Category Archives: Treatment

Preventing Malaria Drug Resistance in the African Setting …

and Dealing with it Should Resistance Occur

Professor Joseph Ana, Africa Centre for Clinical Governance Research & Patient Safety in Calabar, Nigeria shares his experiences and concerns in this blog.

Drug resistance is one of the biggest challenges facing health care systems in the world today. Around 25,000 people die each year from resistant viral and bacterial infections in Europe, but no new classes of antibiotics have come on the market for more than 25 years. The figures are difficult to obtain for Africa and other developing countries.

Medicine shops may sell inappropriate malaria medicines, thus contributing to resistance

Medicine shops may sell inappropriate malaria medicines, thus contributing to resistance

Drug resistance is considered important in the failure of control and treatment of diseases its consequences, and it is considered to be one of the causes of emergence of new strains of infective organisms and re-emergence of once-controlled diseases. The occurrence and impact of the phenomenon is worse in Africa and parts of Asia for malaria according to WHO and the US CDC. Viral and bacterial diseases are also affected in this region.

Therefore, there is urgent need for global sustained action to prevent drug resistance from happening, and to control it, if it happens. The causes of Drug resistance are varied including lack of or poor implementation of the control of access to drugs, population migration and movement, misdiagnosis, under-treatment and irrational drug prescription and use.

Global Report malaria drug resistanceTo prevent drug resistance, countries need to legislate and implement adequate control of access to drugs, sustain public education on the dangers of drug resistance, educate health workers on and enforce rational drug prescribing and use. Effective monitoring of treatment outcomes is also important to know when drug resistance is occurring. With the global and country by country best efforts drug resistance may still occur because of mutation and adaptation of infective organisms.

For diseases like Malaria for which resistance to the most effective drug today, artemisinin-combination drugs, is being reported from Southeast Asia, the development of new drugs alongside vector control is essential by all countries, particularly in Africa.


Professor Joseph Ana – BM.BCh (UNN), FRCSEd, FRSPH, JtCertRCGP-UK, DFFP (RCOG)-UK, DipUrology-UK, Cert.ClinGov.UK; Lead Consultant Trainer / CEO; joseph ana <jneana@yahoo.co.uk>; Contact: Africa Centre for Clinical Governance Research & Patient Safety; @Health Resources International (HRI WA); Consultants in Clinical Governance & Patient Safety (MDCN Accredited CPD Provider); 8 Amaku Street State Housing  (& 20 Eta Agbor Road UNICAL Road),  Calabar, Nigeria.

Visit Website: www.hriwestafrica.com; email: hriwestafrica@gmail.com    Tel: +2348063600642

Tanzania – Malaria Indicators Low, Still Need Work

Success in the war against malaria is not guaranteed. Two articles to that effect have appeared The Citizen of Dar es Salaam following presentation of findings from the most recent (2015-16) Tanzania Demographic and Health Survey (DHS)/Malaria Indicator Survey (MIS).

Slide2On Tuesday (21 June 2016) the news story noted the increase in malaria prevalence among children below the age of 5 years, which was attributed to “the decline in the use of mosquito nets and low distribution of nets to households.” Then in a Wednesday (22 June 2016) Editorial, the paper noted that this “backtracking” is a “worrisome situation, for malaria is a problem that puts such a heavy burden on the government and the country’s economy.”

Slide1A look at the preliminary DHS does confirm the concerns about insecticide treated nets (ITNs).  After nearly 10 years of progress, reported ITN availability in households declined. This was reflected in a drop in reported use by children below 5 years of age as well as pregnant women. It should be noted that targets set in 2000 in the Roll Back Malaria Abuja Declaration had been 80% by the year 2010, and those had almost been achieved in 2012, but the fall to around 50% in 2015-16 is discouraging.

Another preventive measure has also faced difficulty. Pregnant women should receive doses of Sulfadoxine-pyrimethamine (SP) as part intermittent preventive treatment (IPT) during antenatal care (ANC).  Until 2012 the recommendation was two contacts, but the World Health Organization has raised this to three or more depending on the number of times a woman attends ANC. So far IPT has not reached 40% or half of the Abuja target.

Slide3This low IPT coverage is ironic since most women attend ANC at least once in Tanzania. At present only 68% of women who had been pregnant received the first dose of IPT even though 98% registered for ANC. Granted that some may have registered in their first trimester when they would not yet be eligible for IPT, but the gap is quite large and signals missed opportunities, which are often caused by stock-outs. Even though the proportion of women attending up to ANC visits could be better, these attendances should produce better delivery of the 3rd IPT dose.

