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Monthly Archive for "November 2013"

HIV &Research Bill Brieger | 29 Nov 2013

Don’t Forget Malaria on World AIDS Day

logo-wad2World AIDS Day coming up on Sunday 1 December 2013 is not just a time to think about progress and challenges of one infectious disease, but the interaction between HIV and other infections, especially Malaria.  Adu-Gyasi and colleagues express the relationship well in their article on malaria among HIV patients in Ghana: “Malaria is associated with an increase in HIV viral load and a fall in CD4-cell count. Conversely, HIV infection disrupts the acquired immune responses to malaria and the efficacy of antimalarial drugs.” Recent research provides continued insight that we must look at the two diseases as a joint problem in malaria endemic regions.

Research was conducted on mice that were infected with P. chabaudi malaria. The mice showed increased gut and genital mucosal T cell immune activation and HIV co-receptor expression. The implication of the findings was that malaria infection might enhance the sexual acquisition of HIV in humans, and the authors recommended further research to learn more.

In another study researchers looked at Malaria and HIV co-infection and their effect on haemoglobin levels from three health-care institutions in Lagos, Nigeria. The data showed that the total number of malaria infected patients were significantly higher in HIV sero-positive patients 47.7% (31/65) when compared with their HIV sero-negative counterparts 25.8% (262/1015) P = 0.047.  Not only was there a higher prevalence of malaria in HIV infected patients but also patients co-infected with malaria and HIV were more likely to be anaemic.

DSCN4965smBoth HIV and malaria in pregnancy present serious problems. Another recent study looked at Cotrimoxazole (CTX) prophylaxis versus mefloquine (MQ) intermittent preventive treatment (IPT) to prevent malaria in HIV-infected pregnant women. The study concluded that, “CTX alone provided adequate protection against malaria in HIV-infected pregnant women, although MQ-IPTp showed higher efficacy against placental infection. Although more frequently associated with dizziness and vomiting, MQ-IPTp may be an effective alternative given concerns about parasite resistance to CTX.”

Concern about malaria and HIV in pregnancy also focuses on the child. Research examined malaria diagnosis in pregnancy in relation with early perinatal mother-to-child transmission (MTCT) of HIV.   The authors reported that “HIV MTCT risk increased by 29% (95% CI 4-58%) per MIP episode. Infants of women with at least two vs. no MIP diagnoses were 2.1 times more likely to be HIV infected by 6 weeks old (95% CI 1.31-3.45).”

Finally since concurrent experience of both malaria and HIV infections means taking multiple drugs, researchers have also looked at the potential challenges of drug interaction. “An extensive literature search produced eight articles detailing n = 44 individual pharmacokinetic interactions.”  While various HIV medications either increased or decreased the exposure to malaria drug components including lumefantrine and artemisinin, artemether-lumefantrine or artesunate combinations generally had little effect on the pharmacokinetics of HIV-antivirals (with two exceptions).

It is difficult to say which disease is closer to reaching elimination goals, but unless both are understood from their mutual impacts on transmission and treatment of the other, both will continue to elude control efforts.

IPTp &Malaria in Pregnancy &Reproductive Health Bill Brieger | 21 Nov 2013

Malaria Products Must be Included in Life Saving Commodities for RMNCH

According to the Every Woman Every Child website (EWEC), “A strong focus on reproductive, maternal, child and newborn health (RMCNH) is integral to improving global health. RMNCH is linked to all 8 Millennium Development Goals (MDGs).  MDGs 4 (Reduce Child Mortality), 5 (Improve Maternal Health) and 6 (combat HIV/AIDS, malaria and other diseases) each have specific targets and indicators related to RMNCH.” In order to achieve these goals life saving commodities must be made available to all women and children, and as implied in the statement above, they must include commodities that prevent and treat malaria in pregnancy.DSCN8011 IPTp

The website further states that, “Based on these criteria, an initial list of 13 affordable, effective, but underutilized life-saving commodities were identified for consideration by the Commission. The UN Commission on Life-Saving Commodities for Women and Children aims to increase access to life-saving medicines and health supplies for the world’s most vulnerable people.”  Ironically this suggestive list does not include medicine for intermittent preventive treatment of malaria in pregnancy (IPTp), insecticide treated nets (ITNs), malaria rapid diagnostic tests or artemisinin-based combination therapy medicines for malaria treatment.

