The Long and Winding Worm, 1986-2018

Recent reports draw attention that Guinea Worm persisted in small numbers in 2017 in two countries, Chad and Ethiopia. Mali and South Sudan were the only other two countries monitored because of recent cases, but each reported none for 2017.

Guinea Worm Wrap-Up #251

We recall that 32 and 23 years have passed since the challenge to eradicate the disease was posed and the hoped for date of eradication was to be achieved. There is no doubt that the 30 cases reported in 2017 is a gigantic drop from the 3.5 million estimated globally when the war on the worm started in 1986.

To date eradication has been achieved for only small pox (though its reemergence from labs as a potential biological war agent is feared). Could it return as global warming melts permafrost (and bodies) in the permafrost of northern latitudes?

Besides Guinea Worm, only polio and malaria have received calls for eradication (malaria for the second time in history). One wonders if even small pox could be eradicated in today’s world of conflicted and failed states – the last case of smallpox was in Somalia. Both Ethiopia and Chad border South Sudan’s civil conflicts.

What had made guinea worm, like smallpox, imminently eradicable was the fact that humans were the main reservoirs of infection (not counting the defenseless crustacean, the cyclops, that served as an intermediate host for work larvae). That has not changed. WHO observed that in Ethiopia both baboons and dogs have been infected with guinea worm in the same communities where humans suffer from the disease. While it was possible to ‘contain’ the infection in dogs, that is preventing them from contaminating water supplies, it was not surprisingly difficult to do the same for baboons. The dog problem has existed in Chad for at least 5 years.

Another problem in Ethiopia was the infection of seasonal laborers who could potentially take the disease back to other areas of the country. Although a system of rewards had been put in place this did not lead to the timely identification of all cases by either community members or health workers.

The road to disease eradication is clearly not a straight line from A to B. The twists and turns should be expected as time passes because ideally an eradication should be a short-term effort that is time-limited in order to provide a clear focus and adequate funding on the end goal.

What are the implications for malaria and polio? Conflict led to the hiding of polio cases in Nigeria and longer term efforts allowed vaccine derived poliovirus to emerge. Malaria is now found in Monkeys in Malaysia and Brazil, and parasite resistance to medicines and vector resistance to pesticides threatens effective interventions.

Time is not a commodity that favors eradication. In these days of plateauing financial support for global health, the call for eradicating deadly and economically debilitating infections needs to be louder.

Comprehensive Cholera Prevention and Control: Lessons Learnt from the United Republic of Tanzania

Dafrossa Lyimo of the Ministry of Health, Tanzania presented Tanzania’s experience in preventing and controlling cholera at the 4th African Regional Immunization Technical Advisory Group (RITAG) meeting in Johannesburg, 5-8 December 2017. Those experiences are summarized below.

Cholera outbreak in Tanzania started with the index case detected in Dar es Salaam Region on 6 August 2015. The World Health Organization was notified by Ministry of Health on 15 August 2015. By 31 December 2015 the outbreak spread to 22 out of 26 regions in Tanzania Mainland. Zanzibar started reporting cholera cases on 20 September 2015 from Urban West District in Unguja Island. By December 2015, the outbreak spread to all 10 districts of Pemba and Unguja.

Cumulative cases on the Tanzania Mainland were 12 619 cases with 199 deaths (CFR 1.57%) in 2015, 11 360 cases with 172 deaths (CFR 1.5%) in 2016, and up through Nov 2017, 3 615 cases with 61 deaths (CFR 1.7%). Likewise the Cumulative cases in Zanzibar were 1 143 cases with 15 deaths (1.31%) in 2015, 3 187 cases with 53 deaths (CFR 1.66%) in 2016 and as of Nov 2017, 358 cases with 4 deaths (CFR 1.12%). The last case reported 11 July 2017

Best practices for controlling cholera in the country fall in four domains. In the area od Coordination Tanzania established a Public Health Emergency Operations Centre (PHEOC) in the Ministry of Health. To support this the Ministry appointed an Incident Manager, Deputy Incident Manager, and a PHEOC Manager for the cholera outbreak response. The National Task force Team was established with a wider composition which meeting every Friday discussing issues and giving way forward. National Rapid Response Teams were trained. these teams worked based on national response guidelines which were developed and distributed to all districts.

