) and during antenatal care (ANC). The program disseminates malaria and ANC guidelines, tablets, job aids, and standard operating procedures. It also continues to facilitate supportive supervision and mentorship through the MSDQI tool to build providers’ capacity in identified areas.

Among the challenges reported, Supervisors need to be trained in more than one module to reduce cost. There is turnover of MSDQI supervisors. Cases that come back positive for diseases other than malaria are not investigated further. The use of Android smartphones sometimes interfered with data collection and the reporting system. • Regions/districts depend on donor support to implement MSDQI activities.

In conclusion, effective implementation of the MSDQI tool requires regions, districts, and facilities to be well informed and given clear instruction so they can form supportive supervision teams. This should be done by:

  • Orienting teams on roles and responsibilities
  • Training teams on relevant competencies, resource allocation, and tablet

use for data collection

The team learned that MCM improved in OPDs and during ANC as a result of the MSDQI assessment. Improved access to quality MCM (diagnosis) nationwide. Frequency of malaria testing increased during the first ANC contact. Testing increased from 87% in April–June 2017 to 96% April–June 2018, a 9% change (see Figure 3). Second doses of intermittent preventive treatment of malaria in pregnancy (IPTp2) coverage increased by 15% on average in Boresha Afya-supported regions between October 2016 and June 2018 (see Figure 4).

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 USAID Boresha Afya and do not necessarily reflect the views of USAID or the United States government.

Malawi Makes Progress and Plans to Defeat Malaria: Directions from the 2017 Malaria Indicator Survey

Children, Equity, IPTp, ITNs, Monitoring

Malawi has conducted four Malaria Indicator Surveys (MIS), with the most recent being in 2017. Such surveys are crucial tools for [planning and evaluating efforts by national control programs and their partners. Dr. Dan Namarika, Secretary for Health, Ministry of Health in the preface to the 2017 Report sums up the context and progress best, and so first, we have reproduced his narrative below.

Then we look at the example of the insecticide treated net (ITN) data as a way to guide future planning. The MIS format itself has seen improvements with much better color graphics in addition to the traditional tables. Some of these are also shared herein.

According to Dr Namarika, “Malaria is a major public health problem in Malawi where an estimated 4 million cases occur each year. Children under age 5 and pregnant women are most likely to have severe illness. The Ministry of Health, in collaboration with partners, has developed the Malawi Health Sector Strategic Plan 2017-2022, which articulates the priorities for health sector development in the next 6 years and prioritizes malaria. In line with that emphasis, the National Malaria Control Program has just finished the development of the National Malaria Strategic Plan 2017–2022 with the goal of scaling up malaria interventions to reduce morbidity and mortality by 50% in 2022.

“We strive for progress in achieving prompt, effective malaria treatment. We hope to improve access to early intervention and treatment by expanding village clinic services, using insecticide-treated nets, spraying inside residences, managing the environment, encouraging changes in social behaviour and communication, and preventing malaria in pregnancy. We have set for ourselves high targets for these interventions, and we are confident that we will achieve our strategic goals of halving the incidence of malaria and deaths, as well as reducing the prevalence of malaria and malaria-related anaemia.

“Surveys such as the current Malaria Indicator Survey (MIS) are essential measures of progress towards these goals. Without measurement, we can only guess about progress. The 2017 Malawi Malaria Indicator Survey (MMIS) is the country’s fourth nationally representative assessment of the coverage attained by key malaria interventions. Interventions are reported in combination with measures of malaria-related burden and anaemia prevalence testing among children under age 5.

“Overall, there has been considerable progress in scaling up interventions and controlling malaria. We noted a decline in malaria prevalence from 33% in 2014 to 24% in 2017. Insecticide-treated net (ITN) ownership has increased from 70% in 2014 to 82% in 2017.

