Posts or Comments 20 July 2024

Monthly Archive for "March 2014"

coinfection &Epidemiology &Tuberculosis Bill Brieger | 24 Mar 2014

World TB Day: considering malaria coinfection

Typical of our big disease mindset, most donor agencies think of HIV-Tuberculosis coinfection when addressing a connection among the three Global Fund diseases. Take as an example a recent News Flash from the Global Fund: “In a major step toward addressing the growing number of people affected by co-infection with tuberculosis and HIV, the Global Fund is improving the way it approaches treatment programs in countries with high rates of each disease. Millions of people infected with both TB and HIV could benefit from better services.”

World TB DayThe possible neglect of TB and malaria interactions might be understood by the fact that HIV and TB have much wider areas of endemicity than malaria. On the other hand both HIV and TB are disproportionately represented in malaria endemic Africa. At present the main connection between malaria and TB is the fact that they must share out of the same ‘envelope’ when new Global Fund support is distributed through the new funding mechanism to countries, a process that some see as moving more toward donor control and AID effectiveness and away from human rights.

Today the Stop-TB Partnership and related organizations are observing World TB day by noting that at least one-third of newly infected people will not get appropriate treatment. Poor access to or inadequate and inappropriate treatment plagues all three diseases, especially where health systems are weak.  We need an integrated approach to strengthen systems and improve care.

In the meantime, researchers have maintained interest in possible interactions between TB and malaria. For example Ann-Kristin Mueller and colleagues have published a study entitled, “An Experimental Model to Study Tuberculosis-Malaria Coinfection upon Natural Transmission of Mycobacterium tuberculosis and Plasmodium berghei,” using a mouse model. A slide presentation on their work is also seen at the website. As Mueller notes, “Concurrent infections most likely modulate the respective immune response to each single pathogen and may thereby affect pathogenesis and disease outcome. Coinfected patients may also respond differentially to anti-infective interventions.”

Mueller puts is mildly when she says that TB-malaria coinfection “has not been studied in detail.” We might need to step back in time over 2900 years where according to Lalremruata and colleagues, “the notion that the agricultural boom and dense crowding occurred in this region (southwest of modern Cairo), especially under the Ptolemies, highly increased the probability for the manifestation and spread of tuberculosis. Here we extend back-wards to ca. 800 BC new evidence for malaria tropica and human tuberculosis co-occurrence in ancient Lower Egypt.”

In a 2013 review on “Co-infection of tuberculosis and parasitic diseases in humans,” Xin-Xu Li and Xiao-Nong Zhou found only two direct reports of malaria and TB co-infection, one a case report from 1945 and the other on host response in malaria and depression of defense against tuberculosis from 1999.

Finally a review of hospital records from 2007 in Luanda, Angola found that Malaria was diagnosed during admission and hospital stay in 37.5% of TB patients. Clearly the time has come to take coinfection seriously as both a research and service delivery topic.

ITNs &water Bill Brieger | 22 Mar 2014

Water for Malaria

As today is World Water Day it is time to reflect on the relationship between water and malaria. As USAID notes, “The impact of water on all aspects of development is undeniable: A safe drinking water supply, adequate sanitation and hygiene, management of water resources, and improvement of water productivity can help change the lives of millions.”

DSCN9055aThe key to the relationship between water and malaria is the word safe. The breeding of the malaria carrying anopheles mosquito species certainly depends on unsafe collections of “clean” but unmoving sources water that could range from a village pond to a cow hoof print. During certain seasons these are ubiquitous.

Seid Tiku Mereta and colleagues showed us recently that humans may be their own worst enemies when it comes to producing mosquito larval breeding sites.  They found that Anopheline mosquito larvae showed a widespread distribution and especially occurred in small human-made aquatic habitats… In contrast, anopheline mosquito larvae were found to be less prominently present in permanent larval habitats. This could be attributed to the high abundance and diversity of natural predators and competitors suppressing the mosquito population densities.”

The drier parts of northern Benin Republic were studied by Renaud Govoetchan and team.  They also found that human activity created water sources in urban areas in the dry season thereby “maintaining the breeding of anopheles larvae and the malaria transmission.” In the rural areas village ponds provided opportunity for dry season mosquito breeding. Although transmission was lower in the dry season and in the urban areas, it still persisted thanks to human water use behaviors and persistence of unsafe rural water sources.

