Retention of malaria technical and training knowledge and skills by master mentors and general trainers in Myanmar

Ni Ni Aye,* San Kyawt Khine, May Aung Lin, Saw Lwin, Khin Than Win, Khin Lin, May Sandi Htin Aung, and Wyut Yi Shoon Lai Wai presented a poster on “Retention of technical and training knowledge and skills by master mentors and general trainers in three States/ Regions in Myanmar” at the 68 Annual Meeting of the American Society of Tropical Medicine and Hygiene. Their findings are shared below.

The National Malaria Control Program  of Myanmar aims to achieve malaria elimination through equitable and universal access to effective preventive and curative services to all at-risk populations in coordination with communities, national and international non-governmental organizations and other stakeholders.

The PMI-funded Defeat Malaria project supports the National Strategic Plan’s objective to reduce the malaria burden and contribute to malaria elimination in part through capacity development of integrated community malaria volunteers (ICMVs), a new type of cadre introduced in 2017.

Specifically, Defeat Malaria aims to improve this new cadre’s knowledge and skills in malaria epidemiology, prevention, and case management through a community-based intervention approach. 16 State/Regional (S/R) level master trainers (MTs) were trained from Kayin and Rakhine States and Tanintharyi Region, 13 of whom then trained 55 general trainers (GTs) in the same S/R to build the capacity of ICMVs.

Goals of the PMI Defeat Malaria Project (15 August 2016 – 14 August 2021) are to Reduce malaria burden, and to Control artemisinin-resistant malaria in target area Eliminate malaria in Myanmar. The Objectives of Defeat Malaria are to Ahieve universal coverage of at-risk populations, Strengthen malaria surveillance system, Enhance provider technical capacity and Promote community and public- and private-sector involvement in malaria control and elimination.

The specific Objectives of this study were To develop a cadre of core trainers with updated knowledge and skills in community based interventions to carry out cascade training of ICMVs in 3 S/R. It also aimed To evaluate the retention of knowledge and skills in malaria interventions and training techniques pre-training, immediately post-training, and at 9 months post-training, and in the process To improve training skills (facilitation, demonstration and coaching) during subsequent trainings.

Methodology For Master Mentors (MM) was a 5-day technical update session on malaria epidemiology, prevention and case management through a community-based intervention approach was conducted, followed by 5-day training skills course. For the general trainers (GT) a 5-day technical update and training skills course was provided.

Pre-training, immediate post-training and 9-month post-training malaria knowledge assessment was conducted using multiple choice questions. At the 9-month point a post-training assessment of training skills (facilitation, demonstration and coaching) using standardized checklists was undertaken.

In Conclusion, Master mentors who have basic knowledge of malaria technical and training skills became knowledgeable and competent on both skills (i.e. those from State/Regional level). Training modules on coaching skills need to be practiced more in TOT so that General Trainers can improve their skills. Project staff should emphasize why use of checklists to improve training skills is important, as this is a new element for local staff.

MM need continuous coaching to retain updated knowledge on malaria technical skills and their facilitation and coaching skills during the TOT and subsequent trainings. MM who are selected from district level and all General Trainers from Township level need even more practice and support. Project staff need to work with local NMCP staff as they learn coaching and mentoring in technical and training skills of GTs during their supervision visits to ICMVs at village level.

Actions taken in Project Year 3 (2018-2019) were based on assessment findings. MM and GT need more coaching after training to maintain knowledge and training skills. Selection of Master Mentors from State/Regional levels with knowledge of malaria and training skills improves retention of knowledge and skills post-training.

Township level NMCP staff had more time to conduct trainings than the Township Medical Officer so they will be prioritized for further trainings. Translations of knowledge tests for training skills were improved and were more understandable to participants. Project staff increased their support to local NMCP staff during supportive supervision visits to improve their coaching and mentoring skills, which are new skills for most.

Next Steps include Further assessments of knowledge and skills retention will be done for MM and GT 6 – 9 months post training. The project will continue support of NMCP staff as they support GT in subsequent trainings and supportive supervision for ICMV. Translation revisions of the training manuals, particularly knowledge assessments, will continue to ensure that language barriers are addressed.

*Affiliation: Jhpiego/Myanmar, PMI Defeat Malaria Project; University Research Co., Myanmar, PMI Defeat Malaria Project; Myanmar National Malaria Control Program

This poster is made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the terms of its Cooperative Agreement No. AID-482-A-16-00003 and the USAID Defeat Malaria Project. The contents are the responsibility of the authors and do not necessarily reflect the views of USAID, PMI or the United States Government.

