Tropical Health Matters

Jean Louis Ndikumana Mangara, Marcel Manariyo, Michée S. Kabera, Yvette Muyirukazi, Jean Modeste Harerimana, Christine Mutaganzwa, Marie Rose Kayirangwa, Noella Umulisa, Aimable Mbituyumuremyi report on Improving insecticide treated net coverage through antenatal care services in Rwanda at the 2022 Annual Meeting of the American Society of Tropical Medicine and Hygiene.

Malaria in pregnancy (MIP) negatively affects pregnancy outcomes, including maternal and neonatal mortality and adverse fetal outcomes such as low birth weight. Therefore, among other malaria prevention interventions, Rwanda embarked to achieve the insecticide treated net (ITN) universal coverage through the ITN mass distribution to households and routine distribution to the most vulnerable groups including under five children and pregnant women.

In the period of Jan 2020 to Dec 2021, the program improved ITN distribution and the information, education and communication on challenges related to malaria behavior during ANC visits and conducted capacity building of health care providers on malaria diagnostic and case management training, integrated malaria supportive supervision, monthly data review and validation meetings at health facilities and monitoring of use of ITN program at health facility level.

A quarterly review of data from national Health Management Information System (HMIS) on ITN distributed during ANC services and changes in MIP incidence was done in the period of January 2020 to December 2021. The results show an increase from 49% (z-score (-0.8)) (Jan-Mar 2020) to 74% (z-score 0.5) (Oct-Dec 2021) coverage in the distribution of ITN among pregnant women during ANC visits.

There was a decrease in malaria incidence from 65 (z-score (2)) to 17 (z-score (-1)) cases among pregnant visiting ANC services, and a decrease from 88 to 73 malaria cases in all (567,198) pregnant women for10,000 confirmed malaria case during the January-March 2020 to October-December 2021. There has been a moderate negative correlation between the proportion of pregnant women receiving ITN in ANC services and the proportion of malaria cases in pregnancy every quarter r(9) = -0.655, P (value)=0.056.

Although malaria cases among pregnant women have declined and the distribution of ITN in ANC services increased over the studied period, there is a need to strategize innovation to reach the remaining pregnant women.

San Barro, Ousmane Badolo, Mathurin Bonzi, Moumouni Bonkoungou Youssouf Sawadogo, Andre Kone, Thierry Ouedraogo, Mathurin Dodo, Lolade Oseni, Gladys Tetteh, and William Brieger explain an innovation of Sponsorship of target children during the Seasonal Malaria Chemoprevention (SMC) campaign in order to improve malaria prevention follow-up and coverage in the Reo health district of Burkina Faso in 2021.

Malaria is a major public health problem in Burkina Faso. According to health statistics for 2020, malaria accounted for 39.8% of health center consultations, 54.1% of hospitalizations and 27.4% of deaths. Children under 5 years of age pay the highest toll with 72.4% of deaths.

In 2021, the Reo Health District and the other six districts of the Centre-Ouest region were supported by the PMI Impact Malaria Project to implement Seasonal Malaria Chemoprevention (SMC). This includes monthly preventive doses of Sulfadoxine-pyrimethamine/amodiaquine for 4 months during the main malaria transmission season. A recent multi-country article in The Lancet showed that while 75% of eligible children received a dose in any given month, only 53% received a dose on all four months.

Coverage reports indicate that better follow-up is needed once children start the SMC process. Thus, during the SMC Campaign, the district management team introduced an innovation  consisting of “sponsorship” of SMC target children as a new follow-up mechanism. These sponsors are Community Distributors (CDs) or Community Based Organizations (CBOs). They voluntarily agreed to follow up with five children each, between July and October 2021 in order …

1. To ensure that the children actually took the medication
2. To monitor whether these children did not get sick between two cycles
3. To inform the nurse in charge of the health center in case of illness of a sponsored child
4. To encourage parents to use bed nets to protect their children. In total, 1468 children were monitored and 224 (15.26%) had malaria.

This innovation on SMC distribution contributed to protect 84% of the children. Challenges include the lack of financial resources to support the sponsors and the inaccessibility of some areas due to the rains. When medicines are correctly administered to children and they are regularly monitored, protection is better.

Moumouni Bonkoungou, Ousmane Badolo, Mathurin Bonzi, Youssouf Sawadogo, Andre Kone, Thierry Ouedraogo, Mathurin Dodo, Lolade Oseni, Gladys Tetteh, and William Brieger shared information on ?Evaluation of the Implementation of Seasonal Malaria Chemoprevention (SMC) through Independent Monitoring in Burkina Faso during the 2022 Annual Meeting of the American Society of Tropical Medicine and Hygiene.?

