Improving Early ANC Attendance and IPT Uptake through Community Health Volunteers

Community health workers are playing an increasing role in maternal health programming.  Augustine Ngindu, Susan Ontiri, Gathari Ndirangu, Beth Barasa, Evans Nyapada, David Omoit, Johnstone Akatu, and Mildred Mudany of The Matewrnal and Child Survival Program, The Kenya Ministry of Health and Jhpiego share their experiences in Kenya at the 66th Annual Meeting of the American Society of Tropical Medicine and Hygiene in Baltimore on 2017-11-06.  If you are in Baltimore, hear more at Scientific Session 13. Below is an abstract of their presentation

Kenya adopted the use of intermittent preventive treatment with sulfadoxine pyrimethamine in 1998 but the proportion of pregnant women receiving at least two doses (22% (2010) and 56% (2015) has remained below the national target of 80%. In 2015, the country adopted an IPTp3 indicator for monitoring IPTp uptake; that year, the proportion of women taking at least 3 doses was 38% (2015).

Some of the factors leading to low IPTp coverage include poor knowledge on the need for early antenatal care (ANC), distances to health facilities, sociocultural practices and a lack of financial resources. In 2012, community health volunteers (CHVs) were enlisted through a pilot program in one county to deliver messages aimed at increasing the proportion of women starting ANC ? 20 weeks of gestation and thus expand the proportion of women receiving IPTp early in the second trimester.

A community survey in 2013 showed an increase in IPTp2 from 22% in 2010 to 63%. The practice was considered a success story, and was subsequently replicated in 30 sub-counties, in 4 out of 14 malaria endemic counties. The rollout involved training of 9,042 CHVs, in 761 community units. Between 2015 and 2016, the CHVs reached 86,433 women with MiP messages. During this time, there was an average increase in IPTp1 from 51% to 68%, and IPTp2 increased from 42% to 55% (p? 0.001). This could be attributed to early ANC attendance, which increased from 32% to 48% in the same period.

The use of CHVs to sensitize pregnant women to start IPTp early in the second trimester and continue with scheduled ANC visits increases the probability that women will receive the recommended IPTp-SP doses. The rollout of the practice to other malaria endemic counties is likely to have contributed to increase in IPTp uptake in the four target counties.

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Online Survey to Elicit Views of Technical Support from Endemic Country Neglected Tropical Disease Managers

An online survey was part of the process of an evaluation of USAID’s NTD program conducted by the Johns Hopkins Bloomberg School of Public Health. William R. Brieger, Adebamike Oshunbade, Gilbert Burnham, Violetta Yevstigneyeva, Emily Wainwright, and Darin Evans present the process and brief findings from the online survey Monday (20171106) during Poster Session A of the American Society of Tropical Medicine and Hygiene 66th Annual Conference in Baltimore. If you are there, look for Late Breaker Poster #5111. The poster abstract is provided below.

Neglected Tropical Diseases (NTDs) are a diverse group of communicable diseases prevailing in tropical and subtropical conditions in 149 countries and affect more than one billion people, especially those in poverty. Since 2006 The US Agency for International Development has working with global and national NTD partners to control or eliminate 5 NTDs that respond to preventive chemotherapy delivered through mass drug administration at the community level.

As part of an evaluation of this effort, an online survey was conducted with endemic country NTD staff to learn their views on the successes and challenges of USAID NTD program support. A 22-question 3-part survey of closed and open-ended responses was posted online through Survey Monkey.  A list of emails of government, NGO and donor NTD staff from 21 endemic countries was compiled. After 3 contacts, 44 English and 22 French speakers responded.

Most respondents thought Global NTD goals aligned adequately or fully (88%) with national priorities. Respondents valued regular technical assistance from USAID as 76% rated help in annual planning useful or very useful, and well-coordinated with their own annual planning (71%). Most (71%) said the USAID NTD program had been effective in communicating its goals and accomplishments among country partners.

Respondents felt that documentation and dissemination of success stories could be strengthened. Specific USAID contributions were valued: “USAID gives an orientation on the tools to use, shares the guidelines to follow-up and does comments for clarifications.” When asked about integration of NTDs with other programs (WASH, PHC, and MNCH), 81% of respondents felt this was achieved to some degree, but recognized a need for national ministries to take a stronger lead.  Concerning strengthening national leadership, 81% felt USAID support helped.