DSCN8908From the above we can see that safe water alone would not prevent malaria. Water use behaviors must also be targeted. That said, it is interesting how water may also be related to other malaria interventions such as insecticide treated nets and case management with local herbs.

A major factor that influences the durability of the so-called long lasting insecticide treated nets (LLINs) is how often people wash them.  Frequent washing of curtains, bed sheets and of course personal clothing is so routine that villagers may not even consider this hygenic behavior to be harmful. In fact it reduces the potency of the insecticide-treated nets.

Virgile Gnanguenon and co-researchers found that LLINs that might be expected to last 3 years if they were only occasionally washed were in fact only likely to be functional for two years or less. Water issues were prominent among the five factors that predicted net integrity and survival: “washing frequency, proximity to water for washing, location of kitchen, type of cooking fuel, and low net maintenance.”

Finally because primary health care does not reach all, community members still use their indigenous herbs to treat malaria. A recent study by Sabine Montcho and colleagues found an unexpected risk from the herbs. In Benin the plant Senna rotundifolia Linn. is commonly used for malaria treatment. Unfortunately the researchers learned that it was contaminated with lead and cadmium. “In terms of risk assessment through the consumption of Senna, the values recorded for lead were nine times higher with children and six times higher with adults than the daily permissive intake.” Polluted water does not have to be drunk directly to harm people.

Our relationships with water and malaria and the connection between the two are complex. World Water Day should provide us an opportunity to consider how our interventions ranging from appropriate use and care of LLINs, to provision of appropriate malaria treatment to larvae control and environmental management need to take into consideration the importance of water to human survival and disease prevention.

Community &Diagnosis &Treatment Bill Brieger | 20 Mar 2014

iCCM Symposium – Summary from the Accra Meeting

Theresa Diaz, Senior Health Advisor, UNICEF, and colleagues on the integrated Community Case Management (iCCM) Evidence Review Symposium planning committee have made available a summary of the key lessons and experiences from the meeting in Accra as found below, We thank them for their efforts.

cropped-iCCM-web-banner6Symposium summary and conclusions

Between 3 and 5 March 2014, over 400 individuals from 35 countries in sub-Saharan Africa and 59 international partner organizations gathered in Accra, Ghana for an Integrated Community Case Management (iCCM)[1] Evidence Review Symposium. The objective of the symposium was twofold: first, to review the current state of the art of iCCM implementation by bringing together researchers, donors, government, implementers and partners to review the map of the current landscape and status of evidence in key iCCM programme areas, in order to draw out priorities, lessons and gaps for improving child and maternal-newborn health. Second, to assist African countries to integrate and take action on key frontline iCCM findings presented during the evidence symposium around eight thematic areas:

  1. Coordination, Policy Setting and Scale up: The current state of iCCM policies in Africa and challenges in development of policy and scale up
  2. Human Resources and Deployment: Community health worker (CHW) selection, geographic disbursement, motivation and retention
  3. Supervision & Performance Quality Assurance: Strategies to ensure high quality care including strategies for effective training, use of alternative models for supervision, and the role of mHealth to support and motivate CHWs to provide quality care
  4. Supply Chain Management: Which systems ensure continuous supply, how best to forecast needs
  5. Costs, and cost effectiveness and financing: Identifying cost drivers, improving cost effectiveness and the importance of minimizing patient costs
  6. Monitoring, Evaluation and Health Information Systems: Innovations in monitoring, integrating with health management information systems, using results to drive programmatic decision-making and improvements, evaluation design and methods
  7. Demand generation and social mobilisation: The relationship between iCCM and care-seeking, treatment utilisation and treatment adherence, effective strategies to generate demand
  8. Impact and outcome evaluations: Review of 18 iCCM programme studies with coverage or mortality data.


