Tropical Health Matters

A poster entitled “The Improving Malaria Care (IMC) Project’s Contribution to follow up a Pilot to Use Rapid Diagnostic Tests (RDTs) at the Community Level in Burkina Faso” was presented by members of Jhpiego’s Burkina Faso Team: Ousmane Badolo, Stanislas P. Nebie, Moumouni Bonkoungou, Mathurin Dodo, Rachel Waxman, Danielle Burke, William Brieger at the 65^th annual meeting of the American Society of Tropical Medicine and Hygiene in Atlanta. The abstract follows …

CHWs provide malaria testing, treatment and health education

Early and correct case management of malaria in health facilities and at the community level is among the priorities of Burkina Faso’s National Malaria Control Program (NMCP). In line with this initiative, the NMCP piloted use of Rapid Diagnostic Tests (RDTs) by Community Health Workers (CHWs) to confirm malaria cases in the three health districts of Kaya, Saponé and Nouna between 2013 and 2015. With PMI support, follow-up visits were organized to document best practices, as well as challenges, on RDT use by CHWs that could serve as lessons learned for scale-up.

During follow-up visits, malaria commodities management (supply, storage and use) at the community level was examined, use of RDTs was assessed, and implementation at the community level was discussed with all actors at regional, district, health facilities, and community levels. The team examined the monitoring/supervision processes at all levels, used a check list on malaria commodities management, and employed a questionnaire for each type of actor. Both qualitative and quantitative data have been collected. A total of 108 persons were contacted including 32 CHWs, 42 community leaders and 34 health care providers and managers.

Findings revealed frequent stock-outs of RDTs and artemisinin-based combination therapies, non-payment of stipends to CHWs (a demotivator) and insufficient supervision of CHW by health teams. From the community perspective, 66% of community leaders were satisfied with their CHW’s work (diagnosis and treatment of uncomplicated malaria and referral of severe cases to health facilities). However, 46% of community leaders complained of frequent stock-outs and unanimously agreed on the importance of regular payment of premiums to CHW.

Follow up of the pilot was valuable in obtaining community, CHW and health worker perspectives for improving the program. While the community finds the program acceptable, its sustainability will require that solutions be found for stock-outs, non-payment, and insufficient supervision before scale up takes place.

Below is an abstract of a poster presentation today at the American Society of tropical Medicine 65th Annual meeting in Atlanta. The presentation was prepared by Jhpiego’s Angola team including Jhony Juarez, Margarita Gurdian-Sandoval, Julio Bonillo, and William R. Brieger. Please join us at the Late-breaker’s session at noon.

CONTEXT

• Angola has three major belts of malaria transmission
• The north is high transmission and borders on the heavy burden country of the Democratic Republic of the Congo
• The mid-section of the country is meso-endemic
• The south is considered low endemic
• This low endemic area brings Angola into the Southern African Elimination 8 countries.

METHODS: Field visits were made to six northern high burden provinces. Health information system (HIS) data were collected from each provincial health department. Supplementary HIS information was collected from the national malaria control program

FINDINGS: Data from the six high burden provinces reveal an overall upward trend in confirmed malaria. Cases from 2011, but with a jump of over 130,000 confirmed cases from 2014 to 2015. This occurred despite support from government and major malaria partners over the past decade. Overall cases in the country have risen from 2.73m in 2011 to 3.25m in 2015

NATIONAL MALARIA EFFORTS

• Between 2012 and 2015 2 million Long Lasting insecticide treated nets were distributed to a population of approximately 5 million in the 6 provinces
• This exceeded the desired 2 people per net ratio
• Intermittent preventive treatment in pregnancy reached only 59% of women registering for antenatal care in 2015
• Only 44% and 18% of women received the second and third IPTp doses respectively.

CHALLENGES

• A dual challenge makes performance of malaria indicators difficult
• The Global Fund grant had expired for more than a year
• The oil-based economy also suffered from the major global drop in prices

THE WAY FORWARD

• Angola requires concerted efforts by government and partners to scale up malaria control interventions
• Universal coverage targets must be sustained if these high burden northern provinces are to begin seeing a decline in the disease

The Following blog from the 65th American Society of Tropical Medicine and Hygiene Annual Meeting opening keynote address has been re-posted here.

