CSGP Technical Reference Materials - K4Health 2009.doc · Web viewMalaria is a “reemerging ......

UNITED STATES AGENCY FOR INTERNATIONAL DEVELOPMENTBUREAU FOR GLOBAL HEALTH

OFFICE OF HEALTH, DISEASE, AND NUTRITION USAID/GH/HIDN

CHILD SURVIVAL AND HEALTH GRANTS PROGRAM (CSHGP)

TECHNICAL REFERENCETECHNICAL REFERENCE MATERIALSMATERIALS

20092009

MALARIA

USAID/GH/HIDN/Child Survival and Health Grants Program—TRM—MALARIA—2009 i

MCHIP is funded by the United States Agency for International Development, Bureau for Global Health’s Office of Health, Infectious Diseases and Nutrition, Cooperative Agreement # GHS-A-00-08-00002-000

USAID/GH/HIDN/Child Survival and Health Grants Program—TRM—MALARIA— 2009 ii

For further information on the Maternal and Child Health Integrated Program (MCHIP), please contact:Macro International, 11785 Beltsville Drive, Calverton, Maryland 20705(301) 572-0823 ● Email: [email protected] ●Internet: www.childsurvival.com

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http://www.childsurvival.com/

mailto:[email protected]

Table of Contents

Abbreviations and Acronyms................................................................................iv

Introduction to the Technical Reference Materials..........................................viiiNew Additions to the Malaria Module:..................................................................................................................ix

Malaria...................................................................................................................10Introduction.........................................................................................................10Strategic approach...............................................................................................11Getting started: Assessment and Situation Analysis...........................................12

Core Population Coverage Indicators for ROLL BACK MALARIA....................................................................13Malaria Standard Case Management..................................................................14

Community and Household...................................................................................................................................14Health Facility......................................................................................................................................................16Health System and Monitoring Drug Resistance..................................................................................................17

Prevention and Treatment of Malaria in Pregnant Women................................19Intermittent Preventive Treatment........................................................................................................................20Use of insecticide-treated nets..............................................................................................................................21Prompt diagnosis and case management of malaria illness during pregnancy...................................................22Community and Household...................................................................................................................................23Health Facility......................................................................................................................................................24Health System........................................................................................................................................................25

Insecticide-Treated Nets.....................................................................................26Community and Household...................................................................................................................................28Facility and Health System...................................................................................................................................29

Environmental Approaches.................................................................................31Indoor Residual Spraying...................................................................................32Going to Scale.....................................................................................................34

References and Resources.....................................................................................35Introduction.........................................................................................................35Suggested sources for baseline information.......................................................36Suggested URL bookmarks for further reading..................................................38Other useful sources:..........................................................................................42

Annexes...................................................................................................................44Annex 1...............................................................................................................44

Indicators of Population Coverage for RBM Technical Strategies......................................................................44PMI Indicators......................................................................................................................................................44

Annex 2...............................................................................................................45Malaria treatment guideline..............................................................................................................................45WHO Recommendations on Malaria Treatment...........................................................................................45

Annex 3...............................................................................................................47Prompt Treatment — Article by Jane Crawley.....................................................................................................47

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Annex 4 –............................................................................................................52Intervention Strategies for Pregnant Women According to Transmission Intensity............................................52

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Abbreviations and Acronyms

ACT Artemisinin-based Combination TherapyAFP Acute Flaccid ParalysisAI Appreciative InquiryAIDS Acquired Immuno-Deficiency SyndromeAMTSL Active Management of the Third Stage of LaborANC Antenatal Clinic - Antenatal CareARI Acute Respiratory Infection ART Antiretroviral therapyARVs Antiretroviral drugsBCG Bacille Calmette-GuerinBCI Behavior Change InterventionsBHR Bureau for Humanitarian ResponseCA Collaborating AgencyCBD Community-Based DistributorCDC Centers for Disease Control and PreventionCDD Control of Diarrheal DiseaseCHW Community Health WorkerCORPS Community Oriented Resource PersonsCQ ChloroquineCSHGP Child Survival and Health Grant ProgramCSTS+ Child Survival Technical SupportCYP Couple-Years of ProtectionDHS Demographic and Health SurveyDIP Detailed Implementation PlanDOSA Discussion-Oriented Self-AssessmentDOT Directly Observed Therapy/Direct Observation of Treatment or TherapyDOTS Internationally recommended strategy for TB control consisting of 5 components

(originally Directly Observed Therapy, Short-course, although current DOTS strategy is much broader now than these two concepts)

DPT Diphtheria-Pertussis-TetanusDST Drug susceptibility testing DTP Diphtheria-Tetanus-Pertussis vaccine [N.B. International terminology has now

shifted so that the convention is to use DTP rather than DPT.]EBF Exclusive BreastfeedingEMNC Essential Maternal and Newborn CareEmOC Emergency Obstetric CareEOC Essential Obstetric CareEPI Expanded Program on ImmunizationFE Final EvaluationFANC Focused Ante Natal CareFP Family Planning