Slide4Malaria can also be controlled through prompt and appropriate treatment. While testing and treatment of children with appropriate artemisinin-based combination therapy (ACT) has increased, this are is still problematic. In particular, while WHO recommends that all cases of fever should be tested, less than a third received a test (rapid diagnostic test – RDT or microscopy). Testing helps distinguish malaria from other fevers, and ACTs should not be given unless malaria is confirmed. We can see that more ACTs are provided than the number who were tested, so treatment based solely on signs and symptoms is still the norm. Again there is need to explore the availability of both RDTs and ACTs as factors that have made these targets difficult to achieve.

Tanzania continues to receive support from the Global Fund and the US President’s Malaria Initiative, among other partners. It is incumbent on all partners, global and national, to use these results as a wake up call to to plan for better delivery of malaria services and thus a reduction of both the economic and health burden of malaria in Tanzania.

 

An Ideation Model: Attitudes, Beliefs and Practices Relevant to Malaria Prevention and Treatment in Madagascar and Liberia

Stella Babalola, Nan Lewicky, Grace Awantang, Michael Toso, Hannah Koenker, Arsene Ratsimbasoa, Monique Vololona of the Johns Hopkins Center for Communication Programs and the Division for Malaria Control, Madagascar Presented findings on how local perceptions help predict uptake of malaria interventions at the 143rd American Public Health Association Annual Meeting, October 31 – November 4, 2015, in Chicago. Their presentation on Liberia and Madagascar is summarized below.

While Liberia has an average malaria parasitemia prevalence of 28%, malaria is considerable less common in Madagascar and varies by region and altitude. This difference provides an interesting opportunity to observe similarities and contrasts in community perceptions of the disease.

Slide6Theoretical basis of the research is based on the Ideation model which has been described as follows and as seen in the attached figures:

  • “New ways of thinking and the diffusion of those ways of thinking by means of exposure to mass media and social interactions in local, culturally homogeneous communities” – Kincaid, 2000
  • “views and ideas that people hold individually” – van de Kaa 1996

Slide7The ideation model has successfully predicted current use of a contraceptive method as well as accessing childhood immunization. The team took up the challenge to learn whether this model would be applicable to malaria interventions.

Malaria-related ideation was proposed to consist of: Malaria knowledge (cause, symptom, prevention); Perceived susceptibility to malaria; Perceived severity of malaria; Perceived self-efficacy to prevent malaria; and Social interactions about malaria. These may lead to uptake of malaria interventions.

Slide10Items for measuring bed net ideation could include – knowing where to procure a bed net, Willingness to pay for bed net, Having a positive attitudes towards bed net (derived from ten attitudinal statements), Perceived response-efficacy of bed nets, Perceived self-efficacy for procuring and using bed nets, Participation in household decisions about bed nets, Descriptive norm about bed net use and Social interactions about bed net use.

Percent of female caregivers that slept under an ITN on the night before survey increased by level (score) of bed net ideation as seen in the graph. Results (odds ratio) of logistic regression of sleeping under an ITN on bed net ideation and other covariates showed a similar trend.

Slide15Intermittent Preventive Treatment of Malaria in Pregnancy ideation measures included the following:

  • Knows name of the drug for malaria prevention during pregnancy
  • Knows the timing of first dose of IPTp
  • Has positive attitudes towards ANC and IPTp (derived from four attitudinal statements)
  • Perceived response-efficacy of IPTp
  • Woman participates in decisions about own health
  • Social interactions about malaria and pregnancy
  • Descriptive norm about ANC visits

Slide21The percent of women who took at least two doses of IPTp during their most recent pregnancy also increased by level of IPTp ideation Likewise the results (odds ratio) of logistic regression of obtaining at least two doses of IPTp on IPTp ideation and other covariates were highest among those with highest levels of ideation.

Items for measuring case management ideation included –

  • Perceived response efficacy of malaria diagnostic test
  • Perceived self-efficacy for detecting uncomplicated malaria
  • Perceived self-efficacy for detecting severe malaria
  • Descriptive norm about prompt treatment of malaria in children
  • Social interactions about malaria treatment
  • Participation in household decisions about child health
  • Positive attitudes towards appropriate malaria treatment

Slide27Again the percent of children sick with fever in past two weeks who received prompt ACT treatment by caregiver’s increased with increasing level of treatment ideation. As before the results (odds ratio) of logistic regression of prompt ACT treatment on caregiver’s treatment ideation and other covariates shows highest levels of ideation were associated with greated treatment seeking.