From moving quickly to train heads of state in risk communications, to making major decisions based on limited evidence, to sitting with Zika victims whose children had just been diagnosed with microcephaly, the head of the Pan American Health Organization (PAHO) offered a detailed assessment Sunday night of her experience with the sudden explosion of the Zika virus in the Americas.

In her keynote address to a packed hall at opening of ASTMH 2016 Annual Meeting, PAHO Director Dr. Carissa F. Etienne, MBBS, MSc, described the extraordinary experience and lessons learned from encounters with a once-obscure disease that now has been documented in 48 countries and territories in the Americas—and 67 globally.

Dr. Etienne credited “vigilant, astute, front-line health care workers” with first noting the unusual clusters of rash disease in Brazil in late 2014 that turned out to be an early indication that Zika virus had arrived. She noted it was also front-line health workers who first noted the spike in cases of microcephaly and Guillain-Barré Syndrome and connected them to the Zika virus.

Dr. Etienne said their “astute” observations have re-enforced her conviction that, when it comes to protecting the public from infectious disease, there is no substitute for “good clinical judgment and alertness for atypical events.”

Dr. Etienne recalled how quickly the situation escalated and the challenges this presented on a day-to-day basis. For example, heads of state wanted to take charge of discussing the emergency in radio and television appearances. So PAHO moved quickly to provide technical information along with training in risk communications.

There was also the fact that Zika was first discovered while many countries in the Americas were in the middle of preparing for potential Ebola infections and responding to outbreaks of chikungunya. Yet despite this confusing swirl of activity, she said health officials had to move swiftly to declare Zika an emergency, even though they lacked a complete picture of the true extent of the threat.

“Determination of causality needs to run its course, but PAHO cannot wait until the final verdict of the scientific community,” Dr. Etienne said. “We must be willing to make decisions based on incomplete evidence.”

Dr. Etienne said her experience with the Zika response has reminded her of the many ways infectious diseases take their toll on people, communities and countries. She said Zika has been particularly hard on countries in the Americas that already were suffering economically. And she said it was profoundly moving to spend time with parents whose children have been diagnosed with microcephaly linked to Zika.

“It was quite emotional,” she said. “Here are mothers and fathers loving their child and caring for their child but recognizing that this child’s life will probably be marked by disability.”

Dr. Etienne said that given limitations with diagnostic tests and disease surveillance, the current case count probably underestimates the true magnitude of Zika infections in the Americas. She also believes that “microcephaly is merely the tip of the iceberg” and it will take years to assess the full impact of Zika on children whose mothers were infected with Zika during pregnancy.

Among other things, Dr. Etienne said the experience with the Zika outbreak should prompt a re-thinking “of our approach to reproductive health services.”

“There is still a long way to go with Zika,” she said. “This is not going to be a 100 meter dash. This is a marathon in which science and public health must work hand in hand.”

Mathurin Dodo, Stanislas Paul Nebie, Ousmane Badolo, Thierry Ouedraogo, Rachel Waxman, Danielle Burke, William R. Brieger, and Elaine Roman of Jhpiego’s USAID sponsored Improving Malaria Care project based in Ouagadougou, Burkina Faso will be presenting a poster on improving intermittent treatment of malaria in pregnancy at the 65^th annual meeting of the American Society of Tropical Medicine and Hygiene on Monday 14^th November in Atlanta. Their Abstract follows:

Ensuring the inclusion of IPTp3 doses and higher in the national health information system enabled documentation of improved coverage

Malaria remains the first cause of consultation (47%), hospitalization (62%) and death (31%) in health facilities in Burkina Faso (2014 Statistical Yearbook). Pregnant women are among the most vulnerable to malaria. Intermittent preventive treatment in pregnancy (IPTp) is a priority intervention in the Burkina Faso 2011-2015 National Malaria Strategic Plan. In 2012, IPTp2 was low across the country at 53%.

The President’s Malaria Initiative (PMI) supported the National Malaria Control Program (NMCP) in implementing the national malaria control strategic plans. IPTp was promoted through 3 strategies: advocacy and policy updates, capacity building, and behavior change communication. Malaria prevention and management guidelines and job aids updated stressed IPTp in line with WHO recommendations.

185 trainers were trained who in turn organized one-day briefings for over 1,300 healthcare providers from 1081 health facilities (61.3% of health facilities nationally) on the revised guidelines, which were distributed along with job aids. Health information system tools now reflect new IPTp guidance, and 190 district and regional level data managers were trained in their use.