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GAVI Global Alliance for Vaccines and ImmunizationGDF Global Drug FacilityGEM Global Excellence in ManagementGFATM Global Fund for AIDS, Tuberculosis, and MalariaGIVS Global Immunization Vision and StrategyGLC Green Light CommitteeGMAP Global Malaria Action PlanHB Hepatitis BHI Hygiene ImprovementHib Haemophilus influenzae type bHIF Hygiene Improvement FrameworkHFA Health Facility AssessmentHIS Health Information SystemHIV Human Immuno-deficiency VirusHQ HeadquartersHR Human ResourcesID Intravenous DrugIEC Information, Education and CommunicationIMCI Integrated Management of Childhood IllnessesIMPAC Integrated Management of Pregnancy and ChildbirthIPT Intermittent Preventive Treatment IPTc Intermittent Preventive Treatment in childrenIPTi Intermittent Preventive Treatment in infantsIPTp Intermittent Preventive Treatment in pregnancyIR Intermediate ResultsIRS Indoor Residual SprayingISA Institutional Strengths AssessmentITM Insecticide-Treated Material ITN Insecticide-Treated NetsIUATLD International Union Against Tuberculosis and Lung DiseasesIUD Intrauterine DeviceKPC Knowledge, Practice, and Coverage SurveyLAM Lactational Amenorrhea MethodLBW Low Birth WeightLLIN Long-lasting Insecticidal NetLQAS Lot Quality Assurance SamplingM&E Monitoring and EvaluationMCE Multi-Country EvaluationMCH Mother and Child HealthMCP Malaria Communities ProgramMDR-TB Multidrug-Resistant Tuberculosis (resistance to at least rifampin and isoniazid)MIS Management Information SystemMNHP Maternal Neonatal Health Program

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MOH Ministry of HealthMPS Making Pregnancy SaferMTCT Mother-to-Child TransmissionMTCT/HIV Mother-to-Child Transmission of HIVMTE Mid-Term EvaluationNACP National AIDS Control ProgramNGO Non-Governmental OrganizationNIDS National Immunization DaysNMCP National Malaria Control ProgramsNMR Neonatal Mortality RateNTP National Tuberculosis ProgramOPV Oral Polio VaccineOR Operations ResearchORT Oral Rehydration TherapyPAHO Pan American Health OrganizationPEPFAR President’s Emergency Plan for Aids ReliefPHC Primary Health CarePLA Participatory Learning and ActionPMI President’s Malaria InitiativePMTCT Prevention of Mother-to-Child TransmissionPVC Office of Private and Voluntary CooperationPVO Private Voluntary OrganizationQA Quality AssuranceQI Quality ImprovementRED Reaching Every DistrictRBM Roll Back MalariaRDT Rapid Diagnostic TestRFA Request for ApplicationsRTI Reproductive Tract InfectionSBA Skilled Birth AttendanceSCM Standard Case ManagementSDM Standard Days MethodSIAs • Supplementary Immunization ActivitiesSNL Saving Newborn Lives InitiativeSP Sulfadoxine-PyrimethamineSTD Sexually Transmitted DiseaseSTI Sexually Transmitted InfectionTB TuberculosisTBA Traditional Birth AttendantTd combination of Tetanus toxoid and a reduced dosage of diphtheriaTRM Technical Reference MaterialsTT Tetanus ToxoidUSAID United States Agency for International Development

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VA Vitamin AVAD Vitamin A DeficiencyVCT Voluntary Counseling and TestingVVM Vaccine Vial MonitorWHO World Health OrganizationWHOPES WHO Pesticide Evaluation SchemeWRA Women of Reproductive Age

Caretaker: An individual who has primary responsibility for the care of a child. Usually, it is the child’s mother, but could also be his or her father, grandparent, older sibling, or other member of the community.

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Introduction to the Technical Reference Materials

The Technical Reference Materials (TRMs) are a product of the Bureau for Global Health, Office of Health, Infectious Disease, and Nutrition USAID/GH/HIDN. This document is a guide (not an authority) to help you think through your ability and needs in choosing to implement any one technical area of the Child Survival and Health Grants Program. An attempt has been made to keep the language simple to encourage translation for use as a field document.

The TRMs are organized into modules that correspond to the primary technical areas and key cross-cutting areas that are central to the Child Survival and Health Grants Program. Each module is designed to reflect the essential elements to be considered when implementing the given intervention or strategy, important resources that grantees should consult when planning their interventions. Grantees are encouraged to download the specific modules that are most relevant to their proposed programs, or to download the entire package of TRM modules as a zipped file. The TRMs presently include the following modules:

Technical Areas

● Family Planning and Reproductive Health● Maternal and Newborn Care● Nutrition and Micronutrients● Immunization● Pneumonia● Diarrheal Disease Prevention and Control● Malaria● Tuberculosis● Childhood Injury and Prevention