The online survey process was a valuable supplement to time-consuming country visits and ultimately provided useful input from a wider cross-section of persons involved in NTD efforts. The suggestions will guide upcoming technical assistance as countries move toward their control and elimination goals.

Mis-Use of Insecticide Treated Nets May Actually Be Rational

People have sometimes question whether insecticide treated nets (ITNs) provided for free are valued by the recipients. Although this is not usually a specific question in surveys, researchers found in a review of 14 national household surveys that free nets received through a campaign were six times more likely to be given away than nets obtained through other avenues such as routine health care or purchased from shops.

Giving nets away to other potential users, not hanging nets or not sleeping under nets at least imply that the nets could potentially be used for their intended purpose. What concerns many is that nets may be used for unintended and inappropriate reasons. Often the evidence is anecdotal, but photos from Nigeria and Burkina Faso shown here document cases where nets were found to cover kiosks, make football goalposts, protect vegetable seedlings and fence in livestock.

Newspapers tend to quote horrified health or academic staff when reporting this, such as this statement from Mozambique, “The nets go straight out of the bag into the sea.”  The Times said that net misuse squandered money and lives when they observed that “Malaria nets distributed by the Global Fund have ended up being used for fishing, protecting livestock and to make wedding dresses.”

Two years ago the New York Times reported that, “Across Africa, from the mud flats of Nigeria to the coral reefs off Mozambique, mosquito-net fishing is a growing problem, an unintended consequence of one of the biggest and most celebrated public health campaigns in recent years.”5 Not only were people not being protected from malaria, but the pesticide in these ‘fishing nets’ was causing environmental damage. The article explains that the problem of such misuse may be small, but that survey respondents are very unlikely to admit to alternative uses to interviewers.

Similarly El Pais website featured an article on malaria in Angola this year with a striking lead photo of children fishing in the marshes near their village in Cubal with a LLIN. A video from the New York Times frames this problem in a stark choice: sleep under the nets to prevent malaria or them it to catch fish and prevent starvation.[v]

More recently, researchers who examined net use data from Kenya and Vanuatu found that alternative LLIN use is likely to emerge in impoverished populations where these practices had economic benefits like alternative ITN uses sewing bednets together to create larger fishing nets, drying fish on nets spread along the beach, seedling crop protection, and granary protection. The authors raise the question whether such uses are in fact rational from the perspective of poor people.

An important fact is that not all ovserved ‘mis-use’ of nets is really inappropriate use. A qualitative study in the Kilifi area of coastal Kenya demonstrated local ‘recycling’ of old ineffective nets. The researchers clearly found that in rural, peri-urban and urban settings people adopted innovative and beneficial ways of re-using old, expired nets, and those that were damaged beyond repair. Fencing for livestock, seedlings and crops were the most common uses in this predominantly agricultural area. Other domestic uses were well/water container covers, window screens, and braiding into rope that could be used for making chairs, beds and clotheslines. Recreational uses such as making footballs, football goals and children’s swings were reported

What we have learned here is that we should not jump to conclusions when we observe a LLIN that is set up for another purpose than protecting people from mosquito bites. Alternative uses of newly acquired nets do occur and may seem economically rational to poor communities. At the same time we must ensure that mass campaigns pay more attention to community involvement, culturally appropriate health education and onsite follow-up, especially the involvement of community health workers. Until such time as feasible safe disposal of ‘retired’ nets can be established, it would be good to work with communities to help them repurpose those nets that no longer can protect people from malaria.

The Need to Prevent the Spread of Malaria Drug Resistance to Africa

Chike Nwangwu is a Monitoring and Evaluation Specialist who is currently working on his Doctor of Public Health (DrPH) degree at the Johns Hopkins Bloomberg School of Public Health. Here he presents an overview of the threat of parasite resistance to first-line antimalarial drugs and the need to prevent the spread of this problem in Africa which beard the greatest burden of the global malaria problem.

Malaria, remains one of the most pervasive and most malicious parasitic infections worldwide.  Malaria is caused by Plasmodium parasites when they enter the human body. There are currently five known plasmodium species that cause malaria in humans- P. falciparum and P. vivax are the most prevalent globallyThese parasites are transmitted through the bites of infected female anopheles mosquitoes “malaria-vectors” which perpetuate the spread of the parasite from human-human or from host- human.

