Tropical Health Matters

These malaria and related news and abstracts stress the importance of sentinel surveillance systems, strong political and systems commitment to disease elimination, malachite green loop-mediated isothermal amplification for better malaria detection, and the threat of neglected fungal infections. An article from The Lancet shows that it is not just money that is needed to eliminate malaria, but better management and systems. Finally a bit of history from 18th Century North Carolina is shared. Click the links in each section to learn more about each topic.

Implementation of a malaria sentinel surveillance system in Togo: a pilot study

Since July 2017, 16 health facilities called sentinel sites, 4 hospitals and 12 peripheral care units located in 2 epidemiologically different health regions of Togo, have provided weekly data on malaria morbidity and mortality for the following 3 target groups:?<?5-years-old children,???5-years-old children and adults, and pregnant women. Data from week 29 in 2017 to week 13 in 2019 were analysed.

Each sentinel site provided complete data and the median time to data entry was 4 days. The number of confirmed malaria cases increased during the rainy seasons both in children under 5 years old and in children over 5 years old and adults. Malaria-related deaths occurred mainly in children under 5 years old and increased during the rainy seasons. The mean percentage of tested cases for malaria among suspected malaria cases was 99.0%. The mean percentage of uncomplicated malaria cases handled in accordance with national guidelines was 99.4%. The mean percentage of severe malaria cases detected in peripheral care units that were referred to a hospital was 100.0%. Rapid diagnostic tests and artemisinin-based combination therapies were out of stock several times, mainly at the beginning and end of the year. No hospital was out of stock of injectable artesunate or injectable artemether.

These indicators showed good management of malaria cases in the sentinel sites. Real-time availability of data requires a good follow-up of data entry on the online platform. The management of input stocks and the promptness of data need to be improved to meet the objectives of this malaria sentinel surveillance system.

Evaluation of the colorimetric malachite green loop-mediated isothermal amplification (MG-LAMP) assay …

… for the detection of malaria species at two different health facilities in a malaria endemic area of western Kenya. Prompt diagnosis and effective malaria treatment is a key strategy in malaria control. However, the recommended diagnostic methods, microscopy and rapid diagnostic tests (RDTs), are not supported by robust quality assurance systems in endemic areas. This study compared the performance of routine RDTs and smear microscopy with a simple molecular-based colorimetric loop-mediated isothermal amplification (LAMP) at two different levels of the health care system in a malaria-endemic area of western Kenya.

Patients presenting with clinical symptoms of malaria at Rota Dispensary (level 2) and Siaya County Referral Hospital (level 4) were enrolled into the study after obtaining written informed consent. Capillary blood was collected to test for malaria by RDT and microscopy at the dispensary and county hospital, and for preparation of blood smears and dried blood spots (DBS) for expert microscopy and real-time polymerase chain reaction (RT-PCR).

Results of the routine diagnostic tests were compared with those of malachite green loop-mediated isothermal amplification (MG-LAMP) performed at the two facilities.
A total of 264 participants were enrolled into the study. At the dispensary level, the positivity rate by RDT, expert microscopy, MG-LAMP and RT-PCR was 37%, 30%, 44% and 42%, respectively, and 42%, 43%, 57% and 43% at the county hospital. Using RT-PCR as the reference test, the sensitivity of RDT and MG-LAMP was 78.1% (CI 67.5–86.4) and 82.9% (CI 73.0–90.3) at Rota dispensary.

At Siaya hospital the sensitivity of routine microscopy and MG-LAMP was 83.3% (CI 65.3–94.4) and 93.3% (CI 77.9–99.2), respectively. Compared to MG-LAMP, there were 14 false positives and 29 false negatives by RDT at Rota dispensary and 3 false positives and 13 false negatives by routine microscopy at Siaya Hospital. MG-LAMP is more sensitive than RDTs and microscopy in the detection of malaria parasites at public health facilities and might be a useful quality control tool in resource-limited settings.

Terminating Trachoma. How Myanmar eliminated blinding trachoma.

Download the book  from WHO New Delhi: World Health Organization, Regional Office for South-East Asia; 2020. Licence: CC BY-NC-SA 3.0 IGO.  Myanmar’s three-phase approach to eliminating trachoma has been a great success, which will certainly continue. The country’s visionary National Eye Health Plan 2017-2021, which is closely aligned with international policies for prevention of blindness, gives confidence that Myanmar will maintain its elimination status. This book chronicles how a combination of good leadership, effective partnerships, health-care facilities and hardworking health-care personnel helped Myanmar eliminate trachoma as a public health problem.

Health sector spending and spending on HIV/AIDS, tuberculosis, and malaria, and development assistance for health, SDG Progress

Although the progress towards Sustainable Development Goal (SDG) 3, which aims to “ensure healthy lives and promote well-being for all at all ages”, has been assessed in various works, there is less research focusing on tracking spending towards this goal. In this study, spending estimates were used to determine progress in financing the priority areas of SDG3, examine the correlation between outcomes and financing, and identify where resource gains are most required to attain the SDG3 indicators for which data are available.

From 1995 to 2017, domestic health spending was determined, disaggregated by source (government, out-of-pocket, and prepaid private) for 195 countries and territories. Outcomes suggest a global rise in total health spending since the state of the SDGs in 2015, reaching $7·9 trillion (7·8–8·0) in 2017, and is estimated to rise to $11·0 trillion (10·7–11·2) by 2030, although with substantial disparity across countries. Per estimates, low-income and middle-income countries, in 2017, had an estimated spending of $20·2 billion on HIV/AIDS, $10·9 billion on tuberculosis, and $5·1 billion on malaria in endemic countries.

Although there is an increase in both domestic government and DAH spending, across these three diseases, variation in the accompanied changes in outcomes was observed. Malaria was noted to have the most consistent reductions in outcomes across countries as spending has raised. Findings thereby suggest mixed progress towards meeting the SDG3 targets; the progress varied by country and by target. The evidence on the scale-up of spending and improvements in health outcomes suggest a nuanced relationship, such that outcomes do not always improve with increases in spending.

