Author Archives: Alexandra York

Expert Q&A: Innovations and challenges in malaria surveillance

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Monitoring, evaluation and surveillance techniques are central to Malaria Consortium’s work to improve overall performance and maximise the delivery of disease control interventions. Malaria Consortium consistently engages in monitoring and evaluation activities, using the results to guide the design of malaria surveillance systems and implementation of malaria control programmes.

In June 2017, the School of Public Health at the University of Ghana, in collaboration with MEASURE Evaluation, hosted the 7th Annual Workshop on Monitoring and Evaluation of Malaria Control Programmes (http://bit.ly/2s0gIWj). The aim of the workshop was to provide professionals with the skills in fundamental concepts, surveillance, and practical approaches to monitoring and evaluation of malaria programmes in sub-Saharan Africa.

The event was co-facilitated by Malaria Consortium’s Head of Monitoring and Evaluation, Dr Arantxa Roca-Feltrer. In this Q&A, Arantxa discusses the importance of surveillance activities, innovations in surveillance processes and the challenges encountered by surveillance practitioners in the control and elimination of malaria.

What is malaria surveillance?

Malaria surveillance is the systematic and regular collection of information on the occurrence, distribution and trends of malaria with sufficient accuracy and completeness to inform decision-making. The latest World Health Organization (WHO) Global Technical Strategy (GTS) identifies malaria surveillance as an intervention that encompasses the tracking of diseases (including malaria), programmatic responses, and taking action based upon the received data.

Is surveillance done differently in Asia and Africa?

Malaria surveillance is not intended to be implemented differently in Asia or Africa. The difference in the surveillance process depends on where the country lies in relation to the elimination spectrum. In countries with a high malaria burden aiming to control the disease, surveillance is focused on collecting aggregated data for use in planning, implementation and evaluation of public health practices. Surveillance in malaria eliminating countries, on the other hand, is focused on gathering individual level data, where programmes implement activities related to the identification, investigation and elimination of continuing transmission, the prevention and cure of infections, and the final proof of claimed elimination.

Why should we monitor and evaluate surveillance systems?

Monitoring and evaluating a country’s existing surveillance system is important for several reasons. Firstly, there is a need to ensure that the surveillance system follows national malaria control or elimination priorities. Secondly, we need to document the effectiveness of the surveillance system as well as its linkages with existing health information systems such as the national health management information system. Finally, monitoring and evaluation allows government teams to introduce new surveillance methods or techniques that might strengthen the system once proven evidence has been gathered through small scale pilot evaluations, such as reactive case detection or cross border surveillance techniques.

How can we monitor and evaluate what makes a good surveillance system?

The World Health Organization considers several quality criteria:

  • Simplicity
  • Adaptability and flexibility
  • Acceptability
  • Performance (sensitivity, specificity, predictive positive value, predictive negative value)
  • Representativeness
  • Ability to respond and identify actions

One example of a good surveillance system can be seen in Southeast Asia, where Malaria Consortium has been supporting strategies for rapid malaria elimination through cross-border surveillance in areas with high levels of artemisinin resistance. In Uganda and Ethiopia, we have been monitoring the changes in the epidemiology of malaria and the effectiveness of interventions through our Beyond Garki project.

What were the key lessons learnt from the MEASURE workshop on malaria surveillance?

The workshop highlighted that malaria surveillance activities should be adequately budgeted and resourced to enable the effective implementation of case notification and investigation activities. Also, the use, interpretation and feedback of data are key for a successful malaria surveillance system, and this requires proper training and a cultural move towards ‘using data for action’.

Are there any novel or innovative approaches to surveillance?

The WHO GTS Framework for Malaria Elimination emphasises the importance of research and innovation for malaria elimination. This document states that ‘investment in basic science and product development must be sustained to create new tools and strategies for malaria elimination and its eventual global eradication’. It goes on to say that the ‘operational feasibility, safety and cost-effectiveness of new tools and strategies should be evaluated by context-adapted operational research as a basis for reliable policy recommendations by national policy-makers and WHO’.

The operational research agenda within the WHO GTS Framework, which covers a range of topics, is currently exploring the use of digital strategies to improve the rapid reporting of malaria cases. It also looks at other participatory surveillance approaches that include and deliver interventions to groups at the greatest risk. With over seven years of experience in mobile health (mHealth) and health systems strengthening, Malaria Consortium believes that effective digital health strategies can help governments manage malaria and disease control programmes better. In the countries we work in, we have explored how digital strategies can play an important role, particularly to improve the motivation and supervision of community health workers, to provide effective diagnostic tools, and to strengthen surveillance and data management.

Given that the new WHO elimination strategy incorporates malaria surveillance, how can we prioritise surveillance and what challenges might we face?

Strengthening surveillance is crucial for implementing country-wide malaria elimination activities. Malaria surveillance systems require new functionalities which facilitate/incorporate surveillance, such as data visualisation, and new data quality features for the effective implementation of surveillance activities, such as timeliness and comprehensiveness. Other priority areas include product development of medicines, diagnostics, vector control methods and vaccines.

However, countries also face specific challenges that are unique to their context. These require careful attention – particularly at the community level – in order to ensure feasibility, user acceptability at various health levels, sustainability and long-term system flexibility. Therefore, it is important to stress that a ‘one-size-fits-all’ approach does not apply to malaria surveillance and information systems, and that contextual factors must be taken into consideration when strengthening malaria surveillance activities.

 

Links to the projects as stated above:

  1. UpSCALE: http://www.malariaconsortium.org/inscale/pages/about-upscale
  2. inSCALE: http://www.malariaconsortium.org/inscale/pages/inscale-project
  3. IMMERSE: http://www.malariaconsortium.org/pages/immerse_project.htm
  4. Trans-border malaria: Mapping high-risk populations and targeting hotspots with novel intervention packages, Cambodia and Thailand: www.malariaconsortium.org/resources/publications/743/
  5. Targeting malaria infection and artemisinin resistance in formal/ informal border points, Cambodia-Laos border: www.malariaconsortium.org/resources/publications/620/
  6. Innovative Malaria M&E Research and Surveillance towards Elimination (MESA), Cambodia, Myanmar, Thailand: www.malariaconsortium.org/resources/publications/262/
  7. Moving towards malaria elimination: developing innovative tools for malaria surveillance, Cambodia: www.malariaconsortium.org/resources/publications/257/
  8. Transitional, Enhanced, Accessible Malaria Surveillance (TEAMS), Myanmar: www.malariaconsortium.org/resources/publications/975/
  9. Pioneer project 2009-2014: A holistic systems strengthening approach towards malaria control in mid-western Uganda: www.malariaconsortium.org/resources/publications/408/
  10. Beyond Garki: http://www.malariaconsortium.org/beyondgarki/

 

Related Links (journals and learning papers):

The time to invest is now: fighting malaria in the Sahel

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Children in sub-Saharan Africa are 14 times more likely to die before the age of five than those living elsewhere in the world. Preventable and treatable diseases, such as malaria, claim hundreds of thousands of lives each year.

Since 2014, leading players in malaria prevention have come together to deliver seasonal malaria chemoprevention (SMC) to children under five in the Sahel. SMC – a World Health Organization recommended intervention – is an antimalarial medicine given to children each month for up to four months of the rainy season, when 60 percent of malaria cases occur. It provides a high degree of protection, with about 90 percent efficacy and has the potential to reduce cases of malaria by 75 percent.

After concentrated efforts from the UNITAID funded ACCESS-SMC project, led by Malaria Consortium in partnership with Catholic Relief Services, and other organisations’ SMC programmes, roughly 12 million children received SMC in 2016. Over 6.4 million of those children were reached through ACCESS-SMC across seven countries[1].

Many children will still miss out on receiving SMC in 2017 though, due to lack of funding and production capacity for quality assured medicines used in SMC (SP+AQ). Nine million children in Nigeria alone, will remain unprotected this rainy season.

With areas in the Sahel having the highest incidence of malaria in the world, it is time to look towards reaching all 25 million eligible children. For less than $5, one child is protected with SMC each year. To support our continued efforts as a GiveWell Top Charity protecting all 25 million children in the Sahel from malaria visit http://www.givewell.org/charities/malaria-consortium.

 

[1] Burkina Faso, Chad, Guinea, Mali, Niger, Nigeria, The Gambia

Dr Sylvia Meek’s contribution to malaria elimination in Asia

It is with deep sorrow that Malaria Consortium must announce the passing of Dr Sylvia Meek, Malaria Consortium’s Global Technical Director, on 11th May 2016, after an 18-month battle with cancer.

Sylvia’s contribution to the fight against infectious disease, and malaria in particular, through her own, and Malaria Consortium’s work, cannot be overstated. From her ground-breaking work as an entomologist to her high-level policy work, she placed Asia in the epicentre of this fight.

Originating from Hull in Northeast England, Sylvia had a passion for the environment and disease control that led her to study Zoology at Oxford and later Animal Parasitology at the University College of North Wales, Bangor, followed by a PhD in mosquito genetics and control at the London School of Hygiene & Tropical Medicine and Liverpool School of Tropical Medicine. Her research at the London School laid some of the early foundations for current work on what are now termed ‘Wolbachia-infected mosquitoes’.

Sylvia as an entomologist
One of her dear friends, Dr Jeffrey Hii, Senior Vector Control Specialist at Malaria Consortium, remembers sharing a laboratory with Dr Sylvia Meek back in 1979-1980 when she was studying the inheritance of susceptibility to infection with Brugia pahangi and Wuchereria bancrofti in the Aedes scutellaris group of mosquitoes. These were the days before the advent of DNA sequencing techniques, so laboratory crosses were complex. Nevertheless, Sylvia was later able to show from these laboratory crosses that geographical isolation has probably been a very important factor in speciation within the Ae. scutellaris group (Meek, 1988).

During 1985 to 1989, Jeffrey and Sylvia’s paths crossed twice. “Firstly Sylvia joined our entomological team in the Bone-Dumoga forest reserve, in north Sulawesi  during the 1985 Project Wallace expedition organised by the Royal Entomological Society of London and Indonesian Institute of Sciences (LIPI),” he recalls. “She assisted in larval collections which led to the re-description of An. (Cellia) sulawesi Waktoedi, a hitherto incompletely described species.”

“We then met again in Chiang Mai where Sylvia informed me of her new job as World Health Organization (WHO) malaria adviser for the antimalarial programme in the Solomon Islands. We both participated at a WHO Special Programme for Research and Training in Tropical Diseases consultation on forest malaria in 1989 in Chiang Mai, Thailand. Sylvia’s presentation on forest malaria formed the basis of her landmark paper on ‘Vector control in some countries of Southeast Asia: comparing the vectors and the strategies’ (Meek 1995[1]).”

Throughout her career, Sylvia kept research close to her heart, contributing her expertise to shaping the various studies conducted in the Asia region.[2]

“During the past two years in Malaria Consortium, I have had the pleasure to work with Sylvia in research about ways to improve access to interventions that have been shown to work but have not reached many of the people who could benefit from them,” Jeffrey says.

Dr Sylvia Meek presenting at JITMM in Bangkok 2013

Dr Sylvia Meek presenting at JITMM in Bangkok, 2013 (© Malaria Consortium)

From research to helping refugees
Sylvia’s work with WHO took her around the world, during which time she gained the nickname ‘Mosquito Sylvia’. She also worked with the World Food Programme and the United Nations Development Programme, setting up and running disease control programmes for 200,000 refugees.

Dr Prudence Hamade, Malaria Consortium Senior Technical Advisor, another close friend and colleague describes this experience: “Sylvia worked in the refugee camps along the Thai-Cambodia border and although an entomologist she was soon diagnosing and treating malaria among the many patients there as well as doing her work and research into the entomology and providing protection for the refugees. During her stay there she had dengue at least a couple of times and has described to me how she lay on the floor of a hut with a high fever and had to get up and travel on the next day.”

Regional expertise and policy advice
Prudence continues, “She was instrumental in conducting the Cambodia malaria indicator surveys, the first of their kind in the Greater Mekong Subregion in 2004. In 2007 she supported both Thailand and Cambodia to develop their Global Fund bids and conducted Malaria Programme Reviews in Thailand and Myanmar to advise governments on how to improve their malaria programmes.

At WHO Technical Expert Group meetings, Sylvia provided well-thought logical arguments and brought the Asia view to the WHO Malaria Policy Advisory Committee (MPAC) which helped to drive some of the key policy changes related to malaria control and elimination in Asia. Through MPAC and drug resistance WHO regional meetings, Sylvia contributed to the recommendations of the treatment policies for Cambodia, a country particularly affected by multi- drug resistance. She was also an active member of the Emergency Response to Artemisinin Resistance (ERAR) in the Greater Mekong Subregion working groups.

“Sylvia’s impact on Malaria Consortium and our partners was, and continues to be, immense,” says Jeffrey. “She was an inspiration and everything we could ever admire in our profession and our personal lives. Sylvia’s values will be carried on by those she mentored, collaborated with and taught, and her inspiration has instilled a generation of malaria programme staff and entomologists in Solomon Islands, Greater Mekong Subregion, sub-Saharan Africa and elsewhere. She will be remembered for her subtle sense of humour, her enormously infectious curiosity and enthusiasm, her friendship and kind and generous nature.”

