Category Archives: Diagnosis

Pneumonia and Malaria – similar challenges and pathways to success

ConcentrationOfPneumoniaDeathsWorld Pneumonia Day (WPD) helps us focus on the major killers of children globally. While Pneumonia is responsible for more child mortality across the world, in tropical malaria endemic areas both create nearly equal damage (see WPD graphic showing Nigeria and DRC which are both have the highest burden for pneumonia, but also malaria). Of particular concern is case management at the clinic and community level where there is great need to differentiate between these two forms of febrile illness so that the right care is given and lives are saved.

WPD_2014_logo_portraitDiagnostics are a particular challenge. While we now have malaria rapid diagnostic test kits that can be used at the community level, we must rely on breath counting for malaria. The Pneumonia Diagnostics Project (see video) “is working to identify the most accurate and acceptable devices for use by frontline health workers in remote settings in Cambodia, Ethiopia, South Sudan and Uganda.”

Ease of use at low cost must be achieved. One approach to solve the pneumonia diagnostics challenge at community and front line clinic level is to find “mobile phone applications or alternative energy for pulse oximetry,” to test low oxygen levels.

PneumoniaCareVaccine development for both diseases is underway. The challenge for malaria results from the different stages of the parasites life-cycle. Lack of affordable vaccines for pneumonia limits at present widespread preventive action, though public-private partnerships offer hope.

Dispersable and correct dose for age prepackaged malaria drugs are already available. Now more child-friendly medicines for pneumonia are being developed. In low resource settings, “amoxicillin dispersible tablets are a better option, particularly for children who can’t swallow pills. They have a longer shelf-life, are cost-effective, don’t need refrigeration, and are easy to administer.”

Similarities in the problems and solutions to control these two diseases require that interventions must continue to be developed and implemented jointly in order to benefit children the most. As can be seen again from the WPD graphics (right), many children do not get needed treatment. Integrated case management at all levels is the answer.

Evaluation of Community Malaria Worker Performance in Western Cambodia: a Quantitative and Qualitative Assessment

Sara E. Canavati de la Torre and colleagues[1] conducted a study of Community health workers who focus on malaria. They are sharing their results with us below.

Village/ Mobile Malaria Workers (VMWs/MMWs) are a critical component in Cambodia’s national strategy to reduce malaria morbidity and mortality. Since Sara map image0162004, VMWs have been providing free malaria diagnosis and treatment using Rapid Diagnostic Tests and Artemisinin-based Combination Therapies in hard-to-reach villages (>5km from closest health facility).

VMWs play a key role in control and prevention, diagnosis and treatment of malaria as well as in delivering behavioral change communication (BCC) interventions to this target population. Out photos shows a village malaria worker at a health center registering number of patients diagnosed and treated during a month.

Sara CHW image013Overall the study aimed to evaluate the implementation of these activities performed by VMW/MMWs, a quantitative and qualitative assessment was conducted in 5 provinces of western Cambodia in order to:

  • understand job satisfaction of VMWs and MMWs vis-a-vis their roles and responsibilities;
  • assess their performance according to their job descriptions;
  • gain insights into the challenges faced in delivery of diagnosis, treatment and health education activities to their communities.

A total of 196 VMWs/MMWs were surveyed in October 2011 using a combination of quantitative and qualitative methods. Triangulation of quantitative and qualitative data helped to gain a deeper understanding of the success factors of this intervention and the challenges faced in implementation. The Map of Provinces shows ODs and HCs visited by the field team in zones 1 and 2 of the containment project.

Sara Results image018The Figure shows that overall, levels of VMW performance were in line with the expected performance (80%) and some were higher than expected. However, some performance gaps were identified in the areas of knowledge of malaria symptoms, treatment regimens, and key messages. In particular, there were low levels of practice of the recommended direct observed therapies (DOTs) approach for malaria treatment (especially for the second and third doses), reportedly caused by stock-outs, distance and transportation.

The national malaria program should aim to focus on improving knowledge of VMWs in order to address misconceptions and barriers to effective implementation of DOTs at community-levels. In addition to the findings, the tools developed, will potentially help the national program to come up with better indicators in the near future.

