The recently concluded Global Health Systems Research Symposium in Cape Town featured a number of abstracts that touched directly or indirectly on malaria. Malaria services and movement toward malaria elimination cannot be achieved in a country without a strong health system that involves both communities, program staff and policy makers.

Below is an abstract by Nana Yaa Boadu (IDRC), John Amuasi (University of Minnesota), Daniel Ansong KATH Kumasi), Edna Einsedel (University of Calgary), and Stephanie Yanow, (University of Alberta) on malaria/febrile illness testing in Ghana. Other abstracts will appear subsequently.

“The test-based malaria management guideline in Ghana reflects a 2009 recommendation by the World Health Organization, to confirm suspected cases before providing treatment. The guideline aims to limit inappropriate antimalarial use, which contributes to emerging drug resistance. Rapid diagnostic tests (RDTs) enable confirmatory malaria diagnosis in peripheral settings without microscopy.

“Yet healthcare providers frequently prescribe antimalarials without a test, or despite negative test results. This study investigated poor providers’ compliance with the malaria testing guideline. The findings are useful to streamline antimalarial prescribing practices, to improve malaria management, and to limit drug resistance development in Ghana.

“A focused ethnography conducted between November 2011 and October 2012 involved 50 providers at six different primary healthcare settings in the Atwima-Nwabiagya district. Observations, semi-structured interviews and focus groups involving providers revealed reasons for poor compliance. Consultations with local and national policy representatives identified system-wide factors affecting providers’ compliance, including national health insurance.

“Poor availability and quality of RDTs, heavy workloads, and insufficient guideline knowledge limited providers’ readiness to test before treating suspected malaria. Knowing the risks and consequences of delayed treatment, providers were unwilling to withhold antimalarials from suspected cases. Due to frequent RDT stock outs testing was sporadic, often conducted after treated patients returned with unyielding signs and symptoms.

“Limited healthcare delivery capacity created tension for providers between recommended and achievable practice standards, which restricted effective guideline implementation. Perceived patient risk and poor RDT quality undermined providers’ willingness to test, leading to precautionary treatment practices. These factors interdependently influenced guideline compliance.

“Training should enhance providers’ knowledge of policy, practice, and technology for diagnosing malaria. However, health system capacity-building is critical to bolster providers’ confidence in RDT and guideline utility for managing malaria.”

The African Health Initiative (AHI), established in 2008 by the Doris Duke Charitable Foundation, seeks to catalyze significant advances in strengthening health systems by supporting partnerships that will design, implement and evaluate large-scale models of care that link implementation research and workforce training directly to the delivery of integrated primary healthcare in sub-Saharan Africa.

During the upcoming Third Global Symposium on Health Systems Research in Cape Town (30 September-3 October, the five AHI country projects (Ghana, Mozambique, Rwanda, Tanzania and Zambia) will be sharing their experiences in panel presentations. We will be tweeting at each panel presentation, and you can follow at: #HSG2014 and “Health  Systems Global” and “Bill Brieger Malaria“.

The first AHI panel is entitled “The Design, Implementation, and Preliminary Results of African Health Initiative (AHI) Strategies for Improving the Quality of Primary Health Care in Five Countries.” Please see an overview below.

Ever since the historic Alma Ata Conference called for national and international action to develop and implement primary health care throughout the world, research has been focused on the challenge of improving the accessibility and quality of health services in Africa. Although many promising interventions have emerged from such efforts, their full potential to improve the health of African families has been hindered by inter-connected systemic manpower, logistics, management, resource, and leadership problems. As a result, basic primary health care remains inaccessible and unaffordable to most families living in this region.

The African Health Initiative (AHI) aims to develop and test feasible means of solving these problems by implementing comprehensive packages of health strengthening interventions in Ghana, Mozambique, Rwanda, Tanzania and Zambia. The country teams participating in the AHI have created important healthcare-related innovations and have research capabilities that can be used to rigorously evaluate each project’s impact. All five projects have developed means of improving the quality of health services and assessing the impact of respective systems improvement strategies on childhood survival.

