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Saving lives and transforming communities in rural Nigeria

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Originally published on Medium

Lessons from the field

In the village of Njediko in Nigeria, Kadigiti Mohammad gently calms her young son, who has a high fever. Her son is being seen by the village community health worker, who confirms it is malaria. He is given medicine before mother and child are sent back home.

I met Kadigiti on a recent visit to Njediko where Malaria Consortium is supporting the Rapid Access Expansion (RAcE) programme in Nigeria. She was worried for her child, but assured that he would recover because he was able to get medication quickly.

It was during this visit when I saw what receiving immediate access to care meant for mothers like Kadigiti and how this transformed the communities they live in.

Reaching the most remote populations

The RAcE programme was launched in Nigeria in 2013, pioneering the implementation of integrated community case management (iCCM) in the country. iCCM is now being scaled-up to increase healthcare access through trained community health workers who can treat pneumonia, diarrhoea, malaria and malnutrition among children at community level.

In Niger State, Malaria Consortium is implementing iCCM in underserved communities in six local government areas. The two communities that I visited, Njediko and Etsu Gudu, were among some of the hardest-to-reach.

The walk downhill to the village of Etsu Gudu (left) / A river blocks the road to a remote community in the local government area of Rafi (right)

 

The journey into these communities involved a two hour drive from the capital of Niger State. The roads were mostly rough and occasionally blocked by small rivers. Another hour travelling along narrow dirt roads led into the communities. Come nightfall, the roads were pitch black.

I thought of Kadigiti having to carry her sick child in these conditions. It was clear that urgent action was needed to reach out to populations who cannot easily access a health centre.

Bringing healthcare closer to the home

Typically, in many remote communities in rural Nigeria, access to healthcare is made difficult as there are no nearby health centres.

Mothers would carry their sick child, often on foot, to the closest health centre which can be miles away and can sometimes take days. During the rainy months, the roads and footpaths can become impassable. Sometimes, upon reaching the health centre, medicines may not be readily available.

One mother who lost a child from malaria said, “if we had immediate access to care and medicine then, my child could have had a chance to survive”.

Such was the challenge mothers faced in Njediko and Etsu Gudu until iCCM was introduced. Today, mothers like Kadigiti no longer need to travel far. Instead, they can immediately take their sick child to a community health worker.

This means that unnecessary deaths are prevented, as children can be treated for pneumonia, diarrhoea and malaria right in their village.

Empowering communities

Community health workers are trained, supervised and equipped to provide free and timely treatment of malaria, pneumonia and diarrhoea. And because they are selected by their own community and live in the community they serve, they have become a valuable resource in remote and rural villages that otherwise have no means of accessing healthcare.

The community health workers I met were hardworking, proud of what they do, and deeply committed to the health of their people.

In Ndejiku and Etsu Gudu, village leaders and parents talked about how their community health workers helped improve the health of their children and how they no longer face the burden of the cost of healthcare and making the long journey to a hospital.

Across the community, this appreciation is shown in extraordinary ways.

“When I am treating children all day, the people bring me firewood and help me with the farming,” says Miriam, community health worker in Etsu Gudu.

“The community raised money collectively to build me a house, so I can continue doing my work,” says Muhammed, the community health worker in Njediko.

Miriam Mohammed, community health worker in Etsu Gudu prepares to test a young child for pneunonia using a respiratory rate timer (left) / Community health worker Mohammed Jiya stands in front of the house his community built for him in Njediko (right)

An effective and sustainable solution

In Niger state, results from the RAcE programme show that iCCM is an effective and sustainable approach to decreasing childhood mortality.* At community-level, one way for iCCM to become sustainable is community support for community health workers.

In Njediko and Etsu Gudu, I saw evidence of all these. I saw progress in reduced child deaths, as a result of access to life-saving health services in rural and remote areas.

But I also saw people owning their own health, community leaders advocating for the health of their people, and communities coming together to sustain the health services they now have.

