Posts or Comments 18 July 2024

Monthly Archive for "September 2012"

Elimination Bill Brieger | 30 Sep 2012

Towards Malaria Elimination: Recommendations of the First Rwanda Malaria Forum

dscn9941-sm.jpgThe First Rwanda Malaria Forum was organized by the National Malaria Programme from the 26th to 28th September 2012 in Kigali Rwanda. The aim of the Forum was to recommend actions that Rwanda should take to accelerate the attainment of zero malaria deaths. The forum brought together experts from Rwanda, East Africa, Southern Africa, the United States of America and Europe. WHO was prominently represented by the Director Disease Prevention and Control on behalf of the Regional Director WHO AFRO.

The Forum recognized the remarkable progress Rwanda has made in reducing malaria morbidity and mortality and recommended that by 2017 Rwanda should aim to achieve zero deaths due to malaria and achieve pre-elimination status. The following were the key recommendations:

A) Maintain the remarkable achievements and further reduce malaria morbidity to pre-elimination levels countrywide

  • Increase funding to the fight against malaria (domestic and external)
  • Achieve 90% coverage of the population at risk of malaria with locally appropriate vector control interventions based on evidence
  • Improve malaria case diagnostics to 100% and treatment at all levels including the private sector.
  • Develop a comprehensive advocacy, communication and social mobilization aimed at shifting the understanding of malaria pre-elimination by the leadership and other policy makers, the community and all levels of the health system.
  • Develop capacity for malaria pre-elimination including in entomology and epidemiology
  • Conduct operational research to support programme implementation and robust documentation of the process

B) Achieve zero malaria deaths by 2017

  • Strengthen prompt access to treatment of severe malaria
  • Conduct malaria death audits for all cases

C) Investigate and classify all cases and foci in low endemic districts

  • Gradually, strengthen epidemiological, entomological and therapeutic surveillance
  • Strengthen malaria stratification for local and eventually imported malaria cases
  • Further strengthen the health system in readiness for pre-elimination using the WHO 6 pillars
  • Strengthen an integrated quality assurance and control system for diagnosis and treatment of malaria cases.

D) Develop and strengthen local and international collaborative and partnership initiatives to accelerate malaria control and pre-elimination in Rwanda and the region.

  • Strengthen linkages with other players in the health non-health sectors within the country
  • Create a multi-sectoral malaria pre-elimination group
  • Develop, with other East African Countries, a cross border strategy to accelerate malaria control and pre-elimination in the region

Borders &Elimination Bill Brieger | 30 Sep 2012

Rwanda Malaria Elimination Forum’s Working Group on Cross-Border Initiatives

cross-border-malaria-focus2.jpgA key focus of the recently completed First Rwanda Malaria Forum was on cross-border initiatives to help eliminate malaria.  The two most malaria-endemic districts in Rwanda are situated at borders with other malaria endemic countries. Nyagatare borders Uganda and Tanzania, while Gisagara borders Tanzania and Burundi.  The Democratic Republic of Congo, which has some of the highest malaria burden in the world, shares a long border with Rwanda, too.

The Working Group on Cross Border Planning and Initiatives consisted of Nancy Mock (Tulane), Charles Paluku, Okui Albert Peter (Uganda), James Banda (WHO/GMP), Carol Asiimwe, Harriet Pasquale  (South Sudan), Simon Kunene  (Swaziland), Dorothy Memusi (Kenya), Corine Karema (Rwanda), Felicien Ndayizeye (Burundi), Patrick Moonasar ( Rapporteur), Georges A. Ki-Zerbo (WHO/AFRO).  Their overall strategic considerations are found in the table below.


Key action points focused on defining the problem and drafting a concept paper. Defining the problem would require Two meetings with all 5 countries supported by RBM’s East Africa Regional Network (EARN)Earn Support. The first meeting would focus on a conducting situational analysis and drafting of framework for data collection (before 15 December 2012). The second meeting would bring evidence based on Framework for collaboration in moving towards malaria elimination and a draft concept paper (March 2013).