The team concluded that the same ideation model with demonstrated validity for family planning, child immunization, WASH and other health behaviors is relevant for malaria prevention and treatment. Strategically designed messages and interventions addressing ideational variables can help foster adoption of health-protective malaria prevention and treatment behaviors.

The authors acknowledge The US President’s Malaria Initiative (PMI) for technical guidance on the implementation of the surveys and The Ministry of Health and Social Welfare in Liberia and the Ministry of Health in Madagascar for their collaboration on the surveys.

Case Management of Malaria: A Review and Qualitative Assessment of Social and Behavior Change Communication Strategies in Four Countries

Kamden Hoffmann1 and Michael Toso2 presented a poster today at the 143rd annual meeting of the American Public Health Association in Chicago. Their findings are posted below.

report coverIntroduction. With the introduction and growing availability of combination therapy and rapid diagnostic tests, case management of malaria has evolved and expanded in scope. Social and behavior change communication (SBCC) activities have been developed to influence prompt care seeking behavior, adherence to test results, and completion of full treatment regimens. This review describes SBCC programming, and the extent to which it has been evaluated for impact, in Zambia, Ethiopia, Rwanda, and Senegal.

Objectives. The purpose of this review is to identify promising SBCC practices related to case management at both community and service provider levels in the four focus countries: Zambia, Ethiopia, Rwanda and Senegal. Essential for any large-scale communication strategy is a form of impact assessment. Impact assessments aim to answer the question, “Did the communication strategy achieve the specified objectives?” Impact assessments look at the difference that the strategy made in the overall program environment. The indicators can vary depending on the approach and channels used in the strategy.

An example of an impact indicator for malaria case management could be: the proportion of children under five years old with fever in the last two weeks for whom treatment was sought. Typical data sources include:

  • Population-based household surveys, such as the Demographic and Health Survey, the Malaria Indicator Survey, or the Multiple Indicator Cluster Survey.
  • Sub-national household surveys, particularly in areas where malaria communication activities were targeted.

Countries Picture1

Methods. An initial review was undertaken, consisting of a thorough PubMed search for articles related to malaria case management that mentioned SBCC, in the four countries. Malaria case management country-level documents, project reports and related SBCC materials were also collected. Implementing partner reports were gathered from each country related to SBCC and/or malaria case management. A comprehensive list of search terms were used for all four countries.

Qualitative analysis consisted of Key Informant Interviews (KIIs) with members of NMCP SBCC/BCC units within the Ministry of Health, USAID implementing partners, and President’s Malaria Initiative staff. A semi-structured questionnaire was used to gather information related to perceptions and first-hand experiences. A total of nine interviews and four written responses were collected. All interviews were recorded and transcribed. The transcribed interviews and written responses were entered into NVivo 10. An initial codebook was developed based on the semi-structured interview guide. Open and axial coding enhanced the initial codebook as themes were generated in the software.

Countries Picture2

Conclusions. The review was not able to find a substantial amount of material to show gains in the ability to measure impact of SBCC interventions in malaria case management outcomes. Several programs were able to measure changes in care-seeking behavior and uptake of ACTs; however, these types of programs need to be refined in order to measure the specific contribution of malaria SBCC interventions. Each country reviewed presented a program related to either the care group model or a model with a strong community component, and holds promise for further exploration in terms of launch points to expand the measurement of SBCC impact.

MToso IMG_0503Author Affiliations.

1 Insight Health, 710 Sutter Gate Lane, Morrisville, North Carolina 27560

2 Johns Hopkins Bloomberg School of Public Health, Center for Communication Programs, 111 Market Place Suite 310, Baltimore, MD 21202, USA

Funding for this study was provided by the US President’s Malaria Initiative.

References.

1 Kidane G, Morrow R. Teaching mothers to provide home treatment of malaria in Tigray, Ethiopia: a randomized trial. The Lancet 2000.

2 Innovation for Scale: Enhancing Ethiopia’s Health Extension Package in the Southern Nations and Nationalities People’s Region (SNNPR) Shebedino and Lanfero Woredas, October 1 2007-September 30 2012. Report of the Final Evaluation. December 2012.

3 Linn AM, Ndiaye Y, Hennessee I, et al. Reduction in symptomatic malaria prevalence through proactive community treatment in rural Senegal. Trop Med Int Health. 2015;20(11):1438-1446.