The community of Njediko, where child deaths have significantly reduced since the introduction of iCCM

Portia Reyes is Publications Manager at Malaria Consortium. She recently visited communities in Niger state as part of a project to document the impact of iCCM. Malaria Consortium is working with the Ministry of Health and partners in Niger state to implement iCCM through the RAcE programme.

View our latest film, Saving lives and transforming communities, to learn more about our work on iCCM in Nigeria

The Rapid Access Expansion (RAcE) programme is funded by the Government of Canada through the World Health Organization to support the scale-up of iCCM in five malaria-endemic countries in sub-Saharan Africa.

More from Malaria Consortium

Malaria Consortium in Nigeria: reflections from a new Trustee

Malaria’s Consortium’s approach to community delivery

Malaria Consortium’s RaCE project: Implementing iCCM in Nigeria

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

Projects in pictures: Trans-border malaria programme Cambodia

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In Cambodia, malaria infection is highest in border regions and among mobile and migrant populations who often live in remote parts of the country, work in forests or travel through endemic areas. The remoteness and mobility of these communities often means they have poor or infrequent access to health care which can lead to malaria cases going undetected and untreated. In other situations, people seeking treatment do so at unregistered private providers, leading to unreported malaria cases and unknown and possibly unsuitable case management practices.

Malaria Consortium’s Trans-border Malaria Programme, in partnership with the Raks Thai Foundation and Population Services Khmer, is strengthening early malaria detection and treatment services and surveillance activities in Thailand and Cambodia.

This programme is being funded by the Global Fund to fight Aids, Tuberculosis and Malaria.

pIn the northern Cambodia Malaria Consortiumnbsphas trained and hired 21 mobile malaria workers to detect hotspots of malaria transmission and to identify people who are at risk of malaria infectionp
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Photos: Luke Duggleby/Malaria Consortium

ACCESS-SMC: Smoothing the road to the prevention of malaria

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ACCESS-SMC is a three-year UNITAID-funded project, led by Malaria Consortium in partnership with Catholic Relief Services, which is supporting National Malaria Control Programs to scale up access to seasonal malaria chemoprevention (SMC) to save children’s lives across seven countries in the Sahel. By demonstrating the feasibility and impact of SMC at scale, ACCESS-SMC will promote the intervention’s wider adoption. This case study highlights the impact SMC has had in the fight against malaria. Malaria can be prevented- in the Sahel, SMC can play a crucial role.

“If we succeed in further reducing malaria we can begin to reallocate the budget for treatment of malaria to other development matters. We need to carry on.” – Dr. Smaïla Ouedraogo, Minister of Health for Burkina Faso at the SMC Implementation Meeting (February 13th, 2017)

At the end of 2016, ACCESS-SMC had successfully administered seasonal malaria chemoprevention (SMC) to approximately 6.4 million children in seven countries. In the Sahel, where malaria incidence increases with the rainy season, there are 25 million children who can benefit from this life-saving treatment. Three years before the project began the World Health Organization (WHO) issued policy recommendations on SMC as an effective tool to prevent malaria in children (3-59 months). However, before the first ACCESS-SMC campaign in 2015 less than 4 percent of eligible children had benefited from this intervention.

Countries in the Sahel have a shortage of skilled health workers, and simply making antimalarial medicines available does not automatically ensure success. This is why ACCESS-SMC has been working closely with National Malaria Control Programs to effectively train community health workers (CHWs) on how to deliver, administer and begin dialogues around SMC. By delivering basic preventative health services to remote populations, CHWs improve access to and coverage of rural communities in low-income countries.

Family out in the fields farming

Agriculture is the primary economic activity in Burkina Faso. During the rainy summer months, when many families are out in the fields cultivating their crops, CHWs play a crucial role in protecting young children from malaria. They have to work extra hard to make sure every eligible child is reached. In the small rural town of Ziniaré, Jules Ouedraogo works long hours going door-to-door during the four distribution cycles, administering SMC to 45-55 different children each day. “Because the rainy season coincides with the period of farming, we are often obliged to join them in the fields when they are absent at home, or sometimes we go back to the homes at night when parents and children have returned from the fields. We will go to homes, fields, churches, markets; wherever there are children.”

