Fighting malaria in Mozambique — digital health, community engagement and collaborative partnership

Approx reading time: 4 mins

Mozambique has been in the news recently following arrests of senior officials and bankers in London, New York and Jo’burg on their alleged involvement with fraud and loan scandals, that led to a financial crisis in the impoverished country.

The country already has some of the highest debt-to-GDP ratio in the world, ranks high on the corruption index and among the bottom ten on the global human development index — leading to increasing and justified calls for the scandalous debts to be written-off by the creditors.

Health challenges for Mozambique are immense –

Mozambique has the highest burden of malaria in southern Africa, with over 8.5 million cases reported in 2016 and all provinces of the country are prone to high malaria transmission.

Nearly half of the population lives below the poverty lineand those in rural communities lack access to basic healthcare services contributing to excess morbidity and mortality.

Each year, over 80,000 children lose their lives before their fifth birthday — this accounts to one young life lost needlessly every six minutes — the time it’d take one to read this post.

Malaria, pneumonia and diarrhoea are attributable to over one third of under five deaths — common childhood illnesses that are easily preventable and treatable in similar settings elsewhere.

Maternal malaria and malnutrition are widespread, coupled with insufficient health infrastructure and low coverage of preventative services such as IPTp and immunisation, low exclusive breastfeeding rates and high childhood malnutrition — the odds of losing young lives remains very high.

Since 2005, Malaria Consortium has worked closely with the national ministry of health and partners, to help strengthen systems and improve access to life-saving services for children and communities, in particular at the last mile.

Visiting communities in Inhambane

Late last year, I visited the country to support colleagues and see for myself the impact we’re having on the lives of the most vulnerable across the country; and here’s what I found.

We are at the forefront of community and digital health work in the country — having developed and rolled-out with partners the mobile health app for community health workers (CHWs) over the past 10 years. The innovation enables CHWs, called the Agentes Polivalentes Elementares locally, to correctly diagnose and treat children with common childhood illnesses using the integrated community case management (iCCM) protocols.

Our flagship digital health intervention upSCALE consists of an interactive mobile phone app that guides CHWs through patient registration, routine health checks, diagnosis, treatment, referral and follow-up. The app automatically compiles CHW monthly reports for submission to supervisor online. A complementary CHW supervisor app supports two-way communication and feedback, while integration with the district health information system (DHIS2) enables easy visualisation of aggregated data.

Over the years, upSCALE has helped strengthen community service delivery in a low resource setting, significantly improved access to quality care at the last mile, improved availability of realtime data for monitoring, supervision and district planning. As a result, the government of Mozambique is planning to scale-up this evidence-based intervention across all CHWs and provinces over the next few years.

Adelia — one of the MC supported CHWs in Inhambane

One of our local health heroes, Adelia, is a single mother and committed CHW in Marange, Homoine district. She has been providing community health services over the past 8 years and sees around 300 cases pm. She was one of the first CHWs trained on the upSCALE mobile app and said that she finds it‘really helpful for correct case management and sharing health messages during home visits’.

Working closely with the national CHW programme and provincial health departments, upSCALE started with just 10 CHWs in Inhambane in 2009. Since 2016, the innovation has been scaled-up to 650 CHWs in all districts of Inhambane and Cabo Delgado provinces, and expected to increase to 2250 later this year with the addition of CHWs in Zambezia province.

Similarly, we are working closely with the national malaria control programme and partners to strengthen malaria surveillance across the country, contextualising strategies and interventions for the lower and higher transmission areas in south and north of the country respectively.

We recently completed a national landscape analysis and brought stakeholders together to identify and address bottlenecks in the national malaria surveillance system, and support the collaborative development of a Data-to-Action (D2A) framework to support progress towards malaria elimination by strengthening surveillance in Mozambique.

Awareness of childhood illnesses and health-seeking practices are low across rural communities and only about half of the young children are taken to a health worker for treatment of common illnesses. Nampula province in northern Mozambique has the highest burden of neglected tropical diseases (NTDs) in the country, with high co-endemicity of schistosomiasis, lymphatic filariasis and soil transmitted helminths.

Since 2014, we have worked closely with communities and local authorities in Nampula province using our innovative Community Dialogues approach to improve awareness, prevention and control of NTDs.

Working through community champions and facilitators across 600communities in 4 districts of the province, we have contributed to strengthen community engagement, ownership and capacity to overcome socio-cultural barriers for improved acceptance and uptake of NTDs prevention and control services in target communities.

Community facilitators leading on community dialogues session in Nampula province

Over the years, Malaria Consortium has worked to promote partnerships at community, district, provincial and national levels in Mozambique, collaborating with development partners, international agencies and local researchers such as the health research institute at Manhiça, generating credible evidence and learning that has informed policies and practices of governments and partners, both locally and globally.

Despite the widespread development challenges, Mozambique is blessed with immense resources, not just the minerals and spectacular landscapes, but the rich culture, cuisine and diversity of her people.

I returned greatly impressed with the ingenuity and resilience of the Mozambican people, who are striving to make a difference every day with limited resources — there is no doubt the country has the potential to make significant progress towards malaria elimination, improving health coverage and saving lives, if the current pace of progress is maintained over the coming years.

And it may be on the other side of the world, but I cannot wait to return soon!

Tackling antibiotic resistance – why it matters and how community dialogue can help

Approx reading time: 3 mins
The Community Dialogue approach enables community-based volunteers to host regular community meetings to explore how a health issue affects the community

Antibiotics are lifesavers – they are used to prevent and treat bacterial infections such as pneumonia, tuberculosis and urinary tract infections. However, the misuse of antibiotics in recent years has led to many strains of bacteria becoming resistant to this type of medicines, which means it is now more complex (and sometimes impossible) to treat infections caused by resistant “superbugs”. Unless we urgently change the way we use antibiotics, resistance will continue to spread globally, resulting in higher treatment costs, prolonged hospital stays and, ultimately, more people dying from bacterial infections. The worst case scenario would be a world where antibiotics are no longer effective and people die from common bacterial infections or minor accidents.

A recent report published by the Organisation for Economic Co-operation and Development (OECD) warns that in Europe, North America and Australia alone, 2.4 million people could die between 2015 and 2050 unless urgent action is taken to “stem the superbug tide”. The impact of antibiotic resistance is likely to be even more dramatic in low and middle-income countries, where health systems are weak and access to quality medicines is poorly regulated.

Tackling antibiotic resistance is not going to be an easy task. The development of new drugs and enabling healthcare providers to prescribe antibiotics only when needed will be important cornerstones of efforts to minimise resistant. However, a comprehensive approach will need to address many factors outside the traditional boundaries of the human health sector. For example, one of the ways to minimise the development of resistance is to prevent infections, which requires improvements in access to clean water, sanitation and hygiene. Another major contributor to the spread of resistance is the overuse of antibiotics in livestock and farmed fish, often to stimulate growth and prevent rather than cure infections. Scientists believe that resistant bacteria can spread through the food chain, but also through contaminated water and soils, for example through pollution from inadequate treatment of industrial, residential and farm waste. Because of the many interdependencies, the fight against antibiotic resistance is a prime example of the need to adopt a “One Health” approach – a coordinated, collaborative, multidisciplinary and cross-sectoral approach to improving health and wellbeing.

In November, the Call to Action on Antimicrobial Resistance was held in Accra, Ghana, which brought together policymakers, donors, civil society and researchers from a broad range of countries and backgrounds to discuss the global response to the most critical gaps in tackling the development and spread of drug-resistant infections. The event was co-hosted by the governments of Ghana, Thailand and the UK, with the United Nations Foundation, World Bank and Wellcome Trust and in partnership with the Interagency Coordination Group on Antimicrobial Resistance.

The first day of the event focused on highlighting the work of individuals and organisations taking pioneering action to tackle drug-resistant infections. Malaria Consortium was honoured to be chosen by the Wellcome Trust as one of two “Pioneers” identified through a competitive open call to showcase our work on Community Dialogue to address antibiotic resistance in Bangladesh. The project, a collaboration between the University of Leeds, ARK Foundation and Malaria Consortium, addresses a factor that is often overlooked: what the general public can do to minimise the spread of antibiotic resistance. For example, people should use antibiotics only when prescribed by a health professional, complete the full prescription, and never share antibiotics with friends and family. To bring about positive social and behaviour change among the general public, the project adopts the Community Dialogue Approach, which has been used by Malaria Consortium in different countries and for a range of other health issues. The approach involves enabling community-based volunteers to host regular community meetings to explore how a health issue affects the community, identify solutions to the problem and decide on how the community will address the issue. It builds on the assumption that public discussion and collective decision making will, over time, create a sense of ownership and affect the social norms that shape the behaviour of the wider community, not just those who actively participate in the meetings. In this project, 55 volunteers were trained in the catchment area of five Community Clinics, a total population of 30,000. Since May 2018, over 400 meetings have been held, each involving 40 community members on average. Evaluation of the project is ongoing, but preliminary findings are encouraging, with many participating reporting that they are now more mindful of using antibiotics appropriately.

Delegates at the Call to Action commended the community-level, bottom-up approach to tackling antibiotic resistance. Many were particularly impressed with how the project aimed to embed the approach within the existing health system and community structures to strengthen its sustainability, for example by linking the supervision of volunteers with the network of Community Clinics that provide basic health care in Bangladesh.

In the future, we would like to expand the approach to a larger area and to carry out a robust evaluation of its impact on behaviour. We also see an opportunity to embrace the One Health idea and include the promotion of positive behaviours concerning the use of antibiotics in livestock. Overall, we believe that the approach can be used to help communities to become “resistance fighters” and play a part in tackling the threat of antibiotic resistance.

Learn more

Read our implementation guide for the Community Dialogue Approach

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

Approx reading time: 3 mins

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

Dressing for malaria: testing insecticide treated clothing

Approx reading time: 2 mins
Copyright Malaria Consortium

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

Approx reading time: 4 mins

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.

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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.”

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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

Approx reading time: 3 mins
Copyright Malaria Consortium

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

Approx reading time: 1 min

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

Approx reading time: 2 mins

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.

testing

Reducing the risk of malaria in pregnancy in Uganda – observations from the field

Approx reading time: 3 mins

Alany and Majole are South Sudanese women living in refugee camps in West Nile province, Northern Uganda. Both are pregnant.

I met Alany and Majole as I travelled to a rural health facility, where they were attending their first antenatal care (ANC) visit.  The midwife sat with each of the women and gave them a basic health education lesson. Then there were the physical examinations, followed by the provision of required medicines for their stage of pregnancy – including intermittent preventive treatment in pregnancy (IPTp) to reduce the risk of malaria for themselves and their babies. Before they returned home under the shelter of their sun umbrella, they were each given a mosquito net to protect them further from malaria. These last two aspects of the ANC visit are especially important since pregnant women are at increased risk of malaria – as are their unborn babies.

Malaria in pregnancy (MIP) is a significant public health threat which affects more than 30 million pregnant women each year in malaria-endemic areas. It poses substantial risks to mother and unborn child, including maternal anaemia, stillbirth, miscarriage and low birth weight – a leading cause of child mortality. To prevent malaria infections among pregnant women living in areas of moderate or high transmission, the World Health Organization recommends IPTp, a full therapeutic course of antimalarial medicine given to pregnant women regardless of whether or not they are infected with malaria.

Uganda’s Malaria Control Strategic Plan identifies IPTp as one of three main elements to prevent MIP. It is delivered as part of the focused ANC package and has been implemented countrywide since 2002. Yet, despite having made significant progress, Uganda is far from meeting the government’s target of 85 percent of pregnant women receiving two doses of IPTp by the end of 2015. In 2014-15, less than half of pregnant women in Uganda received two or more doses of IPTp, despite overall one time ANC attendance being 94 percent in Uganda.

What we are doing about it

To explore the factors that continue to impede IPTp uptake, Malaria Consortium is leading a research project to assess and address barriers to pregnant women taking IPTp in Uganda. The study is conducted through COMDIS-HSD, a Research Programme Consortium, and also through our programme partnership arrangement  with funding from the UK government.

We discovered a range of barriers. In particular, health workers were found to have mixed knowledge of IPTp guidelines with regard to dosage, timing, and frequency. They did not always offer IPTp and encourage pregnant women to take it, at times incorrectly judging them to be ineligible.

Based on these findings, we designed a pilot intervention to align with the Ministry of Health training programme on MIP. This pilot intervention is being implemented in West Nile province, complementing the standard training course on MIP by sending daily reminder text messages for five weeks, summarising the key points relating to IPTp of the training. The intervention is being implemented in eight health facilities. A neighbouring district acts as control with a further eight health facilities receiving the training but not the text messages.

How things are progressing

With the text messages having been sent out in June and July, I travelled to Uganda to check up on progress and to gain a better understanding of the project sites. I also visited health facilities in the study districts to observe how things are managed and the processes involved in an ANC visit.  This will feed into the evaluation of the pilot intervention in December, which will also look at data on ANC attendance, IPTp doses, IPTp stock levels, as well as follow up with a random sample of pregnant women who visited the health facilities for their ANC visits.  In preparation for this evaluation, I looked at all of the ANC registers and other records in close detail. I met with health facility staff to ask questions about their ANC clinics – roughly how many pregnant women they see, and how many midwives they have. I also met with some of the midwives to discuss ANC services they provide, specifically relating to malaria.

The visit was a great opportunity to see the hard work going into protecting pregnant women from malaria in West Nile. The pregnant women who visit these clinics return home better equipped to protect themselves and their babies from malaria.

By observing visits and discussing with staff at the ANC clinics, I could see first-hand some of the challenges and barriers to uptake of IPTp and other malaria control measures. For example, some steps of the process are not completed as they should be; medicines which should be taken at the health facility and in front of the midwife are being given to women to take at home at a later time; and shortages of some medicines and of ANC cards have led to difficulties administering the drugs and making sure women attend all of their ANC appointments on the correct dates.

However these obstacles are not insurmountable – and with further study and appropriate action they can be overcome. Obstacles such as these which get in the way of pregnant women receiving the best possible prevention and treatment from malaria are the motivation for studies such as the IPTp study in Uganda, as well as our other work in sub-Saharan Africa and Southeast Asia.

Georgia Gore-Langton is the COMDIS-HSD Research Officer at Malaria Consortium in London.

Malaria is one of the ‘best buys’ in Global Health

Approx reading time: 1 min

Op-ed by Dr James Tibenderana, Malaria Consortium Development Director, on the launch of two new malaria strategies

At this week’s 3rd International Financing for Development meeting in Addis Ababa, the World Health Organization (WHO), along with the Roll Back Malaria (RBM) partnership present their 2015-2030 strategies during a financing for malaria side meeting.

Both strategies – WHO’s Global Technical Strategy for Malaria 2016-2030 (GTS) and RBM’s Action and Investment to defeat Malaria 2016-2030 (AIM) – for a malaria free world – will be shaping the future of health development by saving more than 10 million lives and averting nearly 3 billion cases worldwide. Together, these documents chart the investment and collective actions needed to reach the 2030 malaria goals and reach a malaria-free world.

Malaria Consortium, UK’s leading malaria NGO and a partner of RBM, made a significant contribution to the development of the GTS: through the WHO Malaria Policy Advisory Committee of which our Technical Director Dr Sylvia Meek is a member, by sharing its technical expertise into online consultations and by translating evidence and learning of our work into practical advice for the strategy.

I am delighted to see both strategies highlight the huge health and economic benefits that result from investing in eliminating malaria while demonstrating malaria is one of the ‘best buys’ in Global Health. Meeting the 2030 malaria targets will generate more than US $4 trillion of additional economic output across the 2016-2030 timeframe.

Though the world has made dramatic progress – malaria mortality rates have decreased by 54 percent in Africa, much remains to be done. Nearly 300 million people in sub-Saharan Africa still lack access to a protective insecticide-treated net, and at least 15 million pregnant women do not receive the protective treatment they need to keep themselves and their unborn child healthy. Each year, malaria costs the African continent an estimated minimum of US $12 billion in lost productivity.

History demonstrates that maintaining gains made fighting malaria are dependant on sufficient and sustained investment. Since the 1930s, there have been 75 documented resurgences of malaria reported in 61 countries, the majority linked to reduced or suspended funding for malaria programmes.

We therefore call on governments, donors and partners to continue to work together – within and between sectors and across borders.

I am proud to see today’s event marks a milestone in global health history and the start of a new era in development.

Dr James Tibenderana, Malaria Consortium Development Director