Globally, according to the WHO, an estimated 212 million cases of malaria and 429 000 malaria related deaths occurred in 2015.[1]  The global share of malaria is spread disproportionately across regions; Over 90% of global malaria cases and deaths occurred in the African region, with over 70% of the global burden in one sub region-Sub Saharan Africa. In areas with high transmission of malaria, children under 5 are at the highest risk to infection and death; more than two thirds of all malaria deaths occur in this age group.[2]

Although malaria remains a global concern, malaria is preventable and curable.  Increased efforts in malaria prevention and treatment within the past two decades has led to revolutionary success- 6.8 million lives have been saved globally and malaria mortality cut by 45% since 2001.[3] Globally, within a five-year interval (2010-2015) new malaria transmission and mortality in children under 5 years of age fell by 21% and 29% respectively. This has been the one the greatest public health successes in recent years [4]

The improvement of malaria indices aligns with intensification of efforts, through funding, research, innovation pushing the scale up of key malaria interventions in the malaria prevention- diagnostic- treatment cascade. For example, in Sub-Saharan Africa where malaria is most prevalent, there has been a recorded 48% increment in Insecticide Treated Net (ITN) usage since 2005, 15% rise in chemoprevention in pregnant women and within the same time frame diagnostic testing increased from 40% of suspected malaria cases to 76%.[5]

Treatment/ Emergence of insecticide and drug resistance

Malaria treatment plays a key role in controlling its transmission. First, prompt and effective treatment of malaria prevents progression to severe disease and limits the development of gametocytes, thus blocking transmission of parasites from humans to mosquitoes.[6] Drugs can also be used to prevent malaria in endemic populations, including various strategies of chemoprophylaxis, intermittent preventive therapy, and mass drug administration can be effective.[7] Like other interventions, availability and use of antimalarial has been a success. However, this has also come with some challenges. The emergence of resistance, particularly in P. falciparum and P. vivax to antimalarial-quinine and sulfadoxine-pyrimethamine, has been a major contributor to reported resurgences of malaria in the last three decades.[8]

Distribution of reported resistance to antimalarials. As at 2005, antimalarial resistance was is established in 81 of the 92 countries where the disease was endemic (WHO, 2004)

Falciparum resistance first developed in some areas in Southeast Asia, Oceania, and South America before the 70’s eventually the parasite became resistant to other drugs (sulfadoxine/ pyrimethamine, mefloquine, halofantrine, and quinine. Drug-resistant P. vivax was first identified in 1989 in one region and later spread to other regions of the world.[9] As at 2005, antimalaria resistance to chloroquine and sulfadoxine-pyrimethamine was established in 81 of the 92 countries where the disease was endemic. (Figure 1) In 2005, alongside acetaminophen, antimalarial were among the most commonly abused medications in the African region, with the majority of the population having detectable amounts of chloroquine in the blood.[10]

Antimalarial drug resistance is the decrease in viability of an antimalarial to cure an infection.  Parasite resistance results in a delayed or partial clearance of parasites from the blood when a person is being treated with an antimalarial.[11] Antimalaria resistance occurs as the byproduct of at least one mutation in the genome of the parasite, giving an advantageous capacity to evade the impacts of the drug. Within the human host, drug resistance develops gradually. First, a modest number of drug-resistant parasites survive exposure to the drug whilst the drug-sensitive parasites are eliminated. In the absence of additional drugs and competition from drug-sensitive pathogens, the drug-resistant parasites proliferate and their populace develops. This new population is therefore resistant to additional malaria medications of the same type.

Following the discovery of resistance to quinine and sulfadoxine-pyrimethamine, the development of resistance was initially forestalled by the utilization of a new class of malaria drugs – Artemisinin-derivative combinations. These ACTs (Artemisinin Combination Therapy) work by combining artemisinin and an active partner drug with different mechanisms of action. The WHO, with guidance from extensive drug efficacy tests and research, recommends the use of 5 types of ACTs for treatment of uncomplicated malaria caused by the P. falciparum parasite. By 2014, ACTs have been adopted as first-line treatment policy in 81 countries.[12]

Although ACT use has been a breakthrough in malaria treatment, development of resistance to de novo ACTs poses one of the greatest threats to malaria control efforts. P. falciparum resistance to artemisinin has been detected in five countries of the Greater Mekong sub-region (Lao, Myanmar, Thailand, Cambodia, and Vietnam). To date P. vivax resistance to an ACT has not been detected.

Artemisinin resistance is currently defined within the confines of delayed parasite clearance; it represents partial/relative resistance-i.e. most patients who have delayed parasite clearance do not necessarily have treatment failure. Following treatment with an ACT, infections are still cleared, as long as the partner drug remains effective.  Various factors are believed to contribute to the development and spread of resistance to artemisinin; use of oral artesunate monotherapies (oAMT) inclusive.

