Category Archives: CHW

Experiences and Perceptions of Care Seeking for Febrile Illness among Caregivers and Health Providers in Eight Districts of Madagascar

Andrianandraina Ralaivaomisa, Eliane Razafimandimby, Jean Pierre Rakotovao, Lalanirina Ravony Harintsoa, Sedera Aurélien Mioramalala, Rachel Favero, Katherine Wolf, Patricia Gomez, Jocelyn Razafindrakoto, and Laurent Kapesa of MCSP/Jhpiego (Johns Hopkins University Affiliate), the Madagascar Ministry of Public Health and USAID presented their findings about febrile illness care seeking in Madagascar at the 2018 Annual Meeting of the American Society of Tropical Medicine and Hygiene. Details follow below.

Malaria Care and Treatment in Madagascar is hampered by low perception of malaria risk among caregivers. There is use of self-medication and a lack of health provider knowledge about malaria prevention and treatment in pregnant women. Low-quality care in primary health facilities is another concern (Source: WHO. 2015. Guidelines for the treatment of malaria, 3rd ed.).

As seen in the attached, Study Objectives focus on Caregivers and Pregnant Women as well as Health Providers to determine barriers to effective care seeking of febrile illnesses.

Both Qualitative and Quantitative Approaches were used. Among care seekers we conducted 16 focus group discussion sessions with 128 caregivers and pregnant women. There were also in-depth interviews with 32 pregnant women and 16 caregivers of children under 15. For Health Providers we conducted in-depth interview with 32 public and private health providers and administered 16 knowledge tests and case studies to health providers. We also reviewed logistic management information system records with 16 health

Barriers for Caregivers are seen in the attached table. Barriers were faced by both care seekers and those who did not seek care, but were more common among non-seekers.

Three tables follow that show perceptions of public sector providers, private providers and community health workers. There were positive and negative perceptions of each group of providers.

Health Provider Practices were also studied. They had low adherence to national guidelines for fever and malaria case management. Health workers reported high stock-outs rates of critical commodities (artemisinin-based combination therapy, artesunate). There was also lack of respectful care. Fortunately health provider diagnostic practices included 100% compliance with rapid diagnostic testing in cases of fever. They took temperatures and did physical exams appropriate to client’s symptoms and used microscopy at centers with local laboratory

General Bottlenecks to Timely Care Seeking still existed. There was insecurity due to political situation in some regions. Inability to pay for care or medications was common. Alternative health behaviors included seeking care with traditional healers, and self-medication. There was fear by clients of going to health facilities and inaccurate perceptions of care provided by formal health care system

Recommendations start with the need to train providers and CHWs on national treatment guidelines for managing fever in all age groups and in pregnant women. Efforts are needed to strengthen onsite provider mentoring and supportive supervision and improve respectful care of clients, especially in public sector. Since care seeking still based on cultural norms, there is need to strengthen community/family education about febrile illness dangers and advantages of timely care seeking. Communities can also consider forming “mutuelle” community insurance schemes to relieve cost of care burden.

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.

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.

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.

Community Health Workers Can Enhance Coverage of Intermittent Preventive Treatment of Malaria in Pregnancy and Promote Antenatal Attendance

Among the poster presentations on malaria from Jhpiego, the President’s Malaria Initiative and partners at the 2018 ASTMH Annual Meeting, WR Brieger, J Tiendrebeogo, O Badolo, M Dodo, D Burke, K Vibbert, SJ Youll, and JR Gutman shared the findings from a 15-month intervention that tested the ability of community health workers to deliver intermittent preventive treatment of malaria in pregnancy in 3 districts in Burkina Faso. Please check out the poster and talk to one of the co-investigators at Poster Session A on Monday 29 October. Their results are found below.

Malaria in pregnancy is responsible for a substantial proportion of low-birthweight and stillborn infants in sub-Saharan Africa. To prevent this, the World Health Organization (WHO) recommends that pregnant women receive intermittent preventive treatment of malaria in pregnancy (IPTp) using sulfadoxine-pyrimethamine. Specifically, WHO recommends an optimal three or more doses (e.g., IPTp3, IPTp4).