In the domain of Surveillance, the Ministry initiated a Daily Situation Report (SITREP) for sharing a daily cholera status in the regions and districts , on going interventions and gaps. This group conducted twice a country wide data validation/verification of the reported cases in 17 regions, which also confirmed under-reporting of cases. A Cholera reporting line list register was designed and printed in booklets and distributed to 26 regions in the Tanzania Mainland, to standardize reporting from districts and regions.

The third domain consisted of Water Sanitation and Hygiene interventions. The country distributed 21,600,000 aqua tablets of water guards in 514,285 households. Also distributed were 50 drums 45kg each of 70% High Test Hypochlorite to 83 district water authorities for bulk chlorination. Twenty hand pump boreholes were installed in hotspot villages of Mara and Mwanza regions, thereby Improving the access to clean and safe water. One hundred HACH chlorine testers were distributed for monitoring free residue chlorine in cholera reporting districts.

Social Mobilization was the fourth domain. Cholera leaflets and fliers were designed and distributed in reporting districts. Cholera messages were developed and aired through community media and mobile phone messaging. Community engagement and owning cholera interventions was undertaken using the community social networks and peer groups who focused on Hand washing, Use of treated water, and Use of toilets behaviors.

Cholera control and prevention efforts addressed various Challenges
in Tanzania. one concern was a weak surveillance system starting at the district level in several districts. Lack of reporting cholera cases, under-reporting and late reporting occurred. In some districts that had laboratory capacity, only positive cases were reported, but generally there was inadequate laboratory capacity to test and confirm Vibrio. This meant that samples had to be transported to regional laboratories (long turn around time)

A second challenge was Weak coordination at the region and District level. A third was Inadequate and poor access to WASH. this included a Limited supply of clean and safe piped water in most of districts. Thus 52% of rural population get water from unimproved sources. (Shallow wells, river, lakes and few deep wells). In urban settings, water utilities can supply water not more than 50% and still chlorination is not regularly done. there was low latrine coverage especially in rural areas. About 73% of rural population use unimproved latrines and 13% with no latrines. A fourth challenge was the Misconceptions about cholera causation and some of the interventions.

In the process of addressing these challenges several Lesson were learnt. First, a well established surveillance system helped to in the early notification of cases and quick response. Strong coordination at all level of response is important to ensure the control of outbreak is done on time. Effective social mobilization and community engagement helped in the behaviour change towards the control of cholera. Finally Adequate and good access to WASH ensured the control of spread of cholera

Tanzania has put together a comprehensive cholera prevention program based on surveillance, coordination, water & sanitation and social mobilization. While cases have reduced, Tanzania is not relenting in implementing these key interventions.

Experiences in Vaccine Procurement for Middle Income Countries: the Swaziland Experience

Njabuliso Lukhele of the Ministry of Health Swaziland shared Swaziland’s experiences in Vaccine Procurement at the recent Regional Immunization Technical Advisory Group (RITAG) Meeting, Johannesburg, South Africa, 05-08 December 2017. A summary of his presentation appears below.

As a Lower Middle Income Country (MIC), Swaziland is not and has never been eligible to receive financial support for its immunization programs through the GAVI Alliance. Therefore, 83% of the health care budget is financed through domestic sources, and only 17% comes from from WHO and UNICEF.

Swaziland has a comprehensive Multi-Year plan (cMYP) that drives investment in immunization covering the period 2017–2021. The Government of Swaziland has been fully funding 100% of vaccine costs and average 96% of routine immunization costs over the last years. The Government of Swaziland procures vaccines and distribute to all service providers (government, regional referral and mission hospitals, public as well as private sector clinics and health facilities).