Although more resources may be required by the countries to achieve SDG3, there will also be a necessity for addressing other constraints in the broader health system such as inefficient allocation of resources across interventions and populations, weak governance systems, human resource shortages, and drug shortages.

Ignored fungal infections kill more people annually than HIV and malaria combined

Carolina Pohl-Albertyn says that, “You may also know that there are other infections causing great concern, such as HIV (690 000 deaths/year), tuberculosis (1.5-million deaths/year), and malaria (405,000 deaths/year). But what would be your reaction if you knew that fungal infections (ranging from skin and mucosal infections (e.g. vaginal or oral thrush) to deadly systemic and organ infections (e.g. candidiasis, cryptococcal meningitis, and bronchopulmonary aspergillosis]) affect more than one-billion people each year, of which more than 150-million cases are severe and life-threatening and cause 1.7 million deaths per year?”

Malaria was once scourge in Chowan County, North Carolina

Nicole Bowman-Layton (Editor) provides some history of malaria. It’s fascinating to think that less than 100 years ago this disease was still a major scourge in Chowan County. I’ve wanted to write about this topic for a long time since the coronavirus popped up but was a bit concerned about writing about a somewhat depressing topic.

According to NCPedia malaria came to North Carolina in the 1500s from some of the first European explorers who were bitten by our friendly Anopheles mosquitoes and then transmitted to the native population. And as we well know, we live in a very damp environment surrounded by sitting water which certainly increases the harvest of mosquitos. Some of the most prominent Revolutionary Edentonians suffered from the “Ague” during their lives. Declaration signer Joseph Hewes suffered from “intermittent fever and ague” throughout his life which were certainly symptoms of malaria.

The German traveler Dr. Johan Schoepf wrote in his book Travels in the Confederation, 1783-1784, of “…the sickliness of the inhabitants, especially prevalent in the low, overflowed, and swampy parts of this country, and giving the people a pale, decayed, and prematurely old look. This is the case not only about Edenton, but along the entire low-lying coast, which this fall, from Virginia to South Carolina, was visited with numerous fevers.

We are sharing more updates from newsletters and journal abstracts found online. Issues include mapping malaria in connection with climate change, COVID-19 possibly inhibiting reporting o malaria cases, co-infection with coronavirus and malaria or dengue, Plasmodium knowlesi in northern India, and the effect of sanitation campaigns on infectious diseases. Click on links to read details.

Malaria kills 400,000 people a year, A new map shows where climate change will make it worse

A new study examines the impact of climate change on malaria in Africa. The maps reveal which areas will become more – or less – climatically suitable. Of an estimated 228 million cases of malaria worldwide each year, around 93% are in Africa. This proportion is more or less the same for the 405,000 malaria deaths globally.

That’s why there are huge efforts underway to provide detailed maps of current malaria cases in Africa, and to predict which areas will become more susceptible in future, since such maps are vital to control and treat transmission. Mosquito populations can respond quickly to climate change, so it is also important to understand what global warming means for malaria risk across the continent.

If it is too warm or too cold, then either the malaria parasite or the mosquito that transmits the parasite between humans will not survive. This suitable temperature range is relatively well established by field and laboratory studies and forms the basis for current projections of the impact of climate change on malaria. Yet, surface water is equally crucial as it provides habitat for the mosquitoes to lay their eggs. See original article in Nature Communications.

Malaria Situation in the Peruvian Amazon during the COVID-19 Pandemic

Malaria Situation in the Peruvian Amazon during the COVID-19 Pandemic. This article was originally published in Am J Trop Med Hyg. (2020 Sep 3. doi: 10.4269/ajtmh.20-0889). Online ahead of print. The Peruvian Ministry of Health reports a near absence of malaria cases in the Amazon region during the COVID-19 pandemic.

However, the rapid increase in SARS-CoV-2 infections has overwhelmed the Peruvian health system, leading to national panic and closure of public medical facilities, casting doubt on how accurately malaria cases’ numbers reflect reality. In the Amazon region of Loreto, where malaria cases are concentrated, COVID-19 has led to near-complete closure of the primary healthcare system, and diagnosis and treatment of acute febrile illnesses, including malaria, has plummeted. Here, we describe the potential association of COVID-19 with a markedly reduced number of reported malaria cases due to the reduced control activities carried out by the Peruvian Malaria Zero Program, which could lead to malaria resurgence and an excess of morbidity and mortality.

Dengue, malaria a new threat for Covid patients

Doctors in at least two Delhi hospitals have reported patients with twin infections of Covid-19 and dengue or malaria, a trend that could become worrying since the double disease may be deadlier, and the region is entering its most critical season for mosquito-transmitted diseases. The anecdotal reports tie in with latest findings that suggest a high prevalence of co-infections of diseases such as malaria, dengue and leptospirosis, which together have several symptoms that overlap with a symptomatic Covid-19 illness. Andhra villages see big drop in dengue, malaria, typhoid cases after pilot sanitation drive. Andhra govt data shows cases of seasonal diseases like dengue, typhoid, acute diarrhoea & malaria fell 97.4%, 96%, 81.7% and 50.4%, respectively, after the sanitation drive.

Now, months after the launch of the drive called ‘Manam Mana Parishubhratha’ (Our Cleanliness and Us), these villages have recorded a massive drop in the numbers of patients reporting with seasonal diseases like dengue, typhoid, malaria and acute diarrhoea. a 50.4% decrease in malaria cases (601), said the data.

AIIMS study finds zoonotic malarial parasite in acute febrile illnesses patients.

A zoonotic disease is a disease that can be spread/jump from animals to humans and vice versa. AIIMS researchers have sounded a note of caution after finding the presence of monkey malarial parasite ‘Plasmodium knowlesi’ in the north Indian population while doing a study on patients with acute febrile illnesses (AFI) and pathogens causing them.