“Results of the 2017 MIS also show improvement on use of intermittent preventive treatment during pregnancy (IPTp) by pregnant women age 15-49. Coverage has increased from 64% for two or more doses in 2014 to 77% in 2017. The percentage of women who took three or more doses of SP/Fansidar for prevention of malaria in pregnancy increased from 13% in 2014 to 43% in 2017.

“In addition, numbers of children receiving a parasitological test and artemisinin-based combination therapy continue to increase.

“These results represent the combined work of numerous partners contributing to the overall scale-up of malaria interventions. I would like to request that all partners make use of the information presented in this report as they implement projects to surmount the challenges depicted here.”

According to PMI, “The 2017-2022 National Malaria Strategic Plan (MSP) builds on the successes achieved and lessons learned during implementation of previous strategic plans.” The example of ITN targets is illustrative and is included in the target, “At least 90% pf the population use one or more malaria preventative interventions.”

So in addition to showing progress with ITNs, the MIS 2017 report also points to gaps that require strengthened intervention. While there has been an increase of household net ownership we can see in the graph that the target for universal coverage of 1 net for 2 people still needs work. We can also see in the graphs that equity remains a challenge with a lower proportion of poorer households owning a net. In addition net ownership is lower in the Central Region of the Country.

We learn from the graphs that having access to a net in the household does not guarantee that people will actually use or sleep under them. The tables show us that the traditionally defined ‘vulnerable groups’ like pregnant women (62.5%) and children below the age of 5 years (67.5%) were more likely to sleep under nets than household members in general (55.4%). The push towards universal coverage stresses that all household members contribute to the health, welfare and wealth of the family and should be protected from malaria.

Now we should Return the comments by Dr Namarika on the value of having MIS data. All endemic countries need to ensure their malaria data are up-to-date to ensure they use this information to keep their strategic plans on track to defeat malaria.

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

Advocacy, Case Management, Children, CHW, Community, Elimination, Funding, iCCM, Invest in Malaria Control, IPTp, ITNs

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.

Improved Malaria Case Management of Children under Age 5: The Experience of the MCSP Restoration of Health Services Liberia Project

Case Management, Children

Catherine Gbozee, Birhanu Getahun, Topian Zikeh, Anne Fiedler, and Allyson Nelson of the Maternal and Child Survival Program (Jhpiego and John Snow, Inc.) have presented experiences on improving malaria case management for children in Liberia at the 7th Multilateral Initiative for Malaria Conference in Dakar. Below are their findings.

In malaria-endemic countries, malaria is the second leading cause of mortality for children under the age of 5 years. In Liberia Mortality rate for children under the age of 5 years was 94 per 1,000 in 2013. Malaria accounts for 31% of outpatient mortality for children under the age of 5 years and 51% of all outpatient consultations. Malaria among children under the age of 5 years accounts for 20.5% of all outpatient consultations in Liberia Health services weakened by the epidemic of Ebola virus disease. Over 40% of children under the age of 5 years have tested positive for malaria using malaria rapid diagnostic tests (mRDTs) since 2009 (see Figure 1)

Maternal and Child Survival Program (MCSP) Restoration of Health Services (RHS) Project Objectives for malaria include prevention at facilities, Strengthen infection prevention and control (IPC) practices at 77 health facilities through training, intensive supportive supervision, triage, improvement of waste management, and provision of essential IPC commodities and supplies, Increased utilization of and demand for maternal and child health services—Restore delivery of quality primary health care services through implementation of integrated reproductive, maternal, newborn, child, and adolescent health as part of the Essential Package of Health Services in 77 facilities.

MCSP RHS supported health facilities in three counties

  • Grand Bassa: 30 (91% of health facilities in county)
  • Lofa: 17 (27% of health facilities in county)
  • Nimba: 30 (46% of health facilities in county)
  • Population coverage: 900,000 (20% of total population)

Liberia Malaria Indicator Survey 20164 showed that mRDT was done for only 43% and 44% of children with fever in North Central and South Central regions, respectively. Treatment with artemisinin-based combination therapy (ACT) improved from 43% to 81% from 2013 to 2016. Intervention approaches are outlined at the left.