Compaore Zenabo, a mother and fruit merchant, has two children under the age of five. Her children used to fall sick regularly, especially during the rainy season, but since her children began receiving SMC they have not had malaria and income once spent on malaria treatment is now saved. As a working mother, CHWs have made it easy so she does not have to choose between earning income for her family or the health

Health worker explaining the benefits of SMC

of her children. “They come to us and give medicines to our children. When they do not find us at home, they make the effort to come back or join us at our workplaces. Really, we are pleased with the work of the community distributors.”

Delivery of SMC is complicated by the inaccessibility of villages, made even more convoluted with heavy rains flooding roads. Undeterred by the weather, when roads are flooded CHWs either attempt to cross them with boats or canoes, or wait for the water level to reduce. Their relentless efforts resulted in a 45 percent decrease in the number of malaria cases in children under five after the first campaign in 2015, and over 1.3 million children were protected by SMC during the 2016 campaign.

Patrice Ouibga is a health worker at Ziniaré Urban Health and Social Promotion Center. Before the project began it was normal to treat 800-1,000 cases of malaria a month during the rainy season. “By 2016, this number has dropped considerably and parents are very happy. We now have fewer than 100 cases per month during the rainy season. We hope in the future Malaria Consortium can sustain SMC and extend it to other areas not yet covered to save the lives of many children.”

This success story was prepared by Malaria Consortium thanks to funding from UNITAID under the ACCESS-SMC project. The views expressed here do not necessarily reflect those of UNITAID.

© Malaria Consortium. Published July 2017

Photo credits: Malaria Consortium/Susan Schulman

For more information visit www.unitaid.org and www.access-smc.org

Trained volunteers improve their communities’ health service in rural Myanmar

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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.

Delivering nets at the last mile: success through promoting a culture of net use

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In February and March 2017, USAID’s Malaria Action Program for Districts distributed one million long-lasting insecticidal nets to 1,978,114 people in three districts in Uganda. A focus on promoting positive behavior change on net use led to the successful delivery of the campaign.

Background

In the three districts of Arua, Koboko and Nebbi in West Nile region, malaria, like in most parts of Uganda, is a serious public health problem. In these three disctrict, which has a population of over 1.5 million, over 700,000 confirmed or suspected malaria cases were reported to public health facilities in 2016.  
USAID’s Malaria Action Program for Districts conducted a long-lasting insecticidal net (LLIN) distribution campaign in February and March 2017 as part of its objectives to increase the impact and reach of malaria prevention services. The project took a four-step approach in conducting the LLIN distribution campaign: 1) community sensitization 2) a community-led registration of households, 3) data-entry and verification, and 4) community-led distribution. During community sensitization, emphasis was placed on social behavior change communication (SBCC) to reach all targeted communities with relevant and effective messages on use of LLINs.

Promoting a Culture of Net Use

Prior to household registration, the project team convened a regional advocacy meeting in Arua district with local leaders from the three districts. These included district health officers, resident district commissioners, district health team, chief administrative officers and local council V chairpersons. Local leaders’ understanding of malaria prevention and their engagement in promoting positive behavior towards malaria prevention was key to the campaign’s success.
During this meeting, the project team shared malaria prevention strategies and messages to the local leaders who would then share these with their own communities.
The leaders committed to promoting a culture of net use, highlighting that a significant change in mindset and behavior towards prevention can lead to a ‘malaria-free world’. They shared a vision of a malaria-free district – where communities would have higher levels of productivity, due to less money lost on treating malaria and more time spent on income-generating activities. Leaders also raised the need for adequate community-led mobilization for household registration and subsequent LLINs collection, as well as working with the local wanaichi to create a net use culture.

