Category Archives: Monitoring

Regular data Review Meetings in Mozambique, a Path to Improving Malaria Service Delivery

Health Alliance International (HAI) of the University of Washington, is collaborating with Centro de Investigação Operacional da Beira (CIOB) is based in Beira, Mozambique to improve the quality and use of routine monitoring and evaluation data from the health facility through to the district in Sofala Province. The aim is to strengthen the health system through data for decision making and improve quality and uptake of services. This effort is sponsored by a grant from the Doris Duke Charitable Foundation.

DSCN6314A key feature of the program is a regular data review meeting where representatives from health facilities in a district come together and each presents his/her standard Ministry of Health service indicators in a simple slide format.  After each presentation the speaker received feedback from the group, including members of the district health management team, on successes and challenges and is encouraged to make plans to improve both data quality and service uptake.

The data review meetings started with an overview of all HIV, reproductive, maternal and child health indicators. Separate review meetings for malaria service indicators have been recently introduced.

According to members of the district teams, the individual facility staff presenters have grown more skilled in formatting their data and presenting to an audience. Overall, participants in these meetings appear enthusiastic and interested in the results of their peers. Constructive critiques are the norm, and speakers express appreciation for suggestions on how they can improve their services and the resulting data.

IPTp preA sample chart from a health facility showing a quarterly review of intermittent preventive treatment for malaria in pregnancy (IPTp) is seen to the right.  After viewing this, meeting participants might ask the presenter what are the reasons for the drop-off in coverage. If for example, the problem of late antenatal care (ANC) attendance is mentioned, the group can ask the presenter to consider how to encourage women to attend earlier.

IPTp postIf the presenter then goes back and implements the suggestions, the second chart might reflect the results of improved service uptake. In this way the overall project hopes that close examination of their own data by service providers can strengthen service delivery and the health system.

We look forward to hearing more about this unique process so that it can be disseminated in other malaria endemic countries.

iPhones for household malaria surveys in Sierra Leone

World Malaria Day 2014 was observed at the Johns Hopkins Bloomberg School of Public Health on Friday 25 April. 21 posters were presented. Below is the abstract of a poster presented by Suzanne Van Hull of Catholic Relief Services.iForm Builder picture on iPhone

Catholic Relief Services (CRS) and the Ministry of Health and Sanitation (MoHS) of Sierra Leone (SL) are co-implementing nationwide malaria prevention and treatment activities funded by the Global Fund to fight AIDS, Tuberculosis and Malaria. In order to track progress and impact, CRS and partners led the implementation of a malaria indicator survey (MIS) in early 2013 covering a nationally-representative sample of 6,720 households, inclusive of blood testing to determine prevalence of anemia and malaria. In early 2012, CRS also had the experience of using mobile technology for a Knowledge Attitude and Practices (KAP) study.

Fieldworkers used Apple 3GS iPhones for both surveys to collect data via the iFormBuilder platform, a web-based, software-as-services application with a companion app for the mobile devices allowing for timely data collection, monitoring, and analysis.

This was the first time that iPhones were used for a MIS, and lessons learned include: allowing at least four months to transform paper-based questionnaires into electronic format, giving the program enough time for pre-testing the tool and training data collectors/biomarkers/laboratory technicians, and involving key malaria stakeholders to ensure a nationally-led survey. Global Positioning Systems enabled the MoHS to make in-depth analyses on malaria trends based on geographic locations.

KAP survey on iPhoneOverall the benefits of an electronic versus a paper-based MIS questionnaire outweighed the challenges. The iPhone technology eliminated the need for paper transcribing, allowing for quicker data tabulation, real-time identification of mistakes, faster interviewing through skip patterns, and a close-to-clean dataset by the end of data collection saving time and money.

Survey results will be used to set evidence-based targets for all partners’ future malaria activities, especially the next 3 years of GF-supported malaria grants

World Malaria Report 2013: Surveillance and Monitoring, Getting to the Heart of the Matter

Although “Malaria surveillance, monitoring and evaluation” is the seventh of eight chapters in the 2013 World Malaria Report (WMR), it is in fact the heart of the matter.  Progress on goals, finance, vector control, preventive therapies, diagnosis and treatment and of course impact (chapters 2-6 and 8) could not be produced without the documentation processes discussed in Chapter Seven. So what does WMR 2013 tell us about the status of malaria surveillance?