Yes the list is only suggestive, and yes it is a global list, but WHO estimates that nearly 50 million women will become pregnant in malaria endemic areas each year. That’s a pretty big chunk of the world’s population to neglect.

EWEC does refer to two partner documents for more details on these essential commodities. One document is “The Essential Interventions, Commodities and Guidelines for Reproductive, Maternal, Newborn and Child Health – A global review of the key interventions related to reproductive, maternal, newborn and child Health.”  This document mentions generically “Prevention and management of malaria with insecticide treated nets and antimalarial medicines.”

DSCN7129asmThe second document, “Priority medicines for mothers’ and children’s health, 2011”, also identifies medicines that are in need of enhanced attention and utilization in order to avoid preventable deaths of women and children. This document mentions that commodities exist for malaria services, but refers the reader to the very detailed Global Malaria Program’s “Guidelines for the treatment of malaria” (2nd ed. Geneva, World Health Organization, 2010) that discusses medications for all species of Plasmodium and does not have an easy to view take away on the essential life saving commodities within.

Over the past year the Global Malaria Program of WHO has issued guidance for updating malaria in pregnancy interventions, including more frequency IPTp with sulphadoxine-pyrimethamine (SP). The briefing companion document to this new guidance spells out the following life saving benefits if IPTp with appropriate references:

  • IPTp-SP prevents the adverse consequences of malaria on maternal and fetal outcomes, such as placental infection, clinical malaria, maternal anaemia, fetal anaemia, low birth weight and neonatal mortality.
  • IPTp-SP has recently been shown to be highly cost-effective for both prevention of maternal malaria and reduction of neonatal mortality in areas with moderate or high malaria transmission.
  • Despite the spread of SP resistance, IPTp-SP continues to provide significant benefit, resulting in protection against both neonatal mortality (protective efficacy 18%) and low birth weight (21% reduction in LBW) under routine program conditions.

Over the years rarely has IPTp if ever achieved high and sustained coverage. Factors relating to late antenatal care attendance are often mentioned first, but experience has shown that one of the key factors is stock-out of SP.  Once SP was no longer a first line treatment drug, it was forgotten – a neglected medicine needed by an often neglected but vulnerable portion of the population.  Now is the time to advocate strongly for direct and unconditional listing of SP for IPTp, ITNs and other malaria products among any list of RNMCH life saving commodities.

Elimination &Epidemiology Bill Brieger | 21 Nov 2013

Man’s Best Friend May Harbor Guinea Worm

Border Collie 3smChad had been free of debilitating guinea worm disease for a decade when ten new cases were uncovered in 2010. Logistical factors have prevented containment and the disease persists into the current transmission season. The Ministry of Health in Chad is currently examining 9 cases of human guinea worm but also 50 cases in dogs and one in a cat.

Donald Hopkins and colleagues recently explained that “Guinea worms in dogs have been reported for almost a century in some areas of Asia, Africa, and North America, including in some recently endemic countries that have interrupted transmission, but disease caused by D. medinensis has never been reported again after human transmission was interrupted.” In this situation where the cases in dogs far outnumber those in humans, one wonders hat the future holds for breaking transmission.

foot- close up2 smTwo key lessons from this experience are to be learned by the malaria community. First is the fact that once eliminated, an infectious disease can return.  The context though probably relates to the neighborhood. Post-conflict South Sudan is one of the few remaining countries with continued guinea worm transmission and refugee movement may have contributed to the problem.

The second lesson is the potential for inter-species transmission. Plasmodium knowlesi, a disease of primates, appears about to become entrenched in the human population of Southeast Asia. Cases of monkeys having P. vivax have been documented in South America and Africa.  Elimination of human transmission of malaria may be hampered by non-human reservoirs.

We may not be able to say that elimination has occurred until there is no local transmission of any species of Plasmodium that affect humans in any other life form.  We have a hard enough time tracking malaria in humans when it falls below levels detectable by microscopes and rapid tests. What of the challenges of tracking it in monkeys?  Maybe these complications explain why to date smallpox remains the exception to the eradication rule.