Improved Uptake of Malaria in Pregnancy Indicators: A Case from USAID Boresha Afya Project, Lake & Western Zone, Tanzania

Zipporah Wandia,* Jasmine Chadewa, Agnes Kosia, Goodluck Tesha, Lusekelo Njoge, Zahra Mkomwa, Dunstan Bishanga, Rita Noronha, Bayoum Awadhi, Gaudiosa Tibaijuka, Chonge Kitojo, Erik Reaves, and Abdallah Lusasi presented a poster entitled “Improved Uptake of Malaria in Pregnancy Indicators: A Case from USAID Boresha Afya project, Lake & Western Zone, Tanzania” at the 68th Annual meeting of the American Society of Tropical Medicine and Hygiene. Their findings are seen below.

Magnitude of Malaria in Pregnancy: Malaria in pregnancy (MiP) has been recognized as a major public health concern. It is contributing to poor maternal and newborn health outcomes. In Sub-Saharan Africa, up to 20% of stillbirths are attributable to MiP and contributes to an estimated 10,000 maternal deaths and 100,000 infant deaths each year (Desai M. ter Kuile et al 2018).

Tanzania implements a three-pronged approach to prevent the adverse effect associated with MiP as recommended by WHO including 1)Intermittent preventive treatment of malaria in pregnancy (IPTp) with sulfadoxine-pyrimethamine, 2) Use of long-lasting insecticide-treated bed nets (LLINs), and 3) Strengthened Case management with Prompt diagnosis and treatment.

USAID Boresha Afya Lake and Western Zone Project supports Ministry of Health through the National Malaria Control Program to implements its strategies targeted to improve MiP in seven project supported regions. The Project uses the malaria data dashboard to identify facilities with gaps through:

  • Malaria Service Data Quality Improvement (MSDQI)
  • Supportive supervision
  • On job training and mentorship to capacitate health care providers to provide quality MiP services to improve indicators performanc

Results: USAID Boresha Afya Project in collaboration with the National Malaria Control Program(NMCP) and involvement regional and council health management teams improved uptake of IPTp and MiP indicators in seven regions supported by the project
Improved documentation in Health Management Information System Book 6  and the Antenatal care (ANC) register used in Tanzania’s health facilities. Quarterly follow-up and mentorship for health care workers at ANC were completed between 2016–2018 in 1817 (100%) health facilities.

Uptake of both IPTp2 and IPTp3 increased steadily as seen in the two graphs. The increase between 2016 and 2019 was from 50% to 80% for IPTp2. IPTp3 increased 0 to 63%. General support to antenatal care where IPTp is given resulted in an increase in those women attending for the first time in their first trimester: 15% to 34% over the same time period.

Testing of pregnant women for malaria rose from 75% to 99%. During the period an average of 10% of women tested positive and were given appropriate malaria treatment.

Lessons Learnt: The improvements in MiP indicators in the Project supported regions is partly attributed to:

  • Commitment among health care workers
  • Mentorship and proper documentation
  • Improved the overall quality of ANC services in the supported regions

*Affiliation: USAID Boresha Afya Project – Jhpiego Tanzania; USAID Boresha Afya Project – Path Tanzania; National Malaria Control Programme-Tanzania Ministry of Health, Community Development, Gender, Elderly and Children, Tanzania; US President’s Malaria Initiative-United States Agency for International Development

This presentation was made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of the USAID Boresha Afya and do not necessarily reflect the views of USAID or the United States government.

Malaria Case Management Practice and Elimination Readiness in Five Elimination Districts of Madagascar, 2018

Anjoli Anand,* Favero Rachel, Catherine Dentinger, A. Ralaivaomisa, S. Ramamonjisoa, Elaine Razafimandimby, Jocelyn Razafindrakoto, Katherine Wolf, Laura C. Steinhardt, Julie Thwing, Bryan K. Kapella, M. Rabary, Sedera Mioramalala, Jean Pierre Rakotovao presented a poster on “Malaria Case Management Practice and Elimination Readiness in Five Elimination Districts of Madagascar, 2018” at the 68th Annual Meeting of the American Society of Tropical Medicine and Hygiene. Their findings are shared below.

Madagascar’s Malaria National Strategic Plan 2018-2022 calls for progressive malaria elimination beginning in low-incidence districts (< 1 case/1000). Although an elimination plan has not yet been developed, optimizing access to prompt diagnosis and quality treatment will be its foundation, along with improving outbreak detection and response, and developing an elimination plan.

There was need to understand current practices in preparation for elimination such as estimating current implementation readiness, documenting current diagnosis and treatment practices (case management), Assessing the use of data to inform decision-making and determining the availability of commodities, training and supervision. To assess this readiness and inform planning, we surveyed health facilities (HFs) and communities.

