Category Archives: Refugee

Joint Efforts to Improve Malaria Control in Three Refugee Camps in Kigoma, Tanzania

A team affiliated with the USAID-supported Boresha Afya health project in Tanzania prepared a presentation for the 68th Annual Meeting of the American Society of Tropical Medicine and Hygiene entitled, “Joint Efforts to Improve Malaria Control in Three Refugee Camps in Kigoma, Tanzania: Successes, Challenges and Lessons Learned,” as seen below. Team members included Shabani K. Muller, Juma Ng’akola, Zephani Nyakiha, Godfrey Smart, Tesha Goodluck, Jasmine Chadewa, Agnes Kosia, Zahra Mkomwa, Abdallah Lusasi, Dustana Bishanga, Rita Noronha, Lusekelo Njonge, Ally Mohamed, Gaudensia Tibajiuka, Chonge Kitojo, and Erik Reaves (Affiliations: USAID Boresha Afya Project -Path Tanzania; USAID Boresha Afya Project –Jhiego Tanzania; National Malaria Control Program, Regional Health Management Team-Kigoma. President’s Malaria Initiative/United States Agency for International Development)

Overview of USAID Boresha Afya Lake and Western Zones: USAID’s 5-year project was implemented in seven regions of Tanzania, including Kigoma. It supports the Government of Tanzania increasing access to high-quality, comprehensive, and integrated health services, with a focus on women and children. Its goal is to improve the quality of malaria case management, including malaria in pregnancy.

Malaria prevalence in Tanzania has decreased by half, from 14.8% in 2016 to 7.3% in 2017 (2015 and 2017 Tanzania Malaria Indicator Surveys). Malaria prevalence in Kigoma is 24% (above national prevalence). According to quarterly District Health Information System 2 data at facility level, about 50% of all malaria cases in Kigoma Region are from the three refugee camps.

Overview of Refugee Situation in Kigoma Region: The majority of refugees fleeing conflicts in Burundi and Democratic Republic of the Congo are hosted in Kigoma.
The three major refugee camps in Kigoma are Nyarugusu, Nduta, and Mtendeli.

Interventions to Improve Malaria Case Management included the following

  • Conducted on-the-job training and mentorship.
  • Conducted joint supportive supervision.
  • Discussed challenges and how to address them in refugee camp settings with other malaria partners.
  • Identified poor-performing indicators.
  • Collaborated with community providers.

Results of these interventions included the malaria lab reporting rate increased from 42% to 100%. This means that the rate of facilities reporting laboratory results in the District Heath Information System was very low. Clinical malaria diagnosis decreased from 4% to 0%. Nyarugusu’s malaria positivity rate decreased from 61% to 52%. Kigoma Region’s number of annual deaths due to malaria decreased from 359 in 2017 to 191 in 2018.

Results also showed an increased percentage of pregnant women who received the second dose of intermittent preventive treatment of malaria in pregnancy (IPTp2) from 26.7% in 2017 to 84.3% by June 2019. Increased IPTp3 coverage from 9.4% in 2017 to 13.2% in 2018.

Challenges and Mitigation are outlined in the attached table.

Several Lessons were Learned from the interventions. On-the-job and malaria mentorship training are important components in improving malaria case management in refugee camps. Supportive supervision is mainly based on gaps identification, and mentorship is focused on hands-on skill and capacity-building. Regular supportive supervision, when correctly using the MSDQI Tool, improves malaria service provision.

Working in collaboration with other stakeholders to implement vector control, social and behavior change communication, and other interventions is important in the fight against malaria in refugee camps.

This presentation was made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of the USAID Boresha Afya and do not necessarily reflect the views of USAID or the United States government.

Refugees and Malaria

The 2019 Theme of World Refugee Day is #StepWithRefugees – Take A Step on World Refugee Day. Taking steps in solidarity with refugees ensures that one recognizes that refugees experience several health problems, with malaria being especially devastating. Refugees may come from a malaria endemic area and move to one where there is no malaria and health workers may not recognize and treat it correctly. In contrast they may move from a non-endemic area into one with malaria transmission. Even if refugees move from one malarious area to another, the conditions of the camps where they shelter may lead to increased malaria morbidity and mortality.