The presence of the zoonotically transmitted malaria parasite was found during the study of acute febrile illnesses and causative pathogens in certain patients admitted in AIIMS from July 2017 to September 2018. The All Indian Institute of Medical Sciences (AIIMS) researchers from the Department of Biochemistry, along with clinicians from the Department of Medicine, were involved in the study on the pathogens causing severe fever.

 

 

In Rwanda CHWs are male and female resident volunteers elected by members of the village and are accountable of the village they serve. They should have a Primary 6 education minimum. The system guarantees that CHWs are more accessible, acceptable by clients in their communities and less expensive. Each village has a team of three CHWs. Technical supervision is done by the Health Center staff and administrative supervision by the in-charge of social affairs (cell, sector, district). CHWs receive financial compensation through Performance Based Financing (PBF) based on a set of performance indicators from monthly reports. It is this reporting process from village onwards that is explored in this case study. Services include HIV support, integrated community case management of childhood illnesses, family planning and nutrition.

The structure of the health system is based on 4 Provincial hospitals that receive referrals from 35 district hospitals. Within these districts are 465 health centers whose catchment areas contain 2,148 cells and 14,837 villages. With a goal of 3 CHWs per village (1 female & 1 male pair in charge of iCCM and 1 Female in charge of Maternal Health), Rwanda has trained 44,511 CHWs. All CHWs are organized into cooperatives. Each health center oversees one CHW cooperative (which is the basis of performance-based funding as we discuss in Module 6).

The current system has evolved since 1995, when it was completely paper-based. The Community Health Information Systems, that is the M&E system for community interventions, is carried out through different national data collection and reporting tools ultimately managed by web-based interface[1]. Tools include national standard paper-based source document (registers), paper-based monthly summary form, DHIS-2 and the système d’information sanitaire des communautés/CHW information system (SISCOM), and Rapid SMS

Initially, separate systems existed to gather data on the country’s 45,000 community health workers, HIV services, human resources, and other special programs—these data streams were separate and though the systems were web-based, none of the databases could interact. The Rwandan health system was collecting immense amounts of data, and spending considerable time and money doing so, but it was unable to effectively use that information for strategic planning or immediate action. As reported by staff of the maternal and Child Survival Program (MCSP), since the successful launch of the Rwanda-HMIS[2], many new reporting modules have been integrated into the DHIS 2 platform which include weekly and monthly reporting of community-based health insurance indicators and the CHW information system.

The following community services are tracked: Treatment of sick children (iCCM), Community Based Nutrition Program (CBNP), Malaria Treatment Adults (HBM), RDTs carried out, Family Planning, Home based Follow up of pregnant women, mothers and newborns, Nutritional monitoring, Under-5 vaccination, Maternal and Newborn Death Surveillance, Drugs and supplies, IEC activities, and user payments. These are summarized into a CHW monthly report form and ultimately into the web-based SISCOM monthly summary form. The web-based R-HMIS data tools are accessible to health staff with passwords.[3]

The data flow system moves as follows:

  — Electronic – MOH

­­­  ^ Electronic – District Hospital

  ^ Electronic – Health Center

  ^ Paper-based – Cell Coordinator

  ^ Paper-based – CHW

The coordinator of CHW cooperative submits the monthly summary form to Health Center data manager who enters aggregated data into DHIS- 2/SISCOM. The data entry screen of DHIS-2-HMIS/SISCOM can be accessed at the health center.

According to MCSP, Rapid SMS text-messaging tool is used by the CHW assigned to maternal health to track pregnant women and track the first 1000 days of life up to 5 years. Examples of information submitted include 1) Woman’s pregnancy and delivery, 2) Children under five identified with danger sign, 3) Tracking referrals (track alert sent and responses) and 4) Maternal and under five deaths. Rapid SMS data are accessed at District Hospital and used at the primary level health facilities to respond to maternal and child health emergencies. Rapid SMS sends automated, actionable responses to CHWs when reported events indicate risk, or when antenatal care visits or deliveries are due. Health facilities are notified to prepare for an anticipated delivery and/or to provide ambulance transport.

DHIS/SISCOM from the CHW also report on drug and supply management. Primary level health facilities support community health workers within the catchment area to ensure they have timely and adequate supplies.

At the local administration level (village, cell, sector, district) CHWs data are used for planning, setting and monitoring health related performance contracts. At the Central level (RBC/MOH and development partners), these data inform policies, establish strategies, manage the supply chain management, aid in research, and perform PBF

MSCP explains that feedback mechanisms and data quality are promoted through quarterly community sub-technical working group meeting, Quarterly and annual analysis of community data, and biannual integrated supervision including community Data Quality Assurance (DQA). Quarterly analysis of Community Health data informs decisions by the Management Team. The biannual DQA of community data compares paper vs. electronic sources. Monthly meetings at Health Center level review reported data and link data to quality of service provision. Mentorship included community DQA

There are monthly CHWs meetings with cell coordinator to review reported data. This also aids in Community Performance-Based Financing. Incentives are given to CHW cooperatives in exchange of their performance based on two categories of indicators.  First, quarterly payment for reporting is based on the timely submission of quality data reports related to 29 indicators including –

• Report Quality:  Timeliness, Accuracy and Completeness of Report
• Cooperative   Quality: Legal status, Presence of President, Bank account, etc.

Secondly, Pay-for-indicators are additional payment for improvement in five targeted areas (Nutrition, ANC, SBA, FP referrals and FP new users, LTPM). The average quarterly payment is $900 per cooperative for a 100% quality score.

MCSP notes as an example of success that all CHWs are using standard data collection tools (registers, flipcharts and summary forms). All CHWs are equipped with a mobile phone regularly loaded with airtime for Rapid SMS, communication with HC and other CHWs. The DHIS-2/SISCOM functional countrywide. A strong feedback and coordination mechanism is in place and functional. The PBF includes the CHW reporting rate. MCSP reports that the remaining challenges include turnover of trained CHWs, High workload for CHWs, inadequate response rate on alerts sent through Rapid SMS, disaggregation of data (e.g. FP not disaggregated by method), disparities in CHWs activity as per instructions for Rapid SMS, and sub-optimal use of data. Continued mentoring through CHW meetings addresses community level gaps.

