Category Archives: Treatment

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/

Verifying Malaria Medicines on Your Mobile

On their website Sproxil says that, “Sproxil actively supports Nigeria’s National Agency for Food and Drug Administration and Control (NAFDAC) in the fight against counterfeiting by pioneering Nigeria’s first Mobile Authentication Service.” They note further that …

“On February 2, 2010, NAFDAC launched the NAFDAC MAS, putting the power of product verification right in the hands of the consumer. MAS is powered by Sproxil’s award-winning cloud-based Mobile Product Authentication™ technology, and remains the world’s largest nation-wide implementation of consumer-facing SMS anti-counterfeiting technology in the world.”

Below are two malaria medicine packets recently purchased. After scratching the small label (see it circled, we got the SMS messages as posted.  The NAFDAC registration number alone is not enough to ascertain the validity. This is a smart procedure, even without a smart phone. Of course one still needs to read the expiry dates!

P-Alaxin front scratch off1. OK Genuine P-Alaxin Tablet. Your PIN:949769012921 NRN:04-9495 Problem? Call 08039012929 NAFDAC & Bliss Care Sproxil SMS

Lonart DS back PIN2. OK Original Lonart DS tabs NRN:04-9927 Use mosquito nets to help avoid malaria Problem? Call 08039012929 NAFDAC & GREENLIFE CARE Sproxil Solution

Lessons Learned from a Supervisory Visit to a Medicine Shop

DSCN2943In this posting Hajara Moses John of the Bauchi State Agency for the Control of HIV/AIDS, TBL and Malaria [BACATMA] shares lessons learned in supervising medicine sellers.

Our team had planned supervisory visit last week to patent medicine vendors (PMVs) where shop owners have been taught the correct management of childhood illnesses. Our experience one particular shop pulled together so many lessons about training and supervision, and we are sharing this here. In the first shop we visited that day we found a boy aged 12 behind the counter. I took on the role of a mystery client, and mentioned some symptoms to the boy. “My 5-year old son is at home with catarrh. His nose is really running and his breathing is fast. What do you recommend I give him?”

The boy mentioned a local brand of antihistamine. I asked if there was anything else we should do, and the boy said that should work fine.

Next I said my two-year old daughter was also unwell. She was having fever, shivers with aches and pains. Did he have any suggestions for her? His prompt answer was “Ampiclox.”

I then asked him where the owner of the shop was. He said, “Oh my father has traveled.” I asked what class the boy was in school, to which he said the first class of junior secondary school.

Word of our visit must have spread in the area, because then a woman rushed in who it turned out to be the boy’s mother and asked how she could help us.

We explained that we were from the Ministry and were going around to help medicine shop owners improve the quality of their services. The mother happily reported that she had received training “in malaria and those other small small diseases of pickin,” from the Minsirty fo health and again from a NGO.

I went back to case of the child with a respiratory infection and pointed out the breath counting beads on the table. She said it was her husband who had done the training where the beads were explained but never taught her how to use them. We then spent some time explaining to the mother and her son about the beads and demonstrated how to use them, and also explained about management of fever.

Finally I asked the mother why she was not in the shop since her husband had traveled. She said she was in the kitchen preparing lunch for the children, and as the oldest, the 12-year old was assumed capable of running the shop. We encouraged her to discuss as a family how they could share what they have learned about managing child illness and always ensure that a competent person is available in the shop.

Training of PMVs is not a simple matter. The person trained may not always be in the shop nor share what he/she learned with other salespeople. Supervision is necessary in order to reinforce what was learned during training and provides an opportunity to teach others on-the-job. PMVs provide a large portion of the services in many African communities, and we must ensure that they can focus on quality.

World Malaria Day 2015 Blog Postings Help #DefeatMalaria

wmd2015logoA special World Malaria Day 2015 Blog has been established. So far nine postings are available at http://www.worldmalariaday.org/blog. Please read and share with colleagues.

1. “Investing in integrated health services to defeat malaria”BY ELAINE ROMAN, MCSP Malaria Team Lead.

