Kodjo Morgah, Eric M. Tchinda, and Naibei Mbaïbardoum of Jhpiego based in Chad and Cameroon have been building the capacity of health workers to use malaria data to improve services. A summary of their experiences as seen below is being presented at the 66th Annual Meeting of the American Society of Tropical Medicine and Hygiene.

Cameroon Malaria is the leading cause of morbidity and mortality in Cameroon, where an estimated 500,000 cases occur every year and led to 55% of hospitalizations and 241 deaths among pregnant women in 2010.

In order to measure the long-term impact of malaria prevention and treatment interventions at the facility level through outcome indicators, Jhpiego developed a data analysis process using an affiche de monitorage or data monitoring poster, which includes indicators on case management, suspected cases tested, intermittent preventive treatment for pregnant women (IPTp) and use of long-lasting insecticide-treated net (LLINs).

Jhpiego and the National Malaria Control Program (NMCP) with support from the ExxonMobil Foundation identified inadequate and irregular data collection and data use as a systemic problem throughout Kribi district. In response, Jhpiego developed and implemented training sessions on the data posters that focused on:

• the context and rationale for this type of data visualization
• techniques for data collection, analysis, and interpretation for decision-making, and
• practical sessions enabling health providers to practice mapping data onto the posters

In September 2015, Jhpiego introduced the posters in 26 health facilities in Kribi that were already trained in malaria prevention and case management interventions. Jhpiego then provided blank copies of the data posters and supported sites via biannual supervision visits during which they reviewed data posters for accuracy against facility registers.

Furthermore, supervisors assessed facility’s progress on their objectives, identified gaps and their causes, and discussed corrective actions. As a result of Jhpiego’s efforts by June 2017, 61% of the trained facilities use the data poster for decision-making. With the introduction of the posters, the percentage of health facilities that did not experience stock shortages increased by 17 percentage points, from 21% in October 2016 to 38% in March 2017.

Additionally, the Ministry of Health requested Jhpiego to lead a training of 181 health administrators and providers aimed at scaling-up the use of the data posters across all 9 districts of the South Region of Cameroon.

In the early days of the Ebola outbreak in West Africa much emphasis was placed on avoiding ‘bushmeat’. Health communications materials prominently featured monkeys, bats and deer (oh my!). In mid-2014 a Red Cross team went door to door in Kailahun province, the border region where Ebola first arrived in Sierra Leone on a sensitization mission, explaining to people exactly how the virus spreads and how to avoid it with three simple rules. “Rule three: Don’t eat bushmeat, the meat of wild animals.”

After thousands of deaths, it turns would that most likely only the December 2013 index case in the forests of Guinea was the only one that was associated with wild animals. The rest spread from human to human.

We are happy today that WHO has declared Liberia Ebola-free for the fourth time. With previous declarations from Guinea and Sierra Leone, the region does not have current transmission.

This is not a cause for letting down our guard. As Tolbert Nyenswah, head of Liberia’s Ebola response team, told Reuters, “the country had strengthened its surveillance and response capacity and its laboratory system since the start of the outbreak. We’ve proven we can contain the outbreak, we can intervene very swiftly,” said Nyenswah.

Science Daily reports from the University of Georgia, “Sexual transmission of Ebola is likely to impact course of outbreaks.” Data have shown that “viable Ebola virus remained in the semen of disease survivors for months after it was no longer detectable in their blood — and by a study reporting at least one instance of sexual transmission of Ebola.” Sexual transmission was hypothesized as “the source of Ebola transmission that killed a 17- year-old boy in Liberia” back in the summer of 2015 when another mini-outbreak occurred. As Annalisa Merelli reported, with the worst of the epidemic over, Ebola is essentially an STD.

Ebola is not the only tropical virus that has become an STD. While WHO notes that “Vector control is critical in substantially reducing the risk of Zika transmission … avoidance of unprotected sexual activity with a partner possibly exposed to Zika virus,” is also necessary. As of June 1^st, 11 out of 618 cases of Zika reported to CDC in the U.S. were sexually transmitted.

