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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.

Expert Q&A: No one size fits all in the pursuit of the best pneumonia diagnostic aids

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Malaria Consortium Senior Project Officer, Charlotte Ward, speaks about pneumonia as a global priority issue, how we are attempting to tackle the disease and explore the future of diagnostic devices.

Pneumonia is an acute respiratory infection that affects the lungs and is responsible for 16 percent[1] of deaths of all children under five. This proportion is much higher in low-resource countries where access to healthcare is limited, particularly in South Asia and sub-Saharan Africa.

Yet despite being the single largest infectious cause of death in children worldwide, pneumonia can be diagnosed and treated with low-cost and simple interventions and medication.

 

What are the current challenges in diagnosing and treating pneumonia?

Diagnosis of pneumonia by community health workers (CHWs) is commonly based on counting the number of breaths in 60 seconds in children under five to assess whether the respiratory rate (RR) is higher than the normal parameters for a child of that age. However, manually counting RR can be challenging due to the difficulties in observing and counting chest movements for a full minute and keeping the child calm during this period. Therefore, misclassification of observed rate is common, leading to incorrect diagnosis and consequently inappropriate antibiotic treatment, contributing to the spread of antibiotic resistance.

 What different types of devices are currently being used?

Non-automated devices, assisted RR counting devices and pulse oximeters are currently being used. Non-automated devices are the lowest cost and most commonly used tools. They support manual counting of chest movements by indicating when to start and stop counting. Assisted counting RR devices automate the counting process thus negating the need for manual counting. An example is a mobile RR smartphone app that works by counting the number of times the CHW taps the screen for each chest movement. Pulse oximeters work by measuring the blood oxygen saturation levels in the patient. Three types of pulse oximeters exist: handheld, mobile and finger-tip pulse oximeters.

How do we evaluate the best devices?

Formative research to understand the best class of devices is critical before designing and implementing a device field trial. An example of formative research is pile sorting and accompanying focus group discussions with key stakeholders. Pile sorting is when you ask key stakeholders to sort word, item or picture cards into piles that classify a range of opinions or categories of interest and then capture and explore participants’ decision-making rationale for their sorting using a focus group discussion. In this case, stakeholders including representatives of national and regional Ministry of Health (MoH), regional health bureaus, multilateral organisations such as UNICEF, and relevant NGO staff, would be demonstrated device types and asked to place cards with various device names into different piles according to their perceived usability, and again for their perceived scalability. Devices are then scored based on how they are sorted and those with the highest scores may be carried forward for field testing.

 What challenges will there be in designing appropriate diagnostic aids?

A major challenge is designing appropriate diagnostic aids that appeal to a wide range of stakeholders with differing views and priorities. CHWs and national and regional stakeholders prioritise different characteristics when rating the potential scalability of aids. For example, CHWs emphasise the importance of aids being acceptable to CHWs, parents and caregivers more than national stakeholders who prioritise the need for cost-effectiveness and sustainability. Practical usability is also heavily prioritised by CHWs whereas NGO and MoH stakeholders are strongly invested in ensuring the supply and distribution processes are uncomplicated and inexpensive. Further considerations are whether the device can be used in remote areas with unreliable electricity source, how much training is required to use the device and how durable the device is.

 What are future directions?

Device development is a complex process and the challenges in appealing to a wide range of stakeholders mean that a ‘one size fits all’ approach is unfeasible. However, there is global momentum towards developing automated devices that count RR without the need for human intervention. It is hoped that such devices will offer improved accuracy and effectiveness compared to current practice for classifying the symptoms of pneumonia, therefore improving the treatment of patients at community level. Furthermore, automated devices have the potential to increase caregiver and patient confidence in CHWs, thus strengthening programmes of integrated management of new-born and child health at community level in low-resource settings.

Projects that Malaria Consortium has undertaken on pneumonia

 Related resources:

Charlotte Ward is a Senior Project Officer here at Malaria Consortium. She is currently focussed on the ARIDA project, which is working to bring automated respiratory rate counting aids to wide-scale use by frontline health care workers in resource limited community settings.