DSCN1496The global press has been taken by World Health Organization estimates that deaths from malaria world-wide have reduced by fifty percent since 2000.[i] These claims have been made despite the note in WMR 2013 that, “In 2012, in 62 countries of 103 that had ongoing malaria transmission in 2000, reporting was considered to be sufficiently consistent to make a reliable judgment about malaria trends for 2000–2012. In the 41 remaining countries, which account for 80% of estimated cases, it is not possible to reliably assess malaria trends using the data submitted to WHO. Information systems are weakest, and the challenges for strengthening systems are greatest, where the malaria burden is greatest.”[ii]

WHO explains that, “Improved surveillance for malaria cases and deaths will help ministries to determine which areas or population groups are most affected and help to target resources to communities most in need.”  WHO suggests that the design of malaria surveillance systems focuses on two fundamental factors. First, the level of malaria transmission should be ascertained, and the resources available to conduct surveillance must be made available. WHO has released two manuals to strengthen malaria surveillance depending on whether the country is high burden and still at the level of “Malaria Control,”[iii] or the country is approaching “Malaria Elimination.”[iv]

3T BrocheureThe World Health Organization has issued a series of documents focusing on “Test. Treat. Track.” or ‘3T’.  In short these documents support malaria-endemic countries in their efforts to achieve universal coverage with 1) diagnostic testing, 2) antimalarial treatment, and 3) strengthening their malaria surveillance systems to track the disease.[v]

WHO notes that in elimination settings, surveillance systems should seek to identify and immediately provide notification of all malaria infections, whether they are symptomatic or not. A summary of WHO’s recommendations for the “Track” or surveillance aspect of 3T follow:

  1. Individual cases should be registered at health facility level. This allows for the recording of suspected cases, diagnostic test results, and treatments administered
  2. In the malaria control phase, countries should report suspected, presumed and confirmed cases separately, and summarize aggregate data on cases and deaths on a monthly basis
  3. Countries in elimination phase should undertake a full investigation of each malaria case.

Some country examples of surveillance efforts in the move toward malaria elimination will be featured in the upcoming January 2014 issue of Africa Health. Watch for it at: http://www.africa-health.com/


[i] Pizzi M. WHO: Malaria deaths of young children cut by half, but gains ‘fragile’. Aljazeera America. December 11, 2013. http://america.aljazeera.com/articles/2013/12/11/who-malaria-battlehalfwaywon.html

[ii] WHO GLOBAL MALARIA PROGRAMME. World Malaria Report: 2013. World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland, 2013. http://www.who.int/malaria/publications/world_malaria_report_2013/en/index.html

[iii] World Health Organization. Disease surveillance for malaria control. World Health Organization, Geneva, 2012.

[iv] World Health Organization. Disease surveillance for malaria elimination: an operational manual. World Health Organization, Geneva, 2012.

[v] World Health Organization. Test. Treat. Track. Scaling up diagnostic testing, treatment and surveillance for malaria. World Health Organization, Geneva, 2012.

Malaria Highlights at TropMed2013 Saturday 16th November

Below please find a brief list of some of the presentations coming up today at the American Society of Tropical Medicine 62nd Annual Conference in Washington DC. Click links to view abstracts.

AnnualMeetinggraphic

Rapid clearance of parasitemia by the novel spiroindolone KAE609 in a phase 2 open-label study of adults with acute, uncomplicated Plasmodium falciparum or vivax malaria mono-infection by Nicholas White et al.

In summary, when administered 30 mg daily for 3 days, KAE609 was well tolerated and achieved rapid parasite clearance in adult patients with uncomplicated P. vivax or P. falciparum malaria infection.

Symposium on Implementation of Mass Drug Administration for Malaria Control and Elimination. Symposium Organizer: Roly Gosling, Global Health Group, University of California, San Francisco, San Francisco

With the recognition that a large proportion of malaria infections are low density, below the level of detection by microscopy or Rapid Diagnostic Test, MDA is coming back into favor. The speakers will explore the drug choices available for MDA in different settings; for example, for P. falciparum settings in Haiti, The Gambia and the Artemsisinin Resistance Containment zone, and for P. vivax in Asia and the Pacific.

Innovative Field Tools for Detecting Counterfeit Medicines – The Case Study of Anti-Malarials. Symposium Organizer: JOEL BREMAN, FOGARTY INTERNATIONAL CENTER, NATIONAL INSTITUTES OF HEALTH

The need for innovative field tools for the detection of spurious/falsely-labelled/falsified/counterfeit medicines is becoming increasingly important, particularly in low-resource settings. A global public health crisis is looming, especially in malaria treatment and prevention, where up to 90 percent of antimalarials in surveys done in Asia and Africa are reported to be falsified or substandard.