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[1] Jean de Dieu Gatete, Jovite Sinzahera, USAID Maternal and Child Survival Program (MCSP), Rwanda. Integrating community data into the health information system in Rwanda. Institutionalizing Community Health Conference, Johannesburg. 27-20 March 2017. www.mcsprogram.org

[2] US Agency for International Development (USAID). THE RWANDAN HEALTH MANAGEMENT INFORMATION SYSTEM: Improving Collection and Management of Health Service Data to Support Informed Decision Making. the Integrated Health Systems Strengthening Project. https://www.msh.org/sites/msh.org/files/ihssp_techbr2_final_webv.pdf

[3] Rwanda Integrated Health Management Information System. https://hmis.moh.gov.rw/

Thomson Ngabirano, Espilidon Tumukurate, Innocent Atukunda, Emily Katarikawe, Jimmy Opigo, Martin Muhire, Emily Goodwin, Sam Gudoi, Kassahun Belay, Peter Thomas, James Tibenderana have been working with the following partners in Uganda to improve malaria case management: Jhpiego, United States Agency for International Development’s (USAID) Malaria Action Program for Districts (MAPD) Project, Uganda National Malaria Control Program, Ministry of Health, University Research Co., the USAID ASSIST Project, Malaria Consortium, US President’s Malaria Initiative, and the US Centers for Disease Control and Prevention, Uganda. Their work, seen below, was presented at the 2018 Annual Meeting of the American Society of Tropical Medicine and Hygiene.

Malaria has a 19 percent parasite prevalence in Uganda and is a leading cause of morbidity and mortality in Uganda and in 2014 was responsible for:

• 30-50 percent of outpatient visits
• 15-20 percent of hospital admissions
• 20 percent of inpatient deaths.[1]

In an effort to reduce its malaria burden, in 2016 the Ministry of Health in Uganda incorporated a number of World Health Organization recommendations into its National Malaria Policy Guidelines. The main elements in these guidelines implemented by health workers were:

• testing all suspected malaria cases with malaria rapid diagnostic tests (mRDT) or microscopy before treatment
• using artemisinin-based combination therapy (ACT) to treat only positive malaria cases
• providing at least three doses of intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP).

However, a number of challenges for malaria service delivery were encountered during

implementation, including incomplete, inaccurate, and inconsistent malaria records and reports; health workers not adhering to the malaria test, treat, and track policy; and malaria causing high caseloads at outpatient and inpatient service points.

To overcome these issues, and in particular to improve adherence to the malaria test, treat and track policy and strengthen the quality of data collection and recording, USAID’s Malaria Action Program for Districts (MAPD) implemented a collaborative quality improvement approach (CQI).

A CQI approach was introduced to MAPD in November 2017 and implemented using both qualitative and quantitative methods. These included reviewing malaria indicators on the District Health Information System, identifying 10 high-volume facilities across MAPD’s five operational regions with poor malaria indicators (see Figure 1), holding entry meetings with the district health teams, conducting collaborative data reviews and problem analysis with health facility staff, and presenting the results of data reviews to health facility staff to identify inaccurate reporting and non-compliance with the test, treat and track policy. Interventions also included working with health facility staff to identify potential solutions and interventions, implementing agreed interventions and reviewing indicators, monitoring progress using documentation journals, holding learning sessions led by a CQI coach, agreeing on new actions.

Malaria data indicators reviewed include accuracy and completeness of cases in lab register and OPD, number of fever cases tested for malaria using mRDT or microscopy, number of malaria-negative cases treated with ACTs, number of malaria-positive cases treated with ACTs, and number of pregnant women receiving three or more doses of IPTp-SP.

In a sample of 300 cases from a June 2018 lab register, taken eight months after the CQI approach was introduced, all 300 (100 percent) were recorded in the respective OPD register. This represents a 108 percent increase from when an equivalent sample was first reviewed in November 2017. In a sample of 300 patients that were treated using ACTs in June 2018, all patients were tested for malaria using mRDTs or microscopy and no patients were treated that had tested negative. This represents an 89 percent decrease from November 2017 when 27 (nine percent) malaria-negative cases were incorrectly treated using ACTs.

Of the total 264 expectant mothers (who were 28 weeks pregnant and above) that attended ANC visits in July 2018, 142 (54 percent) received three or more doses of IPTp-SP. This is a marked increase on the 43 percent of pregnant women who received three or more doses in November 2017.

Feedback from discussions with health workers in facility meetings and regional learning sessions showed that health teams now accept that there is a need for accurate and complete data and understand the importance of adhering to the National Malaria Policy Guidelines. In conclusion … The CQI approach was found to promote accurate data collection and improve adherence to the malaria test, treat, and track policy among health workers at 10 health facilities in five regions of Uganda.

[1] Reference: Uganda Bureau of Statistics (UBOS) and ICF International. Uganda Malaria Indicator Survey 2014-15. Kampala, Uganda and Rockville, Maryland, USA: UBOS and ICF International; 2015. Available at https://dhsprogram.com/pubs/pdf/mis21/mis21.pdf

MAPD is a project (running from 2016-2021), funded by the US President’s Malaria Initiative, USAID, UK aid, and the government of Uganda, which aims to improve the health status of the Ugandan population by reducing malaria-related morbidity and mortality among children and pregnant women. This poster was made possible by the support of the American and British People through the United States Agency for International Development and UK aid from the UK government. The contents of this poster are the sole responsibility of USAID Malaria Action Program for Districts and do not necessarily reflect the views of USAID or the United States Government and do not necessarily reflect the UK government’s official policies. For more information, please contact; 1. Dr Thomson Ngabirano, Malaria in Pregnancy Specialist Thomson.Ngabirano@Jhpiego.org 2. Dr Sam Siduda Gudoi, Chief of Party s.gudoi@malariaconsortium.org

Maya Tholandi, Lolade Oseni, Anne McKenna, Herbert Onuoha, Solofo Razakamiadana, Elsa Nhantumbo, Alain Mikato, Elaine Roman of Jhpiego and the Johns Hopkins Bloomberg School of Public Health shared important Baseline Readiness Assessment Findings from Democratic Republic of the Congo, Mozambique, Madagascar, and Nigeria from the UNITAID-supported TIPTOP on Intermittent Preventive Treatment of malaria in pregnancy at the 2018 Annual Meeting of the American Society of Tropical Medicine and Hygiene as seen below.