Cross-cutting Areas

● Capacity Building● Sustainability● Program and Supply Management● Behavior Change Interventions● Quality Assurance● Monitoring and Evaluation ● Integrated Management of Childhood Illness (IMCI)

● Health System Strengthening

The present TRMs are regularly reviewed and updated with input from technical specialists in the USAID Collaborating Agency (CA) community, CORE Group Working Groups, and USAID technical staff. The date of revision of each specific TRM module can be found at the bottom of each page of the module. The TRMs are updated regularly to ensure that they remain up to date and reflect current standards relevant, and useful to the PVO community. With this in mind, we ask that each user of this document over the next year please keep notes and inform us on the usefulness of these references, information that should be amended or changed, additions and subtractions, and general comments. This will help us keep this document alive and responsive to your needs throughout the life of your programs. Please share comments and any (electronic) translated copies with Michel Pacqué at MCHIP, [email protected].

The 2009 edition was coordinated by Michel Pacqué, MCHIP, who is grateful for the many contributions and reviews by staff of the different Offices of the Bureau of Global Health, and many of their collaborating agencies, the CORE Group working groups and most of all to our PVO partners who continue to use this guide and provide valuable insight on how to improve it.

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New Additions to the Malaria Module:

The 2009 edition of the Malaria TRM module includes new sections on the President’s Malaria Initiative (PMI) and its Malaria Communities Program (MCP) providing small grants to NGO and community-based organizations that may be new to partnering with the USG and are working in the PMI focus countries.

The section on mosquito nets was updated to reflect current recommendations regarding the roll-out of Long-lasting Insecticidal Net (LLIN).

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MalariaIntroduction

Malaria is a “reemerging infectious disease” with increased parasite resistance to classic treatments, increased vector resistance to pesticides and a growing geographic spread due to climatic changes.

The facts speak for themselves 40% of the world’s population is at risk of malaria—those living in the poorest countries are most

affected.

In 2000, there were between 350 and 500 million cases of acute illness and at least 1 million deaths.

90% of deaths due to malaria occur in Africa, south of the Sahara desert—mostly amongst young children.

In Africa 1 in 5 of all childhood deaths are caused by malaria, making it the number one killer of young children in Africa.

Malaria kills an African child every 30 seconds.

30 million pregnant women and their newborns are at risk of malaria. Pregnant women and children under 5 are the most vulnerable to dying from malaria.

Malaria is preventable and treatable .(Adapted from RBM/WHO factsheets1)

The 2008 World malaria report estimated that there were 247 million cases of malaria worldwide in 2006, which led to 881,000 deaths2. Most of the malaria deaths are in children under 5 years and most are in Africa, where one out of every five childhood deaths is caused by malaria. Plasmodium falciparum, the parasite responsible for most malaria associated deaths, affects children in three ways: acute malarial illness; chronic or persistent malarial parasitemia with anemia; and malaria infection in the mother can affect the newborn. Children die because they lack access to proper care and life saving drugs, or do not have access to preventive measures such as insecticide treated mosquito nets (ITNs).

Every year in African endemic areas alone, 25 million pregnant women and their newborns are exposed to the burden of the disease. In areas of stable malaria transmission, pregnant women are at an increased risk for maternal anemia, have an increased risk of having low birth weight babies with poor infant survival and development. In areas of unstable malaria transmission, pregnant women are at an increased risk for maternal anemia, spontaneous abortion, severe malaria and still births. Co-infection with HIV and malaria exacerbates the negative effects of malaria illness for the pregnant woman and her unborn baby.

Malaria interventions are appropriate and important in endemic, as well as epidemic areas where the disease makes a substantial contribution to under five mortality. The goal of a malaria intervention in a child survival project is to reduce malaria-associated mortality and morbidity, especially in children and pregnant women.

1 WHO/RBM info-sheet: http://www.rbm.who.int/cmc_upload/0/000/015/372/RBMInfosheet_1.htm2 World Malaria Report, WHO, 2008. www.who.int/malaria

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http://www.rbm.who.int/cmc_upload/0/000/015/372/RBMInfosheet_1.htm

Where children are directly affected by malaria in most of sub-Saharan Africa, in some areas of South and Southeast Asia, the disease affects mostly the adult population, but inflicts an economic burden on the entire family.

Progress in Malaria Control

In recent years, malaria has received greater international attention. Malaria has been included among major international development targets and acknowledged as a contributor to global poverty. The United Nations’ Millennium Development Goals call for halting and reversing the incidence of malaria by 2015. In the Abuja Declaration in 2000, African leaders affirmed their commitment to halving malaria mortality by 2010. These initiatives have led to increased attention and funding to fight the disease in the past 10 years. In April 2008, the UN Secretary General has called for universal coverage by the end of 2010 to halt malaria deaths.

(Global Malaria Action Plan3)

Strategic approach

RBM’s strategy of “home as the first hospital” places an increased emphasis on caretaker’s recognition of malaria and treatment seeking in both formal and non formal health care systems. This radical shift requires new tools and skills for national malaria control programs and public health systems and provides an exceptional opportunity for Non-Governmental Organizations (NGOs) to play a vital role in the local implementation and national adaptation of this policy. Their extensive experience in working with communities for health and development combined with their expertise in linking the community with health facilities assuring “household-to-hospital continuum of care” could be instrumental in making the approach successful.