Scores for all technical areas, including malaria, improved
from baseline to endline (see Figure 2). Median facility scores for adherence to malaria clinical standards improved by 75% between baseline and endline in half of MCSP facilities sampled (see Figures 3 and 4). Percent of malaria cases in children under 5 years of age receiving ACT for malaria in MCSP-supported facilities improved from 76% to 82%, despite sporadic stock-outs of ACT (see Figure 5)

Challenges included Frequent stock-outs of mRDTs and ACT. There were Bad roads and broken bridges challenging for supportive supervision, malaria commodity distribution, and facility accessibility to users.

Lessons Learned included Task-shifting and comprehensive hands-on health workforce improvement approaches are essential for revamping and improving quality care provision in post-disaster settings such as Liberia. Uninterrupted and sustained supplies of mRDTs, ACT, and malaria commodities are key for quality malaria case management.

References

1. World Health Organization (WHO). 2015. MCEE-WHO methods and data sources for child causes of death 2000–2015. WHO website.
http://www.who.int/healthinfo/global_burden_disease/ChildCOD_method_2000_2015.pdf. Accessed April 2, 2018.

2. Liberia Institute of Statistics and Geo-Information Services (LISGIS), Ministry of Health and Social Welfare Liberia, National AIDS Control Program Liberia, et al. 2014.
Liberia demographic and health survey 2013. Demographic and Health Surveys Program website. https://dhsprogram.com/pubs/pdf/fr291/fr291.pdf. Accessed April 2, 2018.

3. Liberia Ministry of Health. Liberia Ministry of Health Annual Report 2015. Monrovia, Liberia: Ministry of Health.

4. National Malaria Control Program, Liberia Institute of Statistics and Geo-Information Services, and The DHS Program. 2017. Liberia Malaria Indicator Survey 2016.
The Demographic and Health Surveys Program website. http://dhsprogram.com/pubs/pdf/MIS27/MIS27.pdf. Accessed April 2, 2018.

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.

African Leaders Malaria Alliance Recognizes Country Achievements, Adds NTDs to its Scorecard

Advocacy, Borders, Children, Conflict, Costs, Epidemiology, Funding, Human Resources, Leadership, Monitoring, Mortality, NTDs, Partnership, Surveillance

The 30th African Union (AU) Heads of State Summit at its headquarters in Addis Ababa, Ethiopia provided an important opportunity to bring the challenges of infectious diseases on the continent to the forefront. Led by the African Leaders Malaria Alliance (ALMA), two major activities occurred, raising greater awareness and commitment to fighting neglected tropical diseases (NTDs) and recognizing the contributions countries have made in the fight against malaria.

For many years ALMA has maintained Scorecard for Accountability and Action by monitoring country progress on key malaria interventions. It later added key maternal and child health indicators.  At the AU Summit ALMA announced that NTD indicators would be added to the scorecards which are reported by country and in summary.

The scorecard will now “report progress for the 47 NTD-affected countries in sub-Saharan Africa in their strategies to treat and prevent the five most common NTDs: lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted helminths and trachoma. By adding NTDs to the scorecard, African leaders are making a public commitment to hold themselves accountable for progress on these diseases.”

In the press release Joy Phumaphi, Executive Secretary ofALMA, explained that, “Malaria and NTDs both lay their heaviest burden on the poor, rural and marginalised. They also share solutions, from vector control to community-based treatment. Adding NTDs to our scorecard will help give leaders the information they need to end the cycle of poverty and reach everyone, everywhere with needed health care.” This will be an opportunity to demonstrate, for example, that, “In 2016, 40 million more people were reached with preventive treatment for at least one NTD than the year before.”

The combination is based on the logic that NTDs and malaria are both diseases of poverty. Malaria and several NTDs are also vector-borne. Also community platforms are a foundation for delivering needed drugs and supplies to tackle these diseases. Ultimately the decision shows that Heads of State are holding themselves accountable for progress in eliminating these diseases.

