Category Archives: Refugee

Malaria News Today 2020-09-22: covering three continents

Today’s stories cover three continents including Surveillance for imported malaria in Sri Lanka, community perceptions in Colombia and Annual Fluctuations in Malaria Transmission Intensity in 5 sub-Saharan countries. In addition there is an overview of microscopy standards and an Integrated Macroeconomic Epidemiological Demographic Model to aid in planning malaria elimination. We also see how COVID-19 is disturbing Seasonal Malaria Chemoprevention activities in Burkina Faso. Read more by following the links in the sections below.

Will More of the Same Achieve Malaria Elimination?

Results from an Integrated Macroeconomic Epidemiological Demographic Model. Historic levels of funding have reduced the global burden of malaria in recent years. Questions remain, however, as to whether scaling up interventions, in parallel with economic growth, has made malaria elimination more likely today than previously. The consequences of “trying but failing” to eliminate malaria are also uncertain. Reduced malaria exposure decreases the acquisition of semi-immunity during childhood, a necessary phase of the immunological transition that occurs on the pathway to malaria elimination. During this transitional period, the risk of malaria resurgence increases as proportionately more individuals across all age-groups are less able to manage infections by immune response alone. We developed a robust model that integrates the effects of malaria transmission, demography, and macroeconomics in the context of Plasmodium falciparum malaria within a hyperendemic environment.

The authors analyzed the potential for existing interventions, alongside economic development, to achieve malaria elimination. Simulation results indicate that a 2% increase in future economic growth will increase the US$5.1 billion cumulative economic burden of malaria in Ghana to US$7.2 billion, although increasing regional insecticide-treated net coverage rates by 25% will lower malaria reproduction numbers by just 9%, reduce population-wide morbidity by ?0.1%, and reduce prevalence from 54% to 46% by 2034. As scaling up current malaria control tools, combined with economic growth, will be insufficient to interrupt malaria transmission in Ghana, high levels of malaria control should be maintained and investment in research and development should be increased to maintain the gains of the past decade and to minimize the risk of resurgence, as transmission drops. © The American Society of Tropical Medicine and Hygiene [open-access]

Microscopy standards to harmonise methods for malaria clinical research studies

Research Malaria Microscopy Standards (ReMMS) applicable to malaria clinical research studies have been published in Malaria Journal. The paper describes the rationale for proposed standards to prepare, stain and examine blood films for malaria parasites. The standards complement the methods manual(link is external) previously published by the World Health Organization and UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR). The standards aim to promote consistency and comparability of data from microscopy performed for malaria research and hence to strengthen evidence for improvements in malaria prevention, diagnostics and treatment.

Microscopy is important in both malaria diagnosis and research. It is used to differentiate between Plasmodium species and stages and to estimate parasite density in the blood – an important determinant of the severity of disease. It is also used to monitor the effectiveness of drugs based on the rate at which parasites recrudesce or are cleared from the blood.

While rapid diagnostic tests have replaced microscopy in some contexts, microscopy remains an essential tool to support clinical diagnosis and research. The standardisation of methods allows direct comparisons from studies conducted across different points in time and location. This facilitates individual participant data meta-analyses, recognised as the gold standard approach to generate evidence for improvements in interventions and hence patient outcomes.

Estimating Annual Fluctuations in Malaria Transmission Intensity and in the Use of Malaria Control Interventions in Five Sub-Saharan African Countries

RTS,S/AS01E malaria vaccine safety, effectiveness, and impact will be assessed in pre- and post-vaccine introduction studies, comparing the occurrence of malaria cases and adverse events in vaccinated versus unvaccinated children. Because those comparisons may be confounded by potential year-to-year fluctuations in malaria transmission intensity and malaria control intervention usage, the latter should be carefully monitored to adequately adjust the analyses. This observational cross-sectional study is assessing Plasmodium falciparum parasite prevalence (PfPR) and malaria control intervention usage over nine annual surveys performed at peak parasite transmission. Plasmodium falciparum parasite prevalence was measured by microscopy and nucleic acid amplification test (quantitative PCR) in parallel in all participants, and defined as the proportion of infected participants among participants tested. Results of surveys 1 (S1) and 2 (S2), conducted in five sub-Saharan African countries, including some participating in the Malaria Vaccine Implementation Programme (MVIP), are reported herein; 4,208 and 4,199 children were, respectively, included in the analyses.

Plasmodium falciparum parasite prevalence estimated using microscopy varied between study sites in both surveys, with the lowest prevalence in Senegalese sites and the highest in Burkina Faso. In sites located in the MVIP areas (Kintampo and Kombewa), PfPR in children aged 6 months to 4 years ranged from 24.8% to 27.3%, depending on the study site and the survey. Overall, 89.5% and 86.4% of children used a bednet in S1 and S2, of whom 68.7% and 77.9% used impregnated bednets. No major difference was observed between the two surveys in terms of PfPR or use of malaria control interventions. © The American Society of Tropical Medicine and Hygiene [open-access]

Community perception of malaria in a vulnerable municipality in the Colombian Pacific

Malaria primarily affects populations living in poor socioeconomic conditions, with limited access to basic services, deteriorating environmental conditions, and barriers to accessing health services. Control programmes are designed without participation from the communities involved, ignoring local knowledge and sociopolitical and cultural dynamics surrounding their main health problems, which implies imposing decontextualized control measures that reduce coverage and the impact of interventions. The objective of this study was to determine the community perception of malaria in the municipality of Olaya Herrera in the Colombian Pacific.