A global response has been mounted to curtail the spread of ACT resistance to other regions, especially to regions like Sub-Saharan Africa. Research on the mechanisms of drug resistance has steered efforts in the direction, recently the identification of the PfKelch13 (K13) mutations has allowed for a more refined definition of artemisinin resistance that includes information on the genotype. [13]  In addition, stricter policies have been developed for malaria control; Therapeutic efficacy studies (TES) are conducted and used as the main reference from which national malaria control programmes determine their national treatment policy.[14]  These studies help to ensure the efficacy of treatments with recommendations to ensure that these medicines are monitored through surveillance at least once every 24 months at established sentinel sites and in regions with emerging resistance, the creation of additional sentinel surveillance sites. [15]

Preventing and containing antimalarial drug resistance- Recommendations to countries

As research is being done to fully understand the mechanisms of antimalarial resistance; basic recommendations to limit its spread have been disseminated.[16] First, the production and use of oral artemisinin-based monotherapy should be halted and access to the use of quality-assured ACTs for the treatment of falciparum malaria should be ensured. In countries where antimalarial treatments remain fully efficacious; correct medicine use must be promoted, with weight placed on encouraging diagnostic testing, quality-assured treatment, and good patient adherence to the treatment.  Lastly, to reduce the burden of the disease, and prevent the spread of resistance, in regions where there is still high transmission, intensification of malaria control efforts is key, rapid elimination of falciparum malaria would accelerate efforts.

  • [1] World Malaria Report 2016, World Health Organization, Geneva, 2016
  • [2] ibid
  • [3] CDC, Malaria Fast Facts 2017
  • [4] ibid
  • [5] World Malaria Report, 2016
  • [6] Gosling RD, Okell L, Mosha J, Chandramohan D. The role of antimalarial treatment in the elimination of malaria. Clin Microbiol Infect. 2011;17:1617–1623.
  • [7] Greenwood B. Anti-malarial drugs and the prevention of malaria in the population of malaria endemic areas. Malar J. 2010;9
  • [8] White NJ. Antimalarial drug resistance. J Clin Invest. 2004;113:1084–1092
  • [9] CDC, Malaria Fast Facts, 2017
  • [10] White NJ. Antimalarial drug resistance. J Clin Invest. 2004;113:1084–1092.
  • [11] Peter B. Bloland, Drug resistance in malaria, World Health Organization, 2001
  • [12] World Malaria Report, 2016, World Health Organization, Geneva,2016
  • [13] Artemisinin and artemisinin-based combination therapy resistance April 2017,World Health Organization, 2017
  • [14] Responding to antimalarial drug resistance, World Health Organization, 2017: http://www.who.int/malaria/areas/drug_resistance/overview/en/
  • [15] ibid
  • [16] Ibid

Committing to Preventing Malaria in Pregnancy From the National to State to Local Level in Nigeria

Bright Orji recently shared an overview of the Transforming Intermittent Preventive Treatment for Optimal Pregnancy (TIPTOP) Project in Nigeria, a joint venture to protect pregnant women from malaria organized by Jhpiego with support from Unitaid, the National Malaria Elimination Program, The State Ministries of Health in Ebonyi, Niger and Ondo and the local communities.  He shares some highlights from the project launch this past week. The project will strengthening antenatal care services to reach out and involve communities in the grassroots delivery of intermittent preventive treatment of malaria in pregnancy (IPTp).

Her Excellency Chief (Mrs.) Rachel Umahi wife Executive Governor Ebonyi State flags off TIPTOP

Among those in attendance were wife of the Ebonyi State Executive Governor and representatives from the State Ministry of Health, the State Malaria Elimination Program, the State Primary Health Care Development Agency, the Ebonyi State House of Assembly, the Ministry of Justice, the Ministry of Local Government, the Ministry of Women Affairs, the School of Nursing and Midwifery, the School of Health Technology Ngbo, the Ohaukwu local government council and the community members.

The media documented the active participation, involvement and commitment by all stakeholders. Other partners present were the World Health Organization representing all UN Agencies in Nigeria and ISGlobal of Barcelona. Furthermore, the villages, families, and traditional rulers of the 16 communities that made up Ohaukwu Communitywelcomed the new project.

In order to emphasize an integrated approach to preventing malaria in pregnancy Ebonyi State, pregnant women given long lasting nets during the TIPTOP launch

Her Excellency Rachel Umahi, wife of the Ebonyi Governor said that, “TIPTOP project came at the right time, and I pledge to join hands to stop malaria in the state.”  She was joined by the Ohaukwu Local Government Chairman Barr Clement Oda who shared that, “Today marks a special day in the history of Ohaukwu LGA, Ebonyi State and Nigeria at large as TIPTOP project launch will put the state and her people in the global map. This TIPTOP project will receive a very good support and cooperation from my administration. We shall not relent on what or things we need to do to make this project a success in Ohaukwu LGA worthy for this project.”

The National Coordinator National Malaria Elimination Program, Dr. Bala Audu, explained that, “The choice of Ebonyi state and Ohaukwu LGA in particular is not unconnected with the low utilization of the antenatal care services and low performance in IPTp utilization when compared with other LGAs in the southeastern region. We hope the LGA and the state will use this opportunity to redeem her image in malaria in pregnancy performance in Nigeria.” He pledged his support to Jhpiego and the malaria programs in the three participating states.

Dr. Ugo Okoli, Deputy Country Director Jhpiego in Nigeria pointed out the synergies possible within the state through noting that the, “Maternal and Child Survival Project funded by USAID will collaborate with TIPTOP in Ebonyi State to ensure that ANC is strengthened, and communities mobilized to utilize services.”

Bright Orji will provide updates from time to time in these efforts to reduce the high mortality through community efforts from malaria in pregnancy in Nigeria.

Transforming Intermittent Preventive Treatment For Optimal Pregnancy (TIPTOP) Project in Ebonyi State Nigeria

Bright Orji who is the Project Manager for the Jhpiego and UNITAID Transforming Intermittent Preventive Treatment For Optimal Pregnancy (TIPTOP) Project in Nigeria shares remarks that introduce the program in Ebonyi State of Nigeria.

The project will help protect pregnant women from malaria. Malaria is very dangerous to pregnant women and unborn babies. It causes abortion, low birth weight in babies as well as responsible for about 11% (6,050) of maternal deaths of Nigerian women

Jhpiego’s original community IPTp in Akwa Ibom State involved community volunteers in preventing malaria in pregnancy

Building on Jhpiego’s effort to ensure Intermittent preventive treatment in pregnancy (IPTp) reaches all women in the community. Between 2007 and 2010, Jhpiego collaborated with the National Malaria Elimination Program (NMEP), Reproductive Health division of the Federal Ministry of Health and provided technical assistance to the Ministry of Health in Akwa Ibom State to introduce a community directed approach with a focus on malaria in pregnancy with support from the ExxonMobil Foundation. That project reached over 35,000 pregnant women representing an increase in IPTp uptake by 35.3% going from 21.7% at baseline to 57.0% at the endline.

With support coming from Unitaid, Jhpiego and her partners will be implementing Transforming Intermittent Preventive Treatment for optimal pregnancy – shortened to TIPTOP project reach all pregnant women in Ohaukwu, Ebonyi State (South-East), Suleja in Niger State (North Central and Akure south in Ondo State (South West).

Bright Orji and Colleagues review clinic records on malaria in pregnancy

These States were selected on the basis of malaria prevalence rate; national commitment to generate evidence across the six geographical zones; given that similar project has been implemented in Akwa Ibom State representing South-South, and Sokoto state representing North West. Poor status of IPTp interventions in the selected Local government areas; and to further complement our on-going efforts with Maternal and Child Survival Project funded by the United States Agency for International Development (USAID/MCSP); Presidential Malaria Initiatives (PMI), Global Health Funds for Tuberclosis, HIV/AIDs and Malaria.

In this effort, we will work with the National Malaria Elimination Program (NMEP) that is charged with the responsibility of coordinating all malaria prevention and control activities in Nigeria; Reproductive Health Division of the Family health department, Federal Ministry of Health, State Ministries of Health, Local Governments authorities, communities development partners including World Health Organization (WHO); UNICEF, World Bank and other stakeholders (PMI/USAID, AFENTH etc).