The lines dividing zoonotic, infectious and sexually transmitted diseases are blurring. The common thread is the need for strong surveillance systems and proper communication of research findings so that the public can protect itself.

As human population expands and people move into once seemingly remote wilderness, there is greater contact between people and various animals and the greater chance for the spread of zoonotic disease. The West African Ebola outbreak is a case in point.[i] Now as the Lunar Year of the Monkey has begun, it is an important time to highlight the potential of shared disease between humans and their primate cousins.

The most widely known form of malaria that people acquire from monkeys occurs in Southeast Asia, Plasmodium knowlesi. The blame has been laid squarely on the shoulders of deforestation caused by human expansion into what was previously the primary domain of macaque monkeys. The discovery of the parasite is credited to Giuseppe Franchini in 1927[ii]. Published studies in English date back to the late 1930s.[iii]^,[iv] and for the next seven decades the primary focus of most research was on the effect on monkeys themselves as well as use of the parasite to model human disease.

African primates have been implicated in malaria transmission also. Researchers working in Gabon foundPlasmodium falciparum, the most common species of malaria in Africa in the greater spot-nosed monkey (Cercopithecus nictitans).[v] Today wild chimpanzees and gorillas throughout central Africa are endemically infected with parasites that are closely related to human P. vivax, with the implication that, “All extant human P. vivax parasites are derived from a single ancestor that escaped out of Africa.” [vi]

Duval and colleagues studied malaria in chimpanzees and gorillas in Cameroon. They found that, “One chimpanzeePlasmodium strain was genetically identical, on all three markers tested, to variant P. ovale type,” found in humans.[vii]Again in Cameroon, Duval and co-researchers identified samples of Plasmodium species in gorillas and chimpanzees that related to Plasmodium falciparum.[viii]

As long as the potential for zoonotic malaria transmission from primates to humans exists along with the potential for adaptation of such parasites to humans and subsequent transmission among humans, our goals of eliminating malaria as a human disease by 2030 are at risk.[ix] Ironically it is human activity that heightens this risk.

To date it does not appear that primate to human malaria transmission is occurring in Africa. Unlike the Plasmodium knowlesi situation Southeast Asia, “African apes harboring parasites do not seem to serve as a recurrent source of human malaria.” This is an important finding and potential reprieve for ongoing control and eradication measures in Africa.[x]

In a broader context Faust and Dobson explain that, “The diversity and distribution of primate malaria are an essential prerequisite to understanding the mechanisms and circumstances that allow Plasmodium to jump species barriers, both in the evolution of malaria parasites and current cases of spillover into humans,”[xi] implying it is not a matter of if humans and primates might share malaria disease in Africa, but when it will happen on the scale seen in Southeast Asia.

[i] Pigott DM, Golding N, Mylne A, Huang Z, Henry AJ, Weiss DJ, Brady OJ, Kraemer MUG, Smith DL, Moyes CL, Bhatt S, Gething PW, Horby PW, Bogoch II, Brownstein JS, Mekaru SR, Tatem AJ, Khan K, Hay SI. Mapping the zoonotic niche of Ebola virus disease in Africa. eLife 2014;10.7554/eLife.04395. http://dx.doi.org/10.7554/eLife.04395

[ii] Franchini G (1927) Su di un plasmodio pigmentato di una scimmia (On a pigmented plasmodium of a monkey). Arch Ital Sci Med Colon 8:187–90. http://www.cabdirect.org/abstracts/19272901681.html

[iii] Coggeshall LT and Kumm HW. Effect of repeated superinfection upon the potency of immune serum of monkeys harboring chronic infections of Plasmodium knowlesi. J Exp Med. 1938 Jun 30; 68(1): 17–27. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2133656/

[iv] Eaton MD, Coggeshall LT. Complement fixation in human malaria with an antigen prepared from the monkey parasitePlasmodium knowlesi. J Exp Med. 1939 Feb 28;69(3):379-98. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2133745/