The vaccine Procurement Process begins as Requisitions are sent by Expanded Program of Immunizations (EPI) unit to the procurement unit through the chief pharmacist through documented minutes. This Minute is approved by the Financial Controller (FC) acknowledging availability of funds to furnish the procurement of the vaccines. Then a Tender document is drafted by both the EPI and procurement unit. Advertisement of tender document then takes place. Tender runs for 30 days as per procurement policy. Procurement of vaccines is done through open tender.

The 5 top vaccines (PCV, IPV, OPV, Rota, Penta) in Swaziland represented 98% of the total costs in 2015-16. While this is a major internal financial obligation, Vaccine procurement for the relatively small population of Swaziland represents approximately 0.2 percent of the overall African market by volume and about 0.4 percent by value. This puts smaller countries at a disadvantage in terms of getting good pricing and negotiating with suppliers.

Swaziland was one of the first countries for the Middle Income Country (MIC) strategy mission The MIC strategy mission recommended the need on generating efficiencies in the management of the programme, in particular in the area of procurement, with a need to explore pooled procurement as well as other options with the aim of maximizing savings on the high costs of vaccines. Government desires to achieve economic efficiency in procurement and consideration of pool procurement mechanism.

The current supplier charged 81,256,196.50 Swaziland Lilangeni (SZL) or roughly $5.8 million for the total package of vaccines needed in 2016. If UNICEF were to provide the same package it would cost SZL 62,215,336.34. or $4.5 million. While commercial suppliers can be paid on delivery, UNICEF requires approval from Ministry of Finance for the advance payment with the need to make sure the funds are sufficient for full payment.

This comparative information had valuable advocacy effect. Earlier this year (2017) a MOU signed between MOH and UNICEF. A commitment letter was sent to UNICEF supply division. Now Swaziland has a more reliable supplier and a more affordable cost, enhancing the Ministry’s capacity to save lives of its citizens. Swaziland can also serve as an example for the many other MICs and countries who are ‘graduating’ from GAVI support.

Prof Lateef A Salako, 1935-2017, Malaria Champion

Professor Lateef Akinola Salako was an accomplished leader in malaria and health research in Nigeria whose contributions to the University of Ibadan and the Nigeria Institute for Medical Research (among others) advanced the health of the nation, the region and the world. His scientific research and his over 140 scientific publications spanned five decades.

His research not only added to knowledge but also served as a mentoring tool to junior colleagues. Some of his vast areas of interest in malaria ranged from malaria epidemiology, to testing the efficacy of malaria drugs to tackling the problem of malaria in pregnancy. He led a team from three research sites in Nigeria that documented care seeking for children with malaria the acceptability of pre-packaged malaria and pneumonia drugs for children that could be used for community case management. Prof Salako was also involved in malaria vaccine trials and urban malaria studies.

As recent as 2013 Prof Lateef Salako, formerly of NIMR said: “It is true there is a reduction in the rate of malaria cases in the country, but to stamp out this epidemic there is the urgent need for a synergy between researchers, the government, ministries, departments and agencies and involved in malaria control. That will enable coordinated activities that will produce quicker results than what obtains at the moment.”

At least one website has been set up where people can express their condolences.  As one person wrote, “Professor Lateef Salako was an exceptional student, graduating with distinction from medical school; an unforgettable teacher, speaking as a beneficiary of his tutelage; an exemplary scholar, mentoring many others; an accomplished scientist, making indelible contributions to knowledge. May his legacy endure.”

Readers are also welcome to add their own comments here about Prof Salako’s contribution to malaria and tropical health.

Oral Cholera Vaccination in Emergencies: Experiences from Freetown, Republic of Sierra Leone

Dr Denis Marke, CH/EPI Program Manager at the Sierra Leone Ministry of Health shared his experiences from a recent natural disaster at the WHO African Regional Immunization Technical Advisory Group meeting in Johannesburg, 5-8 December 2017. Below find his observations.