Session: Malaria Epidemiology – Tracking Trends and Finding Foci, Village-level characteristics associated with spatial distributions of malaria-infected individuals in an area of Southern Zambia receiving mass screening and treatment by David A Larson et al.

Varying spatial distributions of malaria-infected individuals appear to be driven by vector abundance and gametocyte prevalence in the population. The ability to clearly delineate village malaria prevalence may assist in developing mechanisms for focused interventions to optimize their effectiveness.

Session: Malaria Epidemiology – Tracking Trends and Finding Foci. Reservoirs of asymptomatic malaria in Malawi: results of two cross-sectional studies by Jenny A. Walldorf et al.

In Malawi and potentially in other endemic settings, school age children represent important reservoirs of asymptomatic infection and should be targeted for interventions to interrupt transmission.

Session: Malaria Epidemiology – Tracking Trends and Finding Foci. Sustained Declining Burden of Malaria at Community level in Northeastern Tanzania. by Acleus S. Rutta et al.

The reported decline of malaria in most parts of Tanzania has some implication on accuracy of malaria diagnosis and management. The current remarkable and sustained decline in malaria suggests that these areas might be moving from control to pre-elimination levels.

Community registers in Akwa Ibom State, Nigeria track malaria treatment and integrated services

Below is the abstract for a poster being presented by a team from Jhpiego at the upcoming 62nd annual meeting of the American Society for Tropical Medicine and Hygiene November 13-17 2013 at the Marriott Wardman Park in Washington DC.  If you are at the conference, stop by poster number LB-2289 on Friday and discuss with Bright Orji.

Community Directed Distributors bring their registers to the nearby clinic for monthly supervision meetings

Community Directed Distributors bring their registers to the nearby clinic for monthly supervision meetings

Community Directed Treated with Ivermectin (CDTI) for onchocerciasis successfully reached 100,000 African villages with locally selected volunteers known as Community Directed Distributors (CDDs). Recognizing CDTI’s potential other health programs added a variety of interventions to the work of CDDs. Jhpiego (an Affiliate of Johns Hopkins University) successfully engaged communities and their CDDs in Akwa Ibom State, Nigeria to control malaria in pregnancy from 2007-11, and subsequently found the communities willing to expand into integrated community case management (ICCM) of malaria, diarrhoea and pneumonia. This report documents iCCM services given by CDDs.

The project mobilized 108 kin groups (100 +/- people) in 6 clinic catchment areas two Local Government Areas of the State. Each kin group selected 1-2 CDDs. Overall, 152 CDDs were trained by staff of local health centers. CDDs continued to provide intermittent preventive treatment of malaria in pregnancy using sulfadoxine-pyrimethamine and then added malaria rapid diagnostic tests (RDTs); Artemisinin-based Combination Therapy for positive RDT results; oral rehydration solution and zinc tablets for diarrhea, and cotrimoxazole for pneumonia.

Data were extracted one year’s information from a sample of 68 community registers by three health staff using a checklist. During the period 2,202 clients were seen by CDDs with ages ranging from infancy to adulthood. Overall 33.3% were treated for malaria, 20.3% for pneumonia and 7.8% for diarrhoea (a few had multiple problems). Among the client visits, 30.6% were for pregnant women receiving a dose of IPTp.

RDTs were used with 1550 clients (70.4%) who had suspected malaria and 44.1% were positive. The breakdown of the 734 treated for malaria was positive RDT (93.1%), negative RDT (2.2%) and no test (5.2%). Community registers have shown that volunteer CDDs can provide a variety of front line health services, and can fairly correctly follow malaria testing and treatment procedures.

Challenges in Malaria Health Information Collection and Coordination

Today This Day Live News reported on challenges of data coordination in the health system in Nigeria. Ndubuisi Francis reported that, “The multiplicity of conflicting data on health by various agencies is a major impediment to an effective and efficient health care delivery system in the country. Director, Disease Control and Immunisation, National Primary Health Care Development Agency (NPHCDA), Dr. Emmanuel Abanida, said resolving the conflict in the national health management information system (HMIS) is a step towards getting the system right.” The problem is not unique to Nigeria.