The purpose of this panel is to explain and contrast the design and implementation of project strategies for improving quality of care and to review preliminary results of project success. The targeted audience for this panel is health systems practitioners, clinical educators, researchers involved in the implementation or evaluation of community health workers programs.

AHI projects demonstrate practical means of utilizing research to develop and implement service quality improvement. Although evaluation designs differ, all focus on assessing the impact of improving service quality on childhood survival. As a set of initiatives, projects provide guidance on ways to achieve adaptive development of system strengthening in resource constrained settings.

The session will start with an overview of the AHI rationale and its focus on quality of care improvement. A presenter from each country team will review respective strategies for quality of care development. The Rwanda and Zambia projects will lead the discussion, as their projects enhance facility-based quality of care.

Rwanda, which introduced a district-wide initiative known as “All Babies Count”, combines a mentoring intervention with a learning collaborative for improving worker and system performance. In Zambia, the Better Health Care Outcomes through Mentorship and Assessment (BHOMA) project improves rural outpatient care quality by restructuring structured clinical information, the use of electronic technologies for transmitting patient data, and feedback to service personnel, managers and communities.

The “Ghana Essential Health Intervention Programme’s will discuss its strategy for evidence-driven quality improvement for prioritizing in-service training and emergency referral operations. The Tanzanian Connect project will illustrate the use of training, supervision, and community governance to develop and sustain quality assurance.

The Mozambique Strengthening Integrated Primary Health Care project will conclude by presenting their strategies for improving the delivery of health care by giving key health managers the skills and tools to identify and address service quality and efficiency problems.

World Malaria Day 2014 was observed at the Johns Hopkins Bloomberg School of Public Health on Friday 25 April. 21 posters were presented. Below is the abstract of a poster presented by Antonio M. Quispe (aquispe@jhu.edu) and Josiah L. Kephart of the U.S. Naval Medical Research Unit Six (NAMRU-6), Lima, Peru and Johns Hopkins Bloomberg School of Public Health, Baltimore.

After a decade of decline, malaria prevalence in the Peruvian Amazon quadrupled from 2010 to 2013.(1) The most plausible explanation for this reemergence is administrative, as a concurrent dengue outbreak has forced authorities to reallocate their resources away from malaria and towards dengue. The current surveillance system provides epidemiological analysis on a macro level only, limiting decision-makers ability to efficiently distribute resources towards both diseases simultaneously by targeting outbreaks on a micro level and in a timely manner.

We have developed the Free Surveillance Application (FREESAPP), an online application that facilitates epidemiologic analysis and cost-effectiveness decision trees using data already collected by the malaria surveillance system. By leveraging free and publicly available software (Google Docs, R, etc.), the app provides public health decision-makers with the ability to transform weekly epidemiological reports into exploratory analysis, monitor epidemiologic thresholds, and assess the cost-effectiveness of deploying various control methods.

FREESAPP enables users to visually contrast malaria incidence rates with   epidemiological thresholds. When the weekly epidemiologic report is uploaded, the visualization will automatically update, providing a signi?cant time-advantage over the current system of annual   reporting. These comparisons can be also performed across reporting levels, from the regional   to individual health center levels (Fig 1).

The app facilitates follow-up analysis through the ability to combine or adjust for various relevant covariates (incident rate, population size, P. vivax proportion, time, etc.) using several display options (bubble, bar, and line charts) and offering a variety of mathematical transformations (linear and logarithmic) (Fig 2).

FREESAPP allows decision makers to get a sense of the relative costs of deploying a team of health workers to perform either active case detection (ACD) or reactive case detection (RCD) in responses to an outbreak or malaria elimination effort within a particular community. ACD targets the malaria burden (symptomatic cases only) by searching for malaria cases among the entire population at risk, while RCD targets the malaria reservoir (both symptomatic and asymptomatic cases) by focusing on malaria infections within high-risk sub-populations.(2) To compare these methods, we have developed a decision tree that assists in the decision-making process of the optimal strategy for outbreak responses and malaria elimination initiatives, adapting the model developed by Shillcut et al.(3)

By utilizing publicly available software, FREESAPP can provide public health decision-makers with valuable insight into malaria outbreaks and cost-efficient responses. Present malaria and dengue control efforts in Peru are limited by a lack of access to timely epidemiological analysis across all health-system levels. FREESAPP offers valuable and accessible tools to improve public health leaders’ ability to leverage data from existing surveillance systems of malaria and other infectious diseases to implement efficient and effective interventions.