4 Landegger, J., et al. CHW Peer Support Groups for Integration of Health Service Delivery and Improved Performance: Learning from a Peer Group Model in Rwanda

5 Limange, J., et al., Evaluation: Mid-Term Evaluation of the USAID/Zambia Communications Support for Health Program, January 2013, USAID.

6 Salvation Army/Zambia (TSA), Salvation Army World Service Organization (SAWSO), and TSA Chikankata Health Services Chikankata Child Survival Project (CCSP), 2005?2010, Final Evaluation Report. December 2010.

Community Directed Interventions to Enhance PHC and MCH

William Brieger of the Department of International Health, JHU Bloomberg School of Public Health, delivered the keynote address to the Community Based Primary Health Care Working Group at the 2015 American Public Health Association in Chicago. The focus was on Community Directed Interventions (CDI) as a way to enhance implementation of primary health care and maternal and child health. Some excerpt from the talk follow.

Ivermectin coverageThe origins of the CDI Approach are based in Onchocerciasis Control and the implementation research done by the Tropical Disease Research (TDR) Program of WHO and collaborating agencies to help establish the foundational guidance of the African Program for Onchocerciasis Control in 1995. Since then we have seen an expansion of CDI into other health issues

We should start discussion with an understanding of ‘community’ which Rifkin et al. (1988) defined as a group of people living in the same defined area sharing basic values, organization, and interests. White (1982) proposed that community is an informally organized social entity which is characterized by a sense of identity. Manderson et al. (1992) in their work for TDR defined community as a population which is geographically focused but which also exists as a discrete social entity, with a local collective identity and corporate purpose.

Communities are people sharing values and institutions. Community is based on locality (geographic), interdependent social groups, interpersonal relationships expressed through social networks and built on s culture that includes values, norms, and attachments to the community as a whole as well as to its parts. Prior to developing any community intervention we must understand the boundaries, composition and structure of a community from the perspectives of its own members, as their local knowledge and participation are central to success.

community systemsCommunity Systems Strengthening has been taken up by the Global Fund in order to enhance coverage of various health interventions such as HIV drugs and bednets to prevent malaria. Community systems are community?led structures and mechanisms used by communities through which community members and community based organizations and groups interact, coordinate and deliver their responses to the challenges and needs affecting their communities. Many community systems are small?scale and/or informal. Others are more extensive – they may be networked between several organizations and involve various sub?systems. For example, a large care and support system may have distinct sub?systems for comprehensive home?based care, providing nutritional support, counselling, advocacy, legal support, and referrals for access to services and follow?up.

Efficacy, Social Control and Cohesion are important characteristics of communities that enable them to take on project and solve problems. Collective Efficacy is a perceived ability to work together. Social control provides evidence that communities are able to enforce their norms. Cohesion describes social interaction that brings people together. A strong sense of identity and a sense of belonging describe communities that can get things done. These characteristics lead to community competency to collaborate effectively in identifying the problems/needs of the community, achieve a working consensus on goals and priorities, agree on ways and means to implement the agreed-upon goals, and collaborate effectively in the required actions.

Communities chooseIt is important to distinguish between Community Based Intervention (CBI) and Community Directed Intervention. CBI takes place in the community but a Health/Development agency exercises authority over decisions on project design and implementation. Project activities (e.g., service delivery dates and procedures) are designed by the agency. Activities simply happen in the community.

With CDI the community exercises authority over decisions and decides on acceptable method to implement projects. This ensures sensitivity to local decision-making structures and social life. Activities happen both in and by the community; the community is in control.

CDI was pioneered for Onchocerciasis (River Blindness) Control as community directed treatment with ivermectin (CDTI). When communities are in charge, coverage is better than when ivermectin distribution is centrally organized by a health agency. The original 1995 CDI field testing showed better ivermectin coverage when the community was in charge of distribution. Since the beginning of CDTI, over 200,000 villages in 18 African countries have been distributing ivermectin annually through their own efforts. Lessons learned over the years are that CDI works best when 1) the smallest level of an organized community is the basis of action (e.g. a hamlet, a clan/kin group) and 2) communities are encouraged to choose as many CDDs as they think they need to get the job done. This means that the community is in charge, not individual volunteers who can be replaced anytime the community finds the need.

With CDI for onchocerciasis or any other health program, Communities plan and chose how to deliver services. This may be house-to-house, central place distribution or a combination. Health workers provide training and supervision to volunteer village health workers called community directed distributors (CDDs).