IPTp Bill Brieger | 20 Nov 2013

In vivo Efficacy of Sulfadoxine-Pyrimethamine for Intermittent Preventive Treatment of Malaria in Pregnancy — Mansa, Zambia

People continue to question the efficacy of Sulfadoxine-Pyrimethamine for intermittent preventive treatment of malaria during pregnancy as a preventive measure. Kathrine R. Tan, Bonnie R. Katalenich, Kimberly E. Mace, Michael Nambozi, Steve M. Taylor, Steven R. Meshnick, Ryan E. Wiegand, Victor Chalwe, Scott J. Filler, Mulakwa Kamuliwo, and Allen S. Craig presented information at the recent American Society of Tropical medicine and Hygiene 62nd Annual meeting that should allay these concerns.  Below are the main points from their poster.

Fig 1Intermittent preventive treatment of malaria in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) decreases adverse effects of malaria during pregnancy SP resistance threatens IPTp–SP strategy.  Mutations on the P. falciparum genes for dhfr and dhps are associated with SP drug resistance. Quintuple mutant haplotype (substitutions in N51I, C59R, S108N in dhfr and A437G and K540E in dhps) is a marker for SP treatment failure in non-pregnant patients.  Prevalence of molecular markers for SP resistance among pregnant women and how this translates into efficacy of IPTp-SP is unknown.

Fig 2The study objectives were 1) To determine the efficacy of IPTp-SP in clearing peripheral parasitemia in asymptomatic pregnant women , 2) To estimate prevalence of molecular markers for SP resistance among pregnant women in Mansa and 3) To describe the relationship of therapeutic efficacy of IPTp-SP with prevalence of molecular markers for SP resistance.

Tab 1Setting and population focused on Pregnant women attending two antenatal clinics in Mansa, Zambia, an area with high malaria transmission between January 2010 – March 2011 . Inclusion criteria were Pregnant women in their second trimester (by last menstrual period), HIV negative, no prior antimalarials or IPTp-SP in the current pregnancy, and asymptomatic parasitemia. The In vivo therapeutic efficacy study  looked for

  • Asymptomatic parasitemia determined by fever history, temperature measurement, and rapid diagnostic test (confirmed with malaria smear)
  • Follow up weekly for five weeks to assess for fever, parasitemia by blood smear, and hemoglobin
  • Polymerase chain reaction (PCR) of parasites on follow up to determine reinfection or recrudescence
  • Main Outcomes observed were –
  1. Adequate parasitic response — no parasitemia on follow up
  2. Parasitological failure — recrudescence
  3. Survival analysis done to describe time to failure and included those with incomplete follow up

Fig 3Molecular markers include PCR of Day 0 specimens to detect mutations on genes for dhps and dhfr.

Figure 1 shows Enrollment and disposition of study participants with Molecular Markers on 84. Quintuple mutant was seen in 51 (61%). There was No association between quintuple mutation and in vivo therapeutic efficacy outcome. Triple mutant only was 20 (24%) ; Double mutant only 7 (8%); and  Sextuple mutant (quintuple mutation plus mutation at codon 581 of dhps) 2 (2%). Table 1 shows the Characteristics of the study 92 participants.

Figure 2 provides Outcomes of in vivo therapeutic efficacy study. A Summary of outcomes found Parasitological failure in 7 (14%)  and Adequate parasitological response in 44 (86%). Figure 3 depicts the Kaplan-Meier survival estimates. Time to failure for all study participants (n=92, top panel) was 33.6 days, and did not significantly differ by gravidity (bottom pannel).

The study had some limitations including Small sample size — underpowered. There were No refusals for participation, but high rates for incomplete and loss to follow up — women may have enrolled as a socially desirable response, then later dropped out. Efficacy of IPTp-SP was examined in terms of parasite clearance. Care must be taken in extrapolating these results to effectiveness of IPTp-SP to prevent outcomes such as low birthweight and neonatal mortality.

IPTp-SP in Zambia still has in vivo efficacy and should be continued especially since there are no other drug alternatives for IPTp. Low in vivo failure rate relative to the moderate prevalence of molecular markers in Mansa was observed. There was No association between presence of the quintuple mutant and parasitologic failure, This is the First time the sextuple mutant has been described in Zambia. This study contributes to the paucity of data on in vivo efficacy of IPTp-SP in the setting of intermediate prevalence of SP resistance markers. Zambian IPTp-SP guidelines have been updated to reflect current WHO guidelines stressing IPTp at each ANC visit after quickening.