[1] Sara E. Canavati de la Torre1,2,8 Po Ly2, Chea Nguon3, Arantxa Roca-Feltrer4,9, David Sintasath5, Maxine Whittaker6, Pratap Singhasivanon7 – 1Faculty of Tropical Medicine, Mahidol University/ Malaria Consortium Cambodia, Phnom Penh, Cambodia; 2The National Centre of Parasitology and Malaria Control, Phnom Penh,, Cambodia; 3The National Centre of Parasitology and Malaria Control, Phnom Penh, Cambodia; 4Malaria Consortium Cambodia, Cambodia; 5Malaria Consortium Asia Regional Office, Bangkok, Thailand; 6 Australian Centre for International and Tropical Health, University of Queensland, Queensland, Australia; 7Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; 8Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; 9London School of Tropical Medicine and Hygiene, London, UK

Individual and Household Level Risk Factors Associated with Malaria in Mutasa District, Zimbabwe: a Serial Cross-Sectional Study

Mufaro Kanyangarara and her PhD thesis adviser, Luke Mullany of the Johns Hopkins Bloomberg School of Public Health Department of International Health, have been looking into the challenges of controlling and eventually eliminating malaria in a multi-country context in southern Africa. We are sharing abstracts from her pioneering work including the following which explores risk factors on the Zimbabwe-Mozambique order.

Background: Malaria constitutes a major public health problem in Zimbabwe, particularly in theMAP 2000 and 2015 S Africa north and east bordering Zambia and Mozambique. In Manicaland Province in eastern Zimbabwe, malaria transmission is seasonal and unstable. As a result of intensive scale up of malaria interventions, malaria control was successful in Manicaland Province. However, over the past decade, Manicaland Province has reported increased malaria transmission, and the resurgence of malaria in this region has been attributed to limited funding, drug resistance and insecticide resistance. One of the worst affected districts is Mutasa District. The aim of the study was to identify malaria risk factors at the individual and household levels to better understand what is driving factors associated with malaria and consequently enhance malaria control in eastern Zimbabwe.

Methods: Between October 2012 and September 2014, individual demographic data and household characteristics were collected from cross-sectional surveys of 1,116 individuals residing in 316 households in Mutasa District. Factors characterizing the surrounding environment were obtained from remote sensing data. Factors associated with malaria (measured by rapid diagnostic test [RDT]) were identified through univariate and multivariate multilevel logistic regression models.

Results: A total of 74 (6.4%) participants were RDT positive. Parasite prevalence differed by season (10.4% rainy and 2.9% dry, OR 4.52, 95% CI 2.11-9.69). Sleeping under a bednet showed a protective effect against malaria (OR 0.54, 95% CI 0.29-1.00) despite pyrethroid resistance. The household level risk factors protective against malaria were household density (OR 0.89, 95% CI 0.87-0.97) and increasing distance from the border with Mozambique (OR 0.86, 95% CI 0.76-0.97). Increased malaria risk was associated with recent indoor residual spraying (OR 2.30, 95% CI 1.16-4.56).

Conclusions: Malaria risk was concentrated in areas located at a lower household density and in closer proximity to the Mozambique border. Malaria control in these “high risk” areas may need to be enhanced. These findings underscore the need for strong cross-border malaria control initiatives to complement country specific interventions.

Malaria Status in the 2014-15 Rwanda Demographic and Health Survey

Rwanda is experiencing low and very low levels of malaria test positivity rates, thought there are a few districts near the borders with Uganda, Tanzania and Burundi that have relatively higher transmission. Overall the country is strategizing how to move toward the pre-elimination phase on the pathway to malaria elimination. This is defined as a test positivity rate of less than 5% during the high transmission season.

DHS 2010 Malaria Prevalence in Children 6-59 MonthsIt is important to distinguish between test positivity rate and prevalence rate. The most recent survey report that gives prevalence is the DHS 2010 with a rate of 1.4% in children below 5 years of age and 0.7% among women of reproductive age. During 2010 the health management information system shows that among those tested (microscopy or RDT) for malaria, 24% were positive. The population for test positivity reports is a much smaller group that is already suspected of having malaria. That said, 24% or the 2013 rate of 29% is still far from the 5% cut-off for pre-elimination status.