CDI study 2008TDR observed that CDI naturally expanded to include other services wanted by the community such as immunization, community development, water and sanitation, agriculture and forestry, HIV-AIDS, family planning, guinea worm, Vitamin A. TDR and APOC then decided that CDI with other service components should be systematically tested. The project sites added in a systematic manner other interventions to existing CDTI programs including home management of malaria, ITN distribution & promotion, TB DOTS, Vitamin A in addition to continued ivermectin distribution. These services varied in complexity and communities responded by dividing the work among several different volunteers.

Appropriate malaria treatment CDI studyCoverage of interventions like malaria case management, ITN promotion and Vitamin A distribution was higher in the intervention areas compared to the delivery of these services through the routine health system. TB DOTS presented the only challenge because of the social stigma associated with the disease. The study concluded that CDI can effectively incorporate high impact, evidence based interventions while at the same time maintaining and increasing ivermectin coverage. Since CDI does not rely on one volunteer but whole community effort, the problem of overburdening on community health worker did not arise. Other incterventions ould benefit from CDI such as Misoprostol, Intermittent Preventive Treatment, Deworming, Oral Rehydration solution, Zinc, Cotrimoxazole, Amoxicillin, Soap for handwashing and WaterGuard treatment kits.

MIPJhpiego an NGO affiliate of the Johns Hopkins University used CDI to deliver malaria in pregnancy (MIP) prevention services in Nigeria including Intermittent Preventive Treatment and Insecticide Treated Nets. Contrary to fears that CDI would detract from antenatal care attendance, the work of CDDs actually ensured that ANC attendance increased over time. Through CDI IPTp coverage increased compared to control communities and more pregnant women slept under ITNs regularly.

Community-Clinic modelJhpiego next expanded CDI for MIP into integrated Community Case Management (iCCM), thus taking community case management beyond community based care. Giving communities responsibility for organizing and managing their services using the CDI approach meant greater access to services whenever people need them. Using the CDI approach to iCCM CDDs reached 7,504 clients who presented signs and symptoms of malaria. CDDs successfully conducted malaria diagnosis using the rapid diagnostic test (RDT) kits. Overall, 47.8% tested positive while 52.2% tested negative. CDDs adhered to guidelines and all the 3,587 clients with positive RDT results received appropriate anti-malarial medicines. As appropriate 21.0% were treated for diarrhoea, 11.0% for pneumonia (of whom 68.0% were referred to the health facility)

CDDsA Supervisory Checklist and Performance Standards were developed and used for Assessing CDD performance. The results were discussed at monthly CDD meetings at their nearest health facilities. This led to further improvements in History taking, Examination, Conducting RDTs for Malaria and Illness Management.

TDR has done further scoping to learn if CDI would be acceptable by health workers and community members in Urban, Nomadic and Underserved Rural Communities. CDI was favorable received. In conclusion we have learned over the years that CDI can involve women, families and communities in meeting their own health needs.

Evaluation of Community Malaria Worker Performance in Western Cambodia: a Quantitative and Qualitative Assessment

Sara E. Canavati de la Torre and colleagues[1] conducted a study of Community health workers who focus on malaria. They are sharing their results with us below.

Village/ Mobile Malaria Workers (VMWs/MMWs) are a critical component in Cambodia’s national strategy to reduce malaria morbidity and mortality. Since Sara map image0162004, VMWs have been providing free malaria diagnosis and treatment using Rapid Diagnostic Tests and Artemisinin-based Combination Therapies in hard-to-reach villages (>5km from closest health facility).

VMWs play a key role in control and prevention, diagnosis and treatment of malaria as well as in delivering behavioral change communication (BCC) interventions to this target population. Out photos shows a village malaria worker at a health center registering number of patients diagnosed and treated during a month.

Sara CHW image013Overall the study aimed to evaluate the implementation of these activities performed by VMW/MMWs, a quantitative and qualitative assessment was conducted in 5 provinces of western Cambodia in order to:

  • understand job satisfaction of VMWs and MMWs vis-a-vis their roles and responsibilities;
  • assess their performance according to their job descriptions;
  • gain insights into the challenges faced in delivery of diagnosis, treatment and health education activities to their communities.

A total of 196 VMWs/MMWs were surveyed in October 2011 using a combination of quantitative and qualitative methods. Triangulation of quantitative and qualitative data helped to gain a deeper understanding of the success factors of this intervention and the challenges faced in implementation. The Map of Provinces shows ODs and HCs visited by the field team in zones 1 and 2 of the containment project.

Sara Results image018The Figure shows that overall, levels of VMW performance were in line with the expected performance (80%) and some were higher than expected. However, some performance gaps were identified in the areas of knowledge of malaria symptoms, treatment regimens, and key messages. In particular, there were low levels of practice of the recommended direct observed therapies (DOTs) approach for malaria treatment (especially for the second and third doses), reportedly caused by stock-outs, distance and transportation.