Health facility staff compile monthly data reports

Health facility staff compile monthly data reports

To learn more about how this problem affects malaria data we discussed with two staff of the Jhpiego office in Abuja, Gbenga Ishola and Bright Orji, who have been involved for many years in malaria monitoring and evaluation activities at national, state and local levels.  The results of this discussion follow:

1. Incorporating Community Health Worker Data into HMIS

As the country moved toward community case management to reach coverage targets, the HMIS has worked with NMCP to establish a community data collection template. However, the level of utilization of the community level register is poor. Also the integration of this into facility output remains a key challenge. Furthermore, there has not been a feedback mechanism to the community of data collected from them. So, it is not only collection of data but use of data for decision-making whether at the Local Government (LG) level, facility or community remains part of the challenge.

2. Movement of Data from Facility to District to State to National

There is an existing data flow pattern. Data from facility HMIS registers are expected to be collated on monthly basis into a monthly summary form at facility level. The summary forms are sent to the Local Government Monitoring and Evaluation Unit which then sends this to the state level. Data flow is also not as smooth as intended. Most often facilities do not collate and send to the LG, and thus state data reporting that is suppose to be quarterly is distorted. The obvious complaint is always logistics.

The National Malaria Control Program (NMCP) monitors state data reporting by aggregating total number of facilities reporting each month and determining reporting rate for the states. Each state reports total number of health facilities in the state, and how many of these facilities submitted a monthly report during review period. For example, if a state has 1,000 health facilities but only 500 submitted monthly reports, the state would have scored 50% in data reporting. This is to encourage state to improve on data collection and reporting and is part of the report and discussions at the annual malaria program’s manager meetings.

3. Parallel Reporting Systems

There are two examples of parallel systems through which malaria data move. The National Primary Health Care Development Agency, a section of the Ministry of Health responsible for assisting LGs strengthen their primary care systems collects health data from those facilities in addition to the facilities reporting through the HMIS.  Recently the Director of the HMIS indicated that his unit is trying to harmonize the existing system. The completeness of each system varies depending on how LGs and states decide to report.

DSCN9997smSince the HMIS collects only a limited selection of malaria indicators, the NMCP makes an effort to collect more detailed statistics of all services. Some of the indicators monitored by NMCP are not in HMIS. The consequence is that health workers often abandon the NMCP register because it contains more entries than HMIS.

The HMIS collects 1) Long-lasting insecticide-treated nets (LLINs) provided and 2) doses of Intermittent Preventive Treatment (IPTp) given (1st and 2nd). NMCP additionally tracks number of fever cases, Rapid Diagnostic Tests (RDTs) conducted (and whether RDT results are negative, positive or invalid), and antimalarial medicines administered (whether quinine or ACT).

While the National HMIS unit is working to harmonize the data collection formats for all diseases including malaria cases, bringing the NMCP to participate in meetings and discussions has been a major problem. This makes it very difficult for the HMIS to be able to quote data relating to specific diseases when necessary.

4. Special Data Requirements

As in other countries, the Global Fund expects countries to report of a regular, quarterly basis on achievements based on their currently operating grant. The data required for these reports is essential for maintaining the flow of funding, but this information is not necessarily within the basic HMIS set of indicators. Global Fund is interested in consumption data for forecasting for national needs, but this has been very difficult to collect due to some of the above challenges.

DSCN1485 sm

Bright Orji and Gbenga Ishola review malaria in pregnancy data with local government nurse-midwife

The number and detail of indicators reported to the Global Fund for Nigeria’s Round 8 malaria grant reflect the complexity of reporting required that would not be included in HMIS. Below are a few examples of the malaria treatment related indicators only. HMIS would not be collecting program process data like training and does not really reach the private sector.

  • Number of children under five with uncomplicated malaria receiving ACT treatment according to National guidelines (all oints of care)
  • Number of children under five with uncomplicated malaria receiving ACT treatment according to National guidelines through the public sector
  • Number of people (over 5) with uncomplicated malaria receiving ACT treatment according to National guidelines through the public sector
  • Number of person (over 5) with uncomplicated malaria receiving ACT treatment according to National guidelines through the private sector
  • Percentage of participating health facilities in the public sector reporting no stock out of ACTs for 1 week or more within the last 3 months
  • Number of health care providers trained in malaria case management and prevention
  • Number of CSO members trained on case mangement and prevention of malaria
  • Number of Health care providers trained on pharmacovigilance

In order eventually to eliminate malaria detailed monitoring and surveillance data are needed in real time. Coordinating these data needs with a routine national HMIS will always be challenging because disease elimination is anything but a routine process.