2. “Fake antimalarials: how big is the problem?”

BY DÉBORA MIRANDA, Technical Communications Officer, ACT Consortium (UK).

3. “Why antimalarial medicines matter”WMD15_7_Facebook_Final

BY PROFESSOR PAUL NEWTON AND ANDREA STEWART, Worldwide Antimalarial Resistance Network and Laos Oxford University Mahosot Hospital Wellcome Trust Research Unit.

4. “Malaria as an entry point for addressing other conditions”

BY HELEN COUNIHAN, Senior Public Health Specialist, Community Health Systems.

5. “Bridging the Care-Seeking Gap with ProAct”

BY MATT McLAUGHLIN, Program Manager of Peace Corps Stomping Out Malaria in Africa initiative.

WMD15_6a_Facebook_Final6. “Defeating Malaria in Pregnancy”

BY CATHERINE NDUNGU, ELAINE ROMAN AND AUGUSTINE NGINDU, Jhpiego.

7. “Intermittent Preventive Treatment, a Key Tool to Prevent and Control Malaria in Pregnancy”

BY CLARA MENÉNDEZ, Director of ISGlobal’s Maternal Child and Reproductive Health Initiative.

8. “Widespread artemisinin resistance could wipe out a decade of malaria investment”

BY TIM FRANCE, Asia Pacific Leaders Malaria Alliance.

9. “The long walk to a malaria-free world”

BY DAVID REDDY, CEO Medicines for Malaria Venture.

Highlights from Malawi’s 2014 Malaria Information Survey

Two major forms of malaria data collection help inform national malaria control programs and their supporters about progress and help focus continued resources and interventions. Routine national health information tells us about program implementation on a regular basis. National surveys give us a point-in-time picture of coverage.  For the latter, Malawi has been fortunate in recent times to have conducted Malaria Information Surveys every two years.

Pf_mean_2010_MWIMalawi continues to have endemic malaria as documented by the MAP project in the attached graphic. While some of its neighbors in southern Africa are moving toward elimination, Malawi still experiences prevalence (as measured by rapid diagnostic test) in children below five years of age of 43%, 28% and 33% in 2010, 2012 and 2014 respectively.

In the chart below we can see that malaria preventive measures have varied in coverage over the three survey periods and may be said to be on a very slightly upward trend.  The Roll Back Malaria target of 80% coverage by 2010 and the US President’s Malaria Initiative target of 85% are still illusive.

In fact, simply having an ITN in the home is no guarantee that people will use it. Overall in 2014 72% of people living in a house with a net slept under one the night before the survey. The rate of use was better for children below five years of age (87%) and pregnant women (85%), but a gap remains.

Malawi MIS 2014 HighlightsOverall coverage for two doses of sulphadoxine-pyrimethamine (SP) for intermittent preventive treatment in pregnancy (IPTp) remains low. Now that WHO is recommending IPTp with SP during each antenatal care visit after 13 weeks, we are aiming for 3, 4 or more doses. In 2014 89% pregnant women in Malawi received one dose, 63% received two and 12% received three.

Malaria treatment for febrile children was the indicator with the best performance (not counting the fact that treatment was not always preceded by a diagnostic test).  Most (93%) of children took an artemisinin-based combination therapy (ACT) drug, and 74% took it within a day of fever onset.

The 2014 MIS provides more detailed breakdown by region and socio-economic group, which should be helpful for planning.  The major take home message though is that five years after the RBM target dates, many countries, Malawi included, have not been able to scale up and sustain the high intervention coverage needed to bring down mortality and guide us on the pathway to malaria elimination.

As the 2015 Millennium Development Goals are being replaced with a broader development agenda, we hope that malaria will not become a neglected tropical disease again. Actually using data from the MIS to take timely decisions by national programs and donors is essential to keep us on the path.

“Zero Malaria! Count Me In!”: Senegal’s national commitment to the Last Mile to Malaria Elimination

Yacine Djibo, Founder & President of Speak Up Africa is helping focus International Women’s Day (March 8th) on efforts to protect women from malaria in Senegal. She is highlighting the commitments of 8 strong and beautiful women, in Senegal, that are dedicated to eliminating malaria in their country. These commitments are part of an inclusive mass communication campaign that aims to launch a national movement in favor of malaria elimination in Senegal: the “Zero Malaria! Count Me In” campaign

ZeroPaluInternational Women’s Day, represents an opportunity to celebrate the achievements of women all around the world. This year’s theme is “Empowering Women – Empowering Humanity: Picture it” envisions a world where each woman and girl can exercise her choices, such as participating in politics, getting an education or fighting malaria. Below is the fifth feature on women fighting malaria.

Mrs. Oulèye Bèye, Head of the Prevention & Partnership Department at the National Malaria Control Program (NMCP), likes to remind us the national claim stating that “Technicians cure malaria but communities fight it”. It is a simple, yet powerful statement that summarizes the very purpose of all our endeavors. Efforts to reach remote populations and positively change communities’ behaviors are a constant battle for the NMCP.

3. Ouleye Beye ENG

Mrs. Oulèye Bèye, National Malaria Control Program, Senegal

The scale up of proven interventions recommended by the World Health Organization, have been essential in achieving this drastic decrease in malaria mortality rates over the years. These strategies include ensuring the availability of Artemisinin-based combination therapy (ACT) in health facilities, the mass distribution of free mosquito nets and the introduction of rapid diagnostic tests.

To be effective, all of them require significant and unconditional uptake by beneficiaries. Needless to say that the successes achieved through effective and safe malaria control campaigns, a strong national leadership and a dynamic set of partners are all at risk, if we fail to realize that populations must no longer be considered as plain beneficiaries but as stakeholders of utmost importance.

iwd_squareBy leading the effort around the “Zero Malaria! Count Me In” campaign at the national level, Ouleye strives to create a popular movement and actively engage each and every Senegalese citizen in the fight for a malaria-free Senegal. Sensitization and awareness raising must be the first step of any malaria elimination intervention if we want to achieve positive results in the long run.

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Headquartered in Dakar, Senegal, Speak Up Africa is a creative health communications and advocacy organization dedicated to catalyzing African leadership, enabling policy change, securing resources and inspiring individual action for the most pressing issue affecting Africa’s future: child health.

Fighting Malaria with Community Case Management (CCM) Scale-Up in Kenya

Arianna Hutcheson has posted the following blog on our course website – Social and Behavioral Foundations of Primary Health Care

Screen Shot 2015-03-04 at 11.25.22 AM

Source: https://www.ifrc.org/Global/Publications/Health/Beyond_Prevention_HMM%20Malaria-EN.pdf

Access to health services is particularly difficult for the poor and those in more inaccessible areas of Kenya. This lack of endemic disease treatment for communities has proven to be quite deadly. With more than 11.3 million cases recorded annually, malaria is the leading killer of children under five years of age in Kenya. CCM, supported by organizations such as WHO and UNICEF, allows Kenya to effectively fight Malaria by using evidence-based life saving treatments that increase the availability and quality of proven interventions.

Using a CCM strategy has shown to decrease under-five malaria mortality by 60% overall under-five mortality by 40%. In Kenya particularly, the CCM pilot program has generated convincing results as seen in the graphic below.

Screen Shot 2015-03-04 at 11.34.45 AM

Access to Artemisinin-based Combination Therapy (ACT)  has increased and the education of communities provided by health workers has improved treatment seeking behavior. While the pilot CCM program is an important step to combating malaria, we are in the right time to take the success of this program and implement it country-wide.

Most importantly, CCM is part of the National Malaria Strategy, but it requires a more pronounced place in the plan to implement the successes of the pilot program in all 8 districts.

Action Needed: The Kenyan Ministry of Public Health and Sanitation (MoPHS) needs to commit and push ahead their own stated agenda for putting community health first by integrating malaria treatment into the already implemented diarrhea CCM program by the end of 2015.

Graphic: https://www.ifrc.org/Global/Publications/Health/Beyond_Prevention_HMM%20Malaria-EN.pdf