In Burkina Faso, malaria is the leading cause of children < 5 morbidity (40.6% of severe cases), and 72.4% of death   in 2020. Seasonal malaria chemoprevention (SMC) was recommended by WHO in 2012, and since 2014, it has been implemented in Burkina Faso. SMC consists monthly doses (03 doses) of Amodiaquine Plus Sulfadoxine-Pyrimethamine to all eligible children (3-59 months) during the season of high malaria transmission.

To ensure the quality of the intervention and the coverage achieved, two independent monitoring surveys were conducted at the first (C1) and fourth (C4) rounds (of 2020?). In order to minimize bias, non-health care workers (mainly teachers) were recruited, trained and supervised for the purpose of this survey.

Monitoring was conducted in 43 districts, including 19 in the PMI/USAID Impact Malaria project area, where 838,000 children received treatment. The number of children seen in the houses was 6752 at C1 and 6608 at C4 (10 houses per selected village).

The results show that 98% and 98.2% of the targeted children received treatment at C1 and C4, respectively; 78.8% presented evidence of treatment (cards or empty drug packs) at C1. At C4, 65% of children (73) who did not receive treatment were ineligible. During this cycle, only 57% had cards and 75.6% of the cards were correctly filled in on Day2 and Day3 by the parents.

We also note that 97.1% of the children took the treatment at Day2 and Day3 according to the parent’s declaration at C4 and 97.4% at C1. 2.4% of the parents did not give the medication at Day2 or Day3 compared to the fourth visit. Also, 99.9% (2274) of the parents were satisfied with the SMC at C4, they were 99.7% at C1.

These results show an overall good implementation   in accordance with the guidelines of SMC. We note a reduction of lethality in many districts like Kampti (78%).  However, challenges exist such as outreach communication which needs to be improved, availability and proper storage of treatment cards, referral of cases requiring to be seen by a health care worker. Independent monitoring shows a better figure of the SMC coverage and allow the implementation of qualitative SMC campaign.

Ousmane Badolo, Mathurin Bonzi, Moumouni Bonkoungou, Youssouf Sawadogo, Gauthier Tougri, Mathurin Dodo, Gladys Tetteh, William Brieger reported on Early Seasonal Malaria Chemoprevention (SMC) Implementation Contributed to Reducing Malaria Incidence in Sud-Ouest Region in Burkina Faso at the 2022 Annual meeting of the American Society of Tropical Medicine and Hygiene in Seattle.

They explained that in Burkina Faso, malaria remains a major public health problem. According to 2020 health statistics, malaria accounted for 40% of health service consultations, 54% of hospitalizations, and 27% of deaths. Children under 5 years of age account for 72% of malaria deaths.

To help reduce this burden, the Ministry of Health, with the support of its partners, has organized annual Seasonal Malaria Chemoprevention (SMC) campaigns since 2014 during the high malaria transmission period (July, August September, and October). In 2021, the U.S. PMI Impact Malaria project provided support to the National Malaria Control Program to implement SMC in 19 districts from three regions (Centre-Est, Centre-Ouest, and Sud-Ouest).

One of the innovations of the 2021 SMC campaign was the introduction of five cycles in 7 of these 19 districts, compared to four cycles elsewhere. Therefore, SMC started earlier (in June) while all the others started in July. We compared the incidence of malaria (in the 5 districts of the Sud-Ouest region) in 2020 to that of 2021 when the SMC started earlier.

The malaria incidence is estimated based on the weekly disease surveillance form where the number of malaria cases is recorded, using updated population census data as a denominator. In 2020, the average malaria incidence from May 31 to October 6 in the Sud-Ouest region was 51.44/1000. In 2021, during the same period malaria incidence was 40.94/1000 (a decrease of 20%) The SMC coverage was 103% and 104% respectively in 2020 and 2021.

Starting SMC early can contribute to reduced malaria incidence but key challenges need to be addressed: i) Underestimation of the target population due to IDPs and gold miners; ii) youngest children are with their mothers on the farm so cannot be found at home; iii) insufficient cards for the SMC.