In September 2018, we randomly selected 35 HFs in 5 of the 8 districts identified for elimination, surveyed 41 HWs and 34 community health volunteers (CHVs), and observed 300 clinical encounters between HWs and patients of all ages. Quantitative and qualitative tools were used to collect data. There were a health facility checklist, an interview guide for health facility providers, a clinical observation guide, a community health volunteer CHV) interview guide, and a stakeholder interview guide.

To evaluate elimination readiness, a composite score was assigned to each HF catchment area that incorporates all survey responses based on commodity availability, malaria CM practices, data management, and supervision practices.

In preliminary results, 8 of 34 (24%) CHVs reported that they do not manage children under 5 years (CU5) with fever at the community level. Of 26 CHVs who care for CU5, 18 (69%) identified history of fever as a criterion for suspected malaria, 20 (77%) reported using a malaria rapid diagnostic test (RDT) when evaluating patients reporting fever, and 15 (58%) reported giving antimalarials for a positive RDT. Among treating CHVs, 13 (30%) reported having RDTs, and 11 (42%) reported having antimalarials currently available. A

Among facility-based HWs, 83% identified history of fever as a criterion for a suspected case. Of 120 patients with reported or recorded fever, 56 (47%) were tested with an RDT. Five RDTs were positive; a first-line antimalarial was prescribed to 4 of those patients. This evaluation is a baseline for CM performance as Madagascar establishes elimination targets. In the evaluated districts, CM could be improved by strategies to increase testing at CHV and HF levels and address availability of commodity stocks in the community.

*Affiliations: Epidemic Intelligence Service, Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, United States; Maternal Child Survival Program, Washington, DC, United States; US President’s Malaria Initiative; US Centers for Disease Control and Prevention, Antananarivo, Madagascar; Maternal Child Survival Program, Madagascar, Antananarivo, Madagascar; Maternal Child Survival Program, Antananarivo, Madagascar; US President’s Malaria Initiative, Antananarivo, Madagascar; Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, United States; National Malaria Control Program, Antananarivo, Madagascar

mMentoring, a New Approach to Improve Malaria Care in Burkina Faso

Moumouni Bonkoungou,* Ousmane Badolo, Youssouf Sawadogo, Stanislas Nebie, Thierry Ouedraogo, Yacouba Sawadogo, William Brieger, Gladys Tetteh, and Blami Dao presented their work on “mMentoring, a New Approach to Improve Malaria Care in Burkina Faso” at the 68th Annual Meeting of the American Society of Tropical Medicine and Hygiene as seen below.

Malaria is the leading cause of consultation (43.3%), hospitalization (44.1%) and death (16.1 %) in Burkina Faso. In the Sahel Region, the case fatality proportion due to malaria is 2% compared to 0.8% for the national average. This region is most affected by malaria than others. Also, the Sahel Region is currently experiencing high levels of insecurity making movement of health teams difficult and unsafe.

mMentoring is the use of mobile technology to ensure capacity building and continuing education among health staff. The process started by a workshop to develop messages, and briefing of the main actors.

Each week, messages and quizzes (An automatic answer is sent to each quiz) are sent to 753 providers (nurses, midwives, medical doctors) of the 115 health centers in the Sahel Region. Each month, messages are revised by a team at national level before being sent.

The messages sent were related to several key malaria prevention and control interventions, such as case definition, parasitological diagnosis, clinical case management of simple and severe cases, intermittent preventive treatment in pregnancy (IPTp), pre-referral treatment with rectal artesunate in children under 5 years, insecticide-treated bed nets.

After 10 months of implementation, 64 reinforcement messages on case management and prevention guideline and 63 quizzes were sent. Proportion of correct responses to the quizzes ranged from 43% and 96%. The lowest scores related to topics on management of severe cases while the highest were related to diagnosis of malaria.

The participation rate (number of respondents of the 753 targeted health workers) is on average 22% with 71% of participants from primary health facilities. Also, we notice IPT3 increased from 14.8% in the quarter 3 of 2017 to 45.6% in the same quarter of 2018 (with mMentoring).

The rate of performance of rapid diagnostic tests (RDTs) rose from 67.5% to 77.8%. The case fatality rate during this quarter of 2017 was 3.3% and 1.8% in 2018. As a real platform for continuing training, it would be wise to extend this approach to other regions of the country and also to other health actors like community health workers.