The national malaria program should aim to focus on improving knowledge of VMWs in order to address misconceptions and barriers to effective implementation of DOTs at community-levels. In addition to the findings, the tools developed, will potentially help the national program to come up with better indicators in the near future.

[1] Sara E. Canavati de la Torre1,2,8 Po Ly2, Chea Nguon3, Arantxa Roca-Feltrer4,9, David Sintasath5, Maxine Whittaker6, Pratap Singhasivanon7 – 1Faculty of Tropical Medicine, Mahidol University/ Malaria Consortium Cambodia, Phnom Penh, Cambodia; 2The National Centre of Parasitology and Malaria Control, Phnom Penh,, Cambodia; 3The National Centre of Parasitology and Malaria Control, Phnom Penh, Cambodia; 4Malaria Consortium Cambodia, Cambodia; 5Malaria Consortium Asia Regional Office, Bangkok, Thailand; 6 Australian Centre for International and Tropical Health, University of Queensland, Queensland, Australia; 7Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; 8Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; 9London School of Tropical Medicine and Hygiene, London, UK

Correlates of prompt and appropriate treatment of malaria in children in Madagascar

Colleagues[i] from the Johns Hopkins Center for Communications Programs (CCP), the US President’sToso 1 image Malaria Initiative and the Ministry of Public Health in Madagascar, presented a poster today at the American Society of Tropical Medicine 64th Annual Conference in Philadelphia. Their findings on malaria treatment in Madagascar follow.

According to Madagascar’s 2013 Malaria Indicator Survey, malaria prevalence among children aged 6-59 months was 9.1% (microscopy). Prompt diagnosis and treatment of malaria is critical for minimizing complications and ensuring complete recovery.

In Madagascar, Artemisinin-based Combination Therapy (ACT) is the recommended treatment for uncomplicated malaria. Using survey data collected in 2014 from eight districts. We assessed the socio-demographic, ideational and community factors associated with prompt treatment of fever with ACT among children aged less than five years.

The data showed that about one quarter (24.4%) of households had a child with fever during the two weeks prior to the survey. About three quarters of female caregivers reported that they sought treatment for their child with fever.

Toso 2 imageNonetheless, only about one fifth of the children were reportedly tested for malaria during their sickness: from 4.7% in the Highlands transmission zone to 30% in the Equatorial zone. Overall, less than one tenth (8.9%) of caregivers reported that their child sick with fever in the last two weeks received prompt ACT, varying from 5.4% in the Highland transmission zone to 16.2% in the Equatorial zone.

The factors associated with prompt ACT treatment include district of residence, perceived susceptibility, and malaria treatment ideation (derived from treatment-related perceived self-efficacy, attitudes, and interpersonal communication; perceived response efficacy of malaria diagnostic test, and knowledge of ACT).

The data also showed that female caregivers resident in higher transmission disctricts (Manakara – Equatorial zone; Morombe – Tropical zone) were more likely to obtain prompt ACT treatment for their children compared to their peers resident in lower transmission district of Miarinarivo (Highlands). A high sense of perceived susceptibility to malaria was associated with decreased odds of prompt treatment while high scores for treatment ideation increased the odds.

Programs should continue promoting prompt treatment for malaria targeting both demand and supply sides. The delay in appropriate treatment associated with perceived susceptibility to malaria indicates the need to intensify efforts to strengthen self-efficacy for prompt malaria treatment in areas where malaria is common. A comprehensive program to promote prompt treatment should address the treatment ideation elements assessed in this study.

[i] Stella O. Babalola, Grace Awantang, Nan Lewicky, Michael Toso, Sixte Zigirumugabe, Arsene Ratsimbasoa, Monique Vololona

 

“Nobel” drug discoveries rewarded, but delivery of malaria and filarial medicines to the community also matters

Herbs, soil and hard scientific work have yielded Nobel Prizes in Medicine/Physiology for three scientists whose results now save millions of lives from death and disability due to malaria, onchocerciasis (river blindness) and filariasis (elephantiasis), according to the New York Times. Two of the winners, “Dr. Campbell and Dr. Omura, developed Avermectin, the parent of Ivermectin, a medicine that has nearly eradicated river blindness and radically reduced the incidence of filariasis.” Dr Tu Youyou, “inspired by Chinese traditional medicine in discovering Artemisinin, a drug that is now part of standard anti-malarial regimens and that has reduced death rates from the disease.”