[v] F.Prugnolle, B.Ollomo, P.Durand, E.Yalcindag, C.Arnathau, E.Elguero, A.Berry, X.Pourrut, J-P.Gonzalez, D.Nkoghe, J.Akiana, D.Verrier, E.Leroy, F.J.Ayala and F.Renaud. African monkeys are infected by Plasmodium falciparum nonhuman primate-specific strains. PNAS, 4 July 2011

[vi] Liu W, Li Y, Shaw KS, et al. African origin of the malaria parasite Plasmodium vivax. Nature Communications. 2014; 5:3346, DOI: 10.1038/ncomms4346, www.nature.com/naturecommunications

[vii] Duval L, Nerrienet E, Rousset D, Sadeuh Mba SA, Houze S, et al. (2009) Chimpanzee Malaria Parasites Related to Plasmodium ovale in Africa. PLoS ONE 4(5): e5520. doi:10.1371/journal.pone.0005520

[viii] Duval L, Fourment M, Nerrienet E, Rousset D, Sadeuh SA, Goodman SM, Andriaholinirina NV, Randrianarivelojosia M, Paul RE, Robert V, Ayalak FJ, Ariey F. African apes as reservoirs of Plasmodium falciparum and the origin and diversification of the Laverania subgenus. PNAS 2010; 107(23): www.pnas.org/cgi/doi/10.1073/pnas.1005435107

[ix] Ouma C. How can we defeat malaria by 2030? World Economic Forum. Friday 11 September 2015. https://www.weforum.org/agenda/2015/09/how-can-we-defeat-malaria-by-2030/ (accessed 2016-02-20)

[x] Sundararaman SA, Liu W, Keele BF, Learn GH, Bittinger K, Mouacha F, Ahuka-Mundeke S, Manske M, Sherrill-Mix S, Li Y, Malenke JA, Delaporte E, Laurent C, Mpoudi Ngole E, Kwiatkowski DP, Shaw GM, Rayner JC, Peeters M, Sharp PM, Bushman FD, Hahn BH. Plasmodium falciparum-like parasites infecting wild apes in southern Cameroon do not represent a recurrent source of human malaria. Proc Natl Acad Sci USA. 2013; 110(17): 7020-5. doi: 10.1073/pnas.1305201110.

[xi] Faust C and Dobson AP. Primate malarias: Diversity, distribution and insights for

zoonotic Plasmodium. One Health 2015 1:66–75. http://dx.doi.org/10.1016/j.onehlt.2015.10.001

Many countries are updating their national malaria strategies because of changing global events. There has been a call for serious focus on malaria elimination by 2040. The United Nations has adopted the Sustainable Development Goals that calls for an end of epidemics and universal health coverage and the Global Fund is using national strategies as a basis for its new funding mechanism.

Kenya is no exception. Jhpiego’s Malaria technical Adviser, Augustine Ngindu, who also works with the USAID supported Maternal and Child Survival Program, reports on the launching of the revised version of Kenya’s National Malaria Strategy that takes us into 2018. His summary of the event follows:

Kenya over the last three decades has developed several malaria strategies, the first in 1981 to reduce malaria mortality and reduce prevalence among vulnerable groups; the second a national plan in 1992 to reduce morbidity and mortality by 30% by 2000; the third 2001-2010 to achieve the Abuja Declaration targets; fourth 2009-2017 with a performance monitoring plan to reduce the burden of malaria by use of combined effective interventions.

The revised Kenya Malaria Strategy 2009-2018 was launched by the Principal Secretary, Ministry of Health on 7^th November 2015. The KMS 2009-2018 is a product of the midterm review of the National Malaria Strategy 2009-2017. The midterm review was to address the emerging issues including devolution of health services from national to county governments, new initiatives like countries moving towards malaria elimination.