In fact, Jamie Anderson and colleagues observe that, “Almost two-thirds of refugees, internally displaced persons, returnees and other persons affected by humanitarian emergencies live in malaria endemic regions. Malaria remains a significant threat to the health of these populations.” They found that, “an average of 1.18 million refugees resided in 60 refugee sites within nine countries with at least 50 cases of malaria per 1000 refugees during the study period 2008-2009,” a major disease burden. According to the authors, groups like UNHCR and the UN Foundation’s Nothing But Nets aim to increase LLIN coverage of vulnerable groups in emergency situations.

The US Centers for Disease Control and Prevention offers guidance to health staff in the United States who may encounter refugees coming from a malaria endemic country. These guidelines look at appropriate treatment regimens for either pre-travel or on arrival presumptive treatment. They address the challenges of sub-clinical disease, as well as testing and treatment for people with symptoms. Likewise, the Refugee Technical Assistance Center stresses the need for, “All refugees from malaria endemic areas, including those who have been presumptively treated for P. falciparum, should be tested for malaria if they develop clinical signs or symptoms of the disease.” Stefan Collinet-Adler et al. found that “Overseas presumptive therapy has greater cost-benefits than U.S. based screening and treatment strategies.”

The challenge of refugees moving from one endemic country, such as Burundi, to another was highlighted by MSF staff in Tanzania. Saschveen Singh reported that she, “was well versed in the emergency management of these cases from my previous training and from reading all the MSF clinical guidelines. But it was quite overwhelming to see how many admissions we had on the wards, and to see the outpatient area absolutely overflowing with patients with malarious fevers, and the number of our Burundian staff succumbing to the disease. With malaria, the worst of the worst cases are sadly always children.”

A few years ago, the US President’s Malaria Initiative in Kenya contributed to indoor residual spraying at a refugee camp. “Malaria has also been a recurrent problem in Kakuma Refugee Camp, particularly following large-scale population influxes from South Sudan, where malaria is endemic. Both ITNs and IRS have been used historically for malaria prevention in the camp along with prompt, effective case management for persons diagnosed with malaria. With the pyrethroid donation from PMI-Kenya, NRC implemented a successful IRS program,” covering an estimated 143,000 people.

It is encouraging to note that many agencies, international and domestic, and not just those specializing in refugee needs, lend a hand guaranteeing that refugees have a right to basic malaria prevention and treatment.

Refugees and Malaria

June 20th is World Refugee Day.  The United Nations explains that, “Refugees are among the most vulnerable people in the world. The 1951 Refugee Convention and its 1967 Protocol help protect them.” This protection includes the right to public relief and assistance, and in that context the UN High Commission for Refugees aims to provide refugees with “clinics, schools and water wells for shelter inhabitants and gives them access to health care and psychosocial support during their exile.” Major physical health problems and symptoms of internally displaced persons in Sub-Saharan Africa included were fever/malaria among 85% of children and 48% of adults.

Many of today’s refugees are located in malaria endemic areas of the world, and movement from familiar areas to uncertainly increases refugees’ exposure to malaria. As the Roll Back Malaria Partnership noted, “exposure to malaria is significantly increased when moving from low- to high- transmission areas, because they have no acquired immunity and frequently little knowledge of malaria prevention or treatment.”

Efforts to prevent malaria among refugees who came from South Sudan in in Northern Uganda is crucial as they experience malaria as one of their major health problems. This led to the provision of intermittent preventive treatment for malaria (IPTc) in two refugee camps among children aged 6 months to 14 years through help from Médecins Sans Frontières.

In Australia guidelines for assessing needs for services for refugees include an emphasis on person-centred care and risk-based rather than universal screening for hepatitis C virus, malaria, schistosomiasis and sexually transmissible infections.” Based on country of origin “refugees and asylum seekers to Australia and includes country-specific recommendations for screening for malaria, schistosomiasis and hepatitis C.” This includes use of malaria Rapid Diagnostic tests.

Efforts to reach refugee populations with insecticide treated bednets can be a challenge.  Studies in a displaced persons camp in the Democratic Republic of the Congo found that there was lower access to nets by camp dwelling children than those in nearby settled villages. Considering the high burden of malaria in the area the authors recommended increased attention to net distribution for these internal refugees.

World Refugee Day is a time for people in malaria national control/elimination programs to take note of the refugee and displaced populations within their boundaries and step up efforts to protect everyone.