Community Case Management of Malaria in Rwanda using Rapid Diagnostic Tests and ACTs

Community Case Management of Malaria in Rwanda using Rapid Diagnostic Tests and ACTs

The development of these chemicals into human medicines was a long time coming, and in the case of artemisinin, over 2000 years. The Guardian quotes the Deputy Director of the Liverpool School of Tropical Medicine as saying that, “Artemisinin was discovered when fatalities from malaria were rocketing and the world was terrified we’d be looking at a post-chloroquine era. It has been a real game-changer.”

In fact artemisinin in combination with other medicines or artemisinin-based combination therapy (ACT) rescued many lives in the face of parasite resistance to earlier first line drugs like chloroquine and sulfadoxine-pyrimentamine (though artemisinin resistance is now growing). ACTs are also made freely available to populations in malaria endemic countries through such programs as the Global Fund to fight against AIDS, TB and Malaria (GFATM), the US President’s Malaria Initiative, the World Bank and others.

Avermectin began its medical role as a veterinary drug that killed parasites in livestock. Eventually research by Merck based on the similarities between animal and human filarial worms led to the testing and development of ivermectin to control onchocerciasis through annual doses that killed microfilariae.

Not only are both ACTs and ivermectin on WHO’s essential medicines list, but they form the basis of global efforts to eliminate disease. Once Merck determined that ivermectin was safe and effective in humans, it began donations of the drug to what has become the African Program for Onchocerciasis Control (APOC) and its counterpart that is working to eliminate the disease in the Americas. APOC and its national counterparts now reache people in over 200,000 endemic villages in 18 African countries with annual doses.

Community Directed Distribution of Ivermectin in Cameroon

Community Directed Distribution of Ivermectin in Cameroon

While we celebrate the recognition that the drugs and their discoverers are receiving, we should not lose sight of the fact that without good delivery mechanisms these life saving medicines would not reach the poor, neglected, often remote populations who need them.

Beginning in 1995, APOC and the Tropical Disease Research Program of WHO and partners pioneered what has now become known as Community Directed Interventions (CDI) where the thousands of communities “beyond the end of the road” and their selected volunteers organize the annual ivermectin distributions. This community directed approach works for community case management of malaria, too.

Hopefully in the future, groups like APOC will receive Nobel Prize recognition for ensuring that those in need actually receive the medicines they require. In the meantime we encourage more countries to adopt the CDI approach to reduce malaria deaths and work toward the elimination of malaria, onchocerciasis and filariasis.

Drug-resistant malaria in Myanmar: A call for increased funding to prevent a global catastrophe

We are happy to re-post a blog by Alice Sowinski, Craigen Nes, and Diane Del Pozo in the SBFPHC Policy Advocacy Blog of the Social and Behavioral Foundations of Primary Health Care Course at the Johns Hopkins Bloomberg School of Public Health….

The CDC estimates there are 198 million cases of malaria that occur worldwide with more than 500,000 people dying from the disease every year. Although this disease has slowly declined in recent years, experts believe that certain endemic areas could still be at high risk for drug resistance. One such area includes Myanmar, a Southeast Asian region located on the border between India and China.

myanmar malaria map

Myanmar is a high-risk area for artemisinin resistant malaria

Over 76% of Myanmar’s population lives in regions stricken with poverty and poor health infrastructure that contribute to the mass spread of disease in areas where malaria is endemic. This area in particular is becoming resistant to artemisinin, the first line of defense. Experts suggest Myanmar is a priority region for the elimination of artemisinin resistant malaria (ARM) in order to avoid the international disaster that would result if ARM were to spread to India and Africa. Immediate and large-scale action along with substantial financial support from multiple stakeholders is needed to prevent further spread of ARM and avoid a looming malaria catastrophe.

The Burmese government estimates that it will need US$1.2 billion over the next 15 years or $80 million per annum. The proposed solution would strengthen surveillance, increase rapid diagnostic testing and create new drugs to combat ARM. However, recently the Australian government, one of the 3MDG Fund donors, the largest development fund in Myanmar, has decided to cancel its pledged sum of $42 million in aid to the country. The implications of this withdrawal are uncertain and untimely.

With the ability of the malaria parasite to thwart off once effective drugs, the fear of widespread resistance is now a reality. Scientists believe we have a small window of opportunity to support Myanmar’s national campaign to increase funding to prevent a global health disaster and achieve Myanmar’s 2030 malaria elimination goals.