 

 

 

 

 

*Affiliations: PMI Improving Malaria Care Project, Ouagadougou, Burkina Faso, Ministry of Health, National Malaria Control Program, Ouagadougou, Burkina Faso, Johns Hopkins University, Baltimore, MD, United States, Jhpiego Baltimore, Baltimore, MD, United States

Reduction in malaria-attributable deaths following a rectal artesunate pre-referral treatment pilot in Burkina Faso, 2018

Ousmane Badolo,* Stanislas Nébié, Youssouf Sawadogo, Thierry Ouedraogo, Bonkoungou Moumouni, Mathurin Dodo, Lolade Oseni, Gladys Teteh, and William Brieger, presented a poster entitled, “Reduction in malaria-attributable deaths following a rectal artesunate pre-referral treatment pilot in Burkina Faso, 2018,” at the 68th Annual Meeting of the American Society of Tropical Medicine and Hygiene.

Background: In 2017, 4.32 percent of malaria cases were documented as severe malaria in Burkina Faso. The National Case Management Guidelines (August 2017) recommends that the First line treatment for severe malaria be injectable artesunate except in pregnancy where injectable quinine is used for the 1st trimester and injectable artesunate used for the 2nd and 3rd trimesters.

The guidelines recommend pre-referral treatment of severe disease at peripheral health facilities using rectal artesunate for children under 5, parenteral artesunate, artemether, or quinine for older children and adults. The guidelines also recommend pre-referral treatment of severe disease by community health workers with rectal artesunate for children under 5 only. The National Malaria Control Program is currently piloting pre-referral rectal artesunate for children under five years of age by CHWs in three districts in North and Sahel regions, where malaria mortality is the highest.

Results: Comparison Severe Malaria cases and death among <5 before and after the pre-referral treatment in Sahel region is seen in the Table. Pre-referral treatment was able to reduce fatality by 45%.

Comparison of monthly fatality of severe malaria among <5 year (October 16 to April 17; October 17 to April 18 and October 18 to April 19) in the Sahel region is seen in the Graph. This shows a substantial decline in severe malaria following introduction ofthe  pre-referral rectal artesunate pilot.

Several Lessons were Learned based on the Encouraging preliminary results. The involvement of the community in health activities allows good visibility of the intervention resulting in good acceptability and adherence. The community can take charge of its own health if it is well supervised. Good functionality of the “canary fridge” device when used in hot areas.  Ability to use other meeting and supervisory opportunities to implement the strategy.  Challenges identified can be corrected by close monitoring.

Insecurity in Northern Burkina Faso is a major constraint, but pre-referral treatment of severe malaria is needed to decrease mortality from malaria. Despite implementation difficulties, this experience has contributed to a reduction in deaths due to severe malaria in the Sahel region, which is also facing increasing insecurity.

An evaluation of the implementation with data collection for a one-year implementation period will provide lessons for the national scale up of pre-referral artesunate implementation.

*Affiliations: PMI Improving Malaria Care Project, Jhpiego Baltimore, MD, United States, Johns Hopkins University, Baltimore, MD, United States

This poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID) under Cooperative Agreement No. AID-624-A-13-00010 and the President’s Malaria Initiative (PMI). The contents are the responsibility of the authors and do not necessarily reflect the views of USAID, PMI or the United States Government.

Efficacy of artemether-lumefantrine for the treatment of uncomplicated Plasmodium falciparum infection in Rwanda, 2018

The Efficacy of artemether-lumefantrine for the treatment of uncomplicated Plasmodium falciparum infection in Rwanda, 2018 was investigated by Aline Uwimana, Noella Umulisa, Eric S. Halsey, Meera Venkatesan, Tharcisse Munyaneza, Rafiki Madjid Habimana, Ryan Sandford, Leah Moriarty, Emily Piercefield, Zhiyong Zhou, Samaly Souza, Naomi Lucchi, Daniel Ngamije, Jean-Louis N Mangala, William Brieger, Venkatachalam Udhayakumar, Aimable Mbituyumuremyi.* The results were presented at the 68th Annual Meeting of the American Society of Tropical Medicine and Hygiene and are seen below.

Background: In Rwanda, there were 4,195,013 confirmed malaria cases and 341 malaria-related deaths in 2018[1]. Regular monitoring of artemisinin-based combination therapy efficacy is important to assess drug efficacy and for timely detection of the emergence of antimalarial drug resistance. In Rwanda, national policy is to routinely monitor the first-line antimalarial per World Health Organization (WHO) guidelines[2] The most recent therapeutic efficacy results in Rwanda showed an efficacy of the first-line antimalarial, artemether-lumefantrine (AL), of >97% in Masaka and Ruhuha in a study conducted from 2013 to 2015[3]

Methods: This was an Efficacy trial based on the standard WHO in vivo protocol[2]. Three sites (see map) were selected in Rwanda. Artemether-lumefantrine (AL) was given twice daily; each dose given under observation for 3 days. Participants were treated with AL and followed for 28 days from March 2018 to December 2018.