In stable malaria endemic countries, IPTp coverage remains unacceptably low, at around 19% for IPTp3. Community IPTp might provide an answer. Community delivery can improve coverage as seen in previous study in Nigeria and Malawi, but its effects on antenatal care (ANC) attendance have been mixed. Additional data are needed to determine whether delivery of IPTp-SP by community health workers (CHWs) is effective and does not detract from ANC attendance. Hence the Burkina Faso intervention was designed and implemented

The study piloted community delivery of IPTp (c-IPTp) in three districts of Burkina Faso with high malaria transmission: Po, Ouargaye, and Batie.  Four health facilities per district were randomly selected to participate (two intervention and two control).

In 2017, following a baseline household survey of women who recently became pregnant, implementation of c-IPTp began in intervention areas by existing CHWs trained and supervised by health staff. At Baseline in each of the three study districts, four health centers (CSPSs) and the villages in their catchment areas were selected—two as intervention and two as control. A random sample of 374 women who had been pregnant within the last 9 months were interviewed in CSPS catchment villages. There were no significant differences in ANC attendance (ANC1=90%, ANC4=62%) or IPTp coverage between intervention and control areas:

  • IPTp3 was 81% (intervention) and 86% (control).
  • IPTp4 was 22% (intervention) and 16% (control).

The Intervention consisted of building on Burkina Faso’s existing CHWs. They were trained and monitored by clinic staff. The CHWs encouraged women to attend the first ANC visit to obtain IPTp1. Then the CHWs provided monthly doses of IPTp, submitted monthly reports, and continued to promote ANC. ANC attendance and IPTp uptake were monitored through monthly clinic and CHW reports. The catchment area populations were roughly the same, and monitoring showed that the additional provision of IPTp by CHWs resulted in more women being reached while at the same time ANC attendance remained high.

An endline survey was conducted after 18 months of implementation. Changes over time were compared between baseline and endline in intervention versus control villages. Attendance at ANC1 and ANC4 increased in both groups between baseline and endline but was significantly better for the intervention group. Likewise, coverage of IPTp3 and IPTp4 increased between baseline and endline for intervention and control women, but the difference was significant only in the intervention areas.

Monthly monitoring of CHW and ANC registers and the household surveys both documented that community delivery of IPTp resulted in the desired increased uptake of services without detracting from ANC attendance. Community IPTp may be a promising strategy to improve coverage of IPTp.

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 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

Achieving UHC through PHC Requires an Implementation Plan

The new Astana Declaration says that, “We are convinced that strengthening primary health care (PHC) is the most inclusive, effective and efficient approach to enhance people’s physical and mental health, as well as social well-being, and that PHC is a cornerstone of a sustainable health system for universal health coverage (UHC) and health-related Sustainable Development Goals.” The Declaration outlined a vision, a mission, and a commitment. An opportunity to discuss how to implement this existed at the two-day conference in Astana Kazakhstan celebrating the 40th anniversary of the seminal Alma Ata Declaration.

Ironically the opportunity was not fully grasped. There were many sessions that shared country experiences ranging from finance to information technology.  Youth who will carry PHC forward for the next 40 years gave their opinions and thoughts. Lip-service as well as actual case examples of community involvement were featured. What we did not hear much of was the specifics of how countries, moving forward, will actually implement the commitments spelled out in the document.

One colleague who has worked with the sponsoring agencies was of the view that since much advanced input and work from many partners and countries had gone into the new Declaration, which was already nicely printed, they were reluctant to provide the slightest chance that debate would be reopened.

As they say, fair enough (maybe), but even if one takes the Declaration as a done deal, the matter if implementation needs to be addressed. There was ample criticism that the Alma Ata Declaration was not properly implemented.  This was in part because academics and development agencies jumped the gun and pushed, with focused financial backing, what would be called selective primary health care that was more agency driven, not community directed as envisioned at Alma Ata (now Almaty) in 1978.

In order not to repeat those mistakes and give full voice to the community and key constituents, at minimum the implementation strategies of the pre-agreed Declaration should have been discussed in specific terms. Sure many ideas and examples were aired, but there was no attempt to focus these into workable strategies.

But was the community even there in Astana to take part in strategizing? One community health worker from Liberia received much attention because she was the odd one out. Sure, there were plenty of NGOs, but not the real grassroots of civil society, although the youth involvement aspect of the conference approached that. Some of these NGOs and agencies had themselves been part of the selective PHC agenda.

There was plenty of talk about us involving them, especially when it came to community health workers (CHWs). CHWs should first be integrated into community systems to ensure they are accountable to communities. Then there should be an equal partnership between community systems and health systems. Otherwise CHWs get lost as just front line laborers.