Organizations implementing a malaria program are encouraged to include any or all of the following activities:1. Improved malaria disease recognition and standard case management (including home-based

management of fever, assuring household-to-hospital continuum of care and reduction of anemia).

2. Prevention and treatment of malaria in pregnant women via antenatal services including uptake of intermittent preventive treatment (IPTp) as well as promotion and distribution of long-lasting insecticidal nets (LLINs).

3. Reduction in malaria transmission, especially among young children and pregnant women, through targeted distribution of LLINs, promotion of community-wide use of insecticide-treated mosquito nets (ITNs), and regular re-treatment of nets where necessary.

NGOs should also play a role in the promotion of indoor residual spraying (IRS). Other effective environmental approaches such as environmental engineering measures to malaria control have little impact if not done with robust entomological monitoring and in very particular ecosystems with limited accessible and identifiable larval breeding sites, are hard to do well and generally need intensive maintenance.

3 http://www.rollbackmalaria.org/gmap/1-3.html

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Community-wide administration of anti-malarial drugs for Intermittent Preventive Treatment for infants (IPTi) and children (IPTc) is a promising strategy, but more research resulting in clear recommendations on IPTi and IPTc is needed.

Getting started: Assessment and Situation Analysis

Children are directly affected by malaria in much of sub-Saharan Africa, where most malaria deaths occur. Malaria interventions are appropriate and important in these endemic areas especially where the disease makes a substantial contribution to under-five mortality. Before engaging in malaria interventions, NGOs are encouraged to gather baseline and background information on the malaria situation in their intervention area. This information can be gathered through a review of available epidemiological (and entomological) data on malaria. Before engaging in activities NGOs must also review national policies and strategies, are encouraged to assess community and household practices (preventive, care seeking and treatment), assess availability and quality of care from public and private sectors, community volunteers and the “non-formal” health sector, assess availability of products and drugs and their logistics, and explore local partners and opportunities for collaboration.

Information gathered and analyzed will help program teams and their stakeholders identify which (and where) interventions can have the greatest impact. It may be that interventions are needed across several key areas in order to have an impact. Assessment information collected and program decisions made should be evaluated in the context of:

The presence of other partners working in the program area, focusing on areas of potential collaboration and avoiding duplication of efforts based on the organization’s and partner’s comparative advantages, existing relationships and strengths.

Existing community and health-related services and structures in place. Resources available for program implementation as well as through other partner

organizations.

Baseline information should feed into the project’s monitoring and evaluation plan and we especially recommend that NGOs consult the RBM document “Framework for Monitoring Progress & Evaluating Outcomes and Impact,” and consider those guidelines for indicators for monitoring the progress of malaria control interventions to ensure uniformity in reporting between projects and countries4. In general, NGOs should collect information to monitor their progress versus results and are encouraged to collect core outcome indicators which they can share with the NMCP.

PMI and other partners are working to increase the capacity of NMCPs to monitor and evaluate their programs. NGOs and especially those receiving PMI funding, such as the Malaria Communities Program (MCP) grantees should thus assure that their M&E activities feed into national M&E efforts and should consider collecting the core population coverage indicators.

4 The document Framework for Monitoring Progress & Evaluating Outcomes and Impact can be downloaded at: http://www.rbm.who.int/cmc_upload/0/000/012/168/m_e_en.pdf).


We find the framework below useful to picture a project’s monitoring and evaluation plan and encourage NGO to also consult the Monitoring and Evaluation Technical Reference Materials for more information.

The References and Resources section of the malaria TRM module has an extensive list of suggested sources for baseline information. NGOs are encouraged to consult these documents before starting program planning and implementation. Annex 1 has links to malaria indicators.

Core Population Coverage Indicators for ROLL BACK MALARIA

To Be Obtained from Household SurveysCore population coverage indicators for measuring the RBM technical strategy of vector control via insecticide-treated nets Proportion of households with at least one insecticide-treated net.

Proportion of children under five years old who slept under an insecticide-treated net the previous night.

Core population coverage indicator for measuring the RBM technical strategy of prompt access to effective treatment (among children under five years old) Proportion of children under five years old with fever in last 2 weeks who received antimalarial treatment

according to national policy within 24 hours from onset of fever.

Core population coverage indicators for measuring the RBM technical strategy of prevention and control among pregnant women Proportion of pregnant women who slept under an insecticide-treated net the previous night.

Proportion of women who received intermittent preventive treatment for malaria* during their last pregnancy.

* 2 or more doses


InputIndicators

ProcessIndicators

OutputIndicators

Outcome Indicators

Indicators of Impact

Indicators for monitoring the performance of malaria programs/interventions, measured at the

program level.