To do this, TIPTOP project Nigeria will use a two-pronged approach that will increase the number of pregnant women in the three states who receive key malaria in pregnancy interventions by:

  • Strengthening ANC services in health facilities, ensuring that a strong foundation for MIP services is in place; and
  • Using community directed intervention approach where Community health workers,

Supervised by these strengthened ANC facilities, to initiate MIP interventions at the community level and refer women to the nearest ANC facility

Antenatal Clinics are the base for organizing training and community involvement in delivering Intermittent malaria Preventive Treatment in Pregnancy

Both parts of this approach will also strengthen local capacity in training, supervision, project implementation and evaluation by working with local civil society organizations that have strong ties to the community. As a component of this project, TIPTOP will seek a model for integrating MIP and other prevention services on the platform of ANC. TIPTOP project has planned for operations research that will provide some lessons and evidence and these include:

  • Household surveys to gain understanding how pregnant women think, where they receive services if they are not coming to the health centers, and how we can prove services they receive
  • Anthropological study – that would investigate community acceptability of community IPTp
  • Sulfadoxine-pyrimethamine (SP) resistance monitoring study and
  • Economic study – cost-benefit analysis

We are aware of the challenges ahead, Prof. ‘Dipo Otolorin the former Country Director for Jhpiego and now the Snr. Technical and Programmatic Advisor will always say, “a stick of broom cannot sweep the street, but when you have a bunch of sticks sweeping becomes delightful”. This is an African aphorism for team building.

So, from beginning of the grant application and subsequent development of the approved country operational plan (COP); we have engaged the key stakeholders that work on malaria in Nigeria. This is because we need the collaboration, coordination and cooperation of everyone. We will work together to mobilize all the communities in these three states, conduct community census that will guide us to estimate adequate number of SP doses; enter every kindred, family, household and home of pregnant women. We will identify all the pregnant women, refer them to attend ANC, as well as administer the life-saving medicines to the eligible ones both at facility and community levels. NO PREGNANT WOMAN SHOULD DIE OF MALARIA, BECAUSE IT IS PREVENTABLE, TREATABLE AND WE HAVE EVIDENCE-BASED INTERVENTIONS TO PROTECT THEM.

By the end of the project we would have achieved the goal of increasing the number of women who receive MIP services through strengthened ANC and community-level interventions. TIPTOP project expects additional outcomes from this initiative and these include:

  • Generate evidence for WHO policy change
  • set stage for scale up of community intermittent preventive treatment during pregnancy (IPTp)
  • Increased demand for quality assured sulfadoxine–pyrimethamine (SP) for IPTp and

With this project no pregnant woman should die from malaria. So let us all join hands to stop malaria – and make Nigeria a Malaria free nation!!!

The Forest through the Trees: Themes in Social Production of Health

Recently Professor Ayodele S Jegede of the Faculty of Social Sciences, delivered the 419th Inaugural Lecture at the University of Ibadan, Ibadan, Nigeria, during the 2016/2017 academic session.  Below Prof. Jegede shares an abstract of his lecture.

Prof Ayodele S Jegede

Knowledge of individual actor’s behaviour is a reflection of the society as tree to the forest. As forest produces large quantities of oxygen and takes in carbon dioxide, society produces the needed resources for human beings to survive through culture. This inter-dependence between man and the environment is summarised by the Yoruba adage which says: “irorun igi ni irorun eye” (meaning: a bird’s peace depends on the peace enjoyed by the tree which harbours it).

Nigeria, a country with a population of about 187 million and a life expectancy of 53 years, 54% of the populace are living below the poverty line with limited access to health care services physically and economically. Although universal health coverage is vital to the achievement of the Sustainable Development Goals (SDGs) cultural perception of disease aside from loss of economic and low purchasing power makes people to attribute their illnesses to spiritual cause and therefore seek alternative health care services. This influences resistance to public health interventions in some African communities resulting in suspicion and distrust between health educators and the public.

Strengthening Health Information Systems

For instance, response to childhood immunizable diseases, mental illness, malaria and HIV/AIDS reported in this lecture was driven by how people define the diseases. Their response did result in delay in seeking modern health care until alternative care sources proved ineffective. This confirms W.I. Thomas (1929: 572) postulation that, “If men define situations as real, they are real in their consequences”.

Our stakeholders’ engagement interventions strategies strengthened by knowledge of how people construct their life, socially and culturally, proved to be a potent vaccine for preventing strain relationship between health workers and clients. Since society consists of individuals who constitute the stakeholders conducting health researches as well as management of epidemics and treatment during epidemics and disease episodes require appropriate ethical behaviours.

This suggests that adequate knowledge of the society is inevitable since a tree does not make a forest which confirms Marx Weber’s Action Theory postulation that an act does not become social unless it involves two or more persons. It is, therefore, that government should establish National Disease Observatory System (NDOS) to document diseases by type, location and related local practices for training health care professionals, clinical practice and emergencies preparedness.