The draft a concept paper would cover the following key issues:

  • Disease burden in all neighboring districts
  • Coverage target in all neighboring countries  and other factors e.g. demographic and social factors.
  • Rational for initiative
  • Objectives
  • Activities
  • Budget
  • Coordination mechanism
  • Recommendations
  • Action plan

Facilitators for this effort should be WHO and EARN. Because of Swaziland’s experience with such cross-border efforts the working group identified its National Malaria Control Program Director, Simon Kunene, as an expert who could provide technical assistance.

In summary key recommendations arising from the Working Group deliberations include:

  • A cross border initiative meeting including target district leaders
  • WHO/EARN to provide oversight TA, invite target NMCP managers and District Health Management Teams
  • Each country shall initiate internal discussions on cross border initiatives
  • Each member country to ensure inclusion of Cross-Border initiatives into national strategic plans and share data collection tool at country meetings

Elimination &Vector Control Bill Brieger | 29 Sep 2012

The Role of Malaria Prevention and Vector Control in Rwanda’s Progress toward Malaria Elimination

A second working group at the recently completed First Rwanda Malaria Forum examined issues around “Malaria Prevention and Vector Control.” A key message from the Forum was the need to protect existing vector control technologies (IRS and LLINs) and well as develop and test new ones in the local setting. These can be deployed in a focused manner as better entomological and epidemiological data are available on district, sub-district and cross-border areas.

dscn7129asm.jpgMembers of the group included – Hakizimana Emmanuel, MOPDD-Rwanda; Abraham Mnzava, WHO/HQ; Beata Nukorugwiro, JHPIEGO; Cait Unites, PSI; Beatus Cyubahiro, RBC-MOPDD; Dunia Mwuyakango, RBC-MOPDD; David Wainaina, Bayer; Arielle Mancuso, PMI/RFHP; Moses Turyazooka, CREST Technologies; Richmond Ato Selby, Networks; Christine Ochieng, Vestergaard Frandsen; Tessa  Knox, Vestergaard Frandsen; Levin Nsabiyumva, USAID/Burundi; Kagabo Jean Bosco, World Vision Rwanda; Athanase Munyaneza, RBC/KFHIK; Duschuze Clemence, RBC/MOPDD; Sangala Freddy, Nyagatare Hospital; John Githure, MOPDD/RBC; Francisco Saute, USAID/PMI

The group suggested the following Strategic Objectives to be achieved by or before 2017 …

  1. Generate local evidence to guide optimization and diversification of available vector control interventions
  2. Build sustainable capacity for entomological  monitoring and vector control at national, district and community levels
  3. Formulate policies and procedures for effective and sustainable mobilization of vector control activities
  4. 90% of the population at risk of malaria will have access to locally appropriate vector control  interventions based on evidence
  5. Establish harmonized mechanism for cross border collaboration on vector control interventions

Key Actions For Strategy 1:

  • Establish a national entomological profile (vector ecology and behavior, species composition and distribution, susceptibility to insecticides)
  • Re-enforce and expand entomological  surveillance sentinel sites
  • Determine the appropriateness of vector control interventions – including new tools
  • Conduct operational research on the effectiveness of vector control interventions

Key Actions for Strategy 2:

  • Recruit and train entomologists for deployment at district level for vector control interventions and entomological surveillance
  • Strengthen and expand field lab/insectary facilities for entomological monitoring at sentinel sites
  • Collaborate with the existing Dept. of Environmental Health at the KHI to include medical entomology programme
  • Empower the communities through training on vector control

Key Actions for Strategy 3:

  • Develop insecticide resistance management plan
  • Establish regulatory processes to support timely deployment of existing and new tools as they become available
  • Develop a transition plan for decentralization of vector control activities
  • Re-orient IEC/BCC strategy to better support pre-elimination efforts
  • Evaluate human and other factors influencing the effective lifespan and acceptability of vector control tools

Key Actions for Strategy 4:

  • Maintain universal coverage with LLINs in the population at  risk
  • Rational deployment of IRS in prioritized risk areas
  • Evidence-based deployment of other supplementary vector control interventions (e.g. repellents, screening, LSM) where appropriate


  • Establish a national inter-sectoral steering coordination mechanism for planning and implementation of  integrated vector management (IVM)
  • Enhance entomological capacity in moving towards pre-elimination phase
  • Integrate vector control within district development plans and operational targets
  • Long term financial commitment of Government of Rwanda and development partners is essential to achieve and sustain the gains in malaria prevention

Elimination &Monitoring &Surveillance Bill Brieger | 29 Sep 2012

Surveillance, Monitoring and Evaluation as Rwanda Moves Towards Malaria Elimination

Rwanda’s First Malaria Forum has just concluded in Kigali, producing recommendations to help the country, which is already experiencing very low levels of malaria transmission, develop strategies for the path to malaria elimination. After a series of informative talks other countries in the region and international support organizations, working groups distilled the learning from the forum into suggestions for strategic planning. Below we present the deliberations of the Working Group on Surveillance, Monitoring and Evaluation. Group members included Irenee Umulisa, J. Bosco Ahoranayezu, John MacArthur, Arielle Mancuso, Aafje Rietveld, Eric Tongren, Anna Winters.


Preamble: A paradigm change is necessary within the national malaria surveillance system in order to take Rwanda from the stage of malaria control to pre-elimination. Stratification (epidemiological, entomological and environmental) will be used as the basis for applying different programme approaches in the different parts in the country, including surveillance approaches. In high burden strata, the quality of malaria control surveillance will be optimized. In low endemic strata, WHO recommended elimination surveillance approaches will be piloted and gradually introduced to field-try forms & procedures and build systems capacity.

Goals and Vision: By 2017, every febrile patient on the Rwandan territory will visit a health facility within 48 hours for diagnosis and treatment. Under 5s will be treated at community level within 24 hours. A microscopy and RDT quality assurance system (including external quality control) will be in place, ensuring reliable diagnosis at all diagnostic facilities. Every malaria case diagnosed with RDT and treated at community level will be reported to the health center level within 24 hours, accompanied by a microscopy slide for confirmation of diagnosis.

All malaria cases will be reported into one centralized HMIS, irrespective of the health providers who diagnosed and treated them (public, private, community, army, etc.) and irrespective of the way they were detected (ACD, PCD, surveys).

Health centers in low and moderate malaria burden strata will carry out “enhanced malaria surveillance” allowing foci investigation and classification. Health centers in endemic areas will forward line-listings of patients (ideally also with information about recent travel) to the district level with copy to the central level on weekly basis. Central level will compile from these data weekly updated mapping by village level and track cases against epidemic thresholds.

Strategic objectives and action points:

By 2012, update the stratification map of Rwanda’s malaria burden by including data from HMIS, SIS-COM and any other sources of malaria patient data that may be available. The objective is to be all-inclusive: in malaria elimination every case counts. A more in-depth stratification using entomological and environmental variables and intervention coverage will follow.

  • Merge SIS-COM (community) data collection with existing HMI
  • Use the map to identify 3-4 zones for stratification of surveillance and intervention methods based upon malaria burden.

By 2013, develop/update the surveillance plan to direct the MOH malaria surveillance strategies over the coming 5 years within the changing epidemiological settings, with a view to (a) attain malaria pre-elimination programme status in low and moderate burden strata by 2017; and (b) maintain and improve upon the current control achievements in higher burden strata.

  • Improve and coordinate data management and timeliness.
  • Include a plan for human resources necessary to undertake enhanced surveillance.
  • Include a timeline to achieve strategic objectives and action points.

By 2014, set up the systems to enable and ensure that all suspected malaria cases (100%) are diagnostically confirmed using available tools and in a timely fashion within both public and private clinics.