Of course it is never too late. Regional gatherings may be a better forum that can discuss implementation in a more socially,  economically and culturally appropriate way. Let’s hope we don’t look back in another 40 years and with the Astana Declaration had been better and more faithfully implemented.

Hopefully Malaria Elimination will not be the SaME

The Sahel Malaria Elimination Initiative (SaME) has been launched, but builds on a long history of cooperation in the region. Efforts by eight Sahelian countries to share lessons and strategies mirrors the Elimination Eight group on the opposite end of the continent.

The few rainy season months in the Sahel offer optimum malaria transmission, which SaME is tackling

The Roll Back Malaria (RBM) Partnership to End Malaria announced that in Dakar on 31st August 2018, the health “ministers from Burkina Faso, Cabo Verde, Chad, Mali, Mauritania, Niger, Senegal and The Gambia established a new regional platform to combine efforts on scaling up and sustaining universal coverage of anti-malarials and mobilizing financing for elimination.” The group plans a fast-track introduction of “innovative technologies to combat malaria and develop a sub-regional scorecard that will track progress towards the goal of eliminating malaria by 2030.” This will build on the existing country scorecard that has been developed and implemented by AMLA2030 for all countries in the region and tracks roll out of key malaria and health interventions. The Sahel Malaria Elimination Initiative will be hosted by the West African Health Organization, a specialised agency of the Economic Community of West African States (ECOWAS).

RBM explains that while the eight countries will work together, they do not have a homogenous epidemiological picture or experience with malaria programming. The Sahel experiences 20 million annual malaria cases, according to RBM, and “the Sahel region has seen both achievements and setbacks in the fight against the disease in recent years.” These eight have a highly variable malaria experience. Burkina Faso and Niger continue to be among the countries with high malaria burdens. Cabo Verde is on target for malaria free status by 2020. The Gambia, Mauritania and Senegal are reorienting their national malaria program towards malaria elimination. A benefit of this epidemiological and programmatic diversity is that countries can learn important lessons from each other.

The SaME Initiative will use the following main approaches to accelerate the combined efforts towards the attainment of malaria elimination in the sub-region:3

  • Regional coordination
  • Advocacy to keep malaria elimination high on the development and political agenda
  • Sustainable financing mechanisms
  • Cross-border collaboration and ensuring accountability
  • Fast-track the introduction of innovative and progressive technologies
  • Re-enforcing the Regional regulatory mechanism for quality of malaria commodities and introduction of new tools.
  • Establish malaria observatory, regional surveillance, and best practice sharing

Collaboration across borders on vector control is an example of needed regional coordination. According to Thomson et al., climate variations have the potential to significantly impact vector-borne disease dynamics at multiple space and time scales. Another challenge to vector control in the region is the issue of how mosquitoes repopulate areas after an extended dry season. Huestis et al. examined the response of Anopheles coluzzii and Anopheles gambiae to environmental cues in season change in the Sahel.

Seasonal Malaria Chemoprevention Round 3 of 2018 in Burkina Faso

In addition to a history of cooperation, Sahelian countries share a unique malaria intervention, Seasonal Malaria Chemoprevention (SMC) that as the name implies, built on the reality of highly seasonal transmission in the region. SMC grew out of over five years of research in several African settings to test the effect of what was originally termed Intermittent Preventive Treatment for Infants (and later children) or IPTi.

Like IPT for pregnant women, SMC would be given monthly for at least 3-4 months, but unlike IPTp, SMC would consist of a combination two medicines, amodiaquine plus sulfadoxine-pyrimethamine (AQ+SP), which required a three daily doses (SP alone as used in IPTp consists on one dose). SMC could not therefore, be delivered effectively as a clinic-based intervention, but “should be integrated into existing programmes, such as Community Case Management and other Community Health Workers schemes.” Access to SMC by pre-school aged children as delivered by CHWs was found to be more equitable than sleeping under an LLIN. SMC has been recommended for school-age children, a neglected group that bears a substantial burden of malaria.

Closely linked to surveillance is modeling the spatial and temporal variability of climate parameters, which is crucial to tackling malaria in the Sahel. This requires reliable observations of malaria outbreaks over a long time period. To date efforts are mainly linked to climate variables such as rainfall and temperature as well as specific landscape characteristics. Other environmental and socio-economic factors that are not included in this mechanistic malaria model.