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Plasmodium/Parasite &Severe Malaria Bill Brieger | 17 Nov 2013

Sunday Symposium #176 at TropMed2013 Malaria: Biology and Pathogenesis – Human Responses to falciparum

AnnualMeetinggraphicOn this final day of the American Society of Tropical Medicine and Hygiene’s 62nd Annual Conference, there is a featured symposium on Malaria: Biology and Pathogenesis – Human Responses to falciparum. Presentations are listed below with links to the abstracts online.

Demonstration of enhanced strain-specific Plasmodium falciparum multifunctional T cell cytokine expression among Malian children immunized with the FMP2.1/AS02A vaccine by Shawna F. Graves et al.

The Study suggests that AMA1 vaccination induced an AMA1-specific CD4+ response; however, recognition of the vaccine antigen is not dependent upon c1L alone. In summary, AMA1-specific T cell cytokine expression was notably increased in children vaccinated with an AMA1-based vaccine compared to rabies. The possible role of CD4+ TNF-?+IL-2+-expressing T cells in vaccine-induced strain-specific protection against clinical malaria requires further exploration.

Fatal Pediatric Cerebral Malaria is Associated with Intravascular Inflammation and Coagulation that is Exacerbated by HIV-1 Co-infection by Sarah Hochman and colleagues.

We hypothesize that the intravascular inflammation and coagulation seen in CM autopsies contribute to the pathogenesis of pediatric CM and that dysregulation of these processes in HIV infection contribute to CM mortality.

Immune responses of rhesus monkeys to a self-assembling protein nanoparticle (SAPN) vaccine displaying Plasmodium falciparum CSP B- and T-cell epitopes by David E. Lanar and co-researchers.

We have previously studied in mice the immune responses induced against Plasmodium falciparum circumsporozoite protein (PfCSP) epitopes using a self-assembling protein nanoparticle (SAPN) platform. In conclusion, a PfCSP-KMY-SAPN vaccine for malaria was safe and immunogenic in rhesus monkeys. Immune responses to the vaccine were greatly enhanced if the nanoparticle was formulated with the adjuvant GLA-SE.

Non-invasive Pulse Oximetry to Predict Mortality in African Children with Malaria by Andrea L. Conroy et al.

The mortality rate for children admitted with malaria was 3.1%. We evaluated whether non-invasive pulse oximetry would predict disease outcome in malaria and compared the findings to venous lactate, an established prognostic marker in malaria. These data suggest that pulse oximetry alongside assessment of venous lactate may be useful in the triage and treatment of children with severe malaria. Additional advantages in pulse oximetry are low operating costs and real-time patient monitoring.

Placental malaria induces excessive vasculogenesis by  Tara C. Bracken and colleagues.

Placental malaria (PM) results from sequestration of Plasmdium falciparum-infected erythrocytes and the resulting inflammatory responses in the maternal placental blood space. PM induces maternal anemia, preterm birth, low birth weight, or stillbirth, especially in primigravidae. The active/active chronic group had a significantly higher percentage of excessive vasculogenesis.

Retinal microvascular dysfunction in pediatric cerebral malaria is associated with death and neurological sequelae by Ian J. MacCormick and co-authors.

Our results suggest that central nervous system ischemia and leakage across blood-tissue barriers may be important contributors to the severity of pediatric Cerebral Malaria.

Communication &Diagnosis Bill Brieger | 16 Nov 2013

Impact of behavior change communication on promoting parasite-based diagnosis for malaria

Encouraging both health workers and their clients to use and accept malaria rapid diagnostic tests can be a challenge. Esther Kaggwa, Douglas Storey, John Baptist Bwanika, Angela Acosta, Ron Hess, Emily Katarikawe, Espilidon Tumukurate, Julian Atim, Daudi Ochieng and Matthew Lynch of the Johns Hopkins University School of Public Health Center for Communication Programs addressed the RDT issue at the American Society of Tropical Medicine and Hygiene 62nd Annual Meeting in Washington DC. Their work is summarized below.