Intermittent preventive treatment of malaria in pregnancy (IPTp) is unacceptably low in most of sub-Saharan Africa. A Jhpiego-led consortium is implementing the Transforming Intermittent Preventive Treatment for Optimal Pregnancy (TIPTOP) project, which supports community distribution of quality-assured sulfadoxine-pyrimethamine (SP).

TIPTOP aims to increase IPTp3 coverage from 19% to 50% of eligible pregnant women in project areas in Democratic Republic of the Congo (DRC), Madagascar, Mozambique, and Nigeria. The project, operating from 2017 to 2022, provides quality-assured SP, promotes community awareness, and supports supervision and coordination efforts between health facilities and community health workers (CHWs).

In 2017, a baseline assessment examined facility readiness for malaria in pregnancy management, antenatal care (ANC) provider knowledge, CHW characteristics and health facility linkages, and health management information system (HMIS) quality. TIPTOP assessed 140 facilities and interviewed 175 ANC providers and 67 CHW supervisors.

At project startup, the teams examined SP stock, ANC providers and CHW availability. SP Stock assessment showed a disparate stock maintenance processes and stock-out next steps indicate lack of a coherent and consistent approach to stock monitoring. In half of all cases, caregivers offer a prescription when stock is not available in the facility, with smaller numbers requesting.

Among ANC providers, 80% on average correctly reported that at least three doses of IPTp are recommended. On average, 64% correctly responded that SP should be initiated in the second trimester. Out of the 170 providers interviewed across countries, only five knew all the key signs of suspected malaria.

A low numbers of CHWs in some districts may limit their reach and capacity. Inadequate CHW education and ANC familiarity may diminish training effectiveness. In particular, low numbers of female CHWs may decrease community acceptance and pregnant women’s acceptability of receiving IPTp from CHWs.

Data Quality and Availability from the routine services would affect monitoring of interventions. Over-reporting of ANC contacts and IPTp service provision is a data quality challenge. The HMISs in Nigeria and Mozambique record IPTp3 provision, but only at the local level. Supervising facilities do not always review data before HMIS entry for accuracy.

Concerning Monitoring and Evaluation System Components, Mozambique’s HMIS is the strongest of the four countries in terms of linking to the national system, current tools and reporting forms available in the facilities, and providers reporting an understanding of indicators and data reporting processes. Nigerian facilities had limited knowledge of indicators and their definitions, despite this information being available in Federal Ministry of Health-provided registers. Madagascar struggled with indicator definitions and data management processes. DRC faced the most challenges: Tools and reporting forms were not available in health facilities, and there were limited monitoring and evaluation structures and processes.

In Conclusion, Results from the baseline assessment are Informing efforts to improve data quality and CHW facility data flow in TIPTOP implementation areas. There is need to strengthen ANC provider knowledge through TIPTOP-supported trainings. One also needs to address CHW variation by country and support health facilities to monitor their SP stock. These findings are being shared with ministries of health and key stakeholders to inform malaria implementation and data quality efforts.

Mathurin Dodo, Ousmane Badolo, Stanislas Nebie, Youssouf Sawadogo, Thierry Ouedraogo, Moumouni Bonkoungou, Youssouf Zongo, Maria Gouem, Danielle Burke, Gladys Tetteh, Lolade Oseni, Linda Fogarty, and William Brieger of Jhpiego and the USAID Improving malaria Care Project in Burkina Faso shared the status of malaria control efforts at the 2018 Annual Meeting of the American Society of Tropical Medicine and Hygiene. The focus on vulnerable populations is shared below.

Burkina Faso in 2010-2012 experienced poor capacity in malaria prevention and control, Malaria fatality rate was high:

• Pregnant women: 0.71% in 2010 and 0.66% in 2012
• Children under 5: 2.8% in 2010 and 2.7% in 2012

Improving Malaria Care (IMC) Project funded by USAID/President’s Malaria Initiative, began in 2013. IMC supports National Malaria Control Program to improve prevention and case

Management. IMC’s Strategies include the following:

• Update national malaria prevention and case management guidelines
• Strengthen health care provider capacity
• Align malaria training package with revised guidelines
• Strengthen national malaria health management information system (HMIS)

IMC together with the National Malaria Control Program has been strengthening Health Care Provider Capacity. 54 health districts have been covered by IMC direct support where 1819 providers were trained. Training reached 185 trainers/supervisors on revised training Modules who then trained 1,819 health care providers from 1,349 health facilities in 54 districts on new guidelines

After training 58 supervisors rolled out quality improvement (QI) systems. They oriented 897 providers from referral hospitals on new severe case management guidelines. Formative Supervision, Performance and Quality Improvement efforts were based on an improved malaria supervision guide and tools. Post-training supervision reached each provider. Specifically, malaria supervisions occurred twice a year.

The quality improvement approach, SBM-R® (Standards-Based Management and Recognition) approach, was implemented in 6 regions, 28 districts. Organized data review and validation workshop in 67 districts were another aspect of quality improvement. To sustain quality improvement, IMC conducted 2-day quality assessments and guided developed DQI implementation plans.