RSAP Themed Issue on Pharmaceutical Logistics for integrated Community Case Management (iCCM) – Call for Papers

RSAP_v11_i4_COVER.inddA themed issue for Research in Social and Administrative Pharmacy (RSAP at http://www.journals.elsevier.com/research-in-social-and-administrative-pharmacy/) will feature the challenges of guaranteeing regular and adequate pharmaceutical supplies and commodities for integrated Community Case Management (iCCM). iCCM can be described as a comprehensive approach to providing essential health services in and by the community. iCCM relies on having basic commodities like Rapid Diagnostic Tests (RDTs) and artemisinin-based combination therapy (ACT) medicines for malaria, oral rehydration solution (ORS) packets and zinc for diarrhea, in addition to appropriate antibiotics like amoxicillin and cotrimoxazole for pneumonia available in the community.

Early successes describing the documentation of need and initial procurement of these essential therapies in developing nations have been published; however, this themed issue will share original research, models, and expert commentaries on ensuing stages in procurement and supply chain management (PSM) that will sustain iCCM.

PSM/logistical success for iCCM can occur in countries that have a department or unit that focuses on community health promotion and supports standardized training and equipping of Community Health Workers (CHWs) even in small villages. Unfortunately, most programs lack adequate procurement and supply management systems, especially planning and forecasting. Front-line health center staff who train and supervise village-based iCCM volunteers express concern about the difficulty in acquiring enough medicines for their own clinical needs, let alone supplies for volunteer community health workers.

DSCN5479Other programs reserve iCCM only for selected communities in a catchment area based on distance or availability of community health extension/auxiliary workers. There are also examples of iCCM that are narrowly focused on one or two health problems, while others take a more comprehensive approach. Clearly each has different logistical concerns such as the generic issues of forecasting, procurement, shipping and storage, while others experience the difficulty obtaining funding support when many disease control programs have vertical financial streams.

There are various models for providing medicines at the community level. One is the pioneering work of the World Health Organization’s (WHO’s) Tropical Disease Research (TDR) program in promoting Community-Directed Treatment with Ivermectin (CDTI) for River Blindness Control, which evolved into the Community Directed Intervention (CDI) approach for delivering basic health commodities by the community, itself.[1]

Policymakers, health organizations, and front-line clinicians often say, “no product, no program.” This themed issue will share the experiences and lessons of iCCM, both successes and challenges, to help the global health community see the need for more systematic planning of PSM for iCCM. International agencies and donors clearly recognize that alternative forms of essential health service delivery are needed to achieve coverage targets and save lives. The community as a source of care has a solid foundation as established at the International Conference on Primary Health Care, which produced global guidance through the Alma Ata Primary Health Care Declaration of 1978,[2] but in all those years, actualization of this ideal has been difficult for logistical reasons. This RSAP themed issue should not only help us understand the present challenges, but map a way forward to better access to essential health commodities in communities throughout the developing world.

The themed issue will include various contributions such as:

  • Commentary/Overview from the World Health Organization staff who have spearheaded the iCCM movement
  • Implementation/intervention research on:
    • The link between front-line clinics and community health workers/distributors in guaranteeing iCCM commodities
    • The challenge of providing iCCM commodities for use by nomadic populations
    • Provision of iCCM commodities by different types community workers
    • Successes and challenges in maintaining supplies and commodities for large-scale and national community primary health care programs
    • Comparative lessons from other community based programs such as family planning commodity distribution and home-based care for people living with HIV
  • Documented program experiences including:
    • The challenges of maintaining iCCM supplies and logistics in emergency situations, as with disaster refugee and outbreak situations
    • The role of donors and non-governmental organizations (NGOs) in providing commodities.

We are still seeking additional contributions. If you have a paper or idea for one or more, please contact the guest editors. Papers must be submitted on the Elsevier RSAP platform at http://ees.elsevier.com/rsap/ by February 1, 2016 for publication in fall of 2016.

Guest Editors:

  • William R Brieger, MPH, DrPH, Professor, Department of International Health, Bloomberg School of Public health, The Johns Hopkins University; Senior Malaria Specialist, Jhpiego; RSAP Editorial Board Member. <bbbrieger@yahoo.com>
  • Maria KL Eng, MPH, PhD, Departmental Associate, Department of International Health, Bloomberg School of Public health, The Johns Hopkins University; Instructor for “Pharmaceuticals Management for Under-Served Populations” <meng@jhu.edu>

[1] http://www.who.int/bulletin/volumes/88/7/09-069203/en/

[2] http://www.who.int/dg/20080915/en/