Thierry Ouedraogo, Ousmane Badolo, Youssouf Sawadogo, Moumouni Bonkoungou, Francine Ouedraogo, Mathurin Bonzi, Gauthier Tougri, Alidou Sawadogo, Mathurin Dodo, Gladys Tetteh, and William Brieger report on Reduction in Malaria Case Fatality Rate After Implementation of an Emergency Plan for Improved Case Management in the Bittou Health District, Burkina Faso at the Annual Meeting of the American Society of Tropical Medicine and Hygiene in Seattle.

They observed that in Burkina Faso, malaria remained the leading cause of death between 2014 and 2021. In the Centre Est region, uncomplicated malaria cases among children under five years of age were 11% of the country’s total (3,679,128 cases) and severe malaria cases were 9% of the country’s total (211,093 cases) in 2014. This region, is subdivided into 7 health districts including Bittou.

In 2014, the malaria case-fatality rate (CFR) among children under five years of age in Bittou (1.39%) was higher than the average for all districts in the Centre Est region (1.08). To remedy this situation, the Bittou health district management team (HDMT) implemented an emergency plan in 2016.

The plan included five components: i) sensitization of health facility staff to enable the rapid referral of severe malaria cases to the district hospital (CMA); ii) reorganization of CMA pediatric emergency management to make a physician the first point of contact; iii) Ensuring availability of supplies for severe malaria case management, including the availability of blood; iv) daily medical check-ups of hospitalized patients, and v) reinforcement of skills all HFs.

Other improvements in the health system that were introduced around the same time, but were not part of the emergency plan, included: i) free care for children under 5 years of age; ii) municipal financing of ambulance fuel for transferring patients referred; iii) free blood collection; iv) free telephone calls between the health structures; v) the presence of 5 doctors at the CMA, and vi) coaching and increased dynamism of the HDMT.

After implementation of the emergency plan, the malaria CFR in Bittou went from 1.39% in 2014, and 1.52% in 2015 to 0% in 2016 and 2017, 0.2% in 2018, 0% in 2019, 0.07% in 2020 and 0.05% in 2021. Malaria control remains a challenge in Burkina Faso. However, the improved CFRs seen in Bittou show that effective involvement of HDMT could potentially contribute to substantial reductions in malaria mortality.

Charity Anoke, Bright Orji, Emily Bryce, Elizabeth Oliveras, Joseph Enne, Elizabeth Njoku, Lawrence Nwankwo, Emmanuel Ugwa, Bartholomew Odio, Herbert Onuoha, Christina Maly, Emmanuel Otolorin, Elaine Roman, and Oniyire Adetiloye are presenting a poster for the TiPToP project at the American Society of Tropical Medicine and Hygiene’s Annual Meeting in Seattle. Below is the evidence from maternity record booklets in Ohaukwu, Ebonyi State Nigeria.

Nigeria has the highest malaria burden globally, contributing to 31.9% of global malaria deaths, and is one of the two countries with the greatest burden of malaria during pregnancy. According to the 2018 Nigeria Demographic and Health Survey (DHS), even though up to 57% of pregnant women attend ANC four or more times, only 17% received three or more doses of IPTp as recommended by the WHO.

Nigeria supported this demonstration project of CHWs in delivering intermittent preventive treatment of malaria in pregnancy (IPTp) at the community-level, complementing IPTp at antenatal care (ANC) in three districts. Data were extracted from 735 maternity record booklets (MRB) at 25 public health facilities in Ohaukwu for women presenting for ANC between April and September of 2019. The MRB allowed for the longitudinal analysis of client-level data that is not available from routine data sources.

Sixty percent of women received IPTp doses only in the community, while 28% received IPTp only at ANC and 12% received IPTp in both locations. One-way ANOVA and post-hoc Tukey tests were used to examine the difference in mean number of ANC visits and number of IPTp doses between the three groups. The mean number of ANC visits was significantly higher in the group of women receiving IPTp at both locations compared to those only receiving IPTp in the community (0.89 ± 0.18 visits, p<0.01) and those only receiving IPTp during ANC (0.61 ± 0.20 visits, p<0.01).

There was no statistically significant difference in the mean number of ANC visits between the groups receiving IPTp only in one location (0.29 ± 0.13 visits, p=0.077). The difference in number of doses was statistically significant across all groups, whereby women in the facility-only group received the fewest IPTp doses. Receipt of IPTp in both locations was associated with both greater numbers of ANC visits and IPTp doses. Only receiving IPTp in the community was not associated with a decrease in ANC attendance.

These data suggest complementing ANC-based IPTp distribution with community-based distribution is beneficial.