Social Behavior Change Communication was a central component of IMC. IMC conducted 13 regional advocacy workshops on malaria issues. The project developed and broadcast 2 malaria spots through 27 media, revised 5 diagnostic and case management job aids, distributed 7,440 job aids to health facilities, and reached 792,660 people through community activities and sensitization sessions

IMC Strengthened National Malaria HMIS. This included training 1,300 (72%) health workers to enter data into monthly reporting forms. Also trained were 326 data managers on HMIS and data use for decisionmakers. The malaria data collection system was integrated into national HMIS using DHIS2. To facilitate this the national HMIS manual was revised and distributed.  Data Quality was improved through malaria data review and validation at district levelUltimately these interventions resulted in Improved Malaria Services. More confirmed simple malaria cases received artemisinin-based combination therapy (65% in 2013 to 90% in 2017). More women received three doses of IPTp3 (14% in 2014 to 51% in June 2018). More suspected cases tested for malaria (65% in 2013 to 96% 2017). More women received insecticide-treated nets at antenatal care. There was Better accuracy in reporting of malaria key indicators.

Improved services led to decreased national malaria fatality rate. In the General population there was a decrease in malaria deaths of 34% and a decrease in overall fatality rate by 47%. Among pregnant women there was a decrease in malaria deaths by 91% and a decrease in malaria fatality rate by 93%. For Children under 5 years of age, there was a decrease in malaria deaths by 34% and a decrease in fatality rate 48%

In conclusion the IMC Project Contributed to Lives Saved in Burkina Faso. IMC supported health delivery sites in Burkina Faso (Jan 2014 -Sep 2017). As a result the health system was able to Distribute 33,566,671 courses of artemisinin-based combination therapy. IMC provided 2,175,648 pregnant women with intermittent preventive treatment 2nd dose and distributed 1,146,185 nets to pregnant women during antenatal care visit. These interventions averted estimated 150,390 malaria deaths and 12,866,271 DALYs (Disability-Adjusted Life Years calculated using PSI Impact calculator. 1 DALY=1 lost year of “healthy” life.)

This poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID) under Cooperative Agreement No. AID-624-A-13-00010 and the President’s Malaria Initiative (PMI). The contents are the responsibility of the authors and do not necessarily reflect the views of USAID, PMI or the United States Government.

Haja Andriamiharisoa, Eliane Razafimandimby, Jean Pierre Rakotovao, Jean Eugene Injerona, Zo Harifetra, Lalanirina H. Ravony, Rado Randriamboavonjy, Jocelyn Razafindrakoto, and Laurent Kapesa have been working with the USAID Maternal and Child Survival Program. At the 2018 Annual Meeting of the American Society of Tropical Medicine and Hygiene they presented their experiences on “Improving Procurement and Redeployment of Malaria Commodities Using SMS and Web Mapping at a District Level in Madagascar,” and are also sharing via this posting.

Malaria is a public health problem in Madagascar. In 2016, the frequency of diseases at health center level, places malaria at the 4th cause of hospital morbidity and mortality. Out of about 30 thirty diseases, malaria accounts for 5.6% of all cases.

Health facilities often experience commodity stock-outs of products used for malaria prevention and case management. The existing logistics reporting system does not allow for macro or micro views of the monthly stock situation at the health facility level, which inhibits rapid decision-making.

On January 2018, implementation of a fast data collection system and easy-to-use data visualization began. The tool was based on the use of SMS and web mapping to map the level of monthly keys stock of commodities. The data are sent by providers at facility level via structured SMS and are published by a web server by a web mapping process. Note that sending a monthly SMS costs 9 US cents per facility. Providers at 773 health facilities in 16 regions of Madagascar sent monthly SMS (each message cost $0.09) with ART, ACT, and ITN stock levels.

• Sample message: “Please send the quantity in stock at the end of month in: ART, ACT, ITN.”
• Structure like: “palu csbcode year month ART ACT ITN. Thank you.”
• Sample of answer received: “palu 520241031 D A 200 25 0”

Thus was created an easy-to-use tool from data received. It was free to use, and no password was needed. The SMS is simple and short (of 40 forty characters, composed of:

• “palu” diminutive of malaria so that the system is ready for data collection from other cases
• the health facility code : 520241031
• year : here D : as project has implemented sms data collecting system since 2015 = A
• month : here A that means January
• stock of Injectable Artesunate (ART) : 200
• stock of tablet for Artemisinin–based combination therapy (ACT) : 25
• stock of Insecticide Treated Nets (ITN) : 0

Providers send SMS after completing the Monthly Activity Report. (CSB = Centre de Santé de Base, or basic health center). The received data are then displayed as web mapping on a Google map background, embedded on a web page. From this screen shot, The page displays a map of stock outs for the selected month, and monthly charts of the stock status of the three commodities. Accessing this website, is open, without restriction.

From the end of January to the end of June 2018, a hundred health facilities sent SMS each month. The data we received shows that on average:

• 75% Average stock-out of ITN
• 53% Average stock-out of ART
• 9% Average stock-out of ACT

The attached three-map picture provides a broad view from three screenshots of the system, showing the evolution of stock-outs at a facility level

• Each point represents health facilities:
• When the dot is green, this means that the 03 commodities are available in stock
• When in brown, at least one of the 03 elements is unavailable
• At first sight, there are more stockouts than stock availability and a tendency of the reduction of green points over the months
• Appropriate decision-making would change the points of the map of the following months to green

After this broad view of the country’s overall situation and given the large number of facilities with out of stock, an emergency supply for all districts was done for some medicine since February 2018. Based on maps and stats, we could improve our interventions at a CSB level through rapid and adequate decision-making as in the supply of ITN and ART.

In conclusion, the use of SMS data collection to map stock-outs online can quickly improve input supply through simple spatial analysis. Sending SMSs to alert district-level officials about overstock in facilities at the same district level can solve many stock-out issues. All districts were restocked using this SMS and Web mapping system, but routing to the CSBs remains a challenge. Punctual stock-out reporting could significantly reduce the morbidity and mortality caused by malaria.