208 community health workers were trained in sensitization and community mobilization around early ANC attendance. Over 3000 radio and TV spots were aired on 28 stations on the importance of IPTp.

In 21 project districts in 2013, IPTp2 and IPTp3 coverage rates based on ANC registration were 54% and 0%. Following the interventions, rates in these districts increased to 72% (IPTp2) and 23% (IPTp3) in 2014 compared to 63% and 8% in the other 42 districts.

These efforts have resulted in improvements in IPTp service delivery and reporting. Based on successes, training and guideline dissemination continued in 2015 across the country so that all health facilities received copies of the new guidelines and 82% of districts received training.

Augustine Ngindu of Jhpiego/MCSP Kenya shared with the Jhpiego Malaria Team at their pre-ASTMH 2016 Annual Meeting retreat the experience in Kenya of drug stock-outs and efforts to combat this.

Kenya has experienced periods of Sulfadoxine-Pyrimethamine (SP) stock-outs thus threatening the coverage of intermittent preventive treatment to prevent malaria in pregnant women (IPTp). The situation has stabilized from March 2016 through efforts by Jhpiego and the USAID Maternal and Child Survival Program (MCSP) in collaboration with Kenyan health authorities and partners at national, county and facility levels.

Jhpiego’s key interventions focused at several levels. At the national level technical assistance was provided to relevant Ministry of Health (MOH) departments (e.g. malaria, reproductive health and community strategy). In particular the situation on the ground has been used for advocacy with decision makers and managers on prioritizing procurement of SP.

At the County level Jhpiego is building capacity of counties in provision of MIP services by developing clinical mentors. Again advocacy was carried out on prioritizing inclusion of budget item for SP.

At the health facility level Jhpiego is strengthening the capacity of health facilities to provide MIP services. These activities include training of health care workers and monitoring their performance in terms of maintaining, ordering and redistribution of SP stocks. In addition Jhpiego worked with the MOH to establish malaria in pregnancy (MIP) service standards to enhance the provision of quality services in 336 facilities providing ANC services.

Then at the community level Jhpiego and partners promote MIP service utilization at community level by sensitizing pregnant women to start IPTp early in second trimester. Community health volunteers sensitize pregnant women to start IPTp early in second trimester. Hopefully increased demand will also pressure program managers to supply regular SP stocks.

Concerning the service standards, baseline data collected after immediately training found that 50% of facilities were maintaining SP stocks. A second assessment done during supportive supervision 3 months after training found 86% of facilities now met the standard. As a result of county level advocacy, redistribution of SP was done from over-stocked to under-stocked health facilities.

In conclusion, advocacy is a powerful tool in getting things done as evidenced by responses of County Directors of Health, national government and health development partners on prioritizing procurement of SP. This led to availability of adequate SP stocks to last the country up to 2019.

Results of testing the innovative Urine Rapid Diagnostic Test for Malaria developed by Fyodor Biotech have been published in the Journal of Clinical Microbiology. Authors from multiple collaborating institutions include Wellington A. Oyibo, Nnenna Ezeigwe, Godwin Ntadom, Oladipo O. Oladosu, Kaitlin Rainwater, Wendy O’Meara, Evaezi Okpokoro, and William Brieger. The abstract appears below.

Background: The need to expand malaria diagnosis alongside policy requirements for mandatory testing before treatment motivates exploration of non-invasive rapid diagnostic tests (RDTs). We report the outcome of the first cross-sectional, single-blind clinical performance evaluation of a Urine Malaria Test (UMT) for Plasmodium falciparum (Pf) malaria diagnosis in febrile patients.

Methods: Matched urine and fingerprick blood from participants ?2 years with fever (axillary temperature ?37.5°C) or history of fever in the preceding 48 hours were tested with UMT and microscopy (as gold standard). BinaxNOW® (Pf/Pan) blood RDT was done to assess relative performance. Urinalysis and Rheumatoid Factor (RF) tests were conducted to evaluate possible interference. Diagnostic performance characteristics were computed at 95% CI.