At a malaria-focused side meeting of the AU Summit Dr. Kebede Worku (Ethiopia’s State Minister of Health) shared that his government has been mobilizing large amount of resources to the fight against malaria which has led to the shrinking of morbidity and mortality since 2005. He also stressed that Africans should be committed to eliminate malaria by the year 2030. “Failing to do so is to repeat the great failure of 1960s faced at the global malaria fighting.”

The highlight for the malaria community at the Summit was the recognition of six countries that have made exemplary progress in the past year. The 6 countries that are leading the way to a Malaria-Free Africa by 2030 are Algeria, Comoros, Madagascar, the Gambia, Senegal, and Zimbabwe, recognized by ALMA for their sharp decline in malaria cases. Madagascar, the Gambia, Senegal and Zimbabwe Reduced malaria cases by more than 20 percent from 2015 to 2016. Algeria and Comoros are on track to achieve a more than 40 percent drop in cases by 2020.

H.E . Dr. Barnabas Sibusiso Dlamini, the Prime Minister of the Kingdom of Swaziland, whose King and Head of State is the current chair of ALMA, warned all endemic countries that, “When we take our eyes off malaria, the cost for our countries is huge. Yet if we increase our efforts to control and eventually eliminate malaria, the yield we get from it is tremendous. It is time that we dig deep into our pockets and provide malaria programmes with the needed resources.”

Mentioning the need for resources raises a flag that calls on us to be a bit more circumspect about progress. IRINNews notes that this is a critical time in the fight against malaria, when threatened funding cuts could tip the balance in an already precarious struggle. IRIN takes the example of Zambia to raise caution. They report that the results of malaria control and the government efforts have been uneven. While parasite prevalence among small children is down almost by half in some areas, many parts of the country have seen increases in prevalence

IRIN concludes that, “For now, the biggest challenge for Zambia will be closing the gap in its malaria elimination strategy, which will cost around $160 million a year and is currently only about 50 percent funded – two thirds from international donors and one third from the Zambian government. Privately, international donors say the government must spend more money on its malaria programme if it is to succeed.” Cross-border transmission adds to the problem.

Internal strife is another challenge to malaria success. “The recent nurses’ strike which lasted for five months may have cost Kenya a continental award in reducing the prevalence of malaria during the 30th African Union Summit in Ethiopia on Sunday.” John Muchangi in the Star also noted that, “However, Kenya lost momentum last year and a major malaria outbreak during the prolonged nurses’ strike killed more than 30 people within two weeks in October.”

Finally changes in epidemiology threaten efforts to eliminate malaria in Africa. Nkumana, et al. explain that, “Although the burden of Plasmodium falciparum malaria is gradually declining in many parts of Africa, it is characterized by spatial and temporal variability that presents new and evolving challenges for malaria control programs. Reductions in the malaria burden need to be sustained in the face of changing epidemiology whilst simultaneously tackling significant pockets of sustained or increasing transmission. Many countries like Zambia thus face both a financial and an epidemiological challenge.

Fortunately ALMA is equipped with the monitoring and advocacy tools to ensure that its members recognize and respond to such challenges. The Scorecards will keep the fight against the infectious diseases of poverty on track.

Health for All at the International Institute for Primary Health Care, Ethiopia

Children, CHW, Human Resources, Mortality, Women,

The time is ripe for a revitalization of the primary health care (PHC) movement. “Health for All through Primary Health Care” (HFA) was first envisioned at the 1978 International Conference on Primary Health Care (World Health Organization and UNICEF), and was enshrined in the Declaration of Alma-Ata. The HFA goal of bringing essential, affordable, scientifically sound, socially acceptable  health care provided by health workers who are trained to work as a health team and who are responsive to the health needs of the community, guided by strong community engagement by the year 2000 but has not been fully met. Fortunately the vision of Alma-Ata has taken root, sprouted and flourished in a number of locations.