References

1. WHO. Global Malaria Report 2013. Geneva: World Health Organization, 2013.
2. Moonen B et al. Operational strategies to achieve and maintain malaria elimination. Lancet. 2010; 376(9752): 1592-603
3. Shillcutt S et al. Cost-effectiveness of malaria diagnostic methods in sub-Saharan Africa in an era of combination therapy. Bull World Health Organ. 2008;86(2):101?10

Several of USAID’s Malaria Communities Program (MCP) partners worked to increase coverage of insecticide treated nets. These include EQUIP Liberia, WellShare International Uganda, Aga Khan Foundation (AKF)/Progresso Mozambique, Caritas Senegal, Episcopal Relief and Development (ERD) Ghana, Ajuda de Desenvolvimento de Povo para Povo em (ADPP) Angola, and Episcopal Relief and Development (ERD) Angola. The full case study on these efforts can be found on the Maternal and Child Health Integrated Project (MCHIP) website.

MCHIP collected multiple forms of data from these five partners using qualitative methods including individual interviews with key project personnel and review of key documents. MCHIP then compared data across projects to better understand the overall contributions made by MCP. Some partners conducted surveys and this case study includes relevant quantitative data.

MCP partners 1) increased access to ITNs 2) monitored and tracked ITN ownership and use, 3) increased proper use of ITNs; and 4) identified and addressed challenges to ITN procurement, distribution, and use.

Collaborative partnerships and coordination of efforts with the Ministry of Health (MOH), communities, and other local stakeholders supported efforts to distribute, promote effective use, and maintain ITNs. ITN ownership increased in nearly all MCP project areas (see orange and blue bars in the Chart) where surveys were conducted. Final coverage estimates in project areas are significantly higher than national estimates (yellow and purple bars), even where project baseline coverage was lower than national averages.

Community-level efforts contributed to achieving high coverage and use. MCP partners demonstrated the value of community-level strategies to distribute nets. Strategies included using volunteers and doing door-to-door distribution; community BCC focused on proper net hang-up and use; and net quantification and monitoring from which data were used to procure sufficient quantities of nets, plan for net replacement, and appropriately target net distribution.

The success in project areas that utilized community level strategies (see Charts 1 and 2) underscores the need for continued partnership between national-level stakeholders like NMCPs and community-level facilitators like NGOs.

The following colleagues from the Ministry of Health in Huambo Angola and Jhpiego presented their work at the 141st American Public health Annual Meeting in Boston yesterday: Frederico Juliana, Jhony Juarez, Amandio Natito, and Lelo Zola. Please see their contribution below.

Malaria is the first cause of morbidity and mortality in Angola. Angola has 18 provinces and an estimated population around 17 million. There are three epidemiologic classes: hyper-endemic (Northern part of the country), stable meso-endemic area (Central) and unstable meso-endemic area (South).

In the last ten years, the Ministry of Health, the National Malaria Control Program, and national and international organizations have made efforts to control it. In Huambo Province, where about 14% of the total Angolan population lives, the number of malaria cases decreased by 85% and the deaths decreased by 98% to just 31 deaths between 2008 and 2012.

Factors that have contributed to the reduction of malaria cases include increase in number of health professionals, principally doctors, work with organized communities, health fairs (Uhayele Vimbo) for rural/ isolated populations. In addition major malaria interventions such as rapid malaria tests and microscopes, combined antimalarials, spraying, ITN distribution, improvement in diagnosis and treatment, equipment for spraying, anti-larva projects were deployed more widely.

Reaching all municipalities, communes and neighborhoods with these services and population-level health education campaigns, improvements in the health information system and a rapid alert, earlier care-seeking for malaria symptoms led to lives saved. Number of malaria cases and deaths in Huambo decreased between 2008 2012 from 620,300 to 87,852 and from 1,559  to 31 respectively.