Note also that the lecture was featured in the New Nigerian Newspaper with an emphasis on establishing a national disease observatory.  The Nigerian Tribune also featured the lecture stressing the importance of disease emergency preparedness.

Asymptomatic and Sub-Microscopic Malaria: a Challenge to Elimination Efforts

WHO says that, “In settings where malaria is actively being eliminated or has been eliminated, a “case” is the occurrence of any confirmed malaria infection with or without symptoms.” Several recent studies describe the importance of paying attention to asymptomatic infections.

In the Bagamoyo District of Tanzania Sumari and colleagues collected blood samples and examined them for Plasmodium falciparum prevalence using rapid diagnostic test (RDT), light microscopy (LM) and reverse transcription quantitative PCR. While overall prevalence was higher in symptomatic children using all three methods, asymptomatic children had a higher prevalence of gametocytes using light microscopy and PCR.  They concluded that, “The higher gametocytemia observed in asymptomatic children indicates the reservoir infections and points to the need for detection and treatment of both asymptomatic and symptomatic malaria.”

The health effects of asymptomatic plasmodial infections (API) on children were documented in Rwanda. These included “Plasmodium infection was associated with anaemia, fever, underweight, clinically assessed malnutrition and histories of fever, tiredness, weakness, poor appetite, abdominal pain, and vomiting” and were generally more common with submicroscopic infection.

Besides children other groups are at risk from API.  Malaria during pregnancy is a life and health threat to both the pregnant woman and the unborn child. Thirty-seven percent of asymptomatic pregnant women who had just delivered in Colombia were found to have parasitemia. Using microscopy only 8% were identified, such that without PCR the true extent of the problem would not have been identified. Thus, there is also concern for submicroscopic malaria and well as API generally. Asymptomatic and submicroscopic infections in areas co-endemic for P. falciparum and P. vivax are major contributors to anemia, not only in children but also in adults.

Working along the China-Myanmar border area, Zhao et al. explained that, “Sensitive methods for detecting asymptomatic malaria infections are essential for identifying potential transmission reservoirs and obtaining an accurate assessment of malaria epidemiology in low-endemicity areas aiming to eliminate malaria.” Thus they tried three molecular detection methods side-by-side, namely nested PCR targeting the rRNA genes, nested RT-PCR to detect parasite rRNA, and CLIP-PCR to detect parasite rRNA.

Interestingly the presence of fever is no guarantee that malaria parasites will be found. A study in Gabon demonstrated that among febrile patients only 1% had parasites found through microscopy compared to 32% through molecular testing. These studies have demonstrated the need for a better understanding of malaria transmission across different zones and strata in a country in the light of asymptomatic and submicroscopic malaria, especially gametocytemia. This should lead to better targeting of case detection, improved treatment and better compliance with preventive measures.

Health for All at the International Institute for Primary Health Care, Ethiopia

The time is ripe for a revitalization of the primary health care (PHC) movement. “Health for All through Primary Health Care” (HFA) was first envisioned at the 1978 International Conference on Primary Health Care (World Health Organization and UNICEF), and was enshrined in the Declaration of Alma-Ata. The HFA goal of bringing essential, affordable, scientifically sound, socially acceptable  health care provided by health workers who are trained to work as a health team and who are responsive to the health needs of the community, guided by strong community engagement by the year 2000 but has not been fully met. Fortunately the vision of Alma-Ata has taken root, sprouted and flourished in a number of locations.

Thanks to the vision and intellectual and political leadership of Dr. Tedros Adhanom Ghebreyesus, the then Minister of Health of Ethiopia and recently elected Director General of the World Health Organization, Ethiopia is an outstanding example of the Alma-Ata legacy. Access to PHC services was greatly expanded through the training of 40,000 Health Extension Workers (women from the local area with one year of training, each of whom serve 2,500 people and receive a government salary), recruitment of 3 million community female health volunteers (called the Health Development Army), and engagement with communities to enable them to take responsibility for improving their health.

This expansion of PHC enabled Ethiopia to achieve its health-related MDGs. Child mortality (those younger than 5 years of age) declined from 166 deaths per 1,000 live births in 1990 to 67 in 2016 (MDG 4). Significant progress was achieved in reducing levels of childhood malnutrition (MDG 1). MDG 5 was almost reached, with a decline in maternal morality of 72%, versus the goal of 75%, and the percentage of mothers obtaining a delivery by a skilled provider increased 6-fold between 1995 and 2016. The prevalence rate of modern contraceptive use increased from 6% in 2000 to 35% in 2016. MDG 6 (for HIV, malaria and tuberculosis) was also reached. The number of new HIV infections declined by 90%, and the number of AIDS-related deaths by 53%. Between 1990 and 2015, the tuberculosis incidence and mortality rate declined by 48% and 72%, respectively. The malaria incidence rate declined by 50% and malaria mortality by 60%. Ethiopia’s PHC system is acknowledged as the major factor leading to these impressive health gains.

Representatives from more than half of sub-Saharan Africa countries have come to Ethiopia to see its PHC system in action. Because of this interest, in 2016 the Federal Ministry of Health of Ethiopia established the International Institute for Primary Health Care – Ethiopia, with seed funding from the Bill & Melinda Gates Foundation and technical support from the Johns Hopkins Bloomberg School of Public Health. Our goal is for the Institute to become a global center of excellence for training, knowledge dissemination and research in primary health care, supported by multiple donors.

The Institute has begun to provide formalized short-term training to high-level policy makers and officials, program planners and managers, as well as to those engaged in service delivery, to see first-hand how an effective national PHC system functions. Trainees come from within Ethiopia and around the world. Trainees also visit communities, meet their leaders, and observe primary health care providers at work. Trainees will return to their home country with renewed energy and new vision and skills to revitalize their own primary health care system.

The Institute will also conduct and support research that yields evidence to guide ongoing strengthening of the Health Extension Program, and will rapidly disseminate open access information about recent advances in PHC. The Institute marks a significant step forward on the road to achieving the Alma-Ata vision of Health for All.

A website for IIfPHC-E is being built to provide further information about these programs and will be available at: www.iifphc.org.

This posting was prepared by: Kesetebirhan Admasu1, Michael J. Klag2, Yifru Berhan Mitke3, Amir Aman4, Mengesha Admassu5, Solomon Zewdu6, Jose Rimon7, Henry B. Perry8

1Chief Executive Officer, Rollback Malaria Partnership, Geneva, Switzerland and Chair, Advisory Board, International Institute for Primary Health Care — Ethiopia

2Dean, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

3Minister, Federal Ministry of Health, Government of Ethiopia, Addis Ababa, Ethiopia

4State Minister, Federal Ministry of Health, Government of Ethiopia, Addis Ababa, Ethiopia and Co-Chair, Advisory Board, International Institute for Primary Health Care – Ethiopia

5Executive Director, International Institute for Primary Health Care – Ethiopia, Addis Ababa, Ethiopia

6Health and Nutrition Development Lead – Ethiopia, Integrated Programs, Global Policy & Advocacy – Global Development, Bill& Melinda Gates Foundation, Addis Ababa, Ethiopia

7Director, Bill & Melinda Gates Institute for Population and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

8Coordinator for Johns Hopkins University Support of the International Institute for Primary  Health Care – Ethiopia, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

Population Health: Malaria, Monkeys and Mosquitoes

On World Population Day (July 11) one often thinks of family planning. A wider view was proposed by resolution 45/216 of December 1990, of the United Nations General Assembly which encouraged observance of “World Population Day to enhance awareness of population issues, including their relations to the environment and development.”

A relationship still exists between family planning and malaria via preventing pregnancies in malaria endemic areas where the disease leads to anemia, death, low birth weight and stillbirth. Other population issues such as migration/mobility, border movement, and conflict/displacement influence exposure of populations to malaria, NTDs and their risks. Environmental concerns such as land/forest degradation, occupational exposure, population expansion (even into areas where populations of monkeys, bats or other sources of zoonotic disease transmission live), and climate warming in areas without prior malaria transmission expose more populations to mosquitoes and malaria.

Ultimately the goal of eliminating malaria needs a population based focus. The recent WHO malaria elimination strategic guidance encourages examination of factors in defined population units that influence transmission or control.

Today public health advocates are using the term population health more. The University of Wisconsin Department of Population Health Sciences in its blog explained that “Population health is defined as the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” World Population Day is a good time to consider how the transmission or prevention of malaria, or even neglected tropical diseases, is distributed in our countries, and which groups and communities within that population are most vulnerable.

World Population Day has room to consider many issues related to the health of populations whether it be reproductive health, communicable diseases or chronic diseases as well as the services to address these concerns.