Tanzania, an example of the challenges of achieving malaria targets

malaria-indicators-in-tanzania-nets-sm.jpgPreliminary results of the Tanzania indicator survey for HIV and Malaria have been released. This makes it possible to track over time some of the basic indicators for success in malaria programming using various Demographic and Health as well as Malaria Indicator Surveys.  The trends recall concerns of more than a decade ago when USAID organized the Malaria Action Coalition to address the relative ‘neglect’ in malaria case management and malaria in pregnancy program components.  At least in Tanzania, ten years on, the problem persists.

We can see clear progress in insecticide treated net use by vulnerable populations over time. The push for universal coverage since 2009 seems to have paid off in Tanzania.  We hope this victory is sustainable, but more and more we are receiving reports that the duration of the long lasting aspect of LLINs is far from the hoped for 5 years.  Eighteen months is more realistic.

So after a major campaign to achieve the targets seen in the attached figure we have to ask whether Tanzania is positioned to do massive replacement, either through routine services like immunization programs and antenatal care, over the next several years.

A depressing finding is the last of progress in intermittent preventive treatment for pregnant women as seen below.

  • 2008 – 30%
  • 2010 – 26%
  • 2012 – 32%

malaria-indicators-in-tanzania-act-child-sm.jpgReports over the years have singled out procurement and supply problems arising after Tanzania switched from sulphadoxine-pyrimethamin (SP) to ACTs as its first line antimalarial drug. SP fell off the radar in many places.  One wonders also what this says about Tanzania’s overall commitment to maternal health.

Case management is similarly in the doldrums. This is ironic because Tanzania was one of the beneficiaries of the Affordable Medicines Facility malaria (AMFm) pilot effort that was generally credited with enhancing access to quality malaria drugs.  Tanzania has also pioneered an accredited drug outlet program aimed at upgrading the quality of the typical patent medicine shop.

As is often the case, much soul searching is needed to look at the health systems – especially those delivering child health and maternal health services – to find the bottlenecks to this problem.  Neighboring countries like Rwanda that want to move toward pre-elimination will find it difficult if their neighbors fall behind in implementing the basic malaria interventions.

Surveillance, Monitoring and Evaluation as Rwanda Moves Towards Malaria Elimination

Rwanda’s First Malaria Forum has just concluded in Kigali, producing recommendations to help the country, which is already experiencing very low levels of malaria transmission, develop strategies for the path to malaria elimination. After a series of informative talks other countries in the region and international support organizations, working groups distilled the learning from the forum into suggestions for strategic planning. Below we present the deliberations of the Working Group on Surveillance, Monitoring and Evaluation. Group members included Irenee Umulisa, J. Bosco Ahoranayezu, John MacArthur, Arielle Mancuso, Aafje Rietveld, Eric Tongren, Anna Winters.

rwanda-malaria-forum-2.jpg

Preamble: A paradigm change is necessary within the national malaria surveillance system in order to take Rwanda from the stage of malaria control to pre-elimination. Stratification (epidemiological, entomological and environmental) will be used as the basis for applying different programme approaches in the different parts in the country, including surveillance approaches. In high burden strata, the quality of malaria control surveillance will be optimized. In low endemic strata, WHO recommended elimination surveillance approaches will be piloted and gradually introduced to field-try forms & procedures and build systems capacity.

Goals and Vision: By 2017, every febrile patient on the Rwandan territory will visit a health facility within 48 hours for diagnosis and treatment. Under 5s will be treated at community level within 24 hours. A microscopy and RDT quality assurance system (including external quality control) will be in place, ensuring reliable diagnosis at all diagnostic facilities. Every malaria case diagnosed with RDT and treated at community level will be reported to the health center level within 24 hours, accompanied by a microscopy slide for confirmation of diagnosis.

All malaria cases will be reported into one centralized HMIS, irrespective of the health providers who diagnosed and treated them (public, private, community, army, etc.) and irrespective of the way they were detected (ACD, PCD, surveys).

Health centers in low and moderate malaria burden strata will carry out “enhanced malaria surveillance” allowing foci investigation and classification. Health centers in endemic areas will forward line-listings of patients (ideally also with information about recent travel) to the district level with copy to the central level on weekly basis. Central level will compile from these data weekly updated mapping by village level and track cases against epidemic thresholds.