This presentation was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative Agreement AID-OAA-A- 14-00028. The contents are the responsibility of the authors and do not necessarily reflect the views of USAID or the United States Government.

Swaliho F. Kamara, Wede Tate, Allyson R. Nelson, Lauretta N. Se, Lolade Oseni, Gladys Tetteh of MCSP/Jhpiego are presenting a poster at the 2018 Annual Meeting of the American Society of Tropical Medicine and Hygiene on Malaria Service delivery in rural Liberia. Their findings are shared below:

In Liberia Malaria prevalence in children under 5 is 45% nationally and higher in rural counties (NMCP et al. 2017). The National Malaria Control Program (NMCP) leads the rollout of malaria prevention and control activities to county health teams (CHTs), per the National Malaria Strategic Plan (2016–2020). A key donor supporting malaria prevention and control, the President’s Malaria Initiative (PMI), has been committed to the Ministry of Health and Social Welfare (MOHSW) strategy since 2008, when it began working in three out of 15 malaria-affected counties. PMI supports CHTs in their management of local health systems and service delivery oversight. As part of an expansion program to five additional rural, neglected, high-burden counties in 2017, the United States Agency for International Development (USAID)/ PMI-funded Maternal and Child Survival Program (MCSP) assessed CHTs’ organizational capacity to identify ways to improve the quality of malaria health services.

We assessed CHTs’ capacity using a modified organizational capacity assessment (OCA) tool that was used by the USAID’s Rebuilding Basic Health Services (RBHS) project to assess the capacity of the MOHSW, CHTs, and district health teams (DHTs), capturing four of the six World Health Organization (WHO) building blocks of the Health Systems Framework. We also assessed all 30 districts in five counties. Performed desk review, review of self- evaluations, and face- to-face validation interviews. The assessment focused on processes, not physical systems, so the capacity and knowledge of the respondents may have influenced results in some of counties.

Scoring Structure of the OCA Tool: Following each assessment, MCSP used a detailed summary sheet (Figure 3) to display the aggregate scores for each subarea under all key domains, then generated an overall score for each domain. The total score was then expressed as a percentage for each key domain. The majority of the assessment involved asking specific questions about performing malaria interventions per the project scope.

Effective Interventions were determined:

• Health Workforce Interventions …
  • Trained health care workers.
  • Trained supervisors on revised supervision tool.
  • Performed quarterly supervision and mentoring.
• Leadership and Governance
  • Identified a malaria focal point.
  • Activated functional health-sector coordination committees.
  • Held quarterly review meetings.
• Health Information System
  • Provided health management information systems (HMIS) forms to health facilities.
  • Facilitated in-service training on onsite data verification.

Results showed that CHTs’ overall average score was 87% in service delivery, 65% in health information systems, 78% in health workforce, and 70% in leadership/management. Interventions addressing gaps identified in health workforce, leadership and governance, and health information systems resulted in improved service delivery (see Figure 4).

In conclusion, The OCA tool helps to identify common challenges, assist with systemwide improvements across CHTs or DHTs, evaluate progress, and meet specific needs. Future efforts are needed to improve the tool’s specificity, the weighting attached to different sections and issues, and its relevance to different types of organizations. Training is an important component to capacity-building, but it is just one part of the picture. Need to improve the way organizations and CHTs/DHTs coordinate with partners to improve all health interventions. Need to focus on application and results of capacity-building, not on capacity as an end in itself.

This poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of the Maternal and Child Survival Program and do not necessarily reflect the views of USAID or the United States Government.

Without quality service delivery data, we can never confidently say what progress we are making in improving access and uptake to malaria services. Mathurin Dodo, Ousmane Badolo, Stanislas Nebie, Youssouf Sawadogo, Thierry Ouedraogo, Moumouni Bonkoungou, Youssouf Zongo, Maria Gouem, Danielle Burke, William Brieger, and Gladys Tetteh of the USAID/Jhpiego Improving Malaria Care Project and Burkina Faso Ministry of Health have implemented procedures to review malaria data quality. They share their findings at the 2018 American Society of Tropical Medicine and Hygiene as well as in the text that follows:

In Burkina Faso, malaria seriously affects pregnant women and children under 5 years of age . The malaria fatality rate for children under 5 was 2.8% in 2010, 2.10% in 2011, and 2.7% in 2012. For pregnant women, it was 0.71% in 2011 and 0.66% in 2013. Since October 2013, the United States Agency for International Development/ President’s Malaria Initiative has funded the 6-year Improving Malaria Care (IMC) project to improve malaria prevention and case management in support of the National Malaria Control Program (NMCP). The Ministry of Health and IMC staff conducted two malaria data quality audits (DQAs) in September 2014 and February 2017 that confirmed the poor quality of malaria data. The accuracy of malaria key indicators ranged from 56% to 76%.

A Pre-Data Review Workshop begins the process. IMC supported the NMCP and health management information system to develop a manual of procedures for malaria data review and validation at health district level. IMC assisted in developing a malaria data review sheet based on data validation rules in manual. Each quarter, the district data manager entered data from monthly reports sent by the health facilities in the three health district project areas—Boromo, Dano, and Koupela—into DHIS2.

During the Data Review Workshop the regional data manager asked each health facility manager to verify reports. When correcting each error, the regional data manager and head of the district management team explained to providers the indicator definitions and malaria prevention and treatment guidelines. The district data manager corrected the data in DHIS2.

After three rounds of quarterly reviews, all three health districts saw an overall decrease in the number of reporting errors. After two rounds of quarterly data review workshops, there were no errors due to understanding detected.

Quarterly data review workshops can be used to reinforce the technical capacity of providers. Involving providers who are responsible for malaria prevention, diagnosis, and treatment gives them a better understanding of indicator definitions and linkages between indicators and the services they provide. Working with health care providers to improve data quality at the district level helps providers build capacity in health management information systems and in data collection, verification, and control at facility level. It also improves the quality of malaria services. The malaria data review contributes to malaria data quality improvement. All opportunities should be used to reinforce the capacity of health care providers and improve the quality of malaria prevention and case management services.

This poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID) under Cooperative Agreement No. AID-624-A-13-00010 and the President’s Malaria Initiative (PMI). The contents are the responsibility of the authors and do not necessarily reflect the views of USAID, PMI or the United States Government.

Mobile migrant populations present a special challenge for malaria control and elimination efforts. Nguyen Ha Nam and colleagues* (Nguyen Xuan Thang, Gary Dahl, James O’Donnell, Vashti Irani, Sara Canavati, Jack Richards, Ngo Duc Thang, and Tran Thanh Duong) presented their study of this group at the recent Malaria World Congress. They are also sharing what they learned below.

Mobile Migrant Populations (MMPs) are a key population for containing the spread of malaria in the border areas between Cambodia and Vietnam. The number of imported cases in Viet Nam in 2017. 12,5% of such cases caught in Binh Phuoc and Dak Nong provinces and all of them came from Cambodia. The provinces bordering Cambodia and Vietnam have been had the highest malaria transmission intensity. This borders are frequented by MMPs who have proven difficult to target for surveillance and malaria control activities.

Mobile Outreach Teams (MOTs) provide a potential approach to target malaria elimination activities for MMPs who may not be strongly supported by the regular village-based and clinic-based health services. This work describes the implementation of MOTs in Binh Phuoc and Dak Nong Provinces, which are high-risk regions along the Viet Nam-Cambodia border. These activities were conducted as part of the Regional Artemisinin-resistance Initiative (RAI) in 2017. Each MOT was comprised of 2 Commune Health Staff and 1 Village Health Worker (VHW) from the village nearest to the outreach area.

In the first phase of the pilot, 3 communes of 2 districts in Binh Phuoc and 2 communes of 1 district in Dak Nong with highest malaria cases reported from NIMPE are selected as targeted areas. The Objectives were to …

• Design/tailor Mobile Outreach Information Education and Communication/Behaviour change communication (BCC/ IEC) Toolkit
• Intensify case detection and quality management by increasing the coverage of diagnostics and treatment for hard to reach populations
• Strengthen outreach to high-risk and under-served populations through MOT scouting activities to locate unreached Mobile Communities and map their locations
• Link MMPs with health facilities and Village Health Workers

All MOT members were provided with smartphones and were trained on how to use the EpiCollect5 app to track malaria cases, record mapping information and upload real-time reports of these malaria cases. MOTs conducted 5-day outreach activities every month. These activities began with scouting out locations of the MMP communities.

Once located, the MOTs geo-tagged the location of the community, conducted a short epidemiological survey on the community and screened for malaria using Rapid Diagnostic Tests and blood smear microscopy. Active malaria cases were provided with treatment according to the National guidelines, and Long Lasting Insecticidal Nets were distributed based on results of diagnosis and the survey.

This action has led to increased diagnosis and treatment of hard to reach MMPs with increased access by those communities to malaria services. Improved understanding and increased use of malaria prevention practices hard to reach MMP communities/households. Mapped of previously unreached MMP Communities and unofficial border crossing points with malaria transmission hotspots and highly frequented crossing identified. The number of MMPs were monitored by MOTs were 2,699 accounting for 5.18% of the population in the project sites (2,699/52,095).

These screened MMPs were almost located along the border among project communes in Bu Gia Map National Forest where have a lot of unofficial border crossers, timber camp communities, and other revolving communities. 1,977 targeted people were tested for malaria. This number was achieved 73.25% of mobile migrant people (1,977/2,699). This work highlights how MOTs can target the previously unreached populations of MMPs to strengthen malaria surveillance and active case responses to reduce malaria transmission in Viet Nam.

A system of real-time data collection of malaria cases from VHWs and MOTs using mobile phone uploads was established. Border screening and tracking hard to reach communities is a useful approach to implement to identify imported cases; however, it is labor-intensive, and misses subjects crossing at unofficial borders due to limited working time of MOTs (5 days a month).

Positive cases in Binh Phuoc province are maintained for keeping track after receiving treatment due to no confirmed cases detected in targeted communes in Dak Ngo province, though these communes mainly have numerous transient timber camps moving in deep forests, and highly mobile border-crossers moving between regions and countries frequently. Future work will combine routine support from District health staff and expand the role of VHWs with motorbike provision for each MOT in order to not only to improve their quality outreach activities but also develop stronger Active Case Detection in the next phase of the project.

*Team members represent the National Institute of Malariology, Parasitology and Entomology, Hanoi, Viet Nam; Health Poverty Action, London, UK; and the Burnet Institute, Melbourne, Australia.

References

• Kheang ST, Lin MA, et al. Malaria Case Detection Among Mobile Populations and Migrant Workers in Myanmar: Comparison of 3 Service Delivery Approaches. 2018
• Shannon Takala-Harrison,a Christopher G. Jacob, et al. Independent Emergence of Artemisinin Resistance Mutations Among Plasmodium falciparum in Southeast Asia. 2014.
• Imwong M, Hien TT, et al. Spread of a single multidrug resistant malaria parasite lineage (PfPailin) to Vietnam. 2017.
• Richard J Maude,corresponding author Chea Nguon, et al. Spatial and temporal epidemiology of clinical malaria in Cambodia 2004–2013. 2014.
• Imwong M, Nguyen TN, et al.The epidemiology of subclinical malaria infections in South-East Asia: findings from cross-sectional surveys in Thailand–Myanmar border areas, Cambodia, and Vietnam. 2015.
• Hannah Edwards, Sara E. Canavati, et al. Novel Cross-Border Approaches to Optimise Identification of Asymptomatic and Artemisinin-Resistant Plasmodium Infection in Mobile Populations Crossing Cambodian Borders. 2015.