Rwanda still maintains a policy of universal coverage with insecticide treated nets (ITNs). Rwanda also has a policy that every pregnant woman should receive an ITN during her first antenatal care visit. Ideally in order to reach pre-elimination status, a country needs to sustain high coverage of malaria prevention and treatment interventions at an 80% level for several years.

The newly released preliminary results of the 2014-15 DHS provide an opportunity to examine achievements. The 2014-15 DHS found that 81% of households had at least one ITN, while 43% had achieved the universal coverage target of one ITN per two household members. These numbers remain basically unchanged from the 2013 Malaria Information Survey (83% and 43%), while the 2010 DHS found 82% of households had a net, but did not report on the indicator of one net per two people. In short, it appears that coverage levels have been maintained at a certain level.

DSCN7129a pregnant women get ITNs when register for ANC RwandaDHS 2014-15 shows that 99% of pregnant women in Rwanda received antenatal care from a skilled provider. That means that basically all pregnant women should have received an ITN. 73% of pregnant women had slept under an ITN the night before they were surveyed, while 88% of all women of reproductive age slept under a net. 68% of children below the age of five years slept under an ITN the night before their household was surveyed, while 80% who lived in households that owned an ITN did so.

Indoor Residual Spraying (IRS) is focused on certain high transmission/burden districts. The preliminary 2014-15 DHS does not report on this and the 2013 MIS reports broadly by region, hence one sees coverage reports for IRS in the east (22%) and south (16%), where there is greater malaria burden, but this cannot be linked to specific districts that may have been targeted.

Rwanda also has a policy that all suspected malaria cases should be tested, whether with microscopy in health centers or rapid diagnostic tests by village health workers. It is only those persons testing positive for malaria who are supposed to be given malaria medicine.

DHS shows that 1439 children below five years of age (or 19% of the total) had fever in the two weeks prior to the survey. Of these 36% reported having a blood test performed, and 11% of those with fever received the approved artemisinin-based combination (ACT) therapy drug. The report does not indicate the actual testDSCN7282 results of those receiving ACT.

As Rwanda strategized toward reaching malaria pre-elimination status it can consider ways of enhancing ITN use, not only among vulnerable groups like small children and pregnant women, but all members of the household. As prevalence drops, so does acquired immunity, putting adults at greater risk.

The universal coverage target of at least 1 net for every two people in a household must be maintained, especially since it is nearing three years since the last universal coverage distribution campaign. Either another campaign will be needed or efforts to strengthen delivery of nets to families through routine health services.

In addition prompt and appropriate treatment based on diagnostics can be strengthened. One would have expected more children with fever to have been tested for malaria that the DHS reports.

Internal and external support is needed. Rwanda has been on the verge of reaching malaria pre-elimination status several times in the past decade. Even though malaria is no longer the top cause of death, we should not reduce our efforts to create a malaria-free Rwanda.

AIDS and Malaria: The Challenge of Co-Infection Persists

While the International AIDS Society is holding its 2015 meeting in Vancouver, it is important to remember that individual infectious diseases do not exist in isolation, but in combination make life worse for infected people. The co-infective culprit with HIV/AIDS that usually received the most attention is Tuberculosis, but malaria is not without its dangers. Herein we highlight a few recent studies and publications on the interactions between HIV and malaria.

Just because today malaria is primarily a tropical disease, it does not mean that people living with AIDS (PLHIV) in other parts of the world are not at risk. Schrumpf and colleagues point out that people living with HIV frequently travel to the tropics and thus may be at risk of infection by one of the species of malaria parasite. PLHIV are not unlike other travelers who do not always adhere with travel recommendations for using bednets and taking appropriate prophylaxis, but the consequence of non-adherence may be more severe.

In areas endemic for both malaria and HIV the effects of co-infection continue to be studied.  In westernDSCN6373 Kenya Rutto and co-workers report that, “HIV-1 status was not found to have effect on malaria infection, but the mean malaria parasite density was significantly higher in HIV-1 positive than the HIV-1 negative population.” So do malaria prevention and treatment interventions mitigate any of these problems?

