Category Archives: Seasonal Malaria Chemoprevention

Seasonal Malaria Chemoprevention: An Effective Intervention for Reducing Malaria Morbidity and Mortality

Moumouni Bonkoungou, Ousmane Badolo, Stanislas Nébié, Justin Tiendrebeogo, Mathurin Dodo, Thierry Ouedraogo, Youssouf Sawadogo, Danielle Burke, Bethany Arnold, William Brieger, and Gladys Tetteh of the USAID/Jhpiego Improving Malaria care Project and the Burkina Faso National Malaria Control Program presented implementation of the SMC program at the 2018 Annual Meeting of the American Society of Tropical Medicine and Hygiene as seen below.

Malaria remains a serious problem in Burkina Faso, a high burden country. Data from the 2016 Health Management Information System reports 9,852,097 malaria cases, and 4,440 malaria Deaths. Malaria accounts for 43.38% of Outpatient department visits, 44.63% of Hospitalizations and 21.84% Deaths. The burden of Malaria is highest during the months of July– October. During these months, malaria transmission is intense due to heavy rainfall and intensive biting behavior

Seasonal Malaria Chemoprevention (SMC) is the Intermittent administration of full treatment of antimalarial medicines to children under 5 (age 3-59 months) in areas of high seasonal transmission. It is an important malaria elimination strategy in the West African Sahel. Effective prevention intervention takes place where Malaria transmission is concentrated within a high transmission season. The bulk of clinical malaria cases (> 60%) occur during short rainy season over 4 months.

SMC Implementation started when Burkina Faso adopted SMC in 2013 as key part of National Malaria control strategy. SMC uses Sulfadoxine-pyrimethamine plus amodiaquine (SP+AQ). Four monthly doses are given to children 3?59 months old from July to October by community health workers and other volunteers.

The Improving Malaria Care (IMC) project is implemented by Jhpiego and funded by the U.S. President’s Malaria Initiative (PMI). IMC supports National Malaria Control Program (NMCP) to improve quality of malaria prevention, diagnosis and treatment. NMCP expanded SMC implementation to 7 districts in 2014 and then 59 districts in 2017.

Process of SMC Planning and Implementation in Boromo and Dano Districts in 2017 provides an example of how the program works. Treatment Coverage during the 2017 campaign treated 58,246 children in Boromo District and 50,007 children in Dano,  or 97.3% of target population. The attached flow chart shows the Process of SMC Planning and Implementation in Boromo and Dano Districts in 2017. Microplanning is an important component. Reviewing lessons learned was crucial for planning SMC in 2018.  The attached charts show a Reduction of Severe Malaria Cases in Boromo over the implementation period of SMC as well as a Reduction of Severe Malaria Cases in Dano.

These successes were or without challenges to SMC Scale-up in Burkina Faso. It is difficult access to some villages during the rainy season. Limiting SMC administration to children below 5 years of age makes some parents with older children unhappy, and they also demand the service. As of 2017 there was lack of resources to cover all districts.

In conclusion, the NMCP continues to scale up SMC to reach all eligible children with support of implementing partners/projects like IMC. Moving forward, the NMCP aims to increase efficiency of SMC campaigns, achieve effectiveness of intervention, mitigate known challenges, and anticipate new challenges.

Our partners recommend that to improve coverage, safety, efficacy and health impact we should strengthen interpersonal communication with communities, conduct independent monitoring, optimize coordination of partners’ interventions, and synchronize with neighboring countries.

Acknowledgments: US President’s Malaria Initiative, United States Agency for International Development, Burkina Faso Ministry of Health, National Malaria Control Program

Mapping to Integrate Filariasis and Onchocerciasis Control with Malaria Interventions

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

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

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

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

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

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

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

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

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

Ghana CHWs explain how they conduct MDA

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

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

Multilateral Initiative for Malaria: Posters Range from Prevention to Cost to E-Learning and Beyond

A major feature of all conferences are the poster sessions. These are often overlooked due to timing and placement. Fortunately at the recent 7th Multilateral Initiative for Malaria Conference in Dakar, tea breaks and lunch were made available in the poster tent ensuring more people came to view. Even so some people may have missed the valuable knowledge shared through this medium. We tweeted many of the posters during the event, but below are six posters in more detail.

These range from evaluating a malaria surveillance system to financing systems to sustain malaria drug supplies, including through community pharmacies. The potential of E-Learning for malaria capacity building was explored, and the process pf establishing a national malaria operations research agenda was presented. Several posters examined the seasonal malaria chemoprevention (SMC) program in the Sahel of West Africa including one from Mali as seen below.

Please contact the authors for additional information and updates. Readers who presented a poster at MIM are welcome to share their findings with us.