Thanks to the vision and intellectual and political leadership of Dr. Tedros Adhanom Ghebreyesus, the then Minister of Health of Ethiopia and recently elected Director General of the World Health Organization, Ethiopia is an outstanding example of the Alma-Ata legacy. Access to PHC services was greatly expanded through the training of 40,000 Health Extension Workers (women from the local area with one year of training, each of whom serve 2,500 people and receive a government salary), recruitment of 3 million community female health volunteers (called the Health Development Army), and engagement with communities to enable them to take responsibility for improving their health.

This expansion of PHC enabled Ethiopia to achieve its health-related MDGs. Child mortality (those younger than 5 years of age) declined from 166 deaths per 1,000 live births in 1990 to 67 in 2016 (MDG 4). Significant progress was achieved in reducing levels of childhood malnutrition (MDG 1). MDG 5 was almost reached, with a decline in maternal morality of 72%, versus the goal of 75%, and the percentage of mothers obtaining a delivery by a skilled provider increased 6-fold between 1995 and 2016. The prevalence rate of modern contraceptive use increased from 6% in 2000 to 35% in 2016. MDG 6 (for HIV, malaria and tuberculosis) was also reached. The number of new HIV infections declined by 90%, and the number of AIDS-related deaths by 53%. Between 1990 and 2015, the tuberculosis incidence and mortality rate declined by 48% and 72%, respectively. The malaria incidence rate declined by 50% and malaria mortality by 60%. Ethiopia’s PHC system is acknowledged as the major factor leading to these impressive health gains.

Representatives from more than half of sub-Saharan Africa countries have come to Ethiopia to see its PHC system in action. Because of this interest, in 2016 the Federal Ministry of Health of Ethiopia established the International Institute for Primary Health Care – Ethiopia, with seed funding from the Bill & Melinda Gates Foundation and technical support from the Johns Hopkins Bloomberg School of Public Health. Our goal is for the Institute to become a global center of excellence for training, knowledge dissemination and research in primary health care, supported by multiple donors.

The Institute has begun to provide formalized short-term training to high-level policy makers and officials, program planners and managers, as well as to those engaged in service delivery, to see first-hand how an effective national PHC system functions. Trainees come from within Ethiopia and around the world. Trainees also visit communities, meet their leaders, and observe primary health care providers at work. Trainees will return to their home country with renewed energy and new vision and skills to revitalize their own primary health care system.

The Institute will also conduct and support research that yields evidence to guide ongoing strengthening of the Health Extension Program, and will rapidly disseminate open access information about recent advances in PHC. The Institute marks a significant step forward on the road to achieving the Alma-Ata vision of Health for All.

A website for IIfPHC-E is being built to provide further information about these programs and will be available at: www.iifphc.org.

This posting was prepared by: Kesetebirhan Admasu1, Michael J. Klag2, Yifru Berhan Mitke3, Amir Aman4, Mengesha Admassu5, Solomon Zewdu6, Jose Rimon7, Henry B. Perry8

1Chief Executive Officer, Rollback Malaria Partnership, Geneva, Switzerland and Chair, Advisory Board, International Institute for Primary Health Care — Ethiopia

2Dean, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

3Minister, Federal Ministry of Health, Government of Ethiopia, Addis Ababa, Ethiopia

4State Minister, Federal Ministry of Health, Government of Ethiopia, Addis Ababa, Ethiopia and Co-Chair, Advisory Board, International Institute for Primary Health Care – Ethiopia

5Executive Director, International Institute for Primary Health Care – Ethiopia, Addis Ababa, Ethiopia

6Health and Nutrition Development Lead – Ethiopia, Integrated Programs, Global Policy & Advocacy – Global Development, Bill& Melinda Gates Foundation, Addis Ababa, Ethiopia

7Director, Bill & Melinda Gates Institute for Population and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

8Coordinator for Johns Hopkins University Support of the International Institute for Primary  Health Care – Ethiopia, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

Seasonal Malaria Chemoprevention Implementation in Senegalese Children

Children, Communication

20151028_123042-1Dr Mamadou L Diouf and colleagues[1] from the National Malaria Control Program, Dakar Senegal and the President’s Malaria Initiative/USAID, Dakar, Senegal presented their experiences with Seasonal Malaria Chemoprevention among children aged 3-120 months in four southern regions of Senegal at the 64th Annual Meeting of the American Society of Tropical Medicine and Hygiene. Their findings are outlined below.