Moumouni Bonkoungou, Ousmane Badolo, Mathurin Bonzi, Youssouf Sawadogo, Andre Kone, Thierry Ouedraogo, Gauthier Tougri, Mathurin Dodo, Edward Kenyi, Gladys Tetteh, and William Brieger working with the US PMI Impact Malaria project implemented Seasonal Malaria Chemoprevention (SMC) in collaboration with the National Malaria Control Program (NMCP) of Burkina Faso in 3 regions. Their findings are seen below and are presented at the Annual Meeting of the American Society of Tropical Medicine and Hygiene in Seattle.

According to health statistics for 2020, in Burkina Faso, malaria accounts for 40% of medical consultations and 27% of deaths. Children under 5 years of age account for 72% of malaria deaths. 

In 2021, the SMC consists of the administration of three days of monthly treatments of amodiaquine plus sulfadoxine-pyrimethamine to all eligible children (3-59 months of age) during the high malaria transmission season (June to October). The objective is to maintain therapeutic concentrations of these antimalarials during the period of high transmission. 

In 2021, 19 of 70 health districts (27%) were supported by the project to implement SMC with more than 838,000 children under 5 years treated, including 180,000 from the Sud-Ouest region (Dano, Batie, Kampti, Gaoua, and Diebougou health districts). In this region of high rainfall, the number of severe malaria cases in children under 5 years decreased from 17,760 in 2017 (before SMC) to 14,609 in 2021 with SMC after 4 years of SMC implementation, i.e., a reduction of 17%. 

The number of malaria deaths also decreased from 133 in 2017 (before SMC) to 118 in 2021, a reduction of 11%. Kampti health district recorded the highest reduction of deaths of 78% [33 to 7 deaths] between 2017 and 2021 and Dano district had a reduction in severe malaria cases by 28% between 2017 and 2021. 

The main challenges with SMC include a delay in referral of fever cases by community distributors to health facilities during the campaign, management of vomiting during the 2nd or 3rd dose, and failure to retain the treatment cards by the parents. Seasonal Malaria Chemoprevention is a proven intervention and appears to be an important

component of the malaria prevention strategy in Burkina Faso but consideration should be given to address ongoing implementation challenges.

Marwa Ramadan of the Alexandria Faculty of Medicine, Alexandria, Egypt and William Brieger of the Johns Hopkins Bloomberg School of Public Health are presenting this information at the Annual Meeting of the American Society of Tropical Medicine and Hygiene in Seattle.

Studies have highlighted the potential impact of conflict and displacement on malaria prevention and mitigation efforts, but few investigated the effect of subnational conflict intensity on access and utilization of mosquito nets in fragile countries.

This study bridges the gap by applying a conflict intensity lens to the analysis of access and utilization of Insecticide Treated Nets (ITN) in two conflict-affected fragile states (Nigeria and Democratic Republic of Congo (DRC)), where at least 45 % of global malaria deaths occur.

We used the Demographic health survey (DHS) and the Uppsala Conflict Data Program for information on access and utilization of nets and conflict events respectively. Access was defined as the percentage of population with at least one ITN per 2 household members, while utilization was defined as the percentage of population who slept under an ITN the night before the survey in households with at least 1 ITN.

To define conflict intensity, we linked household clusters to conflict events within a 50 km distance using ArcGIS. Conflict intensity was then categorized into medium or high intensity conflict and no or low intensity conflict using a cut-off of 2 or more deaths per 100, 000 population per cluster. Access and utilization of ITNs was compared by conflict intensity at the household cluster level.

Analysis of data from 281,689 individuals living in 58,183 households revealed that 42.8% (CI: 42.3 – 43.3%) and 39.9% (CI: 39.5 – 40.1%) of members living in neighborhoods with medium and high intensity conflict in DRC and Nigeria respectively had access to ITNS compared to 47.9% (CI: 47.6 – 48.1%) and 51.0% (CI: 50.8 – 51.2%) in no or low intensity conflict.

Similarly, 65.1% (CI: 64.3 – 65.9%) and 62.8% (CI: 62.3 – 63.3%) of those living in medium or high intensity conflict in DRC and Nigeria respectively utilized ITNS compared to 69.2 % (CI: 68.8 %-69.6 %) and 65.7% (CI: 65.4-66.0%) in no or low intensity conflict.

National malaria control programs must consider that access and utilization of ITNS are statistically significantly lower in neighborhoods with medium or high intensity conflict and target supporting interventions accordingly.