PCR correction, differentiating recrudescence from reinfection in late treatment failure samples, was performed using genotyping of seven neutral microsatellites. Microsatellite data were analyzed using a previously published algorithm that assigns each late treatment failure a posterior probability of recrudescence[4]

  • Primary Endpoint: 28-day PCR-corrected efficacy
  • Secondary Endpoints: 28-day uncorrected efficacy, day 3 parasitemia

PCR-corrected and uncorrected efficacies are seen to the left.  Kaplan Meier Curves are presented. Uncorrected (top) and PCR-corrected (bottom) survival functions for time until failure for a 2018 therapeutic efficacy study using artemether-lumefantrine in three Rwandan study sites; ACPR: adequate clinical and parasitological response. Day 3 Parasitemia was identified. Two sites, Masaka and Rukara, had > 10% of subjects with parasites detectable on day 3, a WHO criteria for suspected artemisinin resistance.

With PCR-corrected efficacies greater than the 90% cut-off recommended by WHO, AL remains an effective antimalarial to treat uncomplicated P. falciparum in Rwanda
More than 10% of subjects had day 3 parasitemia at two sites; the relationship with this finding and k13 mutations observed in this study was presented in ASTMH poster LB-5295 (Friday, November 22, 2019).

Periodic antimalarial efficacy monitoring in Rwanda should be maintained, and future studies should incorporate additional methods to assess parasite clearance times and presence of molecular markers of resistance. WHO algorithm indicating that, for this study, even with suspected artemisinin resistance in Rwanda, no change in ACT treatment policy is warranted at this time.

References

  1. Rwanda Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Center, HMIS data, 2018.
  2. WHO, Methods for Surveillance of Antimalarial Drug Efficacy, 2009.
  3. Uwimana A, Efficacy of artemether–lumefantrine versus dihydroartemisinin–piperaquine for the treatment of uncomplicated malaria among children in Rwanda: an open-label, randomized controlled trial, Trans R Soc Trop Med Hyg; doi:10.1093/trstmh/trz009; 2019.
  4. Plucinski MM, Morton L, Bushman M, Dimbu PR, Udhayakumar V. Robust algorithm for systematic classification of malaria late treatment failures as recrudescence or reinfection using microsatellite genotyping. Antimicrob Agents Chemother;59:6096–100; 2015.

Contact Information: Aline Uwimana, MD: aline.uwimana@rbc.gov.rw and Eric Halsey, MD: ycw8@cdc.gov

*Affiliations: Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Centre, Kigali, Rwanda; Maternal and Child Survival Program/JHPIEGO, Baltimore MD, USA; The US President’s Malaria Initiative, Atlanta, Georgia, USA; Malaria Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA; US President’s Malaria Initiative, Washington DC, USA; National Reference Laboratory, Rwanda Biomedical Centre, Kigali, Rwanda; US Peace Corps, Kigali, Rwanda; US President’s Malaria Initiative, Kigali, Rwanda; WHO Rwanda Office, Malaria and Neglected Tropical Diseases Programs, Kigali, Rwanda; The Johns Hopkins University, Bloomberg School of Public Health, Department of International Health, Baltimore, MD, USA

Joint Efforts to Improve Malaria Control in Three Refugee Camps in Kigoma, Tanzania

A team affiliated with the USAID-supported Boresha Afya health project in Tanzania prepared a presentation for the 68th Annual Meeting of the American Society of Tropical Medicine and Hygiene entitled, “Joint Efforts to Improve Malaria Control in Three Refugee Camps in Kigoma, Tanzania: Successes, Challenges and Lessons Learned,” as seen below. Team members included Shabani K. Muller, Juma Ng’akola, Zephani Nyakiha, Godfrey Smart, Tesha Goodluck, Jasmine Chadewa, Agnes Kosia, Zahra Mkomwa, Abdallah Lusasi, Dustana Bishanga, Rita Noronha, Lusekelo Njonge, Ally Mohamed, Gaudensia Tibajiuka, Chonge Kitojo, and Erik Reaves (Affiliations: USAID Boresha Afya Project -Path Tanzania; USAID Boresha Afya Project –Jhiego Tanzania; National Malaria Control Program, Regional Health Management Team-Kigoma. President’s Malaria Initiative/United States Agency for International Development)

Overview of USAID Boresha Afya Lake and Western Zones: USAID’s 5-year project was implemented in seven regions of Tanzania, including Kigoma. It supports the Government of Tanzania increasing access to high-quality, comprehensive, and integrated health services, with a focus on women and children. Its goal is to improve the quality of malaria case management, including malaria in pregnancy.

Malaria prevalence in Tanzania has decreased by half, from 14.8% in 2016 to 7.3% in 2017 (2015 and 2017 Tanzania Malaria Indicator Surveys). Malaria prevalence in Kigoma is 24% (above national prevalence). According to quarterly District Health Information System 2 data at facility level, about 50% of all malaria cases in Kigoma Region are from the three refugee camps.