Several lessons are clear based on the evidence were presented and may serve as recommendations for future iCCM implementation, as relevant:

  • National government leadership is essential.
  • iCCM must be integrated in national health systems and seen as a priority means of delivering care, and embedded as a costed element of national health sector plans, with a clear budget line.
  • Integration is key among all health-related programmes at community level (water and sanitation, nutrition, etc.).
  • Coordination mechanisms should extend beyond health to include other sectors (e.g., finance).
  • Advocacy on the iCCM model is still paramount to its dissemination.
  • There is no single model of human resource management for community based interventions. Countries reported having paid or volunteer CHWs, as well as CHWs with significant skills operating in conjunction with volunteers.
  • Charging fees decreases utilisation.
  • High supervision rates increase quality, utilisation and motivation.
  • Having fewer stock outs increases utilisation.
  • Providing treatment for malaria, pneumonia and diarrhoea combined increases utilisation of services for each illness.
  • Using rapid diagnostic tests (RDTs) decreases malaria and pneumonia treatments suggesting more appropriate antibiotic/antimalarial usage and improved quality of treatment.
  • Private public partnerships should be explored as vehicles for iCCM implementation. In addition, iCCM can be used as vehicle for private sector quality improvement in settings where the private sector is an important source of care for children.
  • New technologies such as Rapid SMS, mHealth, and mTRAC can facilitate monitoring and management.
  • iCCM programmes must be well documented, periodically reviewed and evaluated in order to guide implementation at scale.

In addition, there were two key messages that emerged from the Symposium:

Increase utilisation of iCCM to be more cost efficient and to ensure maximum impact

  • by deploying services to areas of greatest need
  • by assessing demand barriers and addressing them through community engagement and mobilisation
  • by structuring supervision and management to be affordable and effective
  • while maintaining quality of services, continuous supplies and high levels of standardised reporting.

Use routine reporting data to assess progress and only conduct endline evaluations of impact after being at scale (i.e., 80% of providers trained and equipped) with high utilisation for at least 1 year

  • Examine routine data to know if you have been providing high rates of appropriate treatments
  • Once your routine data show you are providing high rates of treatment, collect data on coverage and quality, and model mortality based on the Lives Saved Tool (LiST)
  • Final evaluations should include data from routine sources, as well as contextual, qualitative, coverage, quality of care and costing data
  • Given that we know that iCCM treatments are effective in decreasing mortality, and that there are significant methodological challenges attributing outcomes and impact specifically to iCCM, it is perhaps more critical to conduct operational research that supports programmes to increase treatment rates rather than “impact evaluations of iCCM.” It is also important to use routine programme data to track indicators and household surveys (baseline and follow up) to measure care seeking behaviour, source of treatment and timeliness of treatment to assess if these outcomes are moving in the right direction.

The way forward

With 2015 fast approaching, the time for improving iCCM implementation is now. We have effective interventions that respond to the major causes of child mortality and are well packaged for delivery. We have evidence showing that many treatments can be delivered successfully in the community, and now have innovations that facilitate community-based programming, including Rapid Diagnostic Test (RDTs) and mobile technologies. In addition, there are important new opportunities to mobilise resources from domestic as well as external funds (e.g., the Global Fund to Fight AIDS, Tuberculosis and Malaria) and, in many countries, to integrate public private partnerships with government systems.

Following discussions about the opportunities and challenges in their respective countries, participants are poised to work with their colleagues and partners to ensure that iCCM programmes are based on the latest evidence and are most appropriate for, and integrated into, their particular health systems and contexts.

This Symposium was made possible by the generous support of the Government of Canada and the Bill and Melinda Gates Foundation with additional support from USAID. It was coordinated by UNICEF in conjunction with the US Fund for UNICEF, MCHIP, John Snow, Inc., International Rescue Committee, Malaria Consortium, Management Sciences for Health, Population Services International, the MDG Health Alliance, Save the Children, the World Health Organisation, UNICEF Canada, TDR, and the Journal of Global Health. These organizations endorse the findings from this symposium and encourage countries to base their iCCM programs on the evidence presented.

More information regarding the Symposium is available at

[1] iCCM is a strategy to extend case management of childhood illness beyond health facilities so that more children have access to lifesaving treatments. The iCCM package can differ based on particular contexts, but most commonly includes diarrhoea, pneumonia and malaria, and in some cases newborn health and malnutrition as well. In the iCCM model, community health workers (CHWs) are identified and trained in diagnosis and treatment of key childhood illnesses, and also in identifying children in need of immediate referral (Source: CCM Central,

Community &Coordination &Integration Bill Brieger | 06 Mar 2014

iCCM needs collaboration among varied stakeholders

CAM02760Integrated community case management (iCCM) of common illnesses, as we learned at the just completed evidence review symposium on iCCM in Accra, Ghana, requires a number of key inputs ranging from adequate procurement and supply of commodities, well stated supportive policies and human resources from the district to the clinic to the community.  One input, the collaboration among stakeholders needs constant reinforcement.