Co-infection is not the only shared problem of these two diseases in areas where both are endemic. Yeatman et al. reported that, “In malaria-endemic contexts, where acute HIV symptoms are commonly mistaken for malaria, early diagnostic HIV testing and counseling should be integrated into health care settings where people commonly seek treatment for malaria.”

Mozambique has updated its guidelines for managing anemia among HIV-infected persons. The updated “guidelines for management of HIV-associated anemia prompts clinicians to consider opportunistic conditions, adverse drug reactions, and untreated immunosuppression in addition to iron deficiency, intestinal helminthes, and malaria.” Brentlinger and colleagues concluded that the guidelines are valuable in helping clinicians address anemia through a variety of interventions.

In areas where anti-retroviral treatment may be delayed, use of long lasting insecticide treated nets (LLINs) might help. Again in Kenya, Verguet and fellow researchers conducted a cost analysis and concluded that, “Provision of LLIN and water filters could be a cost-saving and practical method to defer time to ART eligibility in the context of highly resource-constrained environments experiencing donor fatigue for HIV/AIDS programs.”

Introduction of universal cotrimoxazole prophylaxis for all HIV positive patients in Uganda is seen to have a positive effect on reducing malaria infections among HIV positive patients. Rubaihayo and research partners found this effect as well as reported on several other studies with similar results.

One key overall lessons from these studies is the need to have integrated services for prevention, detection and management of both malaria and HIV. National health programs as well as global donors should make integrated service delivery a priority.

Malaria or Ebola … Ebola or Malaria

The similarity of initial signs signs and symptoms for Malaria and Ebola have been a cause for concern since the beginning of the deadly West African outbreak of Ebola over a year ago. A year later we find that the confusion persists.

DSCN7914 Island ETU MonroviaUS News and World Report in a story on the three new Ebola cases that have ‘mysteriously’ appeared in the suburbs of Monrovia, Liberia addressed the treatment received by the teenager whose infection with Ebola was not determined until after he died. “Authorities have traced about 175 people who had contact with the dead teen, who first became ill June 21 and went to a local health facility where he was treated for malaria and discharged.”

In contrast the Journal of the Royal Army Medical Corps has reported on the disturbing management of a sick nurse serving in Sierra Leone. “A 27-year old British nurse (was) admitted to the Kerry Town Ebola Treatment Unit, Sierra Leone, with symptoms fitting suspect-Ebola virus disease (EVD)
case criteria. A diagnosis of Plasmodium falciparum malaria and heat illness was ultimately made, both of which could have been prevented through employing simple measures not utilised in this case. The dual pathology of her presentation was atypical for either disease meaning EVD could not be immediately excluded. She remained isolated in the red zone (of an Ebola Treatment Center) until 72 hours from symptom onset.”

DSCN2552aIn both cases uninfected people are put at risk because of misdiagnoses. The health staff and community members in the Liberian example, the patient herself in Sierra Leone. In the Liberia situation it appears that health worker education is not complete if staff are not remaining on guard. Also as the number of specialized Ebola treatment units have closed, the triage process to identify and separate patients may have broken down.

The Sierra Leone example points out the need to maintain and enhance malaria prevention efforts to also prevent such mix-ups. Unfortunately public health efforts in the three affected countries to prevent malaria with insecticide treated nets were delayed, meaning the nurse’s experience may not be unique.

Once started, it appears that Ebola does not disappear completely. Another news report today looks into investigation of new suspected Ebola cases in the Democratic Republic of the Congo, where Ebola was first recognized in 1976. Misdiagnosis can be deadly.

Increased Commodity Availability Improve Malaria Diagnosis among Children Under five in Sokoto State, Nigeria

Zainab Mohammed, Nosa Orobaton, and Mohammed A. Ibrahim from the Targeted States High ImpactTSHIP Project (TSHIP), USAID Nigeria and the JSI Research & Training Institute, Inc. are sharing their experiences in Sokoto State, Nigeria concerning the importance of primary care health workers practicing appropriate malaria diagnostics prior to prescribing malaria medicines.

Despite the national efforts to reduce indiscriminate use of antimalarial and to secure improvements in malaria diagnosis, presumptive treatment of malaria is still high in Sokoto State, Nigeria. Just 3% of children under five years with fever had a blood test for malaria (NDHS 2013). Therefore Zainab and colleagues set out to answer the question, “Does increased availability of diagnostic kits improve quality of malaria case management?” Their work was based on the following objectives

  1. To determine the effect of malaria Rapid Diagnostic Test (mRDT) kits availability in malaria case management among children U5 years in Sokoto State.
  2. To document the effect of multi-strategy approach in improving malaria case management among children under five in Sokoto State.

DSCN3005aTheir methods included secondary data collection from the Sokoto State Health Management Information System (HMIS) from 2011 to 2014. No mRDTs were supplied to the State in 2011. In August 2012 – 108, 000 and 807, 850 kits were supplied by USAID/PMI through USAID/TSHIP with logistic support from USAID’s JSI/DELIVER to State Medical Store and distributed directly to HF. Service providers were trained on the job. Other activities included house-to-house education and counselling by community volunteers, radio phone in programs, face-to-face dialogue by ward development committees and radio jingles.

They found that although only 3% of health facilities (HF) provided malaria diagnostic services across the State, the percent of all facilities that provided the service had increased to 22% in August 2012 through 2015. The percent of children under five with fever symptoms and had confirmatory diagnostic tests for malaria was 19% and 20% in 2011 and 2012 respectively. By 2013, the coverage had tripled to 57% and had quadrupled to 84% in 2014. Overall, the percent of fever cases subjected to confirmatory diagnosis for malaria increased from 19% in 2011 to 84% in 2014.

In conclusion, the observed improvement in quality of malaria case management can be attributed to the availability of free mRDT at the HFs. Also contributing to the outcome were continuous training & mentoring of service providers and quality of awareness creation at community and HF level as well as through the media. Therefore, it is recommended that commodity logistics in support of supplying mRDT is strengthened to improve quality of malaria case management.

Malaria Care: Investing in Infection Prevention to Save Health Workers’ Lives

wmdlogoThe recent World Malaria Day observances called on all partners to “Invest in the Future, Defeat Malaria.” The word ‘investments’ brings to mind huge supplies of insecticide treated nets and malaria medicines. The recent and ongoing Ebola crisis has shown how vulnerable health workers are when trying to diagnose and manage malaria when investments have not been made in safety equipment and training.

The Ebola epidemic in West Africa as well as its predecessors in Central Africa has taken a disproportionate toll on health workers. In the early stages of the outbreak, health workers regular front line clinics became infected when patients with Ebola, a disease which none had seen before, were initially thought to have malaria or other endemic febrile illnesses.

Health worker demonstrating RDT, using glovesContact with the various bodily fluids of these febrile patients during physical examination, including parasitological testing of blood for malaria diagnosis, combined with a lack of personal protection/infection prevention supplies and materials, resulted in many unnecessary health worker deaths. Many clinics closed, while those that remained open saw a drop in clients due to fears from beliefs that the unknown disease was emanating from the clinic.

It is necessary to ensure that health workers do not face such a fate again, nor be exposed to other blood borne pathogens like HIV and Hepatitis B. In addition attention is needed to protect others on the front line such as patent medicine shop workers and community health volunteers. A two-pronged approach is needed that combines education/training with a strong procurement and supply system for infection prevention and personal protection materials.

RDT Job AidWe should take advantage of World Health Organization guidance for infection prevention related to hemorrhagic fevers and within that has stressed the importance of general protection. Performing Rapid Diagnostic Tests (RDTs) for malaria is the time when most front line health workers could come into contact with a patient’s blood. Training materials and job aids as pictured here, stress the importance of hand washing and use of gloves, but the availability of regular water supplies and disposable gloves in many front line clinics is low or non-existent. The US Centers for Disease Control and Prevention (CDC) also offers the following guidance for malaria diagnosis and case management in countries where both Ebola and malaria are endemic. In addition to front line health staff, we have learned that community volunteers can safely practice infection prevention while performing RDTs by wearing gloves and correctly disposing the used materials.

Efforts to enable medicine shop workers to use RDTs have begun. They do become more vulnerable during Ebola outbreaks as public clinics may close due to health worker deaths. In Liberia medicine sellers who were taught to use RDTs were asked to stop the practice until safety could be assured.

Continuous investment in RDTs themselves as well as the safety and protective supplies and treatment is needed. RDTs if performed properly can save lives of community members. Infection prevention steps and equipment can save the lives of the health workers who care for the community.

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A longer version of this posting will appear in the May 2015 issue of Africa Health.

Fyodor UMT Researchers at ASTMH

Recently we shared the news that Fyodor Biotechnologies’ new Urine Malaria Test (UMT) has been approved by Nigeria’s food and drug agency. The research team from the University of Lagos and Fyodor will be at the American Society of Tropical Medicine and Hygiene Annual Meeting.

ASTMH 2014The poster abstract is outlined below, but please visit the actual poster on Tuesday at #882 Poster Session B starting at noon, to learn more from the researchers and discuss the implications for the future of malaria case management.

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Effective case management of malaria requires prompt diagnosis and treatment within 24 hours. Despite current policy guidelines that mandate confirmed parasitological diagnosis before treatment, access to diagnostic testing remains low in sub-Saharan Africa.

Today, malaria diagnosis is only by blood-tests (microscopy and rapid diagnostic tests, RDTs), which are invasive, multistep and therefore  relatively complex to perform, require technical expertise, and not available in most public and private sector healthcare settings where more than 65% of the population seek care.

umt1Here, we report the results of a multicenter pivotal clinical trial of Fyodor Urine Malaria Test (UMT) – a simple  (one-step, no blood, no reagents, no equipment) dipstick test that detects Plasmodium falciparum parasite proteins shed in the urine of febrile malaria patients. A total of 1,893 participants (?2 years) with fever (axillary temperature ?37.5°C) or history of fever in the last 48 hours were enrolled at 6 primary healthcare centers in rural and suburban communities in Lagos State, Nigeria, over a 7-month period that covered both rainy and dry seasons.

Matched patient urine and fingerprick blood sample were tested using the UMT, Binax NOW (Inverness) (HRP-2/pLDH) test, and microscopy. A total of 358 participants (18.9%) had confirmed malaria by microscopy; Fyodor UMT, 450 (23.8%); Binax NOW (pLDH), 386 (20.4%) and Binax NOW RDT (HRP-2), 731 (38.6%).

Statistical data analyses to determine test performance characteristics are ongoing and will be made available within a month. The UMT has the potential of expanding access to malaria diagnosis especially in settings where blood test is not possible.

Authors: Wellington A. Oyibo, Nnenna Ezeigwe, Godwin Ntadom, William Brieger, Wendy O’Meara, Anne Derrick, Bao Lige, Oladosu Oladipo, Eddy C. Agbo

Marketing approval for UMT from the Nigeria NAFDAC

FyodorFyodor Biotechnologies Inc. has sponsored a study to evaluate the clinical performance of the one-step Fyodor Urine Malaria Test (UMT), to determine its accuracy (sensitivity and specificity) for the diagnosis of Plasmodium falciparum malaria in febrile patients.

A total of 1500 properly consented children and adults presenting with fever (axillary temperature ?37.5°C) or history of fever in the last 48 hours (Group 1), 250 apparently “healthy” individuals (Control, Group 2), and 50 patients with Schistosoma hematobium and Rheumatoid arthritis (Group 3), were recruited.

UMTMatched urine and fingerprick (capillary) blood samples were collected and tested using the UMT and, Binax NOW® malaria rapid diagnostic test (blood test) and thick smear microscopy, respectively. The overall agreement of the UMT results to the Binax NOW analysis and thick smear microscopy was used to establish UMT sensitivity and specificity.

The UMT showed comparable performance with blood-based tests. The UMT has the potential of expanding access to parasitological confirmation of malaria in both the public and private health sector as well as the community

As a result, Fyodor has now received marketing approval for the UMT from the Nigeria NAFDAC (food and drug agency).

According to the Principal Investigator, Wellington Oyinbo of the University of Lagos, “This is a defining moment for malaria case management and hopefully, countries will be able to meet their set national targets for parasitological confirmation of malaria. Important as well is the fact that a strip of nitrocellulose paper is able to fast-track malaria diagnosis in an otherwise weak health/diagnostic system.”