Malaria is major cause of disease and death in infants and children, with seasonal transmission, highest in the southern and eastern regions which are the wettest areas. SMC is administration of a complete treatment course of AQ+SP at monthly intervals to a maximum of 4 doses during the malaria transmission season to children aged between 3 and 59 months in areas of highly seasonal malaria transmission (where both drugs retain sufficient antimalarial efficacy).

Health post nurse training volunteersTarget areas for implementation are areas where more than 60% of clinical malaria cases occur within a maximum of 4 months, the clinical attack rate of malaria is greater than 0.1 attack per transmission season in the target age group, and AQ+SP remains efficacious (>90% efficacy).

Adoption of SMC in 2013 as a new intervention in malaria control policy. Four south-eastern regions eligible according to WHO criteria for SMC (Tambacounda, Kédougou, Sédhiou and Kolda) chosen

The poster presented Senegal’s experience implementing SMC and focuses particularly on process, challenges and lessons learned. Available information generated from the national SMC implementation guidelines, technical documents, field activity reports, and SMC impact evaluation survey were reviewed.

The medication distribution strategy relied on a door to door campaign strategy with community volunteers. On the first day, the volunteers, trained by health workers, administer drugs to the children under surveillance of their mothers or guardians. For the 2 remaining days, mothers administer the medication.

campaign resultsIn 2014, the SMC Campaign was conducted in the four regions for three months covering the high transmission season (August, September, October, and November). Kedougou, was the only region that conducted 2 SMC rounds as it started implementing in 2013.

The target was extended to children from 3 to 120 months (624,139 estimated in target age group). This age group extension, compared with WHO recommendations (3 to 60 months,) was based on shift of vulnerability towards the ages from 60 to 120 months shown by the epidemiologic data on malaria morbidity in Senegal.

Administrative coverage rates for the 3 passages respectively was 98.6%, 97.9% and 98.0%. Information was obtained from the SMC impact evaluation survey in the south of Senegal, 2015 July by Dr JL Ndiaye.

SMC districtsKey interventions and process began with the National and regional Steering Committees involving NMCP, health staff, donors/partners and researchers. There was development and update of tools and materials (guidelines, planning forms, data collection and analysis support. Training of staff took place at all levels and operational actors

Early field planning was held with staff at regional and district level: identification of activities, dates, estimation of household/child targets, estimation of resources needed (budgets, HR, logistics, etc.). Early delivery of drugs, tools, supports was ensured to be available at health post level at least 1 week before the 1st campaign day.

Rigorous selection of volunteers and supervisors was based on specific criteria. Develop communications activities took place at least 2 weeks before and during the campaign period focusing on SMC gains, HH census, administration by mothers for the 2 remaining days, and possible side effects.

New casesCampaign roll out included supervision of the process at the districts and health posts (organization model, administration). There was mobilization of logistics for transportation of volunteers, drugs, and materials. Day to day monitoring took place with regional debriefing to analyze data from districts, geographical progression, target coverage progression and identify issues and challenges. Daily electronic distribution of “SMC bulletin” to health staff and partners helped to disseminate information on districts performances.

Post campaign evaluation took place at all levels: workshops for sharing and validating data and information, identification of key issues, lessons learned, and formulation of recommendations to improve future campaigns. Local health agents, NMCP staffs, partners and authorities were involved.

Spontaneous pharmacovigilance system tracked and treated side effects. This consisted of distribution of yellow cards to health facilities, case notification by health agents, availability of a side effects line listing, and immediate and free-of-charge case management.

