Author Archives: Marian Blondeel

Trained volunteers improve their communities’ health service in rural Myanmar

During a one-year pilot project in Myanmar’s western Sagaing region, malaria volunteers from 90 selected communities received continuous training on how to diagnose and treat three of the top child killing diseases (malaria, pneumonia and diarrhoea) and screen for malnutrition, an approach called integrated community case management (iCCM). The communities were selected because of their remoteness, lack of government health staff, the relatively high numbers of malaria and high rates of children under five with pneumonia and diarrhoea.

Malaria volunteers undergo refresher training in Kalay District

Malaria Consortium organised the first training of trainers in June 2016, under the leadership of the Ministry of Health and Sports, with monthly refresher trainings since January 2017.

Township health staff and the regional malaria control programme team were trained to become master trainers. These master trainers then cascaded their knowledge down to the malaria volunteers and their supervisors (midwives and health assistants). They taught the volunteers how to diagnose and treat malaria, pneumonia and diarrhoea and how to screen for malnutrition and midwives and health assistants how to supervise the volunteers practising the iCCM approach.

Malaria Consortium and the master trainers worked closely together to define the content and organise refresher trainings for malaria volunteers. “We learnt from each other,” Dr Moe Myint Oo, Malaria Consortium Myanmar Programme Manager said. “Every month, we analysed patient registers and supervision reports and gaps were addressed at the next month’s training. Particular malaria volunteers with weaker skills would receive more attention during the supervision and training.”

U Phone Myint Kyaw at a monthly supervision visit to Mandar village malaria volunteer U Kyaw Zin Lin

The malaria volunteers were already part of an existing network established by the Ministry of Health and Sports. Thanks to the training, the volunteers have now successfully demonstrated they can take on additional skills to improve the health services in their communities for malaria, pneumonia, diarrhoea and malnutrition. With new skills added to their duties, malaria volunteers remain an important asset to their remote communities.

U Phone Myint Kyaw, health assistant for Mandar village confirmed this, “Our malaria volunteer can treat simple pneumonia and diarrhoea and refer a serious case to the nearest health centre, he learnt to count a child’s breathing rate, prescribe antibiotics properly and record the data. Thanks to the timely treatment and referral, under five mortality can be reduced.”

The pilot’s success is reflected in a grant Malaria Consortium recently won from Comic Relief and GSK which will continue to support the populations of Sagaing region. The project will cover three additional townships (Kathar, Wuntho and Kawlin) for the next two years.

Funding for the pilot came from Vitol Foundation and UK Aid from the UK Government.

Nigerian retail mosquito net market grows thanks to UK Aid

When Malaria Consortium started activities in Nigeria through the UK Aid-funded Support to National Malaria Programme (SuNMaP) in 2008, one of this programme’s key activities focused on expanding the retail market for antimalarial commodities to ensure a steady supply of drugs, rapid diagnostics test kits and long lasting insecticidal nets (LLINs).

To achieve universal LLIN coverage, SuNMaP supported Nigeria’s approach of using multiple channels to distribute them into households. The programme also adopted and implemented a ‘total market approach’ when developing the LLIN market, combining LLIN distribution through all channels – private, public and communities – to drive one single market.

Throughout SuNMaP’s eight years of implementation, this approach was fine-tuned into ‘making markets work for the poor’ (M4P), contributing to Malaria Consortium’s role and reputation as a facilitator. M4P meant that the programme’s support to the commercial (retail) sector was complementing the national continuous net distribution campaign. This minimised the gradual decline in number of nets in households that received them through routine channels, such as ante-natal clinics, and free mass campaigns.

“This approach confirmed our belief that we need all channels – private, public and communities – working well together before you can achieve universal coverage,” said Dr Kolawole Maxwell, Malaria Consortium Nigeria Country Director.
During SuNMaP, Malaria Consortium continuously checked the market, carrying out biannual surveys on people’s malaria prevention practices, and retail outlet surveys on which nets were being sold, price and shape/colour preferences. All net manufacturers received the findings from these surveys.

“By sharing this evidence with everyone, Malaria Consortium kept its position as an objective player. We just wanted the market to grow,” Dr Maxwell explained. “We also helped distributors bring costs down by holding campaigns to boost Nigerians’ awareness of the importance of buying and using mosquito nets. This naturally resulted in increased retail sales.”

When Malaria Consortium received a two-year extension for SuNMaP from UK Aid, the organisation was able to apply one of the key lessons learnt from the previous years of operation: that manufacturers’ support is crucial for developing the local LLIN market. However, the common held belief was that this type of tailored retail market, with its regular leaks, would not interest an investor. Nor would manufacturers want to make nets of a specific shape or colour, despite these preferences being demonstrated by the SuNMaP’s surveys; they would feel demand was too small for their production lines.

Malaria Consortium Nigeria decided to send out a letter to net manufacturers regardless, encouraging them to take a chance on the local market. A turning point was reached when one company came back and accepted the challenge – TANA Netting.
Through SuNMaP Malaria Consortium helped to facilitate TANA Netting’s partnership with the public and private sectors, from the National Malaria Elimination Programme of the Federal Ministry of Health and the Ministry of Finance to local cutting, sewing, packaging and brand companies (Rosies Textile Industries and Prezzo Medicals).

SuNMaP ended in 2016, but the strategy has paid off. Earlier this year, the Nigerian Minister for Health unveiled the first LLINs made in Nigeria by TANA netting on World Malaria Day. Now TANA Netting is planning to produce nets for the retail market and once its capacity is up and running, it will be easier to produce different shaped and coloured nets to meet those specific preferences.
“We are delighted. The driving force of SuNMaP and its partners, we have successfully engaged the private sector, provided them with the right capacity building and support and now they are getting on with it. This is sustainability in action!” Dr Maxwell concluded.

 

Interview by Marian Blondeel

Two experts discuss how to defeat dengue in the Asia Pacific region

This interview was originally published on Break Dengue.

What is dengue and how does it spread?
Sergio Lopes, Malaria Consortium Cambodia Country Technical Coordinator: Dengue is a disease caused by a virus (DENV) that is transmitted through the bite of the Aedes mosquito (sometimes called Tiger mosquito due to its striped black and white appearance). Mosquitoes bite infected individuals and, when later biting another non-infected person, transmit the disease. Aedes mosquitoes have been adapting quite well to human environments, particularly cities and peri-urban environments, which has also contributed to the quick spread of dengue.

Why is dengue a priority issue?
Dr Rabindra Romauld Abeyasinghe, Coordinator, Malaria, other Vectorborne and Parasitic Diseases Unit, Division of Communicable Diseases, World Health Organization, Manila Regional Office: Dengue is a priority issue for governments in the Asia Pacific Region, as explosive outbreaks affect thousands of people. For communities dengue is a priority because of the high morbidity rates (often affecting several members of the same family) or even the loss of loved ones. Many countries in this part of the world are also concerned about the high incidence of dengue reported, because the disease affects work performance, school attendance, tourism and their economies.

Secondly, dengue has recently become a higher priority for most governments in the region, because it is transmitted by Aedes mosquitoes, the same species of Aedes mosquito that also transmits Zika virus disease and chikungunya. Therefore, the urgency to control dengue and these other diseases has become increasingly important.

How can we prevent and treat dengue?
Dr Rabindra Romauld Abeyasinghe: Dengue is caused by four different viral serotypes, which makes it very difficult to control as a single person may experience up to four episodes of dengue during their lifetime. In addition to this, there is a lack of specific treatment and effective vaccine. The only available vaccine, which is currently registered in several countries of the region, is not 100 percent effective and requires multiple doses. It is also recommended for use in children aged nine years and above who have had previous exposure to dengue and, as such, some of the most vulnerable cannot be protected with it.

So for now, prevention through sustainable reductions in Aedes mosquito densities remains the key method. The main interventions for dengue prevention are the reduction of the mosquitoes through vector control and increasing awareness in at-risk communities.

In the Asia Pacific region, the World Health Organization (WHO) is advocating a new approach to vector control, encouraging countries to move away from the previously practiced approach of reacting to dengue outbreaks with vector control because Aedes mosquitoes are transmitting multiple diseases. WHO now recommends countries adopt the new, proactive approach to routinely reduce Aedes mosquito densities in communities, irrespective of whether they are experiencing a dengue outbreak or not. They should reduce breeding opportunities for dengue mosquitoes through sustainable and environmentally-friendly methods and limit large-scale insecticide use for managing outbreaks. The new approach, while being environmentally-friendly, will also contribute to managing insecticide resistance in Aedes mosquito populations.

Regular routine vector control activities that are owned and carried out by empowered communities themselves, with guidance from Ministries of Health, will help to mitigate the challenge posed by dengue and other arboviral diseases. We know that dengue mosquitoes breed in containers, so controlling dengue is about managing where and how we store water, especially in those places where water tends to collect in and around the houses in our communities.

WHO also advocates raising community awareness on the limitations of treatment of dengue and, therefore, the need for early treatment seeking and proper diagnosis. People who are aware that there is dengue in their communities should be encouraged to get themselves tested in good time, seek early treatment and follow medical advice. This can prevent the development of severe forms of dengue.

What are the challenges involved in tackling dengue?
Dr Rabindra Romauld Abeyasinghe: The biggest challenge to tackling dengue effectively is the fact that many people who get dengue aren’t even aware of it, as they have mild symptoms or don’t show any symptoms at all. So in the case of a dengue outbreak, many people in the community are actually carrying the virus and therefore infecting mosquitoes that bite them. This situation makes controlling dengue extremely difficult because people continue to infect the mosquitoes and increase the pool of infected mosquitoes capable of transmitting the disease.

The other challenge is posed by the nature of the disease: only about 10 percent of the people infected actually experience signs of severe disease or are sick enough to interrupt their normal behaviour. People tend to travel with the virus, allowing for dengue to spread very fast within and across countries because these Aedes mosquitoes inhabit all Asia Pacific countries.

The only way to overcome this challenge is to reduce the mosquito density. This will reduce the number of people getting infected and thereby decrease the probability of the disease spreading further.

How is Malaria Consortium contributing to the fight against dengue?
Sergio Lopes: Malaria Consortium has been generating evidence on potential strategies to control dengue in Southeast Asia. There is no treatment for dengue and current treatment is solely symptomatic. Because there is no 100 percent effective vaccine at the moment, most efforts to control dengue rely on reducing the adult mosquito population to prevent infections and train health workers on case management to prevent poor health outcomes when a person gets dengue.
Malaria Consortium has been supporting research and development/adaptation of clinical guidelines for dengue in order to ensure good training to health staff managing the disease. Malaria Consortium trained 100 health workers in four townships in regions with high dengue burden in Yangon and Ayearwaddy, Myanmar.

Regarding vector control, Malaria Consortium has been developing cutting edge research to find alternatives for current vector control strategies. Since mosquitoes (Aedes in particular) are quite prone to developing resistance to available insecticides, Malaria Consortium has tested biological alternatives, such as larvae eating guppy fish, that can work at scale and support an effective reduction in Aedes mosquitoes. This strategy proved to be quite successful and well-accepted by communities affected by dengue.

Malaria Consortium is continuing to investigate alternatives for dengue control and is currently starting a new trial to understand how effective the engagement of school children, parents and teachers can be in supporting vector control activities.

 

How does dengue management differ from malaria management?
Sergio Lopes: The main difference is related to mosquito behaviour. While the malaria mosquito (Anopheles) bites mostly during night, the dengue mosquito (Aedes) bites in the daytime. The use of long lasting insecticidal nets, one of the main tools for malaria control, therefore has limited value in dengue control. This means new control approaches need to be found, which prevent people from being bitten during the day.

Another significant difference relates to the mosquito’s preferred habitat. While Anopheles is mostly a rural mosquito, the mosquito responsible for transmitting dengue has demonstrated an increasing capacity to adapt and survive in urban environments. This makes vector control more challenging, as it requires full integration of several sectors to ensure proper vector control measures are put in place. Megacities and their peri-urban environments are the perfect place for Aedes mosquitoes to thrive since they have multiple artificial containers (gutters, sewage systems, flowers pots, etc.) which can be breeding sites, but which are difficult to target through conventional vector control measures.

Can you talk about the importance of surveillance in dengue management?
Dr Rabindra Romauld Abeyasinghe: When we talk about surveillance, we need to mention two areas: surveillance of both dengue patients and of the mosquitoes.
Surveillance of dengue patients depends on the actual screening or testing of patients to confirm the presence of dengue infection. Given the nature of this disease and the fact that is concentrated in urban areas, many people seek treatment from private practitioners or private clinics. This data doesn’t usually get captured in government surveillance systems and is an issue we need to address.

The second area relates to the surveillance of the mosquitoes: the fluctuation in mosquito density, where and when they breed is important information for implementing control activities. We need sufficient data to target the mosquito breeding sites effectively.

Can you talk about the importance of vector control?
Dr Rabindra Romauld Abeyasinghe: It is clear that even with a 100 percent effective dengue vaccine, we still need to focus on vector control to manage the Aedes mosquito densities and the other diseases they transmit, such as Zika virus disease and chikungunya. So effective vector control will not only contribute to effective control of dengue, but should also prevent possible Zika virus and chikungunya outbreaks.

The recent endorsement of the Global Vector Control Response 2017-2030 at the World Health Assembly highlights the need for a clear shift in focus toward a proactive approach to controlling Aedes mosquitoes.

Can you talk about the importance of community-based initiatives?
Sergio Lopes: Regardless of the environment we are talking about (rural, urban or peri-urban), communities play a central role in fighting dengue. Informed communities who are aware of how dengue is transmitted and how it can be prevented will be more determined to participate in community-based interventions that protect their families and contribute to the wellbeing of their communities. In some places, the community is the only available resource to tackle dengue. As we proved in our recent trial with the guppy fish, communities are highly motivated and engaged in dengue control activities when they understand the interventions’ benefits.

However, the greatest benefit of community-based initiatives is that they are born within the community and owned by them. This is the first step to ensuring total ownership of dengue control strategies and ensure long-term implementation.

Malaria volunteer makes health care in “Elephant” village count

Myanmar MV

Malaria volunteer, Ma May Theint Oo

Ma May Theint Oo, mother of a four-year old boy called My Myo Thit Naing, has been working as a malaria volunteer in Sin village – which means elephant in Burmese – for six years now. At the weekends she attends Kalay University to finish her degree in history before she turns 25 next year.

To mark World Health Worker Week, this article takes a look at the lifesaving role that health workers such as Ma play in their communities.

riverMa’s village is located 24 miles from Kalay, in western Myanmar’s Sagaing region. To reach the nearest health centre, members of her community must travel seven miles, crossing a river by boat and travelling the rest of the way in often extremely high temperatures. In remote rural villages where road conditions are extremely bad, this lack of access to vital health services can prove fatal for children under five, as receiving care in the first 24 hours after onset of symptoms is crucial. Even if they survive, the recovery may be significantly longer, leading to more time for the child out of school and the parent off from work. Malaria Consortium has been piloting an approach called iCCM, or integrated community case management. This approach combines diagnosis and treatment of three common childhood illnesses malaria, diarrhoea, pneumonia, while adding diagnosis for malnutrition, and brings health care to the villagers’ doorsteps.

Malaria volunteers such as Ma can bring prevention, diagnosis and treatments services into the heart of remote communities such as Sin, and thereby act as a link between their village and the official health system.

The network of malaria volunteers in remote rural communities was established by the Ministry of health and Sports to help to prevent, track, diagnose and treat malaria cases. By building on this existing network and adding new iCCM responsibilities to the volunteer’s work, Ma can now treat more illnesses besides malaria, which is becoming less prevalent, and thereby remain  useful to her community.

midwife2

Midwife Daw Yi Yi Aung

Providing iCCM training for the volunteers and their supervisors – health assistants and midwives – is crucial for the success of the project. The training for the volunteers focuses on how to diagnose malaria, diarrhoea, pneumonia and malnutrition, how to administer treatments, and in severe cases, how to refer patients to health centres for acute care.

“I learnt how to treat common illnesses such as diarrhoea and fever and I can now give the right treatment. I also know how to accurately count the child’s breathing rate and to organise a follow-up visit. If the illness is severe, I can refer to the hospital,” Ma explains.

Midwife Daw Yi Yi Aung from the nearest rural health centre supervises Ma and helps her to correct any mistakes. “I truly believe Ma can be successful in her work. One of the mothers told me that she’s very satisfied because her child can get immediate treatment and she doesn’t need to cross the river anymore.”

The supervision is of great help to Ma. “At first I didn’t understand the medicines and their use, but now I am confident I can use them correctly.”

Thanks to her additional iCCM responsibilities, Ma’s status within Sin village has been given a boost. “The parents trust and rely on me and come to me for quick treatment so they are very grateful,” she smiles.

The project is a pilot to demonstrate the feasibility of re-training malaria volunteers to deliver iCCM, and initial results are promising. The project has been successful in improving the health of vulnerable and children under five, and reducing the time spent travelling to seek health services.

familySpeaking of the project, Ma said, “Now parents don’t need to travel as often to the hospital. This is very expensive for people with financial problems. I can give care and medicines to the villagers at no cost thanks to the project.”

When asked about her own future she replies, “I would like to find government work as a teacher, alongside my volunteer’s responsibilities, to continue sorting the difficulties of my community members and provide them with health services.”

The iCCM project is funded by UK aid from the UK Government and Vitol Foundation.

MC in the news: Dengue

Last week Malaria Consortium Myanmar was in the news with a story about dengue. We worked with Oliver Slow, a journalist to talk about our work and the dengue situation in the country.

The story “The dreaded dengue on the rise” was published in Frontier Myanmar print and online newspaper, an “unbiased voice in transitional Myanmar”

The number of reported cases is rising and more countries are being affected, but dengue fever remains one of the most neglected tropical diseases.

For Ko Yan Naing Soe, 18, it started with a high fever. Thinking it was nothing serious, he didn’t seek medical advice.

“But after four days of a constant high fever, my family took me to the township hospital where I was diagnosed with dengue fever,” Yan Naing Soe, who was 13 at the time, told Frontier.

The township hospital did not have the facilities to perform the necessary blood transfusions, so he was transferred to a children’s hospital in Dagon Township.

“It was quite serious for a while, but after about a week I returned to normal and was released after 10 days. It was lucky they diagnosed it early,” he said.

Although rare, in extreme cases dengue can lead to death.

Last year saw a surge in dengue fever cases worldwide. In Myanmar, 43,845 cases and 140 deaths were reported, of which 135 were children under 14, World Health Organization figures show.

“Dengue cases were reported from all States and Regions, among which Sagaing, Ayeyarwaddy and Mandalay had the highest cases reported,” a WHO spokesperson told Frontier.

In 2016, there has been no reported dengue outbreak. To the end of August 1,505 cases had been reported, including 30 deaths, the spokesperson said.

Dengue is transmitted by female Aedes aegypti mosquitoes (the same species that transmits Zika, yellow fever and chikungunya). Female mosquitoes do not actually feed on human blood for their own nutritional purposes; the protein is needed to produce eggs. So really they’re just being good mothers – something to think about the next time you swat at a mosquito buzzing around your ear.

One of the first recorded cases of dengue was noted by a founding father of the United States, Benjamin Rush, who wrote of “bone-break fever” in As It Appeared in Philadelphia, in the Summer and Autumn of the Year 1780 – a book title that doesn’t exactly roll off the tongue.

The Aedes mosquito was wiped out in Central and South America in the 1950s and 1960s, but it would later return. No such eradication was ever achieved in Asia.

“A severe form of haemorrhagic fever, most likely akin to DHF [dengue haemorrhagic fever, a severe form of the disease], emerged in some Asian countries following World War II,” according to a WHO handout on the disease.

Before 1970, only nine countries had experienced severe dengue epidemics, but that has since grown to more than 100 nations worldwide. Southeast Asia is one of the most severely affected regions, together with the Americas and Western Pacific, according to the WHO.

The UN agency’s figures show that cases in the three regions exceeded 1.2 million in 2008 and over 3.2 million in 2015. “Recently the number of reported cases has continued to increase,” WHO said.

“Countries across Southeast Asia are seeing increased prevalence [in dengue],” said Dr Prudence Hamade, senior technical adviser for Malaria Consortium. “Factors include the migration of people, global warming and increased urbanisation.”

She told Frontier that poor living conditions, including a lack of access to clean water and poor sewage disposal, were fertile feeding grounds for mosquitoes and created “ideal conditions” for the spread of dengue in cities.

A major challenge in diagnosing dengue is the similarity in symptoms with other diseases including malaria and Zika, the latter of which has seen its first cases in Southeast Asia in recent weeks. Symptoms for dengue include high fever, severe headaches, joint and muscle pains, and rashes.

In late 2015 and early this year, the first dengue vaccine, Dengyvaxia, was registered for use in people between nine and 45 years of age in endemic countries.

“Some countries are already deploying it, however it is only partially effective in preventing the disease and only useful in patients nine years and older,” said Dr Hamade. Some of the most vulnerable to death from the disease are young children.

“The most effective way to remove the threat of dengue is to control the mosquitoes that spread the disease. It is therefore important to monitor the presence of these mosquitoes and, if found, to take measures to remove them,” she said.

Measures include being active in looking for mosquitoes, removing breeding sites (mosquitoes can breed in a bottle-cap of water) and protecting from mosquito bites during the day.

A major difficulty in combating dengue is that the Aedes mosquito is active during the day, meaning that mosquito nets are not as effective and outdoor workers are more vulnerable, said Dr Jeffrey Hii, senior vector specialist for Malaria Consortium Asia. His organisation is looking into insecticide-treated clothing for people who work outdoors.

Malaria Consortium is also advocating for more funding for dengue programs worldwide. The organisation argues that while malaria programs receive significant attention and funding, those related to the control of dengue are “seriously underfunded”.

Dengue is classified as one of the 17 recognised neglected tropical diseases, which are typically related to poverty, endemic to the tropics and have poor research funding.

“However, even within NTD circles, it has often been further neglected,” said Dr Hii. It was not one of the 10 NTDs selected by the London Declaration in 2012 as a priority disease to be eradicated.

“There has been a major lack of investment in dengue prevention and control, which has also been mirrored by a lack of policy dialogue within the international community and among governments,” said Dr Hii.

“While remarkable progress has been made against the majority of these 10 NTDs … we have not seen the same high-profile announcements or a commitment to tracking data and progress for dengue. Simply put, it is neglected.”