Strategic objectives and action points:

By 2012, update the stratification map of Rwanda’s malaria burden by including data from HMIS, SIS-COM and any other sources of malaria patient data that may be available. The objective is to be all-inclusive: in malaria elimination every case counts. A more in-depth stratification using entomological and environmental variables and intervention coverage will follow.

  • Merge SIS-COM (community) data collection with existing HMI
  • Use the map to identify 3-4 zones for stratification of surveillance and intervention methods based upon malaria burden.

By 2013, develop/update the surveillance plan to direct the MOH malaria surveillance strategies over the coming 5 years within the changing epidemiological settings, with a view to (a) attain malaria pre-elimination programme status in low and moderate burden strata by 2017; and (b) maintain and improve upon the current control achievements in higher burden strata.

  • Improve and coordinate data management and timeliness.
  • Include a plan for human resources necessary to undertake enhanced surveillance.
  • Include a timeline to achieve strategic objectives and action points.

By 2014, set up the systems to enable and ensure that all suspected malaria cases (100%) are diagnostically confirmed using available tools and in a timely fashion within both public and private clinics.

  • Develop (guided by OR) for each strata a clear case definition of a suspected malaria case who should be tested, ranging from a broad definition (fever) in highly endemic areas to a more restricted definition (perhaps including a travel history or additional symptoms) in low endemic areas. Communicate these definitions to all health care providers and the public in the various strata. The purpose is to ensure that every potential malaria case is promptly tested, without unduly overburdening the health workers in low endemic areas.
  • Monitor the use of antimalarials by various health facilities against the numbers of cases diagnosed and reported.

By 2015, pilot “enhanced malaria surveillance” in 1-3 low endemic districts

  • In low and moderate burden areas, begin line listing all confirmed malaria cases including travel history and household location with the goal to map cases (2015-2017). Focus initial line listing and case mapping within Kigali or another accessible low burden district (2013).
  • By 2014, engage the private sector physicians in Kigali for cooperation in malaria surveillance activities (working with the Rwanda medical association). Enforce full cooperation of the private sector by 2017. Restrict availability of antimalarial medicines to registered facilities with access to diagnostic capacity.
  • In low and moderate burden areas, begin collecting weekly malaria data at the health facility level.
  • Gradually include immediate notification and due programme follow up (investigation, classification) of cases detected, starting with one district where this seems doable.
  • Explore business/private coalitions to support a longer term vision of a malaria-free Kigali / tourism areas.

By 2015, pilot line listing in one endemic district, increasing to all endemic districts by 2017

  • Integrate training and data management into existing community health worker programs.
  • Develop and deploy a system for active case detection (ACD) as part of case investigation at the community level.
  • Map all confirmed cases which are passively and actively detected.
  • Develop epidemic thresholds for comparison against weekly case loads.

By 2013, review and start to address the factors that contribute to malaria mortality in Rwanda.

  • Conduct death audits for all reported malaria cases that occurred in 2012. The purpose is to identify risk factors for delays in treatment / inadequate treatment that can be addressed by NMCP programme interventions. Use this study to strengthen collaboration of the NMCP with the national school of public health (or equivalent) by engaging a team of university students / scientists in the study.
  • Explore possibilities for increasing the use of pre-referral treatment with rectal artesunate, based on an understanding of the barriers and behaviours for accessing pre-referral treatment.
  • By 2015, carry out death audits for all reported malaria deaths as they occur, to adjust and target programme interventions.

Continue drug and insecticide resistance monitoring to guide drug and insecticide policies.

Recommendations:

  • By 2014, initiate “enhanced malaria surveillance” following WHO recommended strategies for the elimination phase in 1 low endemic district, increasing to 3 districts by 2015 and all low-endemic districts by 2017. This includes investigation, classification and mapping of cases and transmission foci.
  • By 2015, institute line listing in one endemic district, increasing to all endemic districts by 2017.
  • Encourage and facilitate information sharing among all partners in malaria control.
  • Use available resources in a manner that allows continued high quality surveillance in endemic areas combined with gradual introduction of elimination approaches in low endemic districts. Adopt the philosophy of first building up enhanced surveillance systems and then expanding the system as resources and malaria burdens allow.
  • Consider including Kigali within the first pilot districts for enhanced surveillance, given the low prevalence and focalized transmission patterns, and to encourage political will.
  • Conduct death audits in order to measure progress towards the goal of zero malaria deaths.

