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Achieving, Tracking, and Maintaining High ITN Coverage: Community Strategies

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.

Nets distributed by MCP partners smMCHIP 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.

MCP nets vs national trend smCollaborative 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.

Working together towards success in controlling malaria in Huambo Province, Angola

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.

DSCN7723smMalaria 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.

Number of malaria cases and deaths, HuamboFactors 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.

Mass Screening And Treatment Of Malaria, An Intervention In Flood Disaster Situation, Bayelsa State, Nigeria

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.

IMG_1382 (1024x768) aNigeria 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.

Pan-African Moquito Control Association Launches at MIM2013

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

PAMCA President outlines development steps

The formal launching took place at the 6th 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 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.

PAMCA CAM01482Michael 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 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

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 and join for the $40 membership fee.  Everyone should add their voices to the fight against malaria and mosquitoes in Africa.

Jhpiego at MIM2013 – Harmonizing Malaria in Pregnancy Guidance: A Review from 5 African Countries

Elaine Roman, Patricia Gomez, Aimee Dickerson from Jhpiego (An Affiliate of Johns Hopkins University) and MCHIP developed the following abstract for a poster presentation at MIM2013 in collaboration with the US President’s Malaria Initiative. A copy of the full report is available at MCHIP.

MIP 5 country doc reviewsmThirty-nine countries in sub-Saharan Africa have malaria in pregnancy (MIP) policies in place, including intermittent preventive treatment (IPTp), insecticide treated bed-nets (ITNs) and effective case management.  Nonetheless, IPTp and ITN coverage among pregnant women remains well below international goals.  MIP policies are typically produced by National Malaria Control Programs (NMCP), but are implemented by National Reproductive Health Programs (RHP).

We reviewed MIP policy documents from the NMCP and RHP in Kenya, Mali, Mozambique, Tanzania and Uganda to understand 1) how closely national MIP documents reflect  WHO MIP guidance and 2) how consistent documents produced by the NMCP and RHP are with each other.  We developed a framework to compare MIP documents from RHP and NMCP according to WHO guidance for MIP, including IPTp timing and dosing, directly observed therapy, linkages to HIV prevention programs, promotion and distribution of ITNs, and diagnosis and treatment.

All countries have national documents promoting IPTp, ITN use, and case management of MIP.  WHO guidance was not always reflected in these documents: four countries restrict dosing of the first and second IPTp doses to specific gestational weeks, provide inconsistent guidance on MIP prevention in HIV+ women, and fail to provide clear guidance on the different antimalarial treatment that should be administered in the first vs. later pregnancy trimesters. .  All countries had discordant guidance between RH and NMCP in at least one official MIP guidance document.  For example, all countries had conflicting guidance on the timing or dosing of SP and the mechanism pregnant women should use to obtain ITNs. Considerable discrepancies exist between MIP guidance documents from NMCP and RHP.

These discrepancies contribute to confusion by health workers implementing MIP programs, contributing to the low coverage of IPTp and ITNs.  Harmonization of national MIP documents is urgently needed, with effective re-orientation and supervision of health workers to updated materials to help accelerate implementation.  While this review is targeted primarily at country level stakeholders, the information is important for regional and global level stakeholders as well.  This exercise is being repeated in other President’s Malaria Initiative countries.

MIM 2013 Opens – MIM Chair Speech

MIMExcerpts of opening session speech by Professor Rose Gana Fomban LEKE at 6th 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.

Disease Eradication: Somalia Then and Now

In 1978 the US Centers for Disease Control and Prevention reported that, “As of April 14, 1978, no cases of smallpox have been reported to the World Health Organization (WHO) from anywhere in the world since the last case had onset of rash on October 26, 1977, in Merka town, Somalia. However, a total of 2 years of effective surveillance must elapse before this last endemic area can be confirmed to be smallpox-free.” Thirty-five years later Somalia is linked with difficult efforts to eradicate another disease, polio.

Now unfortunately, “Somalia hadn’t had a case of polio for nearly six years. But in the past few months, the virus has come back,” according to National Public Radio (NPR)  In fact the 73 cases reported from Somalia so far this year, surpasses the 59 cases reported in the rest of the world. NPR further notes that, “Somalia has the rate of polio vaccination in the world after Equatorial Guinea, according to the World Health Organization.”

Thirty-five years ago, challenges hampering disease eradication were the natural environment. “During October and November surveillance in Somalia has been severely hampered by heavy rains that have made it difficult or impossible to travel by vehicle. Since work has had to be continued on foot, there have been some delays in reporting and incomplete search coverage in certain areas,” CDC reported.

Today it is human conflict, not the weather, that inhibits control. NPR’s report notes that, “The Somali government directs the campaigns, but it doesn’t control or have access to vast swaths of the country. Some of the most recent polio cases have occurred in areas that are considered off limits to vaccination teams.” Conflict in Pakistan in December-January also tried to create off limits areas by killing polio workers.

Because polio is a fecal-oral disease it spreads with people. Not surprisingly, cases are appearing in Somali refugee camps in Kenya.  All countries in the region are on alert as extra vaccination efforts will be needed. And as NPR observes, this may draw resources from countries like Nigeria that are very close to eliminating the disease.  Ironically the polio virus strain found in Somalia was traced to Nigeria.

pf_mean_2010_som-sm.jpgPolio cannot be easily compared with malaria which has a vector, and also an larger arsenal of effective tools – insecticide treated nets, indoor residual spraying, chemo-prevention drugs, rapid diagnostic tests and effective medicines.  But the diseases face similar challenges that are more often human than deriving from the natural environment.  Human conflict deters malaria control in eastern Democratic Republic of the Congo, in the Central African Republic and in South Sudan.

Unlike for polio, we are not even close to numbering malaria cases in the dozens, but the as the recent Abuja Summit has shown, we must have the political will to rise above conflict and inefficient health systems and face down these devastating diseases.

(PS – fortunately as we can see in the attached map, malaria is not a pressing problem in Somalia.)

Tribute to Professor Celestine O. Onwuliri

Professor Oladele Akogun ( of the University of Common Heritage Foundation and the Federal University of Technology, Yola, Nigeria pays tribute to his colleague Professor CO Onwuliri

The death has been announced of one of Nigeria’s leading parasitologists, Professor Celestine Onwuliri in the DANA Air crash in Lagos earlier this month.  Professor Onwuliri taught helminthology at the University of Jos, where he made significant contribution to the epidemiological mapping and control of onchocerciasis in Nigeria.

epid-and-psycho-social-impact-osd-sm.jpgHe also trained many parasitologists who now hold positions in academics and policy both in Nigeria and overseas. Professor Onwuliri has also carried out research on malaria in recent times.

Professor Onwuliri was the President of the Nigeria Society for Parasitology in the mid-90s. He has also served as Commissioner in the government of Imo State, Nigeria. He was a university administrator holding position of Deputy Vice Chancellor and Acting Vice Chancellor at the University of Jos before his penultimate appointment as Vice Chancellor of the Federal University of Technology, Owerri.

His most recent position was at the National University Commission (NUC). He was a fellow of the Parasitology and Public Health Society of Nigeria and a member of the Nigeria Academy of Science.  With his departure the Parasitology community will miss one of its most beloved academics and leaders.