  • Develop (guided by OR) for each strata a clear case definition of a suspected malaria case who should be tested, ranging from a broad definition (fever) in highly endemic areas to a more restricted definition (perhaps including a travel history or additional symptoms) in low endemic areas. Communicate these definitions to all health care providers and the public in the various strata. The purpose is to ensure that every potential malaria case is promptly tested, without unduly overburdening the health workers in low endemic areas.
  • Monitor the use of antimalarials by various health facilities against the numbers of cases diagnosed and reported.

By 2015, pilot “enhanced malaria surveillance” in 1-3 low endemic districts

  • In low and moderate burden areas, begin line listing all confirmed malaria cases including travel history and household location with the goal to map cases (2015-2017). Focus initial line listing and case mapping within Kigali or another accessible low burden district (2013).
  • By 2014, engage the private sector physicians in Kigali for cooperation in malaria surveillance activities (working with the Rwanda medical association). Enforce full cooperation of the private sector by 2017. Restrict availability of antimalarial medicines to registered facilities with access to diagnostic capacity.
  • In low and moderate burden areas, begin collecting weekly malaria data at the health facility level.
  • Gradually include immediate notification and due programme follow up (investigation, classification) of cases detected, starting with one district where this seems doable.
  • Explore business/private coalitions to support a longer term vision of a malaria-free Kigali / tourism areas.

By 2015, pilot line listing in one endemic district, increasing to all endemic districts by 2017

  • Integrate training and data management into existing community health worker programs.
  • Develop and deploy a system for active case detection (ACD) as part of case investigation at the community level.
  • Map all confirmed cases which are passively and actively detected.
  • Develop epidemic thresholds for comparison against weekly case loads.

By 2013, review and start to address the factors that contribute to malaria mortality in Rwanda.

  • Conduct death audits for all reported malaria cases that occurred in 2012. The purpose is to identify risk factors for delays in treatment / inadequate treatment that can be addressed by NMCP programme interventions. Use this study to strengthen collaboration of the NMCP with the national school of public health (or equivalent) by engaging a team of university students / scientists in the study.
  • Explore possibilities for increasing the use of pre-referral treatment with rectal artesunate, based on an understanding of the barriers and behaviours for accessing pre-referral treatment.
  • By 2015, carry out death audits for all reported malaria deaths as they occur, to adjust and target programme interventions.

Continue drug and insecticide resistance monitoring to guide drug and insecticide policies.


  • By 2014, initiate “enhanced malaria surveillance” following WHO recommended strategies for the elimination phase in 1 low endemic district, increasing to 3 districts by 2015 and all low-endemic districts by 2017. This includes investigation, classification and mapping of cases and transmission foci.
  • By 2015, institute line listing in one endemic district, increasing to all endemic districts by 2017.
  • Encourage and facilitate information sharing among all partners in malaria control.
  • Use available resources in a manner that allows continued high quality surveillance in endemic areas combined with gradual introduction of elimination approaches in low endemic districts. Adopt the philosophy of first building up enhanced surveillance systems and then expanding the system as resources and malaria burdens allow.
  • Consider including Kigali within the first pilot districts for enhanced surveillance, given the low prevalence and focalized transmission patterns, and to encourage political will.
  • Conduct death audits in order to measure progress towards the goal of zero malaria deaths.

Efficacy &Pharmacovigilence &Treatment Bill Brieger | 17 Sep 2012

Prequalification of Malaria Medicines Needs to be Taken More Seriously

The Leadership newspaper in Nigeria reported on Sunday the launching of a new artemisinin-based combination therapy (ACT) drug knwon by the trade name ‘Artiquick.’  In order to ensure that it is not just another route to ‘profit-quick’, we looked into the WHO prequalification list to see if the Chinese company ArtePharm that makes the drug was listed.