Heavy rains occurred in the early hours of 14th August 2017 that resulted in flash floods and mudslides that affected three communities (Sugar Loaf, Motomeh, and Kaningo) in the Western Area districts. The mudslides and flash floods blocked water ways and contaminated water sources in several low lying communities of Freetown, the capital city. Both mudslides and flooding destroyed houses, killing many people and displacing thousands of people. In addition, water and sewerage infrastructure were damaged.

Data collected from the emergency operations centre set up to manage the incident showed that 496 people died (168 females, 171 males of which 157 children). An additional 5,905 people were registered as displaced. The WHO assessment classified the incident as a Grade 1 emergency.

In analysis of health risks likely to affect the displaced people, cholera was ranked high on the account that there had been no confirmed Cholera outbreak since 2012. All historical outbreaks of cholera were analyzed and documented to a) Sierra Leone had had a history of 9 cholera outbreaks between 1970-2012; b) large outbreaks with case counts above 20,000 had occurred in 1994/5 and 2012; c) improved case-fatality ratios due to improvements in Health Worker skills and competencies in case management; d) almost all cholera epidemics occurred or peaked in the rainy season and e) shortening inter-epidemic periods, and thus another Cholera outbreak had been predicted since 2016.

A preventive Oral cholera vaccination concept for prevention of Cholera in Sierra Leone as part of the interventions in the emergency was mooted by WHO as the lead agency supporting the emergency response. A technical proposal for Oral Cholera vaccination was developed, presented and discussed at the Emergency Operations Centre and approved by the Ministry of Health and Sanitation. Support to implement the Oral Cholera vaccination was received from the Global Outbreaks and Alert Network, ICG, GAVI, UKaid, PIH and MSF.

Preparations for Oral Cholera vaccination broke records in terms of speedy planning and implementation. The OCV concept note was developed and approved by the MOH in 9 days. A proposal and request for OCV was approved by ICG in 72 hours. And the approved OCV doses were delivered in-country in 10 days. The national Regulatory Authority gave a waiver of vaccine registration, on the account of WHO pre-qualification and procurement through UNICEF supply division, and the OCV campaign conducted within 7 days of vaccine receipt. Notably, this was the FIRST cholera vaccination campaign EVER conducted in Sierra Leone and FIRST for that matter in an emergency.

The Objective of the OCV campaign was to provide two OCV vaccination doses to at least 95% of populations above 1 year of age living in communities affected by floods and mudslides and vulnerable populations in slums. The campaign took place in two rounds conducted on 14th – 19th September 2017 (first dose) and 5th – 10th October 2017 (second dose).

The Target Population for the Oral Cholera vaccination was all people aged >1 year resident in flood affected and slum communities of Western Area (Urban/Rural). Based on population projections for the affected communities, the estimated target was planned as 539,692 individuals.

The Oral Cholera vaccine delivery strategy was based on experiences from Oral Polio SIAs and it included four approaches: 1) House to House; 2) Schools-based temporary vaccination sites; 3) Fixed site at 22 affected Peripheral Health Units and 4) Outreach/mobile vaccination posts in camps of displaced people.

Overall the OCV Campaign reached 96.1% of the target population in the first round and 100% in the second round.  Post campaign independent monitoring documented that the overall coverage was slightly lower than was reported using the administrative reporting system. Independent monitors also documented that the main reasons for accepting vaccination were a) health information given out by health workers about the dangers of cholera, b) assurance from health workers and community leaders that the vaccine was safe. Unlike all previous Polio vaccination campaigns, radio, community social mobilizers, health workers and TV were the main source of information about the campaign.

Where non-vaccinated people were found, the major reasons were a) Poor H2H team movements and penetration; b) absence of beneficiary; c)  Acute sickness and d) unaware of vaccination dates/time. The poor team performance was attributed to the challenging terrains and clogged roads.