UMT is winner of innovations prize

Results: Of 1,800 participants screened, 1,691 were enrolled; 566 (34%) were febrile, 1,125 (66%) afebrile; test positivity among enrolled participants: 341 (20%) by microscopy, 419 (25%) UMT, 676 (40%) BinaxNow Pf and 368 (22%) BinaxNow Pan. UMT sensitivity among febrile patients (for whom the test is indicated) was 85% and specificity 84%. Among febrile children ?5 years, UMT sensitivity was 93%, specificity 83%. Area under receiver-operator characteristic curve (AUC) of UMT (0.84) was not significantly different from Binax Pf (0.86) or Binax Pan (0.87), indicating that the tests do not differ in overall performance. Gender, seasons, and RF did not impact UMT performance. Leukocytes, hematuria and urobilinogen concentration in urine were associated with lower UMT specificity.

Conclusion: UMT performance was comparable to BinaxNOW Pf/Pan tests, and is a promising tool to expand malaria testing in public and private healthcare settings where there are challenges to blood-based malaria diagnosis testing.

Many years ago WHO formulated guidance for encouraging 4 Focused Antenatal Care (FANC) that addressed the reality that 1) ANC attendance schedules were not standardized, 2) service package elements were not clearly laid out, and 3) women found it difficult to attend ANC as many times as some countries recommended. The New York Times reported that WHO now recommends 8 ANC visits in large part because greater action is needed in light of the fact that …

“About 300,000 women die in pregnancy or childbirth each year, the agency said, and more than six million babies die in the womb, during birth or within their first month. Many of those deaths can by prevented through simple interventions.”

The new recommendations number 49 and strongly consider the roles of all health workers from auxiliaries to doctors – stressing task shifting to ensure that women have access to life saving services.  Below are extracted some of the aspects that relate to malaria.

• In areas with endemic infections that may cause anaemia through blood loss, increased red cell destruction or decreased red cell production, such as malaria and hookworm, measures to prevent, diagnose and treat these infections should be implemented.
• Malaria prevention: intermittent preventive treatment in pregnancy (IPTp): In malaria-endemic areas in Africa, intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) is recommended for all pregnant women. Dosing should start in the second trimester, and doses should be given at least one month apart, with the objective of ensuring that at least three doses are received.

The above recommendation has been, “Integrated from the WHO publication Guidelines for the treatment of malaria (2015), which also states: ‘WHO recommends that, in areas of moderate-to-high malaria transmission of Africa, IPTp-SP be given to all pregnant women at each scheduled ANC visit, starting as early as possible in the second trimester, provided that the doses of SP are given at least 1 month apart. WHO recommends a package of
interventions for preventing malaria during pregnancy, which includes promotion and use of insecticide-treated nets, as well as IPTp-SP’. To ensure that pregnant women in endemic areas start IPTp-SP as early as possible in the second trimester, policy-makers should ensure health system contact with women at 13 weeks of gestation.”

• Task shifting components of antenatal care delivery: Task shifting the distribution of  recommended nutritional supplements and intermittent preventive treatment in  pregnancy (IPTp) for malaria prevention to a broad range of cadres, including auxiliary
  nurses, nurses, midwives and doctors is recommended.

Readers should download the full set of recommendations for more details on the above. We do offer a challenge. Since the 4-visit FANC processes, that was adopted in part because of the difficulty in getting pregnant women to attend ANC many times, is still not fully achieved (see graph), we must now strengthen community involvement, mobilization and education to double that target to 8 visits. Efforts must focus on women, men, elders and even youth. Health workers also need education and motivation to adopt a client-friendly attitude to make this new schedule work.

The deadly Ebola epidemic of 2013-15 in West Africa was suspected of having started when a child in a remote village of Guinea came in contact with infected bats. After that initial episode NONE of the thousands of subsequent cases were traced to zoonotic causes, and yet the health authorities and the media put high level focus on the need to avoid bush meat – whether bats, monkeys, antelope or others – as a prime way to avoid the disease.

New evidence is emerging that in fact it the evolving relationship between the virus and humans that allowed the disease to spread so widely. within the animal kingdon, humans, not bush meat where the major spreaders of Ebola.

Now two conflicting reports have surfaced about efforts to curb the consumption of bush meat.  First, a research team based in Rivers State, Nigeria, one of the places where Ebola reached, conducted a study that tracked the average number of carcases recorded in each market before and after the Ebola virus spread in Nigeria in June 2014. They reported that …

“The markets were surveyed twice a month between March and September 2014. Our survey found a statistically significant fall in trade for all the main traded types of animals. These included antelopes, monkeys, genets, mongooses, rodents, porcupines, birds, crocodiles, turtles and snakes. In particular, the trade in monkeys and fruit bats almost disappeared. Trade in turtles, crocodiles and other cold-blooded species was less affected.”