Opadiran Oluwatunmobi, Oluwafemi Ajumobi, Victoria Ibeh, Ogu Omede, and Godwin Ntadom from the National Malaria Control Programme, Federal Ministry of Health, Abuja, Nigeria presented their experiences on malaria in an emergency setting at the recently concluded Multilateral Initiative on Malaria 6th Pan Africa malaria Conference in Durban, South Africa. Below, they have shared their experiences with our readers.

Nigeria accounts for 25% malarial disease burden in Africa. Malaria accounts for 25% under-five mortality. In 2012, flood disaster ravaged certain areas of the country leading to internal displacement and significant environmental degradation. Though mass screening and treatment (MSAT) is recommended by world health organization (WHO) in areas in the pre-elimination phase for detection of asymptomatic parasite carriers and rapid reduction of the parasite pool, we explored its use in a disaster situation. We conducted MSAT for malaria amongst displaced persons and at risk groups in Bayelsa, Nigeria.

Residents in Yenogoa local government area, Bayelsa state, Nigeria were mobilised for MSAT and screened for malaria using Histidine Rich Protein-II-based Standard Diagnostic Bioline malaria rapid diagnostic (RDT) test in November 2012. All RDT positive cases were treated with Artemisinin-combination therapy (ACT). Data were analysed using Epi Info version 3.5.3 and Microsoft excel.

Of the 1684 tested, 611(36.3%) were male, 43 (2.6%) were pregnant women, 303 (18%) had fever ?37.5oC, 447 (26.5%): generalised weakness, 536 (31.8%): headache, 368 (21.9%): joint pains, 111 (6.6%): vomiting, 113 (6.7%): diarrhea, 454 (27%): cough, 180 (10.7%) tested positive and 5 (0.3%) had invalid test result. Of the 180 RDT positives, 138 (76.7%) received ACT. Of the 1504 RDT negatives, 64 (0.1%) received ACT.  Of 480 (28.5%) under-fives (U5), 81(16.9%) had fever, 67(14%) had danger signs. Of 51 RDT positive U5, 39 (76.5%) received ACT. Of the 429 RDT negative U5, 29 (6.8%) received ACT. Two RDT positive pregnant women received ACT. Severe malaria cases in U5 were referred to the health facility.

The prevalence of malaria is low. The RDT met the WHO criteria for invalid rate of <5%. Non-rational use of ACTs thought relatively low, was higher in U5. It cannot be assumed that prevalence of malaria is higher in flood disaster victims. The use of MSAT in internally displaced population in disaster situation is necessary to ensure rational use of ACTs.

The idea for a Pan-African Mosquito Control Association (PPAMCA) was floated at the 2009 Multilateral Initiative for Malaria Conference in Nairobi.  As a result, both Kenya and Nigeria formed associations. Now the ground is set for a true launching of the continent-wide association.

PAMCA President outlines development steps

The formal launching took place at the 6^th Pan-African Malaria Conference in Durban today. Chioma Amajoh, former Director of the Nigeria National Malaria Control Program (NMCP), chaired the event.

The PAMAC President, Charles Mbogo, outlined the steps in the formation of PMACA as seen in the photo. He also explained that strong ties with the World Mosquito Control Association and the American Mosquito Control Association would provide guidance in training and new tools for PAMCA and the new country chapters that will hopefully soon be formed.

Maureen Coetzee emphasized that PAMCA can develop new entomological talent

Maureen Coetzee of the Wits University in Johannesburg and a reknown entomologist gave the keynote address. She was worried about predictions that entomologists were going extinct and welcomed PAMCA as a way to foster new talent. She stressed the need for support for vector control, not just from the malaria community but also from the corporate world, examples of while have been presented at MIM2013, the different types of disease organisms ranging from viruses, filarial worms to plasmodia parasites were evidence of the huge job awaiting PAMCA. PAMCA as the umbrella to national chapters can liaise with the AMCA, for example, to develop better monitoring and evaluation tools and with country chapters to facilitate the registration and regulation of chemicals.