Sustaining the Gains

Efforts to eradicate smallpox and guinea worm have taken generations.  In both cases there was a very clear and focal transmission pattern. Smallpox spread only among people and could be stopped with a very effective vaccine. Guinea worm again only infects humans and transmission can be stopped through safe water.

Unlike these other diseases malaria has no one silver bullet and transmission dynamics vary across many different environment types.  At present case containment that was successful in ending smallpox and is effective in guinea worm, is out of the question for malaria.  Malaria must deal with huge health systems challenges ranging from weak procurement and supply management systems to health workforce shortages.  Peak efforts at malaria control have also unfortunately coincided with a world economic downturn.

uganda-malaria-indicators-from-2006-11.jpgDocumentation of malaria control progress is ongoing, if not perfect. A look at indicators from three national DHS/MIS surveys in Uganda make it possible to show how difficult it is to achieve and sustain coverage of the interventions we do have. To date the Roll Back malaria targets of 80% have not been achieved for any indicator, and in the cases of using insecticide treated nets (ITNs) and intermittent preventive treatment in pregnancy (IPTp), there have been drops.

There are a number of ways to measure indicators.  For example, the figures for people who slept under any kind of net are better than those using only ITNs. On the other hand, if we used the data on taking Artemisinin-based combination therapy (ACT) within 24 hours of fever onset, then the figures would be worse.  Of course these figures do not even include whether treatment occurred after a positive rapid diagnostic test.

What we can see is that even with a little more positive nudge, the data are not encouraging.  The guinea worm eradication effort has shown that stakeholders do tire of maintaining disease control efforts year after year.  Many endemic countries are still much too dependent on external assistance to go it alone in eliminating malaria. What will it take to get malaria control and elimination back on track so we can achieve zero malaria deaths by 2015?

Sustaining Gains or Retracting Progress

Currently the Roll Back Malaria (RBM) Partnership’s Malaria in Pregnancy Working Group is meeting in Kigali, Rwanda. Seven country teams present have presented their progress and challenges, including most recent information on coverage/use of long-lasting insecticide treated nets (LLINs) and intermittent preventive treatment for pregnant women (IPTp).  Other working group members have also presented coverage data from other countries.

coverage-of-interventions-for-pregnant-women-33.jpgTwo main challenges emerged. First, for the most part stable endemic countries that are using IPTp and reporting recent levels of coverage for this and for LLINs are hardly reaching the 2010 RBM targets of 80%.  The second challenge is that some countries have actually recorded recent drops in IPTp coverage.

Group members presented experience and research that help explain these challenges.  Coverage with the minimum two doses of IPTp has been hampered by the following:

  • periodic stock-outs of sulfadoxine-pyrimethamine (SP) supplies
  • complexity of the steps involved in providing IPTp properly as directly observed treatment at antenatal clinic
  • poor dissemination of national malaria in pregnancy (MIP) policies and guidelines
  • inconsistencies in IPTp guidelines between malaria control and reproductive/maternal health service units
  • lack of coordinated planning between those two units

sustaining-or-retracting-with-iptp2-coverage-33.jpgThe second problem, as seen in the chart to the left may be due to the above mentioned factors, but also imply more serious health systems problems. SP has become a forgotten step-child in the essential medicines portfolio.  Once reduced treatment efficacy was observed with SP, countries began switching to artemisinin-based combination therapy (ACT) for case management. SP was, according to meeting participants, still efficacious for prevention, but the formal health sector has not always responded by keeping it in stock.

In fact the private sector still stocks SP because customers demand this cheaper alternative to ACT, even though such unregulated use may add to the problem of parasite resistance.  Also donor programs, recognizing that SP is relatively cheap, often rely on endemic countries to purchase their own SP stocks, which some are reluctant to do.

IPTp saves lives in countries with stable malaria. The pregnant woman herself may not ‘feel’ the results of malaria that is concentrated in her placenta, but the fetus is deprived of nourishment and may be spontaneously aborted, stillborn, or born with low birth weight that increases the likelihood of neonatal mortality.

The 2012 World Malaria Day Theme of Sustain Gains, Save Lives: Invest in Malaria, could not be more timely in light of the charts seen here.  First we still have to make the gains in many countries, especially in respect to protecting pregnant women.  We need to sustain gains, not backslide.  This can only be done if donors and health ministries continue to fund MIP control activities and health program managers in both malaria control and reproductive health sincerely collaborate.