Overview of Refugee Situation in Kigoma Region: The majority of refugees fleeing conflicts in Burundi and Democratic Republic of the Congo are hosted in Kigoma.
The three major refugee camps in Kigoma are Nyarugusu, Nduta, and Mtendeli.

Interventions to Improve Malaria Case Management included the following

  • Conducted on-the-job training and mentorship.
  • Conducted joint supportive supervision.
  • Discussed challenges and how to address them in refugee camp settings with other malaria partners.
  • Identified poor-performing indicators.
  • Collaborated with community providers.

Results of these interventions included the malaria lab reporting rate increased from 42% to 100%. This means that the rate of facilities reporting laboratory results in the District Heath Information System was very low. Clinical malaria diagnosis decreased from 4% to 0%. Nyarugusu’s malaria positivity rate decreased from 61% to 52%. Kigoma Region’s number of annual deaths due to malaria decreased from 359 in 2017 to 191 in 2018.

Results also showed an increased percentage of pregnant women who received the second dose of intermittent preventive treatment of malaria in pregnancy (IPTp2) from 26.7% in 2017 to 84.3% by June 2019. Increased IPTp3 coverage from 9.4% in 2017 to 13.2% in 2018.

Challenges and Mitigation are outlined in the attached table.

Several Lessons were Learned from the interventions. On-the-job and malaria mentorship training are important components in improving malaria case management in refugee camps. Supportive supervision is mainly based on gaps identification, and mentorship is focused on hands-on skill and capacity-building. Regular supportive supervision, when correctly using the MSDQI Tool, improves malaria service provision.

Working in collaboration with other stakeholders to implement vector control, social and behavior change communication, and other interventions is important in the fight against malaria in refugee camps.

This presentation was made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of the USAID Boresha Afya and do not necessarily reflect the views of USAID or the United States government.

Using Seasonal Malaria Chemoprevention (SMC) to Screen for Acute Malnutrition

Moumouni Bonkoungou, Ousmane Badolo, Youssouf Sawadogo, Stanislas Nebie, Thierry Ouedraogo, Yacouba Savadogo, William Brieger, Gladys Tetteh, and Blami Dao (affiliation PMI Improving Malaria Care Project; Jhpiego Baltimore; Johns Hopkins University; Ministry of Health, National Malaria Control Program) presented a poster entitled Using Seasonal Malaria Chemoprevention (SMC) to Screen for Acute Malnutrition at the 68th Annual Meeting of the American Society of Tropical Medicine and Hygiene. Their findings are outlined below.

Malaria and malnutrition remain major public health burdens in Burkina Faso for children under five years of age. In 2017 the case fatality rate of malaria was 1.5 percent among children under five years of age and malaria was responsible for 35.9 percent of deaths in primary health facilities. Malnutrition was responsible for 4.6 percent of deaths in primary health facilities and 3.3 percent of deaths in hospitals in 2017.

What is IMC project? The US President’s Malaria Initiative (PMI) funded the Improving malaria Care (IMC) since 2013 to support National Malaria Control Program (NMCP). The goal is to improve quality of malaria prevention, diagnosis and treatment through 05 strategies.

Malnutrition was detected at the level of health facilities. The nutrition program did not have resources for active screening for malnutrition Since 2018, it has been decided on the couple with the SMC to recruit more children.

What is the strategy? In 2018, Burkina Faso Seasonal Malaria Chemoprevention (SMC) campaign integrated malnutrition screening in 12 health districts supported by IMC. During the SMC campaign, community health workers administer sulfadoxine-pyrimethamine + amodiaquine (SP+AQ).

They also screened for malnutrition using the Shakir sling to measure mid-upper arm circumference to detect for acute malnutrition. Children who are not severely malnourished receive the standard malaria preventative treatment by SP+AQ. Children diagnosed with severe malnutrition do not receive SP+AQ and are referred to health facilities for appropriate case management.

Moderate and severe malnutrition was documented in October 2019. In November, after the last round (October), 427 children with severe acute malnutrition have been reported by health facilities. 81.3 percent of severe acute malnutrition detected during SMC.

Challenges of SMC and malnutrition screening were documented as follows:

  • Inaccessibility of some areas
  • Reference of severe cases for management
  • Adequate home management of moderate cases
  • Proper care of referred children in health facilities
  • Follow-up of referrals
  • Search for those not followed-up

In Conclusion in the context of a limited resource country, SMC is a good strategy for the reduction of malaria cases as well as a great opportunity for the detection and management of malnutrition in children under five years of age. It is recommended to Couple the screening of malnutrition with other activities (immunization, distribution of bednets …). Raising parents’ awareness of the importance of managing cases is necessary as is Encouraging active case finding and community referral.

This poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID) under Cooperative Agreement No. AID-624-A-13-00010 and the President’s Malaria Initiative (PMI). The contents are the responsibility of the authors and do not necessarily reflect the views of USAID, PMI or the United States Government.

Retention of malaria knowledge and skills and adherence to National Malaria Treatment Guidelines by integrated community malaria volunteers

Retention of malaria knowledge and skills and adherence to National Malaria Treatment Guidelines by integrated community malaria volunteers in three States/Regions in Myanmar is the focus of a poster presentation by Ni Ni Aye, Aung Thi, Kyawt Mon Win, Thiha Myint Soe, May Oo Khin, Khant Maung Maung, and Saw Naung Naung at the 68th Annual Meeting of the American Society of Tropical Medicine and Hygiene. They are affiliated with Jhpiego Myanmar PMI Defeat Malaria Project, University Research Co. Myanmar PMI Defeat Malaria Project, and Myanmar National Malaria Control Program.

The PMI-supported Defeat Malaria Project aims to enhance technical and operational capacity of the National Malaria Control Program and providers at all levels of the health system in 3 States/Regions (S/R). In 2017, Myanmar introduced a new type of cadre, Integrated Community Malaria Volunteers (ICMV), as a foundation for integrated malaria control activities at village level.

Defeat Malaria is developing their capacity to ensure malaria case management according to National Treatment Guidelines (NTG). To date, Defeat Malaria has prepared 71 national and S/R level trainers to train and supervise 776 ICMVs caring for a population of nearly 600,000 people.

The study would like to explore the knowledge and technical skills retention of ICMVs working in these three States/Regions and how exactly they follow the national treatment guidelines.  NMCP’s Policy on ICMV notes that Malaria volunteers have been renamed as Integrated Community Malaria Volunteers (ICMV). Their Primary roles are malaria diagnosis, treatment, referral and IEC/BCC activities. They Refer and follow up when other diseases are suspected, including TB, HIV, leprosy, dengue and filariasis.

The Objective of the study was to explore the retention of malaria knowledge and skills of Integrated Community Malaria Volunteers after the training in Kayin and Rakhine States and Taninthary Region.  Also the study explored adherence to National Treatment Guidelines by the Integrated Community Malaria Volunteers in Kayin and Rakhine States and Taninthary Region.

This will be the secondary data analysis of “malaria knowledge and skills retention” using post training follow up tools and checklist during the supported supervision of NMCP conducted jointly with Defeat Malaria team in 2018 -2019 in three state and Region. The study population included 92 ICMVs.

Initial and refresher ICMV trainings included a 5-day modular course for initial ICMV training as well as a 3 days focusing on malaria epidemiology, malaria diagnosis, treatment and referral. There was an IEC/ BCC component focusing on community-based prevention. Another component was a 2-day update on other diseases: TB, HIV, leprosy, dengue and filariasis including referral and follow up of suspected cases.

Another 3-day course for refresher ICMV training one year after initial training was provided. A 2-day session focusing on malaria diagnosis, treatment and referral, case studies and filling register was given. Finally, there was a 1-day update on other diseases.
Improved malaria knowledge among trained ICMVs in two regions (Gwa and Hlaningbwe) was demonstrated. There was reduced gap between pre- and post-test scores at initial vs. refresher training.

Initial training of ICMV and post training assessments of retention of malaria knowledge resulted in 892 ICMV from 14 townships being trained. 54% of ICMV had a passing score (?80%) in pre test for knowledge of malaria. More than 90% of ICMV had a passing score in post test for knowledge of malaria.

Additionally 92 ICMV were followed up after training to assess knowledge of malaria. 42 ICMV were assessed within 6 months after training, and 50 ICMV were assessed after 6 months of training.

Post training assessment of retention of malaria case management skills for ICMV 6 month after training found that 100% of ICMV achieved a passing score using a standardized skills check list during a simulation. Performance improved over the previous year’s 6-month post training assessment in RDT testing. 92% of ICMV told patients about blood testing and provided emotional support, and 100% of ICMV conducted RDT testing according to standardized checklist.

All ICMV disposed of used lancets immediately into safety box after use, and 95% of ICMV gave health education. 90% of ICMV recorded the test result in the main register. 100% of ICMV provide correct treatment according to NTG by using Job Aids. Only 30% of ICMV referred suspected other diseases (TB, leprosy, dengue) with negative RDT to the health centre.

Case management and adherence to NTG by ICMV during supervision period (Oct 2018 – September 2019) also reached 100%.