To verify community coverage, a post OCV Verification Survey was conducted from 21- 29 October 2017 in 140 clusters (enumeration areas). In total 2,908 Households studied and 6,987 individuals interviewed. Among people vaccinated 31.1% received only one dose and 68.6% received two doses.

In addition to oral cholera vaccination, Sierra Leone a) provided standard case definitions for cholera and trained camp commanders in the displaced populations to improve early detection of suspected cases; b) Updated and disseminated case management guidelines before conducting refresher training of case-management teams; c) Procured and prepositioned transport media for stool samples to be taken from suspected cases; d) Stock-piled and prepositioned at least 1 cholera case management kit; e) developed and disseminated IEC materials before conducting community engagement meetings with 48 Ward Councilors, 100 Market women, 120 teachers, 60 religious leaders and 40 CBO staff and f) Assured inclusion of cholera preparedness and response as a standing agenda of all EOC coordination mechanisms

This preventive effort not only kept cholera out of the area but also strengthened capacity to respond to future outbreaks and preventive campaigns. Coordination mechanisms have been established, vaccinators have been trained. Behavior change communication messages have been developed and a monitoring mechanism was tested to verify post-intervention results.  Coming out of the Ebola epidemic of a few years ago, Sierra Leone is encouraged by its new abilities to respond to emergencies and prevent outbreaks.

We acknowledge the assistance of Dr William Baguma MBABAZI, Medical Epidemiologist, EPI/WHO Sierra Leone, in the preparation of this posting.


Challenges in achieving Maternal and Neonatal Tetanus Elimination: South Sudan Experience

Dr. Anthony Laku who is currently the Immunization Program Officer in the South Sudan Ministry of Health presented the status of efforts to eliminate maternal and neonatal tetanus (MNT) in South Sudan at the fourth meeting of the WHO Regional Immunization Technical Advisory Group held 5-7 December 2017 in Johannesburg, South Africa. A summary of key challenges is shared below.

General Challenges to health delivery in South Sudan include a Maternal Mortality Ratio of 2054 per 100,000 live births. Also ~56% of population are not reached by Health Facilities; 60% of roads not accessible for half of the year; 45% of people live without access to safe water; and 86% of women have no formal education.

Delivery of immunization is hampered by persistent insecurity and inaccessibility. As of 31st August 2017, 7.5 million people are affected, and 3.9 million people are displaced, of which 2 million are in neighboring countries. The health services have varying degrees of difficulty in reaching the displaced people with immunization services.

Key strategies to eliminate MNT are as follows:

  • Three doses to all Women of Reproductive Age (WRA) using supplementary immunization activities (SIAs)
  • Provision of at least two doses of tetanus containing vaccines (TT) to all pregnant women and in high-risk areas
  • Promotion of clean delivery services for all pregnant women, and
  • Effective surveillance for MNT

So far the results have been below the targets for elimination. For example, 61% of 80 counties had less than 80% coverage in the third Round of Tetanus Containing Vaccines SIAs with 27/80 counties not reached at all. There was low estimated routine immunization (Penta3) coverage of only 26% in 2016. A limited number of skilled staff were available to ensure clean cord delivery (5% skilled delivery) with challenging implication on MNT elimination validation.

The protracted civil crisis in the country creates an uphill task for reaching key global targets including MNT elimination. Weak economic status in the country has had a ripple effect on staff motivation and commitment (e.g. delayed salaries).

Additional strategies were adopted for coverage improvement in 2017. A “Hit and Run” strategy was developed for insecure areas. Periodic Intensification of Routine Immunization was used in areas of intermittent crisis and or with high buildup of unimmunized populations. Overall the MNT elimination strategic plan was updated for 2018–2022.

Funding gaps exist for this new strategic plan with only 21% of needed finance is pledged. One approach to funding is aligning MNT elimination with funding in related areas such as the RMNCAH and Nutrition strategy and the Human Resource for Health Strategy. Despite these challenges South Sudan is persisting in efforts to eliminate MNT.

Community Based Intervention in Malaria Training in Myanmar

Nu Nu Khin of Jhpiego who is working on the US PMI “Defeat Malaria Project” led by URC shares observations on the workshop being held in Yangon with national and regional/state malaria program staff to plan how to strengthen malaria interventions at the community level. The workshop has adapted Jhpiego’s Community Directed Intervention training package to the local setting.

Yesterday’s opening speech was being hailed as a significant milestone to give Community-Based Intervention (CBI) training teams the knowledge, skills, and attitudes they need to effectively provide quality malaria services and quality malaria information.

This core team is going to train the critical groups of community-level implementers including CBI focal persons and malaria volunteers at the community level.

We embarked this important step yesterday with the collaboration of Johns Hopkins University, Myanmar Ministry of Health and Sports, and World Health Organization Myanmar.

Participants will be developing action plans to apply the community approach to malaria efforts in townships and villages in three high transmission Rakhine State, Kayin State and Tanintharyi Region.

Improving intermittent preventive treatment for pregnant women (IPTp) coverage in 5 districts in Chad and Cameroon

Kodjo Morgah and Naibei Mbaïbardoum of Jhpiego with support from the ExxonMobil Foundation ave been working to increase interventions that protect pregnant women from malaria. The results below were shared at the 66th Annual Meeting of the American Society of Tropical Medicine and Hygiene.

Malaria is the leading cause of morbidity and mortality in Cameroon and Chad, where an estimated 500,000 and 1.5 million cases occur every year, respectively. In Cameroon, 55% of hospitalizations and 241 deaths among pregnant women reported in 2010 were due to malaria. In Chad, malaria accounted for 30% of hospital admissions and 41% of deaths among pregnant women in 2013.

To improve uptake of intermittent preventive treatment for pregnant women (IPTp) for malaria in 5 districts in Chad and the Kribi district of Cameroon, Jhpiego adopted strategies targeting the 4 levels of the health system in each country: updating national policies and guidelines, building capacity of providers, building community health workers’ (CHWs) capacity, and engaging in behavior change communication.

Nationally, Jhpiego provided technical guidance to the Ministries of Health to develop tools including: training and malaria in pregnancy (MIP) reference manuals for providers and CHWs, guidelines on IPTp, and key supervision and data collection tools. At the regional/district levels, 38 supervisors were trained, and they conducted 248 supervisory visits in both countries, reaching 137 health facilities.

At the facility level, 234 providers were trained in malaria prevention and management, MIP, data collection and commodity management. At the community level, 146 CHWs in both countries were trained to raise awareness on malaria prevention and control.

In Chad, CHWs referred 6424 pregnant women for antenatal care/IPTp and 11679 pregnant women for malaria treatment in 2014 and 2015. Health facility and CHW data collection tools were revised and monthly validation of district data was implemented to improve data reliability, completeness, and readiness.

As a result of Jhpiego’s activities in Kribi, IPTp rates increased from the start of the project in 2012 to 2015: from 70% to 83% (IPTp1), 61% to 80% (IPTp2), and 12.7% to 28.1% (IPTp3). Similarly, from 2012 to 2015 in Chad, IPTp1 rates increased from 40% to 83% and from 30% to 50% for IPTp2. These gains are a result of training paired with coaching and supervision activities of trained providers and targeted facilities.


Results of an evaluation of the Toolkit to Improve Early and Sustained Intermittent Preventive Treatment in Pregnancy (IPTp) Uptake in Mozambique and Madagascar

Lalanirina Ravony, Elana Fiekowsky, Lisa Noguchi, Patricia P. Gomez, Jean Pierre Rakotovao, Eliane Razafimandimby, Armindo Tiago, Kathryn Smock, Arsene Ratsimbarisoa, Kristen Vibbert, and Robert Sellke shared their efforts to apply a toolkit to enable health providers to ensure better uptake of intermittent preventive treatment for malaria during antenatal clinics. As seen below, they presented their findings at the 66th Annual Meeting of the American Society of Tropical Medicine and Hygiene.