Dr Sylvia Meek surrounded by her colleagues at the Malaria Consortium Asia retreat 2015 in Thailand (© Malaria Consortium)

 

[1] Meek, S.R. (1995). ‘Vector control in some countries of Southeast Asia: comparing the vectors and the strategies’. Ann Trop Med Parasitol; 89: 135-147.

[2] Non exhaustive list of some of Dr Sylvia Meek’s recent publications:
Hustedt J, Canavati SE, Rang C, Ashton RA, Khim N, Berne L, Kim S, Sovannaroth S, Ly P, Ménard D, Cox J, Meek S, Roca-Feltrer A (2016). ‘Reactive case-detection of malaria in Pailin Province, Western Cambodia: lessons from a year-long evaluation in a pre-elimination setting’. Malaria Journal.

Edwards HE, Canavati SE, Rang C, Ly P, Sovannaroth S, Canier L, Khim N, Menard D, Ashton RA, Meek SR, and Roca-Feltrer A (2015). ‘Novel cross-border approaches to optimise identification of asymptomatic and artemisinin-resistant Plasmodium infection in mobile populations crossing Cambodian borders’. PLoS One.

Cox J, Dy Soley L, Bunkea T, Sovannaroth S, Soy Ty K, Ngak S, Bjorge S, Ringwald P, Mellor S, Sintasath D, Meek S (2014). ‘Evaluation of community-based systems for the surveillance of day three-positive Plasmodium falciparum cases in Western Cambodia’. Malaria Journal.

Meet the members of a community health committee in Inhambane Province of Mozambique

A facilitator of a community dialogue in Mozambique shows an illustration that demonstrates how to hang up an insecticide treated net.

Felismina lives in Inharrime, a region in southern Mozambique. She has been a member of her community’s health committee since 2013. “The committee meets twice a month: once with the whole community, and once with just the members of the committee. We talk a lot about hygiene – how to take care of latrines and keep your home clean so that people can stay healthy. We also discuss things like how to avoid getting malaria.”

The Ministry of Health has put community engagement at the forefront of its efforts to improve healthcare in remote areas for years. Given the high prevalence of malaria, pneumonia and other infectious diseases, they have encouraged the creation of these community health committees as a way to help spread awareness and offer a platform for discussion. Consisting of elected members, religious leaders and community health workers amongst others, these groups are promoted as an effective means of mobilising communities and getting them to talk about health problems and identify solutions.

“There are 15 regular members of our health committee,” says Adolfo Nhamize, who was elected president of the group. “I am responsible for leading our meetings. I make the reports and conduct dialogues with the community.”

Daimanhane Mausene, Secretary of the Health Committee (2)The committee’s secretary Daimanhane Mausene tells me what topics they cover at their meetings. “We discuss malaria, diarrhoea, pneumonia, HIV. We also educate women on pregnancy,” he says. “We sometimes go house to house and talk to people about the use of latrines, how to boil water so they don’t get sick, and how to take some medicines. Then we come back later and see if they are following our advice.”

Resources for these committees are often scarce, and the lack of attention they receive means that members do not always receive proper training. Malaria Consortium’s Rapid Access Expansion (RAcE) project began working with the committees in 2013 to address some of these obstacles and to apply participatory learning methods within communities. Our team worked with the committees to introduce the community dialogue approach in order to get communities talking. The dialogues focus on increasing demand for (and use of) health services available within the community as well as provide a platform for discussing health problems and identifying solutions. As part of the approach, community health workers and community leaders receive a two-day training to organise and lead the dialogues, using a repeatable 10-step process and focus on the three major childhood illnesses.

“We talk about all sorts of things during the dialogues,” says Felismina. “Sometimes we discuss mosquito nets, because some people don’t use them or don’t have them. Other times, people talk about diarrhoea because of the dirty water.”

“People used to complain a lot about getting malaria,” says Fernando Machapene, a religious leader and member of the committee. “So we told them to go to the hospital and take medicine.” Residents also talk about practical problems and put forward recommendations. “Some people said that we only had one community health workers serving five communities and that we needed more – maybe two or three.”

Community dialogue discussing malaria (54)When I arrived in Inharrime earlier that day, a community dialogue was taking place. The topic was malaria. Gathered under a tree, the health committee fielded questions, gave advice and walked around the group showing illustrations and other educational materials. These included pictures that showed how to effectively tuck in a mosquito net as well as other methods of protection. Unfortunately, the session was interrupted after about 30 minutes by a sudden and unexpected downpour. Some people ran home, while others huddled together under the tree in an attempt to stay dry. It was clear, however, that the dialogue could not continue.

Adolfo, a provincial coordinator of community health workers (called Agentes Polivalentes Elementares, or APEs in Portuguese) tells me that weather is not the only challenge that the health committee faces. “It is sometimes difficult to get people to come to the meetings,” he said. “People might not always show up. They will say that they have plans, or that they have to go to the field to work. One way we try to remind them is by having teachers tell their students, who then tell their parents when they get home.”

Despite these challenges, the community dialogue initiative has proved a good way to improve the community knowledge of some diseases and wrong behaviours. In his community, Daimanhane has also noticed some changes in behaviours. “They try to follow the advice we give them,” he says.

Check out the photo story below to learn more:

pA health committee in Inharrime Mozambique meets to discuss health problems facing the community Malaria Consortiumrsquos Rapid Access Expansion RAcE project began working with these health committees in order to get communities talking about health through an approach called community dialogues The project provides training and materials to help committees organise and carry out these dialoguesp
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Ilya Jones is the Communications Officer at Malaria Consortium

World Malaria Day in Bangladesh

 

In late April 2016, I spent World Malaria Day in Bangladesh after being invited by the Director of Communicable Disease Control, Dr Shamsuzzaman of the Ministry of Health and Family Welfare. Malaria Consortium has been providing technical assistance and funding support to the Bangladeshi organisation iccdr,b to conduct a study in the Chittagong Hill Tracts areas regarding perceptions of health services. In addition, we have recently been in discussions as to where Malaria Consortium could best support the efforts of the government to control malaria, dengue and other neglected tropical diseases, especially focused in the border areas where malaria elimination needs to be accelerated to avoid artemisinin resistance crossing the border from neighbouring Myanmar.

It was a great privilege to be invited by Dr Shamsuzzaman, and we were happy to partially fund the event by providing $3,000 – funds that went towards travel for key government officials, renting of the venue, refreshments and the printing of key malaria materials.

DSC00386It was a hot day in Chittagong, the second largest city in Bangladesh, with lots of people out and about on the streets for the World Malaria Day celebrations. Bands were playing and I participated in the parade and subsequent rally where indoor residual spraying was demonstrated. The slogan of the event was ‘end malaria now’, which was chanted from the crowd and by officials.

After the parade, a large crowd gathered for an outdoor meeting. There were several speeches about how there has been a great reduction in malaria in Bangladesh over the past several decades, with cases now confined mostly to border areas – particularly in the Chittagong Hill Tracts. Given this progress, the focus of the Ministry of Health and Family Welfare has become centred on eliminating malaria in the country.

DSC00420During the panel session of the rally, Malaria Consortium and BRAC – a Bangladeshi international development organisation – were the only two non-governmental organisations to speak. The Minister of Health made an appearance by Skype, and the Directors of Health and Family Planning were also present.

On behalf of Malaria Consortium, I presented the results of a research project in Bandarban that investigated the knowledge, attitudes and practices of community members, facility-based health workers and community health workers in relation to malaria and neglected tropical disease control. We are hoping to be able to work with the family planning division in Bangladesh to train peripheral level health workers to use rapid diagnostic tests for malaria and give out treatments to patients attending community clinics for primary health and antenatal care. We are also looking into possibilities that will allow us to expand into malaria, dengue and community-based care of childhood diseases.

I would also like to thank the icddr,b organisation in Bangladesh for supporting our visit on this important day.

Prudence Hamade is Malaria Consortium’s Senior Technical Advisor

Dressing for malaria: testing insecticide treated clothing

Copyright Malaria Consortium The arm-in-cage repellency test demonstrates mosquito landing and feeding activity on an untreated arm compared to an arm covered with a type of treated cloth.

According to the recent World Malaria Report 2015, around 234 million people are at high risk of malaria in Southeast Asia. The region accounted for 10 percent of global malaria cases and seven percent of deaths in 2015.

There are two types of malaria that cause the most concern in the region – and both can be deadly. Seventy-four percent of P. vivax malaria cases occur in Southeast Asia. P. falciparum resistance to artemisinin, the most effective treatment, is also of grave concern in the region and has now been detected in five countries in the Greater Mekong Subregion (GMS): Cambodia, Lao People’s Democratic Republic, Myanmar, Thailand and Vietnam.

Malaria can be transmitted by biting mosquitoes during indoor and outdoor activities. However, current malaria vector control policy relies almost entirely on methods that address indoor feeding and resting mosquitoes through indoor residual spraying and insecticide treated mosquito nets.  National malaria control programmes are finding that outdoor mosquitoes continue to pose a challenge to their efforts. Certain groups, such as night-time forest workers or migrant populations, are exposed to outdoor transmission on a daily basis.  Nightime activities such as working on rubber plantations or travelling to forested areas can increase the risk immensely. These groups are also less likely to know about malaria and often have less access to preventive measures.

Permethrin is a common synthetic chemical that is widely used as an insecticide for mosquito nets. However, it can also be applied to clothing and other materials and garments. The chemical is approved for use on mosquito nets and garments by the World Health Organization (WHO). Little is known about responses of mosquitoes to permethrin-treated clothing, and whether this intervention has a significant impact on disease transmission.

With funding from UK aid from the UK government, Malaria Consortium has been working together with the Department of Medical Entomology, Faculty of Tropical Medicine Mahidol University and arctec at the London School of Hygiene & Tropical Medicine, to conduct a collaborative study on the laboratory evaluation of permethrin-treated clothing for reducing contact between humans and mosquitoes.

An acceptability and preference study has already been carried out in rubber plantations in Myanmar[1]. Currently, the insecticide treated fabrics are being evaluated in laboratory experiments using WHO cone test bioassays and arm-in-cage repellency tests to determine the level of protection provided by different types of insecticide-treated clothing. Ultimately, the tests will indicate how effective the treated clothing will be in the short- to medium-term when worn by the rubber tappers. The results from the laboratory and acceptability studies will be used to inform decisions on the fabrics that are to be taken forward to a randomised controlled trial to reduce malaria incidence in populations working outdoors, or for dengue prevention.

The photos below show initial laboratory trials from the study. The test will be replicated with all randomly selected clothing, with results compared by an independent laboratory for validation.  It is expected that the outcome of this study will help us develop an effective method for the control of outdoor malaria transmission in Thailand and Myanmar. The results are expected early next year.

pThe armincage repellency test demonstrates mosquito landing and feeding activity on an untreated arm compared to an arm covered with a type of treated clothp
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[1] Crawshaw A, Maung TM, Kyaw MP, Tin MW, Sint N, Win AYN, Celhay O, Nicholas S, Roca-Feltrer, Shafique, Hii J. Acceptability and effectiveness of insecticide-treated clothing for prevention of outdoor malaria transmission among rubber tappers in Myanmar. Abstract oral presentation at the Joint International Tropical Medicine meeting 2015, 2-4 Dec 2015, Bangkok, Thailand.

Wanweena Tangsathianraphap is the External Communications Officer in Asia

Targeting mosquito larvae through Integrated Vector Management

Malaria Consortium is piloting a project on integrated vector management to assess the effectiveness of various control strategies to prevent the transmission of dengue. The study is being conducted in Kampong Cham province, Cambodia and is funded by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH commissioned by the Federal Ministry for Economic Cooperation and Development (BMZ) and UK aid from the UK government.

There has been a marked rise in dengue in the country during 2015. According to a recent  National Malaria Center report, health workers recorded 12,218 cases during the first 41 weeks of 2015. This is an increase of 9,284 compared to the same period in 2014.

Kampong Cham is one of the high-risk provinces, recording several dengue outbreaks in recent years. Cases can skyrocket, especially during the rainy season, where the environment provides mosquitos with more breeding sites and human movements play a major role in the spread of the disease.

Copyright Malaria Consortium

A sample adult mosquito was analysed in the laboratory. Species identification was made using a compound microscope.

“We have tripled the number of cases this year,” said Dr Hay Ra, Dengue Supervisor in Kampong Cham province. “So far, we have recorded 1,556 dengue cases including eight deaths. The most at-risk group is the population under age 15. The high density of population and climate change contributes substantially to these dengue epidemics. This area has high density of population of approximately 200 people per square metre. The rainy season also has changed – last year we had the rainy season start from April and last for seven months, while this year it started in July.”

“In this region the average flight distance for mosquitoes is about 100-200 metres,” explained John Hustedt, Malaria Consortium’s Senior Technical Officer who is leading the project. “In highly dense areas, mosquitoes can spread around the disease more widely as mosquitoes can bite more people in one area.”

At the health centre near the Ou Svay Commune, 20 of the 500 litre water jars containing various colourful guppy fish have been set up. Guppy fish have been used to reduce the mosquito larvae and this place is known by the village health volunteers as ‘the guppy fish bank’ where they can come to collect the guppy fish and provide it to the villagers. It has been under the supervision of the Health Centre Chief, Jeng Meng Hong. “We are responsible for two communes and 20 villages and each village has two health volunteers,” he explained. “So we have about 40 health volunteers who will visit our health centre and collect the fish. Each month, we have a monthly meeting to ensure all their assigned households have guppies in all large containers, and replace them if necessary.”

Copyright Malaria Consortium

Malaria Consortium’s staff inspected the number and condition of guppy fish in water jars at the village health volunteer household.

The fish collected from the guppy bank will be allocated to each household and released in their large water containers. It has been found in previous projects to be effective and acceptable by the local villagers.

Muchh Kounthea is one of the villagers who adopted the practice. The 56 year-old farmer has seven jars in her house, five of which contain the guppies. “I am fine with these fish. I just hope we do not have dengue in the village,” she said. Although she has never had dengue before, she knows about it and can recognise the period of dengue outbreaks. “Dengue usually occurs during rainy season around May to October. I know one child who got really sick because of dengue and had to seek the treatment at the private referral hospital.”

Although there is evidence suggesting the use of guppy fish can be beneficial in dengue vector control, no cluster randomised trials to evaluate their effectiveness nor a proper evaluation of their impact on adult mosquito densities have been conducted.

Copyright Malaria Consortium

Guppy fish are bred and nurtured at the guppy bank at the health centre.

To understand and evaluate the impact of a guppy fish and a combination of new vector control tools to sustainably reduce the Aedes mosquitoes, Malaria Consortium’s pilot project also implemented an entomological survey in the villages. In cooperation with the National Dengue Control Programme (NDCP), the entomological team was deployed to collect larvae, pupae, and adult mosquitoes from the targeted villages. All containers around selected houses were inspected and all samples were taken to the laboratory for further analyses. The survey received a lot of attention from the villagers.

At the same time, a survey on the knowledge, attitudes, and practices surrounding water use and vector-borne disease prevention was also conducted. This separate survey aims to guide and evaluate communication and behaviour change interventions to reduce dengue transmission.

Following the survey, training in behaviour change communication and health education was provided for the community health workers. The vector control intervention started in late November will last a year until the same period in 2016.

Copyright Malaria Consortium

Sample larvae and pupae were collected during the entomological survey.

Wanweena Tangsathianraphap is External Communications Officer for Asia

Laying the groundwork for a successful field evaluation of the pneumonia diagnostics project

Copyright Malaria Consortium VHT preparing to use the RR respiratory rate counter while being observed by the research team

As Programme Coordinator for Malaria Consortium’s pneumonia diagnostics project, I visited Uganda last week to see the preparations underway for the final stage of the project: the field evaluation. During three months, our teams will study the usability and acceptability of previously selected devices to find the best one for diagnosing pneumonia – a major killer of children under five in sub-Saharan Africa.

I recently attended a training conducted by three master trainers in Mpigi town where seven village health team members (VHTs) were learning how to assess the first pair of devices: a respiratory rate phone application called RRate and a pulse oximeter called UTECH. The training went very well, with six out of seven assessors passing with a 90 percent competency score. We will now continue to train all 25 assessors who will be participating in the study for the next three months.

Copyright Malaria Consortium

VHTs focused on the consent process as part of their training Mpigi.

I then joined the Malaria Consortium research team who were conducting assessments in the field with previously trained VHTs. This was to support the research team with on the ground training on conducting this element of the study and on providing supervision to the VHTs to ensure they were able to assess the diagnostic devices.

Copyright Malaria Consortium

VHT preparing to use the RR respiratory rate counter while being observed by the research team

As sensitisation of key audiences before the field evaluation activity is key to the success of this phase, this part of the project was very well planned and executed by the Ugandan team.

Firstly, the team held a pneumonia diagnostics sensitisation meeting with 40 heads of health centres in Mpigi district at the Health Centre IV in the town. The objective was to inform these key stakeholders of the project and ensure they understood why and how patients might come their way during the three-month field evaluation period.

After my presentation on the overall project aims and objectives, I  received interesting comments on inclusion criteria, the rationale for the study and on how pulse oximetry is an unknown tool in Uganda. The master trainers then demonstrated the devices and had good questions on the background for the study and how referrals would be handled. It was agreed that Malaria Consortium would provide an oxygen concentrator to Mpigi Health Centre IV to ensure oxygen would be available for any referred patients if required.

Copyright Malaria Consortium

A master trainer demonstrates a fingertip pulse oximeter to a health centre manager in Mpigi.

Copyright Malaria Consortium

A master trainer demonstrates a fingertip pulse oximeter to health centre managers in Mpigi

On the following day, I attended a sensitisation meeting of 20 district health officials, including the District Health Officer (DHO) and their assistants, at the Mpigi District Health Office where I presented on the project and the implications for the district. The DHO confirmed the need for the study and while expressing his gratitude for the support to date. All attendants were very interested to see the devices and were happy to hear Malaria Consortium had supported the Health Centre with an oxygen concentrator.

The field evaluation started in Mpigi district in October and will continue running during the months of November and December 2015. The dissemination of results on the usability and acceptability of the devices is planned for January and February 2016.

Kevin Baker is the Pneumonia Diagnostics Programme Coordinator

Field evaluation for pneumonia diagnostic tools kicks off in South Sudan

As Programme Coordinator for Malaria Consortium’s pneumonia diagnostics project, I visited South Sudan last month to oversee the start of field evaluations in the country. The field evaluation is the third phase of our pneumonia diagnostics project which works to find the best tool for diagnosing pneumonia – a major killer of children under five in sub-Saharan Africa. During this phase, our teams measure the accuracy of previously selected devices to make sure that they are up to the task of effectively assessing symptoms of pneumonia in children.

First, the team in South Sudan attended the training of six community drug distributors (CDDs) and one first level health facility worker in a hotel in Aweil.  The participants were trained on how to use a respiratory rate phone application called ‘RRate’ as well as the Masimo phone pulse oximeter, which measures oxygen saturation in the blood. All of those in attendance passed the tests and will now go on to participate in three months of data collection, using these devices in their everyday work – at home or in clinics.

Kevin Baker is Programme Coordinator for the Pneumonia Diagnostics project

pCommunity drug distributors CDDs attend training for the pneumonia diagnostics project in Aweil centre Participants were then given devices as well as solar chargers to allow them to charge their devices during the three months of data collectionp
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Presenting our pneumonia diagnostics work at the annual ASTMH meeting

Our pneumonia diagnostics team held a number of interesting sessions at the American Society of Tropical Medicine and Hygiene (ASTMH) in Philadelphia from 25-29 October, 2015. These sessions covered findings, challenges and lessons learnt over the past two years from our work on finding the best tools for diagnosing pneumonia – a major childhood killer in sub-Saharan Africa.

On Wednesday, the team presented two posters. The first went through our findings from the recently-completed ‘accuracy evaluation’ stage of the project, in which we assessed each tool in terms of how accurately it diagnosed pneumonia symptoms. This was the first time this data had been shared. The second poster gave an overview of the current ‘field evaluation’ activity, which evaluates the acceptability of the selected respiratory rate counters and pulse oximeters for frontline health workers.

On the evening of Wednesday October 28th, we held a side meeting at the conference to present on a number of topics.

We began the session by showing a film that outlined the current situation and specifically in Mulago Hospital in Uganda.

Dr Sylvia Meek, Malaria Consortium Technical Director, then gave a presentation that explained why pneumonia diagnostics was important to Malaria Consortium. She explained that because pneumonia remains the biggest infectious killer of children under five years, it is central to our mission to improve child health and builds on our work over the years in integrated community case management.

sylvia

Dr Karin Kallander, Senior Research Advisor, went on to present on the role of respiratory rate timers and pulse oximeters in the detection of pneumonia in children in remote settings.  Dr Kallander highlighted current activities and studies that are focused on developing and improving the management and treatment of pneumonia at the community level.

karin

As Programme Coordinator, I gave the final presentation on data from the accuracy evaluation that was recently conducted for nine devices. This was the first time we presented this data for the five selected pulse oximeters. During the presentation, I proved that community health workers can use a range of pulse oximeters on children to accurately detect the signs of severe pneumonia (defined as oxygen saturation less than 90 percent).  Three out of the five showed a mean difference of less than two percent, which was the agreed measure in this study. This means that these devices are considered to be accurate in the hands of community health workers when used to detect the signs of severe pneumonia. The results also showed that country differences are an important factor and need to be investigated further, in addition to further exploration of the different age strata in the study (0-60 days and 2-59 months), which performed differently (in general, devices were less accurate in the younger age strata).

We finished up with an interactive session where attendees had the opportunity to try out the devices for themselves. Participants found the devices easy to use and could see how they could be used at the community level.  This was followed by a discussion on the need for robust devices which had reliable and long-life, rechargeable batteries.

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