Indicators for evaluating results of malaria programs/interventions,

measured at the population level.

Core population coverage indicators for

RBM

Malaria Standard Case Management

From the RBM 2010 targets

By 2010, through targeting universal coverage:

80% of malaria patients are diagnosed and treated with effective anti-malarial treatments

As the picture illustrates, most fever cases and thus malaria episodes are treated outside the formal health sector. Most often, mothers and other caretakers purchase anti-malarial and anti-pyretic drugs from the informal sector, including local drug vendors or peddlers. Since these drug sellers are not always trained to give appropriate treatment, advice or information on how and how much to take, inappropriate home treatment is a serious problem: children

often receive the wrong type of drug and/or medicine of questionable quality. Even if they have the right drugs, vendors can give inappropriate advice or dosages resulting in children taking incorrect or insufficient amounts of drugs. Moreover, inappropriate treatment may contribute to the development of drug resistance.

First and second line anti-malarial drugs are country specific and implementing organizations should familiarize themselves with local policies regarding drug use at the community level. Current malaria treatment guidelines can be found in Annex 2.

Community and Household

Improving home and community management is a priority, is one of the cornerstones of the Roll Back Malaria initiative and is increasingly recognized by national malaria control programs5. In line with the Community - Integrated Management of Childhood Illnesses (C-IMCI) framework, NGOs working in malaria endemic areas can play a key role in improving home and community care, and assure household-to-hospital continuum of care, thus reducing morbidity and mortality from malaria.

Potential strategies to improve malaria home care can include one or more of the following: behavior change interventions targeted at mothers and other caretakers, combined with increased access to first line antimalarial drugs; working with existing community based providers,

5 The RBM strategy for improving access to treatment through home management of malaria can be found at http://www.who.int/malaria/docs/RBM_Strategy_HMM_sm.pdf.


http://www.who.int/malaria/docs/RBM_Strategy_HMM_sm.pdf

including training and assuring a steady supply of quality drugs; working with drug industry or big distributors, optimizing packaging and instructions; working with national programs and regulatory authorities to support the above interventions; and working with the private sector.

A number of community-level channels can be used to transmit information at both the household and community levels. Community Health Workers (CHW) and/or Community Oriented Resource Persons (CORPS) are particularly useful as links between the community and the facility. CHWs and community based support groups can play an important role in counseling of families on recognition of illness, care-seeking and home care and in assuring compliance with antimalarial drugs. The development of behavior change approaches, messages and materials needs to be based on qualitative and ethnographic research on or knowledge of local perceptions and beliefs about illness and malaria, as well as words and terms used to describe the disease. We recommend that NGOs use the “behave” framework, described in the Behavior Change module of the TRMs to help them design their behavior change strategy.

To avoid deaths and assure adequate treatment, it is important that caretakers recognize early symptoms, but also recognize danger signs (i.e., unable to drink or breastfeed, lethargy or change in consciousness, convulsions, vomiting everything, high fever, fast or difficult breathing), and then seek urgent care from the appropriate provider. Other behaviors that are important for the management of malaria in the home are taking a full course of appropriate antimalarials (dosage and duration); continued feeding and assure increased intake of fluids during illness; and continued fluids and feeding immediately after illness. All infants and children sick or not, need to consume enough micronutrients, especially iron and vitamin A.

Studies have demonstrated that caretakers can be trained to recognize fever and to give antimalarials. This approach can reduce the incidence of severe malaria. In areas with high malaria transmission, and limited access to health providers, this approach may be the only strategy for ensuring early presumptive treatment of malaria.

A number of community-based providers, including shopkeepers, pharmacists, drug vendors, community health workers, community based distributors and traditional healers, have been trained to conduct simple malaria case management and to give antimalarial drugs effectively. The overlapping clinical presentation of malaria and pneumonia is an important consideration in all areas where children are treated for malaria. A substantial proportion of children with fever will also meet a pneumonia case definition (cough or difficulty breathing, and fast breathing or chest indrawing), and almost all children meeting a pneumonia case definition also have fever or a history of fever. Treatment of malaria alone may result in death from pneumonia, thus all malaria protocols for first level health workers in communities or at health facilities should include case detection and management or referral for pneumonia. Standardized case management guidelines based on the IMCI approach are ideal since these guidelines combine the screening and management of malaria and pneumonia with other important causes of childhood morbidity and mortality (see IMCI module of the TRMs).


In recent years there has been increased recognition that to achieve the RBM targets and the MDGs, community-based private providers must be engaged. The importance of the community based private providers or medicine sellers in treatment varies greatly from country to county, but overall in Sub-Saharan Africa a significant proportion of caregivers seek treatment from these sources. There is however a lack of consensus on how and even whether to work with these typically informal medicine sellers. Some countries, such as Kenya, where a high percentage of caregivers go first to medicine shops to seek treatment for childhood illnesses have recognized that medicine sellers’ with improved skills can save lives and have supported interventions to improve their practices.