Malaria in pregnancy (MIP) is a leading cause of maternal and newborn morbidity and mortality; however uptake of intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP), an effective prevention tool, remains alarmingly low across sub-Saharan Africa, including Mozambique and Madagascar.

The WHO 2012 policy recommendations to prevent MIP include early enrollment into antenatal care (ANC), accurate estimation of gestational age (GA) and administration of IPTp-SP during ANC visits beginning early in the second trimester, spaced at least one month apart. Preventing MIP remains a challenge in settings with inconsistent application of these recommendations and inadequate provider training in estimating GA.

To improve adherence to these recommendations, a toolkit was designed which includes a job aid with an algorithm to guide providers during ANC visits to determine IPTp-SP eligibility. Twenty-four providers from 24 facilities in Madagascar and 29 providers from seven facilities in Mozambique were trained on use of the job aid and interviewed three months later about their experience.

Individual providers were interviewed using a questionnaire to assess the clarity and utility to the job aid, and their opinions of the practicality of the orientation. Interviewers also gathered information on years of experience and clinical certification. All providers reported that the job aid reminded them to estimate GA and measure fundal height, which is particularly helpful since few women remember the date of their last menstrual period (LMP).

Health workers also reported that the job helped them encourage the use of long-lasted insecticide treated nets, and reminded them of the proper timing to start IPTp-SP. We conclude that the toolkit is useful to prompt providers to calculate GA and offer IPTp as early as possible in the second trimester.

Future potential directions include revision of all Toolkit components to reflect input from this evaluation, including development of a wall poster version to enhance readability, and inclusion of a pregnancy wheel to facilitate calculation of GA and estimated date of delivery.

This poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of the Maternal and Child Survival Program and do not necessarily reflect the views of USAID or the United States Government.

A New Approach for provider performance improvement with Clinical and Quality Assurance Components in Moramanga, Madagascar

Norohaingo Andrianaivo, Eliane Razafimandimby, Jean Pierre Rakotovao, Marc Eric Rajaonarison Razakariasy, and Lalanirina Ravony share their presentation on ensuring standardized malaria in pregnancy service delivery in Madagascar. The poster was viewed at the 66th Annual Meeting of the American Society of Tropical

Malaria is endemic in 90% of Madagascar. However, the entire population is considered to be at risk for the disease, with pregnant women particularly vulnerable. Madagascar adopted the IPT in pregnancy policy in 2004.

The Malaria Indicator Survey in 2016 in Madagascar showed only 10% of Malagasy pregnant women receiving three doses of SP (IPT3). MCSP previously conducted health provider training in antenatal care in workshop style, with usually one provider per facility attending each training.

To increase the number of providers offering standardized service according to the new WHO recommendations for IPTp, in 2016 MCSP Madagascar began implementing a new low dose/high frequency training approach, with routine supportive supervision. On-site training and supportive supervision provide the opportunity for the trainer and providers to discuss the barriers to delivery of IPTp-SP.

Additionally, with the addition of a new IPTp indicator in the facility dashboard, the trainer/supervisor can monitor the indicator, and discuss plan of action with providers as needed. To date, in Moramanga District, 16 providers in six facilities have benefited from this performance improvement approach.

The qualitative and quantitative study of provider performance and results from January 2017 to May 2017 shows that Providers do follow the WHO’s new recommendations on IPT.  Adequate action plans were implemented to prevent SP stock out and to commit community health workers.

The increase of antenatal care utilization rate in these facilities. The IPT uptake increased This intervention is expected to show that IPT uptake and other maternal and newborn outcomes are improving in Madagascar.

This poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of the Maternal and Child Survival Program and do not necessarily reflect the views of USAID or the United States Government.