Fig1For 2-3 decades, presumptive treatment of malaria was widely practiced. In 2011, only 26% of Ugandan children under 5 with fever in the past 2 weeks received a blood test for malaria.[1] The new WHO policy of parasite·based diagnosis and treatment requires a major change irl household’s case management behaviors.[2]

The “Power of Day One” is a behavior change communication campaign (BCC) promoting testing and treatment for malaria within 24 hours of fever onset for pregnant women and children under 5 in Uganda. It started in June 2011 and ran in six districts: Apac, Katakwi, Kumi, Ngora, Serere and Soroti. Activities included provision of subsidized RDTs, provider trainings, promotion of new services, billboards, community dialogues, home visits, radio spots, a phone hotline, and others.

Fig2Study respondents were selected using multi-stage random sampling that selected not more than 300 persons per district. This sub-analysis included 847 individuals in 3 campaign districts that participated in the survey (Apac, Kumi, and Soroti). Results were analyzed using propensity-score matching to create matched control and experimental groups since exposure to media could not be randomized. The effect of any exposure to Power of Day One and in combination with other malaria campaigns was assessed. Logistic regression controlling for age, gender, wealth index, marital status, education, and rural or urban residence measured the association between level of exposure to Power of Day One and testing for malaria among respondents who had family members with a fever in the past two weeks (n=296).

Fig364% of respondents reported having seen or heard Power of Day One messages during the 12 months preceding the survey. Exposure was higher among respondents from urban areas (80%), those with more than secondary education (84%) and those from the highest wealth quintile (72%).1t was lowest among females aged 35-44 (53%) and respondents with a primary education (58%). 90% of those exposed to Power of Day One correctly recalled a specific message about testing and treatment for malaria within 24 hours.

49% of family members of respondents exposed to any malaria communication campaign that promoted Family members of respondents exposed to Power of Day 1 messages were 71% more likely to get blood drawn from a finger or heel for malaria testing when they had fever compared to those who were not exposed (p<0.001 ), primarily among women. Family members of respondents exposed to 2 or more communication channels were 1.3 times more likely to get tested for malaria than those not exposed.

Fig4Results indicate that communication can boost uptake of testing for malaria. Level of exposure was
also associated with behavior change. Further research on role of communication in promoting adherence to test results is needed.

The survey had some limitations in that the assessed testing behavior related to any family member with fever instead of just children under five. Households’ care-seeking behaviors for young children may differ from that for adults and other family members. Some of the observed effects may be due to other malaria programs, such as trainings on integrated community case management for community health workers which may have also taken place during the evaluation period.

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 responslbllity of the presenter and do not necessa rily reflect the views of USAID or the United States Government.


  1. World Health Organization {WHO). 2012. T3:Test. Treat. Track Initiative, 24 Apri12012. Avallable: http://www.who.lnt/malarla/test_treat_tracklen/index.html. Accessed: 2012 July 5.
  2. Uganda Bureau of Statistics {UBOS) and ICF International inc. 2012. Uganda Demographic and Health Survey 2011.Kampala, Uganda: UBOS and Calverton, Maryland: ICF International Inc.

Monitoring &Surveillance Bill Brieger | 16 Nov 2013

Malaria Highlights at TropMed2013 Saturday 16th November

Below please find a brief list of some of the presentations coming up today at the American Society of Tropical Medicine 62nd Annual Conference in Washington DC. Click links to view abstracts.


Rapid clearance of parasitemia by the novel spiroindolone KAE609 in a phase 2 open-label study of adults with acute, uncomplicated Plasmodium falciparum or vivax malaria mono-infection by Nicholas White et al.

In summary, when administered 30 mg daily for 3 days, KAE609 was well tolerated and achieved rapid parasite clearance in adult patients with uncomplicated P. vivax or P. falciparum malaria infection.

Symposium on Implementation of Mass Drug Administration for Malaria Control and Elimination. Symposium Organizer: Roly Gosling, Global Health Group, University of California, San Francisco, San Francisco

With the recognition that a large proportion of malaria infections are low density, below the level of detection by microscopy or Rapid Diagnostic Test, MDA is coming back into favor. The speakers will explore the drug choices available for MDA in different settings; for example, for P. falciparum settings in Haiti, The Gambia and the Artemsisinin Resistance Containment zone, and for P. vivax in Asia and the Pacific.