A 41-question survey on knowledge, attitudes, and practices (KAP) related to malaria, the perception of actions by the Department of Health, and access to the health services network was conducted. In spite of the knowledge about malaria and the efforts of the Department of Health to prevent it, the community actions do not seem to be consistent with this knowledge, as the number of cases of malaria is still high in the area.

Use of a Plasmodium vivax genetic barcode for genomic surveillance and parasite tracking in Sri Lanka

Sri Lanka was certified as a malaria-free nation in 2016; however, imported malaria cases continue to be reported. Evidence-based information on the genetic structure/diversity of the parasite populations is useful to understand the population history, assess the trends in transmission patterns, as well as to predict threatening phenotypes that may be introduced and spread in parasite populations disrupting elimination programmes. This study used a previously developed Plasmodium vivax single nucleotide polymorphism (SNP) barcode to evaluate the population dynamics of P. vivax parasite isolates from Sri Lanka and to assess the ability of the SNP barcode for tracking the parasites to its origin.

A total of 51 P. vivax samples collected during 2005–2011, mainly from three provinces of the country, were genotyped for 40 previously identified P. vivax SNPs using a high-resolution melting (HRM), single-nucleotide barcode method. The proportion of multi-clone infections was significantly higher in isolates collected during an infection outbreak in year 2007. Plasmodium vivax parasite isolates collected during a disease outbreak in year 2007 were more genetically diverse compared to those collected from other years. In-silico analysis using the 40 SNP barcode is a useful tool to track the origin of an isolate of uncertain origin, especially to differentiate indigenous from imported cases. However, an extended barcode with more SNPs may be needed to distinguish highly clonal populations within the country.

Coronavirus rumours and regulations mar Burkina Faso’s malaria fight

By Sam Mednick, Thomson Reuters Foundation: MOAGA, Burkina Faso – Health worker Estelle Sanon would hold the 18-month-old and administer the SMC dose herself, but because of coronavirus she has to keep a distance from her patients. “If I am standing and watching the mother do it, it’s as if I’m not doing my work,” said Sanon, a community health volunteer assisting in a seasonal campaign to protect children in the West African country from the deadly mosquito-borne disease.

Burkina Faso is one of the 10 worst malaria-affected nations in the world, accounting for 3% of the estimated 405,000 malaria deaths globally in 2018, according to the World Health Organization (WHO). More than two-thirds of victims are children under five. Now there are fears malaria cases could rise in Burkina Faso as restrictions due to coronavirus slow down a mass treatment campaign and rumours over the virus causing parents to hide their children, according to health workers and aid officials.

“COVID-19 has the potential to worsen Burkina Faso’s malaria burden,” said Donald Brooks, head of the U.S. aid group Initiative: Eau, who has worked on several public health campaigns in the country.  “If preventative campaigns can’t be thoroughly carried out and if people are too scared to come to health centres … it could certainly increase the number of severe cases and the risk of poor outcomes.”

During peak malaria season, from July to November, community health workers deploy across Burkina Faso to treat children with seasonal malaria chemoprevention (SMC). This is the second year the campaign will cover the whole country with more than 50,000 volunteers going door-to-door, said Gauthier Tougri, coordinator for the country’s anti-malaria programme. Logistics were already challenging. Violence linked to jihadists and local militias has forced more than one million people to flee their homes, shuttered health clinics and made large swathes of land inaccessible. Now the coronavirus has made the task even harder, health workers said.

People in Cape Verde evolved better malaria resistance in 550 years

Yes, we are still evolving. And one of the strongest examples of recent evolution in people has been found on the Cape Verde islands in the Atlantic, where a gene variant conferring a form of malaria resistance has become more common.

Portuguese voyagers settled the uninhabited islands in 1462, bringing slaves from Africa with them. Most of the archipelago’s half a million inhabitants are descended from these peoples. Most people of West African origin have a variant in a gene called DARC that protects.

Deadly malaria and cholera outbreaks grow amongst refugees as COVID pandemic strains health systems.

Apart from the strain on health facilities during the pandemic, in some countries such as Somalia, Kenya and Sierra Leone, we are seeing that a fear of exposure to COVID-19 has prevented parents from taking their children to hospital, delaying diagnosis and treatment of malaria and increasing preventable deaths. COVID restrictions in some countries have also meant pregnant women have missed antimalarial drugs. Untreated malaria in pregnant women can increase the risk of anaemia, premature births, low birth weight and infant death. According to the World Health Organization (WHO), 80% of programs designed to fight HIV, tuberculosis and malaria have been disrupted due to the pandemic and 46% of 68 countries report experiencing disruptions in the treatment and diagnosis of malaria.

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.