 

[1] http://www.who.int/mediacentre/factsheets/fs331/en/

Distribution of LLINs in Niassa Province: mission accomplished

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After a year of intensive work, Niassa Province in Mozambique, an area with a high malaria incidence rate, has successfully completed its mass long-lasting insecticidal net (LLIN) distribution campaign in its 16 districts.

The Malaria Prevention and Control Project is part of the Universal Coverage Campaign (UCC),  a national initiative led by the Ministry of Health.  It is funded by the Global Fund, and implemented by World Vision as the recipient partner, with Malaria Consortium, Food for the Hungry and Community Development Foundation as secondary recipients.

The UCC aims to ensure that every Mozambican has access to a LLIN to protect themselves from malaria. In Niassa Province, the campaign has reached approximately 415,000 households in the 16 target districts, amounting to a total of 1,058,750 LLINs. Niassa Province covers an extensive area of ​​approximately 123,000 km², with around nine inhabitants per km² in some of the more remote areas.  Access roads are lacking and most are not tarred, which renders the UCC implementation a complex process.

To overcome these challenges and to meet the high demand, the campaign was cascaded down from the central level, on to the provincial level, and finally expanded to the districts, towns and villages. In a combined effort of thousands of people involved.  The local government, the Provincial Health Directorate, District Directorates, support teams, trainers, distributors, registrators and different service providers were all critical to the success of the mass distribution.

According to Dr. Inês Juleca, focal point of the National Malaria Control Programme of the Ministry of Health of Mozambique for the province of Niassa, “The distribution of LLINs is an activity that includes several steps and high-quality coordination, from the consultation of guiding documents, planning, procurement, transportation and packaging, to communication, engagement, mobilisation, training, population registration and distribution itself.”

In this process, the National Malaria Control Programme is responsible for the acquisition of LLINs and led overall planning and implementation through the decentralised structures of the health system. Malaria Consortium is responsible for operational support, which includes financial management, transport, logistics, training, management of service providers, efficient use of resources and effective coordination at provincial, district and field levels.

On the challenges encountered on the ground, Joaquim Chau, Interim Coordinator of the Malaria Consortium in Niassa province, says: “The challenge of coordinating processes is largely to achieve the commitment of all those involved, even with different procedures or practices, sensitivities and institutional hierarchies, to bring together an understanding of the common vision of what is to be achieved. This makes a difference in the process, and in the professional and individual expectations of all the actors involved.”

With the successful completion of the distribution, the team is planning a post-distribution campaign that will focus on effective messaging about the correct use of LLINs. Highlighting the importance of the post-distribution campaign, Dr. Juleca stated: “Malaria prevention does not end with distribution of mosquito nets. We are ensuring that, after the distribution phase, our beneficiaries are knowledgeable about the use of nets and that this process is effectively translated into behaviour change.”

By Xavier Machiana

Mozambique’s unrecognised malaria heroes

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Throughout Mozambique’s Niassa Province thousands of unassuming community members have given up their time to improve community health by volunteering in the distribution of long lasting insecticidal nets (LLINs).

 

The campaign, which is distributing over one million LLINs to 480,000 families in April and May is being organised by the Provincial Health Directorate, District and Community Leadership, civil society organisations, World Vision and Malaria Consortium under the leadership of the Provincial Government of Niassa.

So far, over 3,500 men and women from different ages and backgrounds have volunteered in the campaign, which has been crucial to the organisers efforts to reach all families in the province.

 

These malaria heroes have overcome many hurdles including inaccessibility due to lack of roads. They have walked on foot with bundles of nets on their heads and backs where their vehicles could no longer go. They took boats and canoes to reach remote villages on the islands of Lake Niassa. They have used motorcycles, tractors and all possible means to carry out their work, including crossing dangerous areas, such as Niassa Reserve, which is inhabited by many wild animals.

Community volunteers are essential to the success of many health campaigns. See our #MalariaHeroes webpage and support community health volunteers around the world.

The campaign is part of a national initiative led by the Ministry of Health with the support of the Malaria Prevention and Control Project, a project funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria, and implemented by World Vision as the main partner,  Food for the Hungry, Community Development Foundation and Malaria Consortium.