Innovative Field Tools for Detecting Counterfeit Medicines – The Case Study of Anti-Malarials. Symposium Organizer: JOEL BREMAN, FOGARTY INTERNATIONAL CENTER, NATIONAL INSTITUTES OF HEALTH

The need for innovative field tools for the detection of spurious/falsely-labelled/falsified/counterfeit medicines is becoming increasingly important, particularly in low-resource settings. A global public health crisis is looming, especially in malaria treatment and prevention, where up to 90 percent of antimalarials in surveys done in Asia and Africa are reported to be falsified or substandard.

Session: Malaria Epidemiology – Tracking Trends and Finding Foci, Village-level characteristics associated with spatial distributions of malaria-infected individuals in an area of Southern Zambia receiving mass screening and treatment by David A Larson et al.

Varying spatial distributions of malaria-infected individuals appear to be driven by vector abundance and gametocyte prevalence in the population. The ability to clearly delineate village malaria prevalence may assist in developing mechanisms for focused interventions to optimize their effectiveness.

Session: Malaria Epidemiology – Tracking Trends and Finding Foci. Reservoirs of asymptomatic malaria in Malawi: results of two cross-sectional studies by Jenny A. Walldorf et al.

In Malawi and potentially in other endemic settings, school age children represent important reservoirs of asymptomatic infection and should be targeted for interventions to interrupt transmission.

Session: Malaria Epidemiology – Tracking Trends and Finding Foci. Sustained Declining Burden of Malaria at Community level in Northeastern Tanzania. by Acleus S. Rutta et al.

The reported decline of malaria in most parts of Tanzania has some implication on accuracy of malaria diagnosis and management. The current remarkable and sustained decline in malaria suggests that these areas might be moving from control to pre-elimination levels.

Community &IPTp &Malaria in Pregnancy Bill Brieger | 15 Nov 2013

Improving Intermittent Preventive Treatment in Pregnancy and Antenatal Care Coverage

The Malaria Communities Program (MCP), supported by the US President’s Malaria Initiative, has increased local and indigenous capacity to undertake community-based malaria prevention and treatment activities; built local ownership of malaria control for the long term in partnership with communities and National Malaria Control Programs (NMCPs); and extended coverage of PMI and NMCP interventions to reach a larger beneficiary population. Below is a summary of the third in a series of MCP case studies found on the website of MCHIP – the USAID Maternal and Child Health Integrated Project.

The full case study on improving coverage of two doses of intermittent preventive treatment in pregnancy (IPTp) and attendance at antenatal care clinics, the main platform for delivering IPTp can be found at:

This IPTp/ANC case study focuses on four MCP partners and their contributions to improving the second dose of intermittent preventive treatment in pregnancy (IPTp2) and ANC coverage: Medical Teams International (MTI) Uganda, Episcopal Relief and Development (ERD) Angola, Caritas Senegal, and the Catholic Medical Mission Board (CMMB) Zambia. MCHIP collected multiple forms of data from each MCP partner using qualitative methods, including individual interviews with key project personnel and review of key documents.

MCHIP then compared data across organizations to better understand the total contributions made by the MCP. Some partners conducted surveys and relevant quantitative data are included in this report. Data are limited by a lack of standardized reporting on this topic. Although MIP interventions comprise more than IPTp and ANC, the three sub-themes emerging from this review are: 1) mobilizing communities to increase ANC and IPTp uptake; 2) using behavior change communication (BCC) to inform women and their families about the importance of ANC and IPTp; and 3) improving access to quality ANC services.

IPTp Chart 1 smChart 1 shows results from MCP projects that collected survey data regarding IPTp, and indicates significant improvements in coverage in those project areas. MCP partners built partnerships between communities and health facilities to improve access. As exemplified by strategies such as VHTs accompanying pregnant women to health facilities and assisting midwives in administration of IPTp, when communities and facilities work together the partnership yields not only improved outcomes but also improved attitudes among providers and clients. MTI successfully expanded the Ministry of Health package of Village Health Team services to address malaria in pregnancy in their project area.

MCP partners implemented interpersonal communication strategies to increase demand for and use of MIP-related services. MCP partners also encouraged male participation to increase coverage of MIP-related

Community &Treatment Bill Brieger | 13 Nov 2013

Community directed distributors’ views on their work in community case management of malaria, pneumonia and diarrhoea

Below is the abstract for a another poster being presented by a team from Jhpiego at the upcoming 62nd annual meeting of the American Society for Tropical Medicine and Hygiene November 13-17 2013 at the Marriott Wardman Park in Washington DC.  If you are at the conference, stop by poster number LB-2290 on Friday and discuss with Bright Orji.