Prequalification is based on a comprehensive evaluation of “the quality, safety and efficacy of medicinal products, based on information submitted by the manufacturers, and inspection of the corresponding manufacturing and clinical sites.” The resulting lists of malaria, TB, and HIV drugs and diagnostics is meant to guide various national and international health agencies in their procurement of medicines.

dscn7285sm.JPGThough not stated and often not practiced, it would be ideal if these lists also guided various drug regulatory agencies in malaria endemic countries. Although it is a somewhat arduous process to get prequalification, it is possible and necessary – two new medicines containing artesunate-mefloquine were just added in 12 September.

The prequalified list as of today contains 25 anti-malaria products from only 10 companies. ArtePharm is not among them.  Yet the manufacturer made it known that, “the   new  drug   which  has  proven  very  effective  since  early  this  year  when  it  underwent additional clinical trials, Nigeria can, thus, be very hopeful, on attaining the Millennium Development Goals (MDGs) target on malaria come 2015.”  In addition the manufacturer mentioned to the press that ACTs generally were recommended by WHO, implying that any ACT, including their own, was approved by WHO.

Finally the ArtePharm representative made it know that their product was tested and approved by Nigeria’s food and drug agency NAFDAC. NAFDAC does ensure that products contain the labeled ingredients in the labeled amounts and that the drug is safe to use. It is important in the fight against counterfeit drugs. But NAFDAC has approved hundreds of ACTs for sale and use in the country. Unlike WHO, NAFDAC and other national agencies do not have the reach to inspect the production processes at the root.

Hopefully ArtePharm will begin the journey of the prequalification process soonest, and that countries where it sells its product will also encourage that company and many others to take the responsible steps needed to ensure we have quality antimalarials that will actually eliminate disease and not just eliminate money from patients’ pockets.

Communication &Partnership Bill Brieger | 14 Sep 2012

Ghana Footballers Fight Malaria

News from Ghana by Emmanuel Fiagbey, Ghana Malaria Voices Project:
The Ghana Football Association (GFA) has held a special media event in Accra to highlight Ghana’s progress in the fight against malaria with support from the National Malaria Control Program and the Voices for a Malaria Free Future project of Johns Hopkins University’s Center for Communication Programs.  Just as in the previous Africa Cup of Nations (AFCON), the 2013 event will promote United Against Malaria (UAM) – an international effort for using football to draw attention to and mobilize support for malaria control efforts.

GFA’s 7th September media event was a prelude to the Ghana–Malawi qualifying match and attracted representatives from 21 print and broadcast outlets and malaria-related agencies and NGOs.

The event was opened by GFA’s president Mr. Kwesi Nyantakyi who reminded those present that …

“Because of GFA’s national reach, Mr. Nyantakyi promised to work towards bringing on board the UAM Partnership local football clubs which belong to the Ghana League Clubs Association to support dissemination of important malaria prevention and treatment messages in communities all over the country.”

a-journalist-poses-her-question-uam-20120907-sm.jpgMembers of the Ghana Media Malaria Advocacy Network (GMMAN) and other journalists who participated in the event were very enthusiastic in continuing to disseminate malaria information through their publications. They however called on the Voices Project to keep them regularly posted on developments at the malaria front.

Maybe the GFA’s enthusiastic support for United Against Malaria helped propel them to success as Ghana Beat Malawi in AFCON 2013 Qualifier a few days later!  Of course no national FA in Africa can afford to ignore the threat of malaria to their teams or their communities.

Borders &Elimination Bill Brieger | 13 Sep 2012

Collaborate to Eliminate: sub-regional and cross-border

rbm-sub-regional-networks-strengthen-south-south-collaboration.jpgThe Roll Back malaria Partnership supports four sub-regional networks (SRNs) in East, Southern, Central and West Africa. The SRNs are a mechanism for strengthening South-South collaboration in the fight against malaria. Such collaboration is essential as neighboring countries move closer to elimination and policies and transmission patterns in one can affect the success of elimination efforts in another.

The collaboration is particularly visible and active in the Southern African SRN (SARN), where a meeting has just concluded to plan action along the Angola-Namibia border – otherwise known as the Trans-Kunene Cross-border Malaria Initiative (TKMI). Similar initiatives are ongoing among all of the ten partners  who include  Botswana, Madagascar, Malawi, Mozambique, Namibia, South Africa, Swaziland, URT-Zanzibar, Zambia, Zimbabwe.