Although the project was not iCCM, an implementation research study in 8 sites in Africa that added a package of interventions to existing ivermectin distribution illustrates the need for stakeholder concurrence and collaboration. This 3-year community directed intervention (CDI) Tropical Disease Research Program effort (UNDP/World Bank/Unicef/WHO) was designed to add a package of interventions to the community’s ‘portfolio’ each year in a step-wise manner.  These included antimalarials for community case management, insecticide treated nets, vitamin A and drugs for directly observed treatment of tuberculosis.

While ultimately the community directed approach to distributing these commodities resulted in better coverage in intervention districts than facility based service provision in the control areas, an important lesson from the project occurred in the start-up process the very first year. In fact no real commodity distribution took place that year as originally planned.

What the teams learned is that while community distribution of ivermectin had been taking place for at least 10 years in most of the districts, not all members of the district health teams (DHT) were fully aware of what the onchocerciasis focal person was doing.  It had been hoped a bit naively that the DHT member in charge of immunization and vitamin A, the DHT focal point for malaria and the DHT member in charge of TB/Leprosy would gladly join their onchocerciasis colleague in making their services available through community volunteers.

CAM02763In reality the advocacy process took up the whole first year before other DHT members could be convinced that it was safe and appropriate for community members to take charge of a package of basic health commodities. In some locations, the TB/Leprosy program managers were never convinced.

Even at start-up of onchocerciasis programs in the late 1990s it took much convincing of health workers to ‘allow’ communities to handle drugs like ivermectin. When introducing a larger package through CDI, it became necessary to start this process of convincing and seeking collaboration anew.

A basic iCCM package of ACTs, RDTs, ORS, Zinc and amoxicillin may not appear as complicated as the CDI package added to ivermectin distribution, but in truth a lot of stakeholder advocacy work is still needed.  We learned at the Accra meeting that at minimum malaria and child health programs need to collaborate to provide the basic package and the funding that does with it.  Different programs may in fact have different policies and guidelines. Different donors and different sections of the Ministry of Health must be willing to bring their efforts and resources together and share. This is as much a political as it is a technical process, and scientific evidence that health care interventions delivered in the community save lives may not be enough to overcome politics and vested program interests.

The 300+ delegates to the iCCM symposium are returning home over the next few days.  Hopefully the momentum of the conference will carry them on to engage in collaboration, not only with their colleagues who also attended, but also with those who did not attend and benefit from the sharing of evidence and experience.  It will take a team of people with varied interests to make iCCM a success.

Community &Treatment Bill Brieger | 04 Mar 2014

Moving Toward Community Case Management of Malaria in Malawi

Guest posting by Jhpego‘s John Munthali, Malaria Program Officer on the Support for Service Delivery Integration-Services (SSDI-Services) Project, a reproductive, maternal and child health project in Malawi.

Health Surveillance Assistant Treating Child

       Health Surveillance Assistant Treating Child

Case Management with the appropriate antimalarial drug for children below five years of age in Malawi children within 24 hours has not changed much since the Roll Back Malaria Partnership was launched in 2000. RBM set a target of 80% for the year 2010. In 2000 only 10% received the approved drug of that time within 24 hours. Various national surveys including Demographic Health Survey (DHS), and Malaria Indicator Survey MIS) showed an increase to 23% by 2004, but this has not changed perceptibly in the intervening years with only 24% of these children getting the correct medicine on time in 2012.

Integrated community case management (iCCM) was envisioned as an approach to address these coverage/access challenges. The implementation platform is a sector-wide approach focusing on implementation of the national Essential Health Package (EHP) targeting 13 priority health interventions:  Approaches emphasized promotion of equity by scaling up access to underserved populations through Community Mobilization (CM), iCCM, Community Based Maternal and Newborn Care (CBMNC) and Scaling Up Nutrition (SUN).