The following key challenges were faced:

  • Correct availability of drugs and tools at health posts
  • Complete coverage of all households and children
  • Completion of 2nd and 3rd doses by guardians of children
  • Availability of children and guardians during harvest period and class time
  • Comprehensive communication for population particularly in possible occurrence of side effects
  • Case management of side effects free of charge
  • Availability and promptness of data
  • Long term logistic availability

Rainy SeasonFinally there were some outstanding questions. Can we switch SMC from campaign to routine system at health post level? Can we expand SMC to other regions and with what targets? Also, can we improve formulation and taste of drugs for enhancing children’s compliance?

Financial support: This work was made possible through support provided by the United States President’s Malaria Initiative, and the U.S. Agency for International Development, under the terms of an Interagency Agreement with the Centers for Disease Control and Prevention (CDC). The opinions expressed herein are those of the authors and do not necessarily reflect the views of the U.S. Agency for International Development or the Centers for Disease Control and Prevention.

[1] Dr Mamadou L Diouf, Mr Medoune Ndiop, Dr Mady Ba, Dr Ibrahima Diallo, Dr Moustapha Cisse, Dr Seynabou Gaye, Dr Alioune Badara Gueye, Dr Mame Birame Diouf

Correlates of prompt and appropriate treatment of malaria in children in Madagascar

Children, Treatment

Colleagues[i] from the Johns Hopkins Center for Communications Programs (CCP), the US President’sToso 1 image Malaria Initiative and the Ministry of Public Health in Madagascar, presented a poster today at the American Society of Tropical Medicine 64th Annual Conference in Philadelphia. Their findings on malaria treatment in Madagascar follow.

According to Madagascar’s 2013 Malaria Indicator Survey, malaria prevalence among children aged 6-59 months was 9.1% (microscopy). Prompt diagnosis and treatment of malaria is critical for minimizing complications and ensuring complete recovery.

In Madagascar, Artemisinin-based Combination Therapy (ACT) is the recommended treatment for uncomplicated malaria. Using survey data collected in 2014 from eight districts. We assessed the socio-demographic, ideational and community factors associated with prompt treatment of fever with ACT among children aged less than five years.

The data showed that about one quarter (24.4%) of households had a child with fever during the two weeks prior to the survey. About three quarters of female caregivers reported that they sought treatment for their child with fever.

Toso 2 imageNonetheless, only about one fifth of the children were reportedly tested for malaria during their sickness: from 4.7% in the Highlands transmission zone to 30% in the Equatorial zone. Overall, less than one tenth (8.9%) of caregivers reported that their child sick with fever in the last two weeks received prompt ACT, varying from 5.4% in the Highland transmission zone to 16.2% in the Equatorial zone.

The factors associated with prompt ACT treatment include district of residence, perceived susceptibility, and malaria treatment ideation (derived from treatment-related perceived self-efficacy, attitudes, and interpersonal communication; perceived response efficacy of malaria diagnostic test, and knowledge of ACT).

The data also showed that female caregivers resident in higher transmission disctricts (Manakara – Equatorial zone; Morombe – Tropical zone) were more likely to obtain prompt ACT treatment for their children compared to their peers resident in lower transmission district of Miarinarivo (Highlands). A high sense of perceived susceptibility to malaria was associated with decreased odds of prompt treatment while high scores for treatment ideation increased the odds.

Programs should continue promoting prompt treatment for malaria targeting both demand and supply sides. The delay in appropriate treatment associated with perceived susceptibility to malaria indicates the need to intensify efforts to strengthen self-efficacy for prompt malaria treatment in areas where malaria is common. A comprehensive program to promote prompt treatment should address the treatment ideation elements assessed in this study.

[i] Stella O. Babalola, Grace Awantang, Nan Lewicky, Michael Toso, Sixte Zigirumugabe, Arsene Ratsimbasoa, Monique Vololona