The role medicine sellers will play in delivery of Artemisinin-based Combination Therapy ACTs is a key issue. If ACTs are restricted to public health facilities and the formal private sector, pharmacies and clinics, a significant proportion of the population will not have easy access to ACTs. In areas where ACT is the first line drug, ACT should also be made available at the community level, along with supportive supervision for first line workers to ensure ongoing mentoring and quality assurance. NGOs will need to involve themselves in the RBM country partnerships to ensure that their perspectives and input are made to the relevant national policymakers.

In areas of high stable malaria transmission, children under 5 years of age should be treated on the basis of a clinical diagnosis. In areas with lower levels of transmission, where malaria accounts for a much smaller proportion of all fevers, use of a rapid diagnostic test (RDT) for malaria may be needed to avoid over-treatment, especially in adults. While RDTs can be cost effective in areas of low transmission and for diagnosing adult fevers, there may be problems with quality control, the performance of the health worker, and their actual impact on prescribing practices. Information on RDTs can be found on the WHO website: http://www.wpro.who.int/sites/rdt.

Health Facility

Recognition of illness and appropriate care seeking or treatment of children within the community is the vital first step in reducing morbidity and mortality due to malaria. It is however as important to assure household-to-hospital continuum of care and it is the responsibility of the health worker to ensure that those children who do reach the health facility are given the best possible treatment. This means that children with uncomplicated (mild to moderate) malaria must be given prompt treatment with an effective antimalarial drug, and children with clinical features of severe malaria, who have an increased risk of dying, must be rapidly identified, immediately treated, and/or referred to the appropriate health facility where maximal clinical care is possible.

The clinical presentation of malaria may be nonspecific. In addition, patients often have more than one underlying disease, and where possible children are thus best treated within an IMCI framework (see also TRM module on IMCI). The malaria section of the IMCI algorithm for use at the primary care level includes assessment, classification, treatment, referral of severely ill children, recognition of treatment failure, use of second-line antimalarials, and counseling. Counseling is focused on compliance with antimalarials and antipyretics, recognition of danger signs at home, and other home care strategies such as continued feeding and fluids.

Included in malaria treatment is the recognition and management of anemia. Management includes iron supplementation, de-worming, and counseling of caretakers on nutrition and prevention of anemia. Iron supplementation (3-4 mg elemental iron/kg/day for 14 days) should


http://www.wpro.who.int/sites/rdt

be given to all children with Hb <9 g/dl (Hct <27%). Health workers should also discuss with the mother the advantages of purchasing an insecticide treated mosquito net, which can reduce the incidence of malaria episodes and all-cause mortality in children less than 5 years.

As of now, the use of a rapid diagnostic test (RDT) in children is not a part of the IMCI algorithm, and RDTs are thus not recommended for use at the primary (including household and community) level6.

Children with malaria who fail to receive prompt and appropriate treatment may deteriorate and develop severe malaria over the course of a few days. Mothers and health workers should be aware of the clinical features or danger signs of severe malaria: multiple convulsions, prostration, coma, respiratory distress and shock (less common but to be recognized by health workers: haemoglobinuria and abnormal bleeding tendency). These features of severe malaria may be detected without the need for laboratory investigations.

IMCI guidelines for referral level staff, where cases of severe malaria or anemia are managed, are available. If referral is not available, then consideration can be given to training first-level health workers to manage more complicated cases at the primary level. However, of foremost importance is that those children who are severely ill are recognized and identified for priority treatment. This can be a challenge when staff is poorly trained or overburdened. Even health workers with a limited clinical experience should know that if a child is convulsing, is prostrated or has respiratory distress, s/he MUST be taken to the top of the queue for immediate assessment and treatment. It cannot be stressed enough that rapid treatment saves lives and it is thus imperative that a child with any of these danger signs receives immediate attention.

Antimalarial therapy {quinine or artemisinin derivatives - including artemether, artemisinin (rectal), artemotil and artesunate}, treatment of hypoglycemia and restoration of normal circulating volume are the immediate priorities. The mortality of children with respiratory distress and severe anemia is extremely high and these children should be transfused rapidly. Rapid transfusion of blood is well tolerated, and leads to rapid clinical improvement in the majority of cases. It is important that blood is screened for HIV and Hepatitis viruses to reduce the risk of transmission of HIV/AIDS and hepatitis. In many cases, concurrent bacteremia is found in children with severe malaria and is associated with a three-fold increase in mortality. It is therefore advisable to start parenteral antibiotics in children who remain severely ill following initial resuscitation. See also article by Dr Jane Crawley in Annex 3.

A viable alternative to quinine injections in case of severe malaria (unconsciousness) are artesunate suppositories. The therapeutic efficacy of rectal artesunate has been well documented, but its use in the community and public health value in reducing malaria mortality is less well known.