The group concluded that bush meat, though culturally valued, was “not as important as previously thought for rural people in west Africa.”

The second report, published a few days later, was posted in the Nigerian newspaper, Vanguard, and echos earlier stories.  ”

“Some bush meat sellers in some major markets in Lagos have said the business is booming again barely two years after the country was declared Ebola Virus Disease free. Some of the bush meat sellers told newsmen on Saturday that they were fully back to their business.”

The malaria work of Jhpiego will be featured in 8 posters and two symposia during the upcoming 65^th annual meeting of the American Society of Tropical Medicine and Hygiene in Atlanta from 13-17 November 2016. Below are titles of the posters and descriptions of the symposia along with session information that will help people find the presenters. We will share abstracts closer to the actual time of presentation. Follow the conference on twitter through #TropMed16.

Poster Presentations

1. Collaborative efforts to improve prevention of malaria in pregnancy in Burkina Faso through use of IPTp-SP. Mathurin Dodo, Stanislas Paul Nebie, Ousmane Badolo, Thierry Ouedraogo Presentation No. 304 Poster Session A
2. The Improving Malaria Care (IMC) Project’s Contribution to follow up a Pilot to Use Rapid Diagnostic Tests (RDTs) at the Community Level in Burkina Faso. Ousmane Badolo, Stanislas P. Nebie, Moumouni Bonkoungou, Mathurin Dodo, Rachel Waxman, Danielle Burke, William Brieger Presentation No. 218 Poster Session A
3. Building Capacity to accelerate IPTp uptake through the adoption of 2012 WHO IPTp guidance in Malawi. John Munthali Presentation No. 393 Poster Session A
4. Rwanda Towards Malaria Pre-Elimination: Active case investigation in a low endemic district. Noella Umulisa, Angelique Mugirente, Veneranda Umubyeyi, Beata Mukarugwiro, Stephen Mutwiwa, Jean Pierre Habimana, Corrine Karema Presentation No. 310 Poster Session A
5. The Challenge of Reducing Malaria in Angola. Jhony Juarez, Margarita Gurdian-Sandoval, Julio Bonillo, William R. Brieger Presentation No. LB-5113 Poster Session A
6. Joint efforts, a key to success for the Malaria in Pregnancy Program in Luanda, Angola. Jhony Juarez, Adolfo Sampaio, William R. Brieger, and Domingos F. Gueve Presentation No. 982 Poster Session B
7. Improving pregnancy outcomes: Alleviating stock-outs situation of sulfadoxine pyrimethamine in Bungoma, Kenya. Augustine M. Ngindu, Gathari G. Ndirangu, Waqo Ejersa, David O. Omoit, Mildred Mudany Presentation No. 815 Poster Session B
8. Community health: Improving start of IPTp early in second trimester through promotion of MIP at the community level in Kenya. Augustine Ngindu Presentation No. LB-5383 Poster Session C

Symposia

1. Global Call to Action to Increase Coverage of Intermittent Preventive Treatment in Pregnancy: Progress and Lessons Learned. Symposium 87 Tuesday, November 15, 2016  1:45 PM /  3:30 PM Sponsors: PMI and MCS

Description: The aim of the symposium is to review country progress in sub-Saharan Africa (SSA) in increasing intermittent preventative treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP).  The symposium will expand the knowledge base among Ministries of Health, donors and partners who are working to increase IPTp-SP coverage to address malaria in pregnancy (MiP). In this symposium, speakers from WHO and the President’s Malaria Initiative will describe how they are prioritizing support to scale up MiP interventions including IPTp-SP across SSA.  Burkina Faso, Malawi and Tanzania will present and discuss how they were able to dramatically scale up IPTp-SP through a health systems approach that addresses MiP from community to district to national level.

2. Malaria Pre-Elimination: Ensuring Correct Care of Reproductive Age Women. Symposium 146 Wednesday, November 16, 2016 1:45 PM /  3:30 PM

Description: This symposium will present experiences from four countries – Mozambique, Sierra Leone, Brazil, and Dominican Republic; specifically, looking at how these countries have addressed pregnant women in their malaria pre-elimination strategies. Further the symposium will discuss the important ethical considerations that should be reviewed as countries contemplate standard diagnosis, notification and treatment vs. MDA. The lessons learned shared can be disseminated to guide other countries where these strategies are being considered.