In conclusion, Supportive supervision, mentoring, and attention to language barriers lead to improved post-training retention of knowledge and skills. 1-6 months after ICMV training, retention of knowledge, skills, and decision making related to malaria case management are high in all 3 States/Regions. >6 months after completing training, knowledge retention and skills on malaria case management of ICMV are less in Rakhine and Tanintharyi Regions. Retention of knowledge and skills of ICMV who received lower scores due to language barriers were improved by mentoring during supervision in Kayin State.

After 6 months, a decline was noted in ICMVs’ communication skills for health education during RDT testing. Since most RDT tests are negative, they must use job aids to recall correct treatment for positive case but are still confused about use of primaquine even with job-aids. All ICMV adhered to NTG for positive cases and negative cases. They referred negative cases suspected of having other disease (TB, leprosy and dengue) to the health center.

Moving forward, tablets will be used to gather data during ICMV mentoring visits to facilitate data accuracy and sharing. Data will be uploaded to NMCP through Google. Project staff will continue to accompany NMCP on supportive supervision visits to ICMVs 1 – 6 months post training to model best practices and lend to sustainability of the approach.

This poster is made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the terms of its Cooperative Agreement No. AID-482-A-16-00003 and the USAID Defeat Malaria Project. The contents are the responsibility of the authors and do not necessarily reflect the views of USAID, PMI or the United States Government.

Prioritizing Facilities for Malaria Case Management Training In the Era of Limited Resources

Presenting at the 68th Annual Meeting of the American Society of Tropical Medicine and Hygiene are James Sarkodie, Amos Asiedu1 Eric LaFary, Richard Dogoli, Raphael Ntumy, Lolade Oseni, and Gladys Tetteh who are sharing experiences on “Prioritizing Facilities for Malaria Case Management Training In the Era of Limited Resources”. The authors are affiliated with the PMI Impact Malaria (IM) Project and Jhpiego Baltimore. Below are their findings.

Ghana has made significant recent improvements in malaria control, reducing malaria deaths by 70% (1565 in 2015 to 468 in 2018) with a corresponding decline in under-5 malaria case fatality rate (CFR) from 0.51% to 0.19%. However, significant geographical variations in malaria morbidity and mortality persist and to achieve greater impact, a one-size fits all training approach may no longer be the most effective option.

The training aimed to prioritize facilities for refresher malaria case management training by the US President’s Malaria Initiative-funded Impact Malaria Project in collaboration with Ghana Health Service through systematic evidence-based criteria informed by quantitative and qualitative data. The team gathered information using routine health management information system (HMIS) data from October 2017 to September 2018 including total malaria admissions, malaria deaths malaria case fatality rates were determined for all districts in respective regions.

Districts with high burden malaria mortality and morbidity were ranked using a Pareto chart. Districts with CFRs above the regional average were also identified.

Assessed qualitative data including facility referral patterns, access, and ownership (government, faith-based, private) to explain the observed findings.  Information used by Regional health management teams to prioritize districts and facilities for additional malaria case management training focusing on assessment, treatment and management of complications, effective monitoring and using quality improvement methods to identify change ideas to test to improve malaria case management. Figure 1 shows the Scheme of approach to prioritizing facilities for Intervention.

Analysis of Routine HMIS data for FY-2018 reveals 37 Districts accounted for 33.9% of all districts in the 5 IM Target Regions & 14.2% all Districts in Ghana. There were 183 Malaria Deaths. Fiudings also observed that 90.1% all Malaria deaths in 5 IM Target Regions, and 39.1% of all Malaria deaths in Ghana

A number of districts had child case fatality rates above the regional average. The Districts with under-5 malaria CFR above the regional average were Ashanti Region (AR) – 31%, , Brong Ahafo Region (BAR) – 28%, Eastern Region (ER) – 31% , Upper East Region(UER) – 15% and Upper West Region (UWR) – 27%. Figure 2 shows the Proportion of Malaria Admissions And Mortality Attributable to TOP 10 Facilities In Target Regions – FY-19

The result of selecting districts and facilities using Pareto Charts is seen in Figures 3 and 4. Figure 3 sows the  Distribution of Malaria Deaths in Districts in Ashanti Region, Ghana, FY-2018, and Figure 4 presents the Distribution of Malaria Deaths in Districts in Brong-Ahafo Region, Ghana, FY-2018.

In conclusion, using routine DHMIS2 data backed by qualitative information including access to health facilities, referral patterns and facility ownership, a rational replicable basis for the prioritization of districts and facilities for intervention can be created and facilities prioritized for training based on evidence.

Regional Health Management teams have adopted a rational approach for prioritizing health facilities for intervention with limited resources with the objective of achieving the best outcome.