Health System and Monitoring Drug Resistance

The main components of health system strengthening for malaria are similar to those for other child health intervention areas, and include clinical supervision for trained staff at all levels, including the community; logistics management for essential first and second line drugs, supplies

6 Some countries are beginning to use RDTs at the community level. As with all health interventions, check the policy where you work.


and equipment (including the distribution of mosquito nets and insecticides) at first-level and referral sites; monitoring and evaluation of the quality of care provided as well as other program outcome and impact measures; provision of effective referral systems; developing data-based drug policies; drug resistance monitoring; and improved district level planning and management of program activities. Ongoing monitoring and regular evaluation can help identify areas where malaria is a problem so that activities can be targeted to high-risk sub-populations.

PVOs and NGOs can help to strengthen links between communities and facilities to support effective prevention and treatment efforts. Activities may include bringing all sides (e.g. CHWs, private providers and district managers) together to plan and implement joint programs, leading to improvements in drug/ ITN distribution, supervision, and monitoring, as well as reducing the risk of drug resistance through assuring consistent messaging at all levels.

The spread of drug resistance, even after introduction of ACTs, is a major challenge to malaria control worldwide, and any drug will eventually foster the emergence of resistant strains. Drug resistance needs to be monitored, so that the efficacy of treatment can be followed, and to ensure that alternative drug policies and guidelines can be put into place in a timely fashion.

NGOs and other organizations can collaborate with the MOH to assist with drug resistance monitoring, and can help with logistics support and supervision. The most suitable method for monitoring is measuring the therapeutic efficacy of antimalarial drugs in infected patients. Other, more complex levels of monitoring may include in vitro testing. Details and protocols on monitoring therapeutic efficacy can be obtained locally from the MOH or from WHO 7 The RBM Partnership supports countries for the maintenance of sentinel sites for routine therapy efficacy monitoring and for the interpretation of data to inform policy decisions. Maximum levels of treatment failure, levels at which continued use of a given drug is no longer considered acceptable, have been defined as 15% clinical failure and 25% parasitological failure. Policy needs to be changed well in advance of reaching these levels to ensure that case management practices are consistently effective.

Drug policy changes however are slow and costly, and new therapies are usually more costly. It can take months before policies are changed in accordance to the science and years before drugs become available within the communities. NGOs must thus encourage rational use of antimalarial drugs in a way that will slow development of resistance and prolong their useful therapeutic lifetimes.

7 (Monitoring Antimalarial Drug Resistance at http://rbm.who.int/cmc_upload/0/000/015/800/200239.pdf)


http://rbm.who.int/cmc_upload/0/000/015/800/200239.pdf

Prevention and Treatment of Malaria in Pregnant Women

The RBM target

By the year 2010, through targeting universal coverage:

In areas of high transmission, 100% of pregnant women receive intermittent preventive treatment (IPTp)

Each year, approximately 30 million African women become pregnant in malaria-endemic areas and are at risk for Plasmodium falciparum malaria infection during pregnancy. Most of these women reside in areas of relatively stable malaria transmission, where a person’s level of immunity to malaria will increase as they age. A pregnant woman’s immunity however decreases, with primigravidae women at highest risk. Pregnant women with malaria, in stable transmission settings, are also more likely to be asymptomatic and the principal impact of malaria infection during pregnancy is associated with maternal anemia and with the presence of parasites in the placenta. This results in impairment of fetal nutrition, contributing to low birth weight (LBW) which is a leading cause of poor infant survival and development in Africa.

Simple interventions for pregnant women can reduce the burden and consequences of malaria in pregnancy (MIP). In areas of stable malaria transmission, the WHO supports a three-prong approach which includes the following interventions8:

1. Uptake of intermittent preventive treatment (IPTp), with an appropriate anti-malarial

2. Use of ITNs; and

3. Prompt diagnosis and case management of malaria illness.

Recognizing that malaria in pregnancy is both a maternal and a newborn health issue developing and strengthening the capacity of communities and health facilities to prevent and control malaria during pregnancy, using the three prong approach is a high priority for the Africa region.

8 Strategic Framework for Malaria Control During Pregnancy in the WHO African Region - http://www.who.int/malaria/rbm/Attachment/20041004/malaria_pregnancy_str_framework.pdf


http://www.who.int/malaria/rbm/Attachment/20041004/malaria_pregnancy_str_framework.pdf

In areas of low malaria transmission the focus is on:

1. Use of ITNs; and

2. Prompt diagnosis and case management of malaria illness.

Intermittent Preventive Treatment

The World Health Organization recommends Intermittent Preventive Treatment in Pregnancy (IPTp) using an efficacious, preferably single-dose, antimalarial drug (e.g., sulfadoxine pyrimethamine9—SP or Fansidar®) as the preferred approach to reduce the adverse consequences of malaria during pregnancy in high-transmission settings. IPTp involves the administration of the full, curative treatment doses at predefined intervals during pregnancy, beginning in the second trimester after quickening10.

The potential of IPTp to attain high levels of program coverage and its benefit in reducing maternal anemia and LBW makes it a preferred strategy. IPTp is best delivered through or linked to antenatal clinic (ANC) visits: during antenatal care IPTp dosing with SP should be given to pregnant women under directly observed treatment (DOT) in the clinic.