The Demographic and Health Survey Program has released final and summary reports for both DHS and Malaria Indicator Surveys (MIS) for 2021 from several malaria endemic African countries. Below is a brief summary of some of the findings from Madagascar, Nigeria, Burkina Faso, Mali, Côte d’Ivoire, and Senegal. Click the link on each country to download a copy for yourself.

The proportion of the population who slept under an insecticide treated bednet the night before the survey varied. In Madagascar it was 49%, While in Nigeria it was 59%. Mali achieved the highest coverage at 73%, while Burkina Faso had the lowest previous night coverage at 41%.

Senegal showed a worrying decrease from 63% in 2016 to 46% in 2021. Côte d’Ivoire did not report total household use, but indicated that 72% of homes had at least one net, with 58% of children below 5 years of age and 64% of pregnant women sleeping under them.

At least three doses of sulfadoxine-pyremethamine is recommended for Intermittent preventive treatment of malaria in pregnant women. The national average was 38% for at least 3 doses in Senegal, although ironically 92% had been reached with the first dose. In Mali only 35% received at least a third dose. Burkina Faso started out with 92% for the first dose, but reached 57% with three or more. Côte d’Ivoire started with 80% receiving their first dose and concluded with only 35% receiving a third. Both Madagascar and Nigeria had the lowest 3-dose coverage at 31%.

Malaria testing and treatment using rapid diagnostic tests and artemisinin-based combination therapy (ACT) was reported. Nigeria demonstrates the challenges of following guidelines. Although 63% of children under 5 years of age were reported to have had a fever in the two weeks preceding the survey, only 24% of those received a diagnostic test. The summary results report that 74% of those with fever “who took any anti-malaria medicine” used the recommended ACT. The implication is that many received medicine without confirmatory testing such that some may have gotten ACT who needed another medicine and some who actually had malaria may have missed the correct treatment.

A similar low level of testing was seen in Senegal (22%), Mali (23%), and Madagascar (20%). Côte d’Ivoire reported 38% of febrile children having been tested. Burkina Faso performed better for testing with 65%.

These brief findings indicate that implementation of Malaria interventions are far from ideal. We know that some of the blame can be placed on health service disruptions due to demands of COVID-19 activities by health ministries and partners. Still, with 8 years remaining until 2030, Reinvigorated efforts are needed in all endemic countries if these six examples are indicative of the challenges we face.

Andaratu Wuni has contributed this posting to the Blog site for the JHU site for the course Social and Behavioral Foundations of Primary Health Care.

(Graphic source: https://www.aafp.org/news/health-of-the-public/20210429vacchesitancy.html)

Covid 19 has unarguably wrecked devastating consequences globally since its emergence and has proven to to be a ubiquitous public health health problem. Vaccination against the virus has been shown to be the most effective way of limiting severe disease and mortality. However the spate of vaccine hesitancy in Ghana has continued to rise in the last year. The World Health Organization defines vaccine hesitancy as the delay in acceptance or refusal of vaccination despite availability of vaccination services. This public health problem has far reaching consequences not only in Ghana but globally. Currently the vaccine hesitancy rate in Ghana is about 30% and counting! with people 25 years and under leading the hesitancy core.

(Graph Source: https://figshare.com/articles/thesis/Examining_drivers_of_COVID-19_vaccine_hesitancy_in_Ghana/14494851)

Since Ghana rolled out vaccines to the general public over one year ago, only 25.9% of the population have been fully vaccinated as of August 19,2022.Ghana has a target of vaccinating 22.9million eligible Ghanaians; that is about 60% of the population in order to achieve herd immunity, however only 8.2 million Ghanaians have been fully vaccinated to date.

Many reasons account for the rise in covid 19 vaccine hesitancy in Ghana; from the depletion of rigorous and continuous education and the consequent lack of community engagement, relaxation of covid 19 protocols, to vaccine misinformation and conspiracy theories as well as political influence. It is time for a policy that will mitigate this crucial problem, which the WHO(before the covid pandemic) described as one of the top ten greatest threats to global health.

The truth is, a single policy may not totally solve the problem as the issue of vaccine hesitancy is a complex one. The best approach will be for policymakers to enact policies to make vaccination a condition for other essential services in Ghana.

Intensify mandatory vaccination especially in high risk individuals and high risk locations, eliminate vaccine exemptions based on all but health related reasons, commit to structured community engagements and outreaches using the key stakeholders like the Ghana Medical Association and the Public Health association of Ghana, use stakeholders like UNICEF Ghana and the Ghana Health Service to disseminate accurate and scientifically proven vaccine information and last but not least introduce incentives for citizens who take the vaccine.