CDDs smJhpiego adapted the community directed interventions approach pioneered by the African Program for Onchocerciasis Control and the Tropical Disease Research program of WHO and collaborating agencies to deliver a combination of health interventions in 108 kin groups surrounding six primary health care facilities in Akwa Ibom State, Nigeria.

Volunteer community directed distributors (CDDs) who were selecte dby their co-villagers provided insecticide treated bednets, intermittent preventing treatment of malaria in pregnancy, and integrated community case management (iCCM) of malaria, pneumonia and diarrhoea. Communities selected 1-2 CDDs depending on their size using their own selection criteria.

Experience with volunteer community health workers like CDDs has shown that there are often serious logistical and motivational problems in maintaining a core group of volunteers. The community-selected mainly female CDDs and all had a minimum of secondary school education.

The CDDs were trained by health workers and the nearest primary health care facility. Three nurses who supervised the CDDs asked about their views and experiences as part of the supervisory process. Overall they obtained input from 152 CDDs serving the 108 kin groups. Key reasons why CDDs liked their included rendering service to neighbors (42.6%); reducing malaria (19.5%); reducing death (16.1%); improving Antenatal Care attendance (11.6%) and learning more about malaria (10.2%).

They also voiced discouragements such as working in the heavy rainy season (36.4%); lack of commodities (21.9%); lack of incentives (15.7%); farming season (11.6%); lack of respect from community members (7.2%) and poor road network (0.2%). When the CDDs were asked to identify reasons that they could opt out of the service, lack of commodities topped the list (73.3%). This was followed by lack of incentive (14.4%); and lack of appreciation by the community (9.8%).

The importance of intrinsic perceived benefits as possible motivators augurs well for program continuance. Fortunately few mentioned unsustainable financial incentives. Many of the logistical challenges they face can be tackled by better program management. These views can be incorporated into planning when the CDI approach is expanded into health service areas.

Uncategorized Bill Brieger | 12 Nov 2013

Achieving, Tracking, and Maintaining High ITN Coverage: Community Strategies

Several of USAID’s Malaria Communities Program (MCP) partners worked to increase coverage of insecticide treated nets. These include EQUIP Liberia, WellShare International Uganda, Aga Khan Foundation (AKF)/Progresso Mozambique, Caritas Senegal, Episcopal Relief and Development (ERD) Ghana, Ajuda de Desenvolvimento de Povo para Povo em (ADPP) Angola, and Episcopal Relief and Development (ERD) Angola. The full case study on these efforts can be found on the Maternal and Child Health Integrated Project (MCHIP) website.

Nets distributed by MCP partners smMCHIP collected multiple forms of data from these five partners using qualitative methods including individual interviews with key project personnel and review of key documents. MCHIP then compared data across projects to better understand the overall contributions made by MCP. Some partners conducted surveys and this case study includes relevant quantitative data.

MCP partners 1) increased access to ITNs 2) monitored and tracked ITN ownership and use, 3) increased proper use of ITNs; and 4) identified and addressed challenges to ITN procurement, distribution, and use.

MCP nets vs national trend smCollaborative partnerships and coordination of efforts with the Ministry of Health (MOH), communities, and other local stakeholders supported efforts to distribute, promote effective use, and maintain ITNs. ITN ownership increased in nearly all MCP project areas (see orange and blue bars in the Chart) where surveys were conducted. Final coverage estimates in project areas are significantly higher than national estimates (yellow and purple bars), even where project baseline coverage was lower than national averages.

Community-level efforts contributed to achieving high coverage and use. MCP partners demonstrated the value of community-level strategies to distribute nets. Strategies included using volunteers and doing door-to-door distribution; community BCC focused on proper net hang-up and use; and net quantification and monitoring from which data were used to procure sufficient quantities of nets, plan for net replacement, and appropriately target net distribution.

The success in project areas that utilized community level strategies (see Charts 1 and 2) underscores the need for continued partnership between national-level stakeholders like NMCPs and community-level facilitators like NGOs.

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