All pregnant women in high transmission settings should receive at least two doses, each at least 1 month apart, of the recommended antimalarial drug (e.g. SP) starting at the first regularly scheduled antenatal clinic (ANC) visit after quickening (see figure) and during each regularly scheduled visit thereafter. The WHO presently recommends an optimal schedule of four ANC visits, with three visits after quickening.

BCC/IEC techniques can be used to change behaviors regarding the number of times a mother attends ANC, and helping mothers to understand the need to attend an ANC visit to receive IPTp.

The prevalence and intensity of malaria infection during pregnancy is higher in women who are HIV-infected. Women with HIV infection are more likely to have symptomatic infections and to have an increased risk for

9 Sulfadoxine-pyrimethamine (SP) has a good safety profile in pregnancy, good efficacy in reproductive-age women in most areas, and good program feasibility, with the opportunity to deliver it as a single dose treatment under observation by the health worker. Even in view of the failure of SP in children under five, SP in IPTp is still recommended and is still effective in pregnant women.10 The first perception of the baby’s kicking and movement is referred to as quickening. Quickening usually appears between 14 to 26 weeks of pregnancy.


malaria-associated adverse birth outcomes. Multigravidae with HIV infection are similar to primigravidae without HIV infection in terms of susceptibility to and negative consequences of malaria infection. Therefore, in the presence of HIV infection the risk associated with placental malaria appears to be independent of the number of pregnancies. A minimum of three doses of IPT are required to obtain maximum protection.

HIV infection diminishes a pregnant woman’s ability to control P. falciparum infections and recent findings indicate that they would benefit from monthly doses of IPTp. In areas where HIV prevalence among pregnant women is >10%, a third dose of IPT should be administered at the last scheduled ANC visit. In countries where all HIV+ pregnant women receive cotrimoxazole preventive treatment (CPT) throughout pregnancy, they would not receive IPTp at all.

For pregnant women living in low-transmission or unstable malaria settings, IPTp is not currently recommended by WHO. In these settings, where women are unlikely to have asymptomatic infections with malaria, improved case management, use of ITNs and rapid treatment-seeking for fever during pregnancy are likely to be the best advice for the present.

Use of insecticide-treated nets

The second component of the prevention package is the use of Insecticide Treated Nets (ITNs). The use of an ITN by a pregnant woman benefits the woman as well as her family. ITN use during pregnancy in areas of stable transmission provides significant protection against maternal anemia and LBW. In addition, ITN use benefits the infant who sleeps under the net with the mother by decreasing exposure to malaria infection, the incidence of anemia, and the risk of death, while enhancing development.

Priority should be placed on developing ANC-based programs that support both IPTp and ITNs, along with other essential elements of the antenatal care package. However, in areas with poor access to ANC or low ANC attendance, it is important to develop the community-based distribution of ITNs, targeting pregnant women through women groups and community health workers, including traditional birth attendants. The distribution of ITNs and the development of effective community-based infrastructures to achieve high levels of compliance is a major challenge. Locally defined and applied strategies that engage both communities and facilities in the promotion and ownership of healthcare will be most successful.

In highly malarious western Kenya, studies indicate that women who were protected by ITNs every night during their first four pregnancies delivered approximately 25% fewer babies who were either small for gestational age or born prematurely than did women who were not using ITNs.

Because of their biological vulnerability, pregnant women should be eligible to receive (fully or partially) subsidized ITNs; for example, using a voucher approach linked with the commercial distribution or through the health clinics and community health workers. The subsidized portion could partially or fully cover the price of the ITN, depending on the national policy and local context.

BCC/IEC activities should always accompany ITN distribution, to ensure that pregnant women understand the need to sleep under a mosquito net each night, throughout the year. Incorporation


of messages to women during antenatal, well and sick child visits about the benefits of ITN use will be important in achieving high levels of use. (See also below for more on ITNs.)

Prompt diagnosis and case management of malaria illness during pregnancy

Case Management of malaria illness is another essential component of malaria control during pregnancy in all areas where pregnant women are at risk for malaria. Pregnant women with symptomatic malaria are at higher risk for fetal loss, premature delivery, and death, and they need to be urgently treated. Treatment of malaria during pregnancy aims to completely cure the infection, as any level of parasitemia is of consequence to the mother and fetus.

Each country where malaria is transmitted requires a policy that guides effective case management for malaria illness in pregnant women. These guidelines need to address the unique clinical features of malaria infection in pregnant women as well as specific indications, contraindications, and potential complications associated with antimalarial drugs during pregnancy. There is insufficient information on the safety and efficacy of most antimalarials in pregnancy, particularly for exposure in the first trimester, and so treatment recommendations are different to those for non-pregnant adults. The antimalarials considered safe in the first trimester of pregnancy are quinine, chloroquine, proguanil, pyrimethamine and sulfadoxine–pyrimethamine. The WHO recommends that the following drugs not be used during pregnancy: halofantrine, tetracