Category Archives: Surveillance

Establishing Mobile Outreach Teams (MOTs) for strengthening Active Case Detection with Mobile Populations in Vietnam 2016-2020

Mobile migrant populations present a special challenge for malaria control and elimination efforts. Nguyen Ha Nam and colleagues* (Nguyen Xuan Thang, Gary Dahl, James O’Donnell, Vashti Irani, Sara Canavati, Jack Richards, Ngo Duc Thang, and Tran Thanh Duong) presented their study of this group at the recent Malaria World Congress. They are also sharing what they learned below.

Mobile Migrant Populations (MMPs) are a key population for containing the spread of malaria in the border areas between Cambodia and Vietnam. The number of imported cases in Viet Nam in 2017. 12,5% of such cases caught in Binh Phuoc and Dak Nong provinces and all of them came from Cambodia. The provinces bordering Cambodia and Vietnam have been had the highest malaria transmission intensity. This borders are frequented by MMPs who have proven difficult to target for surveillance and malaria control activities.

Mobile Outreach Teams (MOTs) provide a potential approach to target malaria elimination activities for MMPs who may not be strongly supported by the regular village-based and clinic-based health services. This work describes the implementation of MOTs in Binh Phuoc and Dak Nong Provinces, which are high-risk regions along the Viet Nam-Cambodia border. These activities were conducted as part of the Regional Artemisinin-resistance Initiative (RAI) in 2017. Each MOT was comprised of 2 Commune Health Staff and 1 Village Health Worker (VHW) from the village nearest to the outreach area.

In the first phase of the pilot, 3 communes of 2 districts in Binh Phuoc and 2 communes of 1 district in Dak Nong with highest malaria cases reported from NIMPE are selected as targeted areas. The Objectives were to …

  • Design/tailor Mobile Outreach Information Education and Communication/Behaviour change communication (BCC/ IEC) Toolkit
  • Intensify case detection and quality management by increasing the coverage of diagnostics and treatment for hard to reach populations
  • Strengthen outreach to high-risk and under-served populations through MOT scouting activities to locate unreached Mobile Communities and map their locations
  • Link MMPs with health facilities and Village Health Workers

All MOT members were provided with smartphones and were trained on how to use the EpiCollect5 app to track malaria cases, record mapping information and upload real-time reports of these malaria cases. MOTs conducted 5-day outreach activities every month. These activities began with scouting out locations of the MMP communities.

Once located, the MOTs geo-tagged the location of the community, conducted a short epidemiological survey on the community and screened for malaria using Rapid Diagnostic Tests and blood smear microscopy. Active malaria cases were provided with treatment according to the National guidelines, and Long Lasting Insecticidal Nets were distributed based on results of diagnosis and the survey.

This action has led to increased diagnosis and treatment of hard to reach MMPs with increased access by those communities to malaria services. Improved understanding and increased use of malaria prevention practices hard to reach MMP communities/households. Mapped of previously unreached MMP Communities and unofficial border crossing points with malaria transmission hotspots and highly frequented crossing identified. The number of MMPs were monitored by MOTs were 2,699 accounting for 5.18% of the population in the project sites (2,699/52,095).

These screened MMPs were almost located along the border among project communes in Bu Gia Map National Forest where have a lot of unofficial border crossers, timber camp communities, and other revolving communities. 1,977 targeted people were tested for malaria. This number was achieved 73.25% of mobile migrant people (1,977/2,699). This work highlights how MOTs can target the previously unreached populations of MMPs to strengthen malaria surveillance and active case responses to reduce malaria transmission in Viet Nam.

A system of real-time data collection of malaria cases from VHWs and MOTs using mobile phone uploads was established. Border screening and tracking hard to reach communities is a useful approach to implement to identify imported cases; however, it is labor-intensive, and misses subjects crossing at unofficial borders due to limited working time of MOTs (5 days a month).

Positive cases in Binh Phuoc province are maintained for keeping track after receiving treatment due to no confirmed cases detected in targeted communes in Dak Ngo province, though these communes mainly have numerous transient timber camps moving in deep forests, and highly mobile border-crossers moving between regions and countries frequently. Future work will combine routine support from District health staff and expand the role of VHWs with motorbike provision for each MOT in order to not only to improve their quality outreach activities but also develop stronger Active Case Detection in the next phase of the project.

*Team members represent the National Institute of Malariology, Parasitology and Entomology, Hanoi, Viet Nam; Health Poverty Action, London, UK; and the Burnet Institute, Melbourne, Australia.

References

  • Kheang ST, Lin MA, et al. Malaria Case Detection Among Mobile Populations and Migrant Workers in Myanmar: Comparison of 3 Service Delivery Approaches. 2018
  • Shannon Takala-Harrison,a Christopher G. Jacob, et al. Independent Emergence of Artemisinin Resistance Mutations Among Plasmodium falciparum in Southeast Asia. 2014.
  • Imwong M, Hien TT, et al. Spread of a single multidrug resistant malaria parasite lineage (PfPailin) to Vietnam. 2017.
  • Richard J Maude,corresponding author Chea Nguon, et al. Spatial and temporal epidemiology of clinical malaria in Cambodia 2004–2013. 2014.
  • Imwong M, Nguyen TN, et al.The epidemiology of subclinical malaria infections in South-East Asia: findings from cross-sectional surveys in Thailand–Myanmar border areas, Cambodia, and Vietnam. 2015.
  • Hannah Edwards, Sara E. Canavati, et al. Novel Cross-Border Approaches to Optimise Identification of Asymptomatic and Artemisinin-Resistant Plasmodium Infection in Mobile Populations Crossing Cambodian Borders. 2015.

Pilot Mapping, Real Time Reporting and Responding in High Risk Malaria Areas of Viet Nam

Viet Nam is among the Asia-Pacific countries focusing on eliminating malaria. Mapping helps target malaria interventions. Nguyen Xuan Thang and colleagues (James O’Donnell, Vashti Irani, Leanna Surrao, Ricardo Ataide, Josh Tram, An Le, Sara Canavati, Tran Thanh Duong, Tran Quoc Tuy, Gary Dahl, Gerard Kelly, Jack Richards, Ngo Duc Thang) presented their pilot mapping efforts at the Malaria World Congress in Melbourne recently and below share their experiences with us.

Viet Nam is focused on eliminating malaria by 2030. Viet Nam saw a 73% reduction in cases between 2013 and 2017 (NIMPE data), yet border provinces still have a high burden of malaria. However, some provinces still have a high burden of malaria. To achieve malaria elimination, it is essential to deploy targeted interventions in these locations.

Spatial Decision Support Systems (SDSS) can be used by National Malaria programs to integrate geographic elements in the management of malaria cases and facilitate targeted malaria interventions in these high-risk settings.

The objective of this work was to pilot a SDSS system for Binh Phuoc and Dak Nong Provinces in Viet Nam to facilitate ongoing surveillance and targeted malaria, as part of the Regional Artemisinin-resistance Initiative (RAI). This objective was achieved by:

  • Collecting data with cell phones

    Collecting baseline GIS data at household level and environmental characteristics associated with the area;

  • Establishing a routine data collection system that will be reported by mobile medical staff by mobile phone;
  • Integrating this data to form a spatial decision support system (SDSS);
  • Using the SDSS system for direct reporting to malaria control programs that provided strategic solutions for the prevention of disease spread and the elimination of malaria

Sample cell phone data screens

In Phase 1, a household and mapping survey was conducted in collaboration with commune, district and village health workers. Epicollect5 software was used on smartphones with GPS functionality to record mapping information (latitude and longitude) and general information on household members. During Phase 1, 10,506 households were surveyed and data was aggregated in a custom Geographic Information System (GIS) database.

The majority of the surveyed individuals were of the Kinh ethnicity (19,282; 35.4%), followed by M’Nong (4,669; 8.6%) and Mong (3,359; 6.2%). Data related to malaria among mobile populations were included in the GIS as a means to identify and describe groups at high risk for malaria e.g. forest-goers. The survey data were reviewed, cleaned and matched using the ID numbers, then aggregated with relevant administrative boundary data and linked on ArcGIS 10.2 software. This database is located in a custom GIS system and can be visualized as a spatial transmission model to support appropriate decision-making

Dots representing households

Phase 2 focused on ongoing surveillance with rapid case reporting and responses. Malaria cases diagnosed at public and local health facilities were entered into the system by Commune Health Officials. Village Health Workers were immediately notified and went to the patient’s home to undertake case investigation including further household mapping and active case detection activities. The Viet Nam National Institute of Malariology was also notified, and organized local officials to carry out an investigation into the sources of transmission (i.e. ‘hotspots’) and to implement timely interventions.

Dots representing cases

When the cases were identified, Village Health Workers went to the patient’s home to undertake operational procedures including geographic exploration, household mapping to identify the location and to identify the list of affected households. They also collected this data on EpiCollect5. Collated information on cases, transmission point, zoning of the target villages allowed for early detection of malaria outbreaks. The National Institute of Malariology can also issue guidelines when the hotspots are identified and when disease outbreaks occur

These activities are ongoing. In conclusion, a custom GIS database was developed using a household survey in Binh Phuoc and Dak Nong province of Viet Nam. Malaria cases were mapped to identify hotspots of malaria transmission and enable further active case detection and targeted interventions. This established GIS database aims to support routine case notification and to enhance the role of surveillance for active case detection and responses to achieve malaria elimination.

The authors are affiliated with the National Institute of Malariology, Parasitology, Entomology (NIMPE), Viet Nam; Burnet Institute, Australia; and Health Poverty Action, UK. Contact: xuanthang.nimpe@gmail.com

Global Civil Society for Malaria Elimination (CS4ME)

CS4ME was created during the Global Malaria Civil Society Strategising and Advocacy Pre-Meeting jointly convened by the Global Fund Advocates Network Asia-Pacific (GFAN AP) and APCASO held on 29th and 30th June 2018, prior to the First Malaria Wor1d Congress in Melbourne, Australia, with the support of the Malaria World Congress, Global Fund to Fight AIDS, Tuberculosis and Malaria, and the Burnet Institute. An interim working group mode up of individuals that attended the Pre-Meeting was established to coordinate, recommend processes and mechanisms, identify resources and support necessary for CS4ME going forward.  For more Information please contact Ms Olivia Ngou Zongue <ngouolivia@gmail.com> of the Interim Working Group of CS4ME for further information. The Declaration arising from their meeting if provided below.

GLOBAL CIVIL SOCIETY FOR MALARIA ELIMINATION (CS4ME) DECLARATION
MALARIA WORLD CONGRESS 1ST-5TH JULY 2018
MELBOURNE, AUSTRALIA

Firm in the belief that empowered community and civil society are game-changers in health responses,  we, representatives of national, regional and global malaria communities and civil society attending the First Malaria World Congress, have come together and formed the Global Civil Society for Malaria Elimination (CS4ME) as part of our commitment to joint advocacy for more effective, sustainable, people-centred, rights-based, equitable, and inclusive malaria programmes and Interventions.

At a time when the world has the resources and tools to prevent and treat malaria, it is unconscionable how people – mainly from impoverished, vulnerable and underserved communities – continue to die from the disease. While we commend the efforts of governments and the international community that brought the world closer to malaria elimination, we call for greater accountability, political will and action, resource investments, and sense of urgency to eliminate the disease.

CS4ME makes the following call to the governments of implementing countries, donor countries and other duty bearers:

FRAME MALARIA RESPONSES IN THE CONTEXT Of SOCIAL JUSTICE AND HUMAN RIGHTS, AND WITHIN UNIVERSAL HEALTH COVERAGE

Significant progress has been attained during the past 10 years to reduce the burden of malaria throughout the world and in working towards achieving malaria elimination. As countries enter into the elimination phase, we see again and again the epidemic concentrating among the most marginalised, remote, and disenfranchised communities. In South East Asia, the concentration of malaria among communities barred from accessing quality and affordable health services has accelerated the emergence of drug resistance that now threatens the wor1d at large. Everywhere, the last mile of elimination becomes a matter of access to health for impoverished and marginalised communities, in particular, refugees, ethnic minorities, indigenous communities, migrant and mobile populations – with many of the risks faced by these groups compounded further amongst women and girls.

Including the most local, represents a strategic investment contributing to appropriate, effective service delivery and people-driven surveillance and response.
We call on national governments, international institutions, bilateral and multilateral donors to prioritise and increase funding allocations for community-driven community and civil society initiatives. We request that specific funding streams be made available to community groups, and their access supported through peer-to-peer technical assistance.

Furthermore, we request that key performance indicators that enable accountability for bringing malaria services to the underserved be developed and implemented.

PARTNER WITH CIVIL SOCIETY AND COMMUNITY ACTORS FOR AN EFFECTIVE MALARIA SURVEILLANCE AND RESPONSE

As surveillance becomes an essential pillar for malaria elimination, the need for timely and robust data is increasingly critical. Essential evidence includes routine data, qualitative and quantitative research, as well as experience, lessons learned and the voices from affected communities. Support is required to build the ability of civil society to generate evidence, as well as to communicate it effectively to ensure that community-generated evidence will be able to influence decisions and result in sustained change.
To eliminate malaria, surveillance requires a response. Communities and civil society are the first responders, and will have the clearest insight Into what responses are effective in their context or on behalf of their constituents.

We demand that communities and civil society organisations be given equitable access to data and other information that can inform field-level response. We call for transparent information systems and multi-directional information flows in order to enable dialogue, and inform decisions at all levels. We urge the building up of surveillance systems that involve communities as analysts, advisors, decision-makers and responders.

We, malaria communities and civil society, offer our support, expertise, and lived experiences In contributing towards our shared vision of malaria elimination. We are fully committed to working alongside other stakeholders to build stronger, more inclusive and effective partnerships and sustainable responses towards elimination of malaria in this lifetime.

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.

 

Malaria Should Lead to Compassion, Not Hate

In August 2017 the ‘Almost Impossible’ happened decades after the last of local malaria transmission stopped in Italy. NPR shared news from the Italian newspaper Corriere della Sera that, “A 4-year-old girl has died of malaria in Italy, where the disease is thought to have been wiped out. Troubled health officials are looking for answers.” By coincidence, two children from an African nation were being treated for malaria in the same hospital where the deceased was being treated for diabetes. No epidemiological link could be found.

World Malaria Report: http://www.who.int/malaria/publications/world-malaria-report-2017/en/

Unfortunately that has not stopped anti-immigrant politicians from using the incident to foster hatred.  The political party of a “far-right extremist who wounded 6 African immigrants in a racially motivated shooting rampage in central Italy,” blamed the death of the child mentioned above “from malaria on migrants who ‘bring back to Europe’ once, eradicated illnesses.”

A new article in Malaria Journal reports that even though, “Malaria is no longer endemic in Italy since 1970 when the World Health Organization declared Italy malaria-free, … it is now the most commonly imported disease.”  The study from Parma, Italy reports that, “Of the 288 patients with suspected malaria, 87 were positive by microscopy: 73 P. falciparum, 2 P. vivax, 8 P. ovale, 1 P. vivax/P. ovale, 1 P. malariae and 2 Plasmodium sp. All samples were positive by ICT except 6. ”

Malaria can travel with anyone who has been in an endemic area, whether migrant,  tourist or business person. The likelihood of malaria re-establishing itself in currently non-endemic areas is low, but there is of course value in maintaining epidemiological and entomological surveillance world-wide in the current drive to eradicate the disease.

The identification of malaria anywhere in the world should be cause for concern and compassion, not hate and exclusion.

African Leaders Malaria Alliance Recognizes Country Achievements, Adds NTDs to its Scorecard

The 30th African Union (AU) Heads of State Summit at its headquarters in Addis Ababa, Ethiopia provided an important opportunity to bring the challenges of infectious diseases on the continent to the forefront. Led by the African Leaders Malaria Alliance (ALMA), two major activities occurred, raising greater awareness and commitment to fighting neglected tropical diseases (NTDs) and recognizing the contributions countries have made in the fight against malaria.

For many years ALMA has maintained Scorecard for Accountability and Action by monitoring country progress on key malaria interventions. It later added key maternal and child health indicators.  At the AU Summit ALMA announced that NTD indicators would be added to the scorecards which are reported by country and in summary.

The scorecard will now “report progress for the 47 NTD-affected countries in sub-Saharan Africa in their strategies to treat and prevent the five most common NTDs: lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted helminths and trachoma. By adding NTDs to the scorecard, African leaders are making a public commitment to hold themselves accountable for progress on these diseases.”

In the press release Joy Phumaphi, Executive Secretary ofALMA, explained that, “Malaria and NTDs both lay their heaviest burden on the poor, rural and marginalised. They also share solutions, from vector control to community-based treatment. Adding NTDs to our scorecard will help give leaders the information they need to end the cycle of poverty and reach everyone, everywhere with needed health care.” This will be an opportunity to demonstrate, for example, that, “In 2016, 40 million more people were reached with preventive treatment for at least one NTD than the year before.”

The combination is based on the logic that NTDs and malaria are both diseases of poverty. Malaria and several NTDs are also vector-borne. Also community platforms are a foundation for delivering needed drugs and supplies to tackle these diseases. Ultimately the decision shows that Heads of State are holding themselves accountable for progress in eliminating these diseases.

At a malaria-focused side meeting of the AU Summit Dr. Kebede Worku (Ethiopia’s State Minister of Health) shared that his government has been mobilizing large amount of resources to the fight against malaria which has led to the shrinking of morbidity and mortality since 2005. He also stressed that Africans should be committed to eliminate malaria by the year 2030. “Failing to do so is to repeat the great failure of 1960s faced at the global malaria fighting.”

The highlight for the malaria community at the Summit was the recognition of six countries that have made exemplary progress in the past year. The 6 countries that are leading the way to a Malaria-Free Africa by 2030 are Algeria, Comoros, Madagascar, the Gambia, Senegal, and Zimbabwe, recognized by ALMA for their sharp decline in malaria cases. Madagascar, the Gambia, Senegal and Zimbabwe Reduced malaria cases by more than 20 percent from 2015 to 2016. Algeria and Comoros are on track to achieve a more than 40 percent drop in cases by 2020.

H.E . Dr. Barnabas Sibusiso Dlamini, the Prime Minister of the Kingdom of Swaziland, whose King and Head of State is the current chair of ALMA, warned all endemic countries that, “When we take our eyes off malaria, the cost for our countries is huge. Yet if we increase our efforts to control and eventually eliminate malaria, the yield we get from it is tremendous. It is time that we dig deep into our pockets and provide malaria programmes with the needed resources.”

Mentioning the need for resources raises a flag that calls on us to be a bit more circumspect about progress. IRINNews notes that this is a critical time in the fight against malaria, when threatened funding cuts could tip the balance in an already precarious struggle. IRIN takes the example of Zambia to raise caution. They report that the results of malaria control and the government efforts have been uneven. While parasite prevalence among small children is down almost by half in some areas, many parts of the country have seen increases in prevalence

IRIN concludes that, “For now, the biggest challenge for Zambia will be closing the gap in its malaria elimination strategy, which will cost around $160 million a year and is currently only about 50 percent funded – two thirds from international donors and one third from the Zambian government. Privately, international donors say the government must spend more money on its malaria programme if it is to succeed.” Cross-border transmission adds to the problem.

Internal strife is another challenge to malaria success. “The recent nurses’ strike which lasted for five months may have cost Kenya a continental award in reducing the prevalence of malaria during the 30th African Union Summit in Ethiopia on Sunday.” John Muchangi in the Star also noted that, “However, Kenya lost momentum last year and a major malaria outbreak during the prolonged nurses’ strike killed more than 30 people within two weeks in October.”

Finally changes in epidemiology threaten efforts to eliminate malaria in Africa. Nkumana, et al. explain that, “Although the burden of Plasmodium falciparum malaria is gradually declining in many parts of Africa, it is characterized by spatial and temporal variability that presents new and evolving challenges for malaria control programs. Reductions in the malaria burden need to be sustained in the face of changing epidemiology whilst simultaneously tackling significant pockets of sustained or increasing transmission. Many countries like Zambia thus face both a financial and an epidemiological challenge.

Fortunately ALMA is equipped with the monitoring and advocacy tools to ensure that its members recognize and respond to such challenges. The Scorecards will keep the fight against the infectious diseases of poverty on track.

Comprehensive Cholera Prevention and Control: Lessons Learnt from the United Republic of Tanzania

Dafrossa Lyimo of the Ministry of Health, Tanzania presented Tanzania’s experience in preventing and controlling cholera at the 4th African Regional Immunization Technical Advisory Group (RITAG) meeting in Johannesburg, 5-8 December 2017. Those experiences are summarized below.

Cholera outbreak in Tanzania started with the index case detected in Dar es Salaam Region on 6 August 2015. The World Health Organization was notified by Ministry of Health on 15 August 2015. By 31 December 2015 the outbreak spread to 22 out of 26 regions in Tanzania Mainland. Zanzibar started reporting cholera cases on 20 September 2015 from Urban West District in Unguja Island. By December 2015, the outbreak spread to all 10 districts of Pemba and Unguja.

Cumulative cases on the Tanzania Mainland were 12 619 cases with 199 deaths (CFR 1.57%) in 2015, 11 360 cases with 172 deaths (CFR 1.5%) in 2016, and up through Nov 2017, 3 615 cases with 61 deaths (CFR 1.7%). Likewise the Cumulative cases in Zanzibar were 1 143 cases with 15 deaths (1.31%) in 2015, 3 187 cases with 53 deaths (CFR 1.66%) in 2016 and as of Nov 2017, 358 cases with 4 deaths (CFR 1.12%). The last case reported 11 July 2017

Best practices for controlling cholera in the country fall in four domains. In the area od Coordination Tanzania established a Public Health Emergency Operations Centre (PHEOC) in the Ministry of Health. To support this the Ministry appointed an Incident Manager, Deputy Incident Manager, and a PHEOC Manager for the cholera outbreak response. The National Task force Team was established with a wider composition which meeting every Friday discussing issues and giving way forward. National Rapid Response Teams were trained. these teams worked based on national response guidelines which were developed and distributed to all districts.

In the domain of Surveillance, the Ministry initiated a Daily Situation Report (SITREP) for sharing a daily cholera status in the regions and districts , on going interventions and gaps. This group conducted twice a country wide data validation/verification of the reported cases in 17 regions, which also confirmed under-reporting of cases. A Cholera reporting line list register was designed and printed in booklets and distributed to 26 regions in the Tanzania Mainland, to standardize reporting from districts and regions.

The third domain consisted of Water Sanitation and Hygiene interventions. The country distributed 21,600,000 aqua tablets of water guards in 514,285 households. Also distributed were 50 drums 45kg each of 70% High Test Hypochlorite to 83 district water authorities for bulk chlorination. Twenty hand pump boreholes were installed in hotspot villages of Mara and Mwanza regions, thereby Improving the access to clean and safe water. One hundred HACH chlorine testers were distributed for monitoring free residue chlorine in cholera reporting districts.

Social Mobilization was the fourth domain. Cholera leaflets and fliers were designed and distributed in reporting districts. Cholera messages were developed and aired through community media and mobile phone messaging. Community engagement and owning cholera interventions was undertaken using the community social networks and peer groups who focused on Hand washing, Use of treated water, and Use of toilets behaviors.

Cholera control and prevention efforts addressed various Challenges
in Tanzania. one concern was a weak surveillance system starting at the district level in several districts. Lack of reporting cholera cases, under-reporting and late reporting occurred. In some districts that had laboratory capacity, only positive cases were reported, but generally there was inadequate laboratory capacity to test and confirm Vibrio. This meant that samples had to be transported to regional laboratories (long turn around time)

A second challenge was Weak coordination at the region and District level. A third was Inadequate and poor access to WASH. this included a Limited supply of clean and safe piped water in most of districts. Thus 52% of rural population get water from unimproved sources. (Shallow wells, river, lakes and few deep wells). In urban settings, water utilities can supply water not more than 50% and still chlorination is not regularly done. there was low latrine coverage especially in rural areas. About 73% of rural population use unimproved latrines and 13% with no latrines. A fourth challenge was the Misconceptions about cholera causation and some of the interventions.

In the process of addressing these challenges several Lesson were learnt. First, a well established surveillance system helped to in the early notification of cases and quick response. Strong coordination at all level of response is important to ensure the control of outbreak is done on time. Effective social mobilization and community engagement helped in the behaviour change towards the control of cholera. Finally Adequate and good access to WASH ensured the control of spread of cholera

Tanzania has put together a comprehensive cholera prevention program based on surveillance, coordination, water & sanitation and social mobilization. While cases have reduced, Tanzania is not relenting in implementing these key interventions.

The Forest through the Trees: Themes in Social Production of Health

Recently Professor Ayodele S Jegede of the Faculty of Social Sciences, delivered the 419th Inaugural Lecture at the University of Ibadan, Ibadan, Nigeria, during the 2016/2017 academic session.  Below Prof. Jegede shares an abstract of his lecture.

Prof Ayodele S Jegede

Knowledge of individual actor’s behaviour is a reflection of the society as tree to the forest. As forest produces large quantities of oxygen and takes in carbon dioxide, society produces the needed resources for human beings to survive through culture. This inter-dependence between man and the environment is summarised by the Yoruba adage which says: “irorun igi ni irorun eye” (meaning: a bird’s peace depends on the peace enjoyed by the tree which harbours it).

Nigeria, a country with a population of about 187 million and a life expectancy of 53 years, 54% of the populace are living below the poverty line with limited access to health care services physically and economically. Although universal health coverage is vital to the achievement of the Sustainable Development Goals (SDGs) cultural perception of disease aside from loss of economic and low purchasing power makes people to attribute their illnesses to spiritual cause and therefore seek alternative health care services. This influences resistance to public health interventions in some African communities resulting in suspicion and distrust between health educators and the public.

Strengthening Health Information Systems

For instance, response to childhood immunizable diseases, mental illness, malaria and HIV/AIDS reported in this lecture was driven by how people define the diseases. Their response did result in delay in seeking modern health care until alternative care sources proved ineffective. This confirms W.I. Thomas (1929: 572) postulation that, “If men define situations as real, they are real in their consequences”.

Our stakeholders’ engagement interventions strategies strengthened by knowledge of how people construct their life, socially and culturally, proved to be a potent vaccine for preventing strain relationship between health workers and clients. Since society consists of individuals who constitute the stakeholders conducting health researches as well as management of epidemics and treatment during epidemics and disease episodes require appropriate ethical behaviours.

This suggests that adequate knowledge of the society is inevitable since a tree does not make a forest which confirms Marx Weber’s Action Theory postulation that an act does not become social unless it involves two or more persons. It is, therefore, that government should establish National Disease Observatory System (NDOS) to document diseases by type, location and related local practices for training health care professionals, clinical practice and emergencies preparedness.

Note also that the lecture was featured in the New Nigerian Newspaper with an emphasis on establishing a national disease observatory.  The Nigerian Tribune also featured the lecture stressing the importance of disease emergency preparedness.

Population Health: Malaria, Monkeys and Mosquitoes

On World Population Day (July 11) one often thinks of family planning. A wider view was proposed by resolution 45/216 of December 1990, of the United Nations General Assembly which encouraged observance of “World Population Day to enhance awareness of population issues, including their relations to the environment and development.”

A relationship still exists between family planning and malaria via preventing pregnancies in malaria endemic areas where the disease leads to anemia, death, low birth weight and stillbirth. Other population issues such as migration/mobility, border movement, and conflict/displacement influence exposure of populations to malaria, NTDs and their risks. Environmental concerns such as land/forest degradation, occupational exposure, population expansion (even into areas where populations of monkeys, bats or other sources of zoonotic disease transmission live), and climate warming in areas without prior malaria transmission expose more populations to mosquitoes and malaria.

Ultimately the goal of eliminating malaria needs a population based focus. The recent WHO malaria elimination strategic guidance encourages examination of factors in defined population units that influence transmission or control.

Today public health advocates are using the term population health more. The University of Wisconsin Department of Population Health Sciences in its blog explained that “Population health is defined as the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” World Population Day is a good time to consider how the transmission or prevention of malaria, or even neglected tropical diseases, is distributed in our countries, and which groups and communities within that population are most vulnerable.

World Population Day has room to consider many issues related to the health of populations whether it be reproductive health, communicable diseases or chronic diseases as well as the services to address these concerns.

A malaria elimination framework that includes high prevalence countries, too

When the Nigeria Malaria Control Program changes its name to Nigeria Malaria Elimination Program (NMEP) a few years ago, people wondered whether this was getting too far ahead of the situation in one of the highest burden malaria countries in the world. The recently released Framework for Malaria Elimination by the Global Malaria Program of WHO shows that all endemic countries can fit into the elimination process.

Recent Webinar by WHO’s Global Malaria Program stressed that all countries have a role in malaria elimination

The Framework stresses that, “Every country can accelerate progress towards elimination through evidence-based strategies, regardless of the current intensity of transmission and the malaria burden they may carry.” The Three pillars of the malaria elimination framework have room for high burden countries. Pillar 1 states that, “Ensure universal access to malaria prevention, diagnosis and treatment.”

First it is important to understand that the Framework defines malaria elimination as the cessation of indigenous mosquito-borne transmission of malaria throughout a country. The Framework also observes that even within countries there are diverse transmission areas. Some are not amenable to malaria transmission, while others may be amenable but do not experience transmission.

It is important to realize that malaria transmission in most countries is characterized by diversity and complexity. Areas where transmission is occurring range from very low transmission zones where hotspots erupt to high levels of ongoing transmission. Thus even high burden countries may have variation that require development of intervention packages tailored to the specific transmission setting.

This stratification and development of appropriate intervention packages requires, “Excellent surveillance and response are the keys to achieving and maintaining malaria elimination; information systems must become increasingly ‘granular’ to allow identification, tracking, classification and response for all malaria cases (e.g. imported, introduced, indigenous).” This should lead to “subnational elimination targets as internal milestones.”

For high burden countries key components of Pillar 1 is, “Vector control strategies, such as use of insecticide-treated mosquito nets (ITNs/LLINs) and indoor residual spraying (IRS), together with case management (prompt access to diagnosis and effective treatment) are critical for reducing malaria morbidity and mortality, and reducing malaria transmission.”

Recommendations like ensuring political commitment, private sector involvement and establishment of an independent advisory committee are valuable at all stages of elimination. A challenge for high burden countries will be maintaining political commitment over many years. Early involvement of the private sector will boost coverage of major interventions. An independent advisory/monitoring group will help track data and progress.

It is important to put in place good monitoring systems to ensure that program coverage is well targeted, achieved and maintained. “Systematic tracking of programme actions over time, including budget allocations and adherence to standard operating procedures.” This enables accountability and enhances political commitment.

Finally the Malaria Atlas Project has mapped most recent data, and as we can see Nigeria does have a variety of transmission settings. We know now that the decision of Nigeria’s malaria program to update its name was appropriate. Hopefully not only the NMEP but also the various state malaria programs will look at their malaria transmission strata and plan according toward elimination.