The Sahel Malaria Elimination initiative offers a unique collaborative opportunity for countries to improve on the quality of proven interventions like SMC and test and take to scale new strategies like school-based malaria programs. Regional coordination can produce better, timelier and longer-term surveillance and better understanding of and actions against malaria vectors. Readers will surely be anticipating the publishing of the regular progress malaria elimination scorecards as promised by SaME leadership.

Mapping to Integrate Filariasis and Onchocerciasis Control with Malaria Interventions

William R Brieger (wbriege1@jhu.edu) and Gilbert Burnham (gburnha1@jhu.edu) of The Johns Hopkins Bloomberg School of Public Health, Department of International Health presented ideas about mapping and integration of neglected tropical diseases and malaria interventions at the Malaria World Congress, Melbourne, Australia, July 2018

Overview: Lymphatic Filariasis (LF) and Malaria share a common vector in sub-Saharan Africa. Mass Drug Administration (MDA) is a strategy that is common to both diseases. Where the diseases overlap there is the potential opportunity to coordinate both vector control and MDA to achieve synergy in program results. The example of Burkina Faso, supplemented with information from Ghana, serves as an example of what could be integrated and what actually happens.

Background: Thirty years ago then veterinary drug, ivermectin, was found effective in controlling neglected tropical diseases (NTDs), specifically two human filarial diseases: onchocerciasis and lymphatic filariasis (LF). The drug manufacturer donates 300 million treatments annually to eliminate both diseases. Since then, annual community based mass drug administration (MDA) efforts have resulted in millions of treatments in endemic countries and great progress has been made toward elimination of transmission. Through observation and experimentation, ivermectin was found to kill malaria carrying mosquitoes when they bite people who have taken ivermectin making it a useful tool for vector control.

CHWs in Burkina Faso demonstrating how to measure height to determine ivermectin dosage

Community Health Workers’ Role: Current research is examining how dosing and timing of treatments may impact national malaria vector control efforts. Comparing maps between malaria and LF can be a starting point for adapting ivermectin MDAs for malaria vector control. Burkina Faso MDAs are operationalized by community health workers (CHWs) who are part of a national program that provides treatment for common illnesses and also conducts village level onchocerciasis and LF MDAs. Vector Control with Long Lasting Insecticide Treated Nets In most of rural Africa, malaria and lymphatic Filariasis are co-endemic and share the same anopheles mosquito vector.

However, that does not mean that there is a coordinated effort to plan distribution of LLINs despite the fact that the intervention meets the needs of both disease control efforts. The current NTD programs in Burkina Faso and Ghana focus on Preventive Chemotherapy (PCT) delivered through Mass Drug Administration (MDA). Vector Control is seen as essential in areas co-endemic with LF, Loa loa and Malaria – mapping helps identify priority areas for vector control.

Vector Control by Chance: In Ghana, the NTD/LF elimination program was unaware of the LLIN coverage data available in the NMCP housed in an adjacent building. This illustrates the lack of collaboration between the two programs. Thus where — and if — vector control benefits the reduction of both diseases, it is often by chance where LF is concerned.  The International NGO, The Carter Center, may be the only one that includes vector control as part of its programming for both malaria and LF in Nigeria. This practice should be replicated by other partners and country programs where possible.

Mass Drug Administration: MDA is the major strategy for control of five PCT diseases in the NTD program, and LF is one of those. Currently MDA anti-malarial drugs has been considered in limited situations in countries where there are areas that have very low transmission In the future countries may consider research that shows mosquitocidal effects of Onchocerciasis and LF MDAs with ivermectin. Otherwise for malaria, a special intervention called Seasonal Malaria Chemoprevention (SMC) is used in an MDA-like approach to reach young children in the African Sahel during high transmission months. In both cases, existing cadres of (usually volunteer) community health workers are the front line providers of MDA.

Burkina Faso LF Map from ESPEN: Mapping shows 10 of 70 health districts are currently doing LF MDA, though all have done it. Thus CHWs in all districts are experienced in ivermectin MDA. The malaria map shows that two-thirds of districts have a malaria incidence of 400/1000 or more while 14 have lower incidence. There is an overlap between current LF MDA districts and higher incidence malaria districts Both LF and Malaria Program Coverage can be seen to overlap in [program maps.