Successes and Impact

The high turnout of community members can be attributed to effective community-led mobilization and the malaria messages that promoted positive prevention behaviors such as net use. In Nebbi district, for example, leaders indicated that sensitizing the community before the distribution was key to its success:

“… you will realise on the day of distribution that there is going to be high turnout of community members […] this has been shown in registration after the community’s sensitisation by political leaders and other stakeholders. When you look at the registration, you feel very happy that these people have been sensitised. The registration was 100 percent. Everybody registered because they understood why the nets are being distributed to them. So this has been a very big achievement.”
– Olweku Fred Jibril, Secretary for Social Services, Nebbi district

The campaign in the three districts reached 98 percent of households registered during the pre-campaign registration. At the wave one review meeting, district supervisors in the three West Nile districts reported that 91 percent of the population was sleeping under a net.

The net distribution campaign was welcomed by the community members and health workers alike:

“…On behalf of my people, we are very happy for this service, in fact, we have been having problems of malaria [for a long time], and case numbers had become so high that we could not manage with the current drugs in the hospitals. So I think with this, it is going to improve our health.”
– Achong Emmanuel, area LCI Oufa Village, Aiivu sub county

“The reason I have come for the net is because we have so many mosquitoes and there is a high rate of malaria, as we are along the river. The mosquitoes are very many. Without nets, there is no sleep here…”
– Net recipient, Rhino Camp

Lessons and Next Steps

Community involvement is instrumental in ensuring a well-supported distribution and to achieve a high proportion of immediate net uptake and sustained use of nets. An SBCC approach before the net distribution campaign allowed community leaders and members to be engaged in education around malaria prevention.
Building on these successes, USAID’s Malaria Action Program for Districts will continue to run an SBCC campaign to create a culture of net use through a community-led approach for promoting the correct and consistent use of nets which is supported by local council leaders.

Download the Success Story in PDF format here.

Nigerian retail mosquito net market grows thanks to UK Aid

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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

Chimbonila: A district committed to fighting malaria

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The district of Chimbonila in Niassa province has a high malaria burden, which can be difficult to manage for a number of reasons.

The district itself is very large. It is located about 30 km from the city of Lichinga and covers an area of ​​8,075 km² with a population of about 87,000 inhabitants. Despite its proximity to the capital city, however, Chimbonila has the typical challenges of the other districts of Niassa: poor roads and high poverty rates, as well as a remote, mostly rural population which relies on an economy based on agriculture (population density of 15.8 inhabitants per km²).

Since 2014, the National Malaria Control Programme of the Ministry of Health and its partners (World Vision and Malaria Consortium) with funding from the Global Fund, has been implementing the Malaria Prevention and Control Project within local communities.

The project in Chimbonila District involves 22 community structures, 428 volunteers, 23 schools, 72 teachers, 14 health facilities and one community radio in a continuous effort coordinated by Health, Women and Social District Services to ensure the prevention and treatment of malaria.

Since 2014, Gabriela Nazaré has been the Malaria Consortium Field Officer assigned to this district. Her role is to coordinate the activities of all project stakeholders, ranging from health facilities to community volunteers.

Every day Gabriela visits the villages by motorcycle, ensuring that all project’s participants have the necessary tools for mobilisation work and that they have a correct understanding about how to prevent malaria and that they know what to do in the occurrence of malaria symptoms.

After three years as Field Officer, Gabriela feels integrated in the community: “I was born and raised in Lichinga. I moved to Chimbonila to work and today I feel at home. Despite the complexity of the job, knowing that I am contributing to the improvement of people’s living conditions is rewarding.”

Rain or shine, her activities don’t stop. Owing to the large number of beneficiaries, her schedule is very busy. “I try to spend as much time as possible in each community. My routine in each village is to visit schools, health facilities and work with community structures.

“Over the years we have been establishing work mechanisms and today it is amazing how communities are engaged in the project in such a way that they now bring in their own initiatives and suggestions for new approaches.”

 

Text and photos: Xavier Machiana

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

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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.