No missed opportunity is aimed for by promotion of integration of EHP services at all levels and by promotion of continuum of care from household to hospital. Jhpiego through USAID’s  Support for Service Delivery Integration (SSDI) project supports iCCM.  iCCM services delivered by Health Surveillance Assistants (HSAs) at village clinics to treat sick children with pneumonia, diarrhea and malaria including malnutrition screening,  use malaria Rapid Diagnostic Tests (mRDTs) and use of rectal artesunate for pre-referral treatment of severe malaria is in the pipeline.

So far 96 trainers refreshed in iCCM. In turn these have trained 722 HSAs on iCCM in all 15 SSDI project districts. The project has also supported ongoing iCCM activities through supervision and mentoring. Equipment for iCCM has been distributed to HSAs. Now there are 1846 HSAs providing iCCM in the 15 districts. They can test and treat for malaria, check for palmar pallor for anemia, and count respirations per minute for acute respiratory infections among other far HSAs have treated 530 000 cases of malaria in the SSDI supported districts.

Challenges include work overload for HSAs, especially when involved in facility work as well. Transport problems affect some HSAs that reside outside the catchment area. Delays in procurement of the necessary equipment negatively affected the roll out of certain services. Inadequate supervision of services, especially at community level is common. There are weak referral linkages and follow up mechanisms between communities and health facilities. Finally there are drug stock-outs in some village clinics.

Therefore need exists to strengthen integration of service delivery at village clinics and health facilities through better supervision of HSAs. Strengthening of referral linkages and follow-up is also required. Community sensitization will continue to stress the importance of early care seeking and compliance with treatment regimens.

Integration &Treatment Bill Brieger | 03 Mar 2014

iCCM – collaboration for commodities

The integrated Community Case Management Symposium (iCCM) in Accra, Ghana this week provides an ideal opportunity to examine the practical issues of getting the commodities to manage cases of malaria, pneumonia and diarrhoea at the community level.

cropped-iCCM-web-banner6Ordinarily one would expect the medicines needed for iCCM would be obtained through a country’s normal essential drug management system. ACTs, ORS, amoxicillin, etc., should be available through the regular primary health system of a country to all front line health facilities. It is from this frontline facility that community health workers (CHWs) delivering iCCM would normally receive training and stocks/supplies.

The reality is that many front line facilities experience frequent stock-outs. They cannot meet the demands for their own clinic services, let alone provide supplies for community volunteers. Whether it is an issue of financial resources or political will, lack of essential medicines makes it difficult to guarantee child survival more than 25 years after UNICEF, WHO, USAID and other partners launched various initiatives to save children’s lives.

Currently countries are placing hopes in international financial programs such as the Global Fund to solve their commodity needs and scale up to prevent child deaths. In particular opportunities to develop a basic iCCM infrastructure and obtain appropriate malaria commodities are potentially available through Global Fund malaria grants. Child health program managers must work with national malaria control program staff to access this resource.

The Global Fund’s new funding mechanism is based on the national malaria strategic plan. If that plan does not address iCCM, it is unlikely countries can use their ‘envelop’ of funds for that purpose. Regardless, the Global Fund support will provide only malaria commodities. Where can counties get ORS, zinc and amoxicillin, especially if they do not have well-funded national medical stores/essential drugs program.

The RNMCH* Trust Fund with support from Norwegian and British aid agencies is being established and may help provide these pneumonia and diarrhoea commodities in stocks large enough to scale up iCCM. USAID child health projects also include diarrhoea and zinc. The long term sustainability of iCCM based on donor assistance is questionable. We are far from eliminating malaria, and there is no serious discussion of eradicating diarrhoeal diseases and pneumonia.

A pilot project to improve access to quality child illness case management that is being designed in Bauchi State, Nigeria demonstrates the challenges of coordinating commodities. Some were available through a World Bank Malaria Booster Program under a malaria plus package concept. USAID was providing ORS and zinc to child health projects. The US President’s Malaria Initiative could provide ACTs and RDTs, but the local governments and medicine shops involved in the project would have to buy amoxicillin through their normal wholesale channels. Getting the right mix of medicines at the right time in the right amounts to the right places is not easy.

Collaboration among different disease and health programs is always a challenge, but in the short term, program managers in both malaria control and child health need to work together to tap all available resources for iCCM. In the long run donors need to address health system strengthening so countries can manage their own essential drug programs successfully.

*Reproductive, Neonatal, Maternal and Child Health