Michael MacDonald, Co-Chair of the Roll Back Malaria Vector Control Working Group emphasized the need for qualified vector control workers at national, provincial, district and local levels. As a consultant to WHO, he outlined new WHO publications on capacity building in vector control that can guide PAMCA.  Dr MacDonald also noted that PAMCA could help members take advantage of new technologies from Geographical Information Systems to mobile technologies.

Sam Awolowo a quiet but dedicated leader of Nigeria’s MCA

Sam Awolowo, President of the Nigeria Chapter lamented that their NMCP could find only 20 qualified medical entomologists in 2010 (although there were more in the agricultural sciences). He said that their chapter is working closely with the NMCP on technical committees as well as strategizing ways to create a arger pool of qualified vector control workers.

Finally the famous singer Yvonne Chaka Chaka, who is also a RBM Good Will Ambassador, lent her support to PAMCA in words and song. In her introduction the Chair noted that not only was she involved in the fight against apartheid in South Africa, but had now transferred her considerable energies to the battle against mosquitoes.

Yvonne Chalka Chaka and RBM Communicationms co-chair Louis da Gama carry the malaria message far and wide

Ms Chaka Chalka said that while she is happy to be some WOMen (well organized men), she would not want to be a female mosquito who carries malaria parasites. She observed that mosquitoes do not carry passports or visas, echoing the importance of cross-border transmission highlighted during MIM2013. She called on Africa’s leaders to train the young ones in skills to control malaria and mosquitoes and offered 100% support for PAMCA as it demonstrates Africans working together to help Africans.

Those who are interested and able to get involved, check out the www.pamca.org and join for the $40 membership fee.  Everyone should add their voices to the fight against malaria and mosquitoes in Africa.

Excerpts of opening session speech by Professor Rose Gana Fomban LEKE at 6^th MIM Pan African Malaria Conference looks at 15 years of the Multilateral Initiative for Malaria.

It’s been 15 years of promoting global co-ordination and collaboration in malaria research. In these years, MIM via its unique organizational structure consisting of multiple supporting mechanisms (MIM/TDR, MIMCOM, MR4 and MIMSEC) converging to strengthen researchers in malaria endemic countries, has been very influential in;

• Developing sustainable malaria research capacity in Africa through funding high quality research,
• Strengthening knowledge transfer between malaria research and control,
• Raising public awareness of the malaria burden and
• Promoting global communication and cooperation between organizations and individuals.

Importantly, MIM has played a significant role in attracting additional funds into malaria research and building research capacity in Africa. An assessment of the MIM/TDR research capability strengthening program in 2007 revealed that 69 competitive grants for research and training had been awarded to 56 African principal investigators working in 33 institutions across Africa. Most of the grants involved national and international collaboration and supported projects which focused on local priorities with potential impact on malaria control. With each grant awarded, funds were allocated to support masters and doctoral training.

A total of a hundred and seven PhD, 96MSc, and 15MPH students were trained within the projects. The projects also offered the acquisition of new skills, competencies through workshops and attachment to more advanced laboratories in collaborating institutions.  Some of the funded projects contributed to the pool of evidence that informed national decisions on;

1. Antimalarial treatment policy,
2. Insecticide resistance profiles and
3. New strategies for effective malaria control.

Likewise, MIM Com with the overarching goal of enhancing communication and internet connectivity, successfully established internet connectivity through satellite- based transmission in 27 sites across 14 countries throughout the African continent. Through the activities of MR4, several African research laboratories have benefited from the free reagents, participated in MR4 organized workshops on the management of reagents, proprietary and ethical issues and quality control for African malaria research laboratories.

The MIM has also created unprecedented opportunities for interaction between scientists across Africa, America, Europe and Asia. From its first meeting in Dakar, Senegal, the MIM meetings have grown in size and quality making it the convener of the largest malaria gathering in the world. What an amazing trajectory over the last 15 years!  This strong pool of researchers, program managers, bilateral and multilateral institutions facilitates discussions on issues in malaria research and control, sharing of results from findings, sharing of best practices, and the forging of new collaborations.