The revision of the KMS 2009 -2018 was informed by the Kenya Health Sector Strategic Plan 2014 -2018, the Kenya Health Policy 2012 – 2030, the Kenya Constitution of 2010. The revision was achieved through a series of consultative meetings involving multi-stakeholder and multi-sectoral participatory process led by national and county governments. Photos from the re-launching can be seen at the Kenya National Malaria Control Program’s Facebook Page.

The future KMS 2009-2018 strategic directions and priorities are –

1. Insecticide treated nets and indoor residual spraying to continue being the mainstay for vector control with an insecticide resistance management plan
2. Prevention of malaria in pregnancy to continue being provided only in malaria endemic counties
3. Increase in target population for case management from 80% -100% including development of a private sector case management strategy
4. Strategies for expanding surveillance for purposes of epidemic preparedness and response in seasonal and low risk malaria zones.

The main challenges remain human resource and health commodity security especially in a state of devolved health services.

The Star Newspaper of Kenya also informs us that, “It will cost the government Sh57 billion to implement its revised malaria strategy from this year to 2018.” They also note that, “The changes in the strategy include the adoption of universal access to testing and treatment and expansion of malaria epidemic preparedness.”

Fortunately, Kenya’s malaria burden has been falling and focal areas of higher transmission have been identified to strategic advantage. We look forward to learning more about other countries’ efforts to update their malaria strategies.

This study was undertaken in seven US President’s Malaria Initiative supported Nigerian States through the Malaria Action Program for States (MAPS) project. Authors include Abiodun Ojo, Bolatito Aiyenigba, Sonny Johnbull, Adamu Onu, Olabanji Ipadeola, Muhammad Salihu, Kolawole Maxwell, Ebenezer Baba, and Abba Umar. Their presentation appeared at the recent annual meeting of the American Society of Tropical Medicine and Hygiene.

The private sector’s role in health services in Nigeria has increased in recent times, and provides approximately 60% of health services. The PMI Malaria Action Program for States (MAPS) project currently supports the implementation of parasitological confirmation of malaria cases in public health facilities only in selected states. A mapping exercise was carried out to identify private facilities providing malaria diagnostic services and determine the gaps in existing malaria diagnostic capacity with the aim of designing a strategy for improvement

Questionnaires were administered to the private health facility owners and location data collected using handheld Global Positioning System (GPS) device. Data were collected from all private health facilities in the state capital of each MAPS supported states (Benue, Cross River, Ebonyi, Kogi, Nasarawa, Oyo and Zamfara) in October 2013.

The questionnaire was designed to assess human resource capacity, method of malaria diagnosis and patient/client workload in the health facility. Data collectors and supervisors were trained on tools and methodology of the survey.

Results revealed that 394 private health facilities in 7 state capitals were mapped. Only 24.6% health workers had received training on malaria diagnosis in the last 12 months preceding the survey, while 35% had no formal or on-the?job training.

Seventy-one health facilities had no routinely available malaria diagnostic services; 55 (77.5%) of these, referred patients to other health facilities where there is availability of malaria diagnosis, 6 (8.5%) prepared microscopy slides and sent to other laboratories for malaria examination, and 10 (14.1%) took no diagnostic action.

Using outpatient and laboratory statistics for the 3 months preceding the survey we found that the overall prevalence of clinically diagnosed malaria in the outpatient clinics was 70.3%. The malaria slide positivity rate was 78.8%. An antimalarial drug was prescribed on average 1.2 times out of every 10 negative malaria test results.

A good pool of human resources exist in private health facilities and their capacity needs to be built on malaria diagnosis especially mRDT for non laboratory staff. Quality of malaria microscopy could be improved with re?training of Laboratory Scientists.

A policy framework that provides for access to quality malaria diagnostic services and commodities while also creating an enabling environment for use of diagnostic results is needed to support the massive scale up of campaigns for malaria control towards elimination

[The contents of the poster/presentation are the responsibility of the Malaria Action Program for States Nigeria and do not necessarily reflect the views of the US Government.]

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.