The northern border area of Namibia is its only malaria endemic region. While the area of Angola just across the border has similar transmission patterns, the whole of Angola farther north is highly endemic.  Angola’s actions can therefore, affect the fate of malaria elimination in Namibia.

At the TKMI meeting in August 2012 Stakeholders reviewed activities during the 2011-12 malaria transmission season and affirmed commitment of the two governments to continue to work together to eliminate malaria in their cross-border region. An important component of collaborative work is the synchronization of operations and harmonization of policies and guidelines such as joint Monitoring and Evaluation and data systems including exchange of information and best practices will ensure that all cases are reported and traced jointly along the border.

kunene-cunene-angola-namibia-a.pngAnother crucial area of collaboration, according to SARN Leadership, is removal of border immigration restrictions and customs requirement will speed up movement malaria workers and malaria commodities especially during epidemics, cross-border referrals, joint outreaches and joint operations/campaigns such as IRS, Larviciding and LLINs mass distribution. This also helps to resolve bottlenecks related to delivery.

Policy and program guidelines for elimination recommended by the stakeholders included test, treat and trace, and hence, they stressed the need for using rapid diagnostic tests and training all health staff in the region to be proficient in these.  Prompt and appropriate case management was also outlined including the need, an mentioned above, for easy cross-border movement of supplies of malaria medicines.  Indoor residual spraying is a very appropriate strategy in these low and unstable transmission areas, and will be more effective if communities on both sides of the border are covered equally.

The TKMI meeting ended with a declaration of the collaborating partners. They observed that the considerable effort in malaria control in the two countries had  “produced good results in the drastic reduction of mortality and morbidity caused by this disease,” and pledged that this will continue through “reinforcement of
harmonization of policies and strategic components.”

The two countries’ stakeholders recognized that common efforts to improve logistics such as “infrastructures, transport, immigration and customs along the common” were just as important as harmonizing program policies and guidelines. In closing “two parties promised to engage in a process of mobilizing more
resources and partnerships at different levels, with the aim to accelerate the universal coverage along the common border border.” This spirit of collaboration is needed throughout malaria endemic regions.

ITNs Bill Brieger | 12 Sep 2012

Net Safety – a burning issue

When we think about safety matters and insecticide treated bednets our first thoughts often go to the chemicals.  As Jamali has observed, “Pyrethroids form the mainstay of preventive measures due to their efficacy and safety in mammals.” Barlow and colleagues pointed out some time ago that while deltamethrin may have some dermal effects, the rick was much lower than the benefit.

More recently there has been concern expressed about health and environmental implications of disposing or re-purposing old nets. One approach has been to treat an old net, even is it has little effective insecticide left, just like a used pesticide container. In reality the potential effects of nets used for unintended purposes, or large collections of nets in community disposal sites are not well researched yet.

dscn1231a.jpgA recent article from Uganda in The Observer has drawn our attention to an important and seemingly neglected aspect of net safety – fire. One of the doctors interviewed shared that a “majority of the cases of burns he handles are as a result of mosquito nets catching fire. He says although rarely talked about, nets are the worst agent of fire that can burn children.” The article further explained …

“Mosquito nets made of polyester are particularly dangerous; when it catches fire and wraps around someone, it causes deep, severe burns. When distributing free mosquitoes nets in the fight malaria campaign, no one is teaching people about safety and how dangerous they are with fire.”

There are many sources of open fire in village homes – lanterns, candles, stoves. Living, cooking and sleeping space may be at a premium and rooms may serve multiple functions, increasing potential fire exposure.

There is a lot we need to do to educate net owners about their nets – even the basics of how to hang and net and when to use are often forgotten in the rush to hand out thousands of nets during a campaign.  In this case we need to be extra vigilant to ensure that a commodity intended for protection from harm does not itself become a death trap.