Ghana CHWs explain how they conduct MDA

Ghana Experiences: Ghana provides a contrasting example. There five regions in central Ghana that are mostly non-endemic for LF but do have moderate malaria transmission In the south two regions with former LF MDA activity overlap with higher malaria endemicity While four northern regions have lower malaria parasite prevalence, they do have current and recent LF MDAs Community Directed Distributors work with LF MDA in Ghana

Conclusions: Malaria elimination will need a mix of strategies to be successful. Therefore, it is not too early for malaria and NTD program managers, as well as their respective donors, to begin comparing maps to identify possibilities for adapting ivermectin MDAs for malaria vector control. Even though one endemic disease is nearing control or elimination, the infrastructure put in place to accomplish this can be mobilized for other disease control efforts – as long as we map where interventions and resources have been targeted.

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.

Acceptance of the Contribution of Community-Based Health Workers (CBHWs) to Improving Prevention of Malaria in Pregnancy in Burkina Faso by Health Center Staff

Efforts are underway to test the a community-based system for providing IPTp to pregnant women in Burkina Faso as a means of increasing coverage. Justin Tiendrebeogo, Ousmane Badolo, Mathurin Dodo, Yacouba Savadogo, Danielle Burke, Susan Youll, and William Brieger share a formative study among health staff concerning their perceptions of the ability of Community Based Health Workers to provide increased doses. This was presented at the 7th Multilateral Initiative for Malaria Conference in Dakar. Below are the findings.

The Burkina Faso Ministry of Health, with support from its partners, initiated a study on the feasibility of increasing provision of intermittent preventive malaria treatment in pregnant women (IPTp) with sulfadoxine-pyrimethamine (SP). Existing community-based health workers (CBHWs) were enlisted to deliver the third and fourth doses recommended by the World Health Organization. Currently, only facility-based health care providers give SP, and women in rural areas have trouble accessing health facilities for the medicine.

Using CBHWs has the potential to reach more women with a greater number of doses of IPTp-SP. Direct training and supervision of CBHWs is the responsibility of frontline health care staff, including antenatal care (ANC) providers. Therefore, to ensure a successful rollout of community delivery of IPTp, it is crucial that these staff accept the new roles of CBHWs. This baseline study was conducted to learn the frontline staff’s views about existing and proposed CBHW activities.

Study’s Geographic Areas. Three districts (Batié, Pô, and Ouargaye) in the southern part of Burkina Faso. Twelve centre de santé et de promotion sociale (health and social promotion centers [CSPS]) were selected in Ouargaye, Pô, and Batié Health Districts. In each district, two CSPS were randomly assigned as intervention catchment areas, for a total of six centers. Then using matching criteria, the remaining six CSPS were designated as control sites.

Health Worker Interviews were conducted among a total of 35 CSPS staff: 23 were men, and 12 were women. Semi-structured interview guides were used in this formative study. Open-ended questions sought the views of ANC providers and CBHW supervisors about the current work of CBHWs and the feasibility of using this health cadre to administer IPTp to pregnant women. The Study sought to understand provider opinions to design an IPTp-SP intervention involving CBHWs.

Qualitative analysis identified common themes in the open-ended responses. Providers like the CBHW program, noting that “CBHWs come from the community” and help with language barriers. However, CBHWs are not always available or move frequently from one community to another. A few male providers noted issues with timely payment of stipends to CBHWs.

Most providers were open to CBHWs providing IPTp-SP to pregnant women: “It will reduce [our] workload.” Unlike female providers, some male providers stressed the need for CBHWs to be “well trained.”

Providers commented that CBHWs were needed and could contribute. For example CBHWs could increase the uptake of IPTp-SP, prevent deaths and malaria, educate women and the community, and prevent stock-outs of SP. While CBHWs do not currently provide IPTp-SP, several providers noted that CBHWs already conduct community education sessions with pregnant women on taking IPTp-SP.

A few noted that CBHWs already monitor adherence to IPTp-SP doses and send women to the health facility when doses are needed. Providers expressed the importance of including information on malaria prevention and treatment, IPTp-SP administration, stock management, and data collection in the CBHW training.

The findings guided discussions and planning with both district and CSPS staff in the design of the CBHW training and IPTp-SP intervention. The results led to development of the training-of-trainers process that started with the district health team, who then trained CSPS staff—the CSPS staff then trained CBHWs.

Gaining the frontline staff’s acceptance of and perceptions about CBHWs—and building on them—will hopefully lead to greater ownership and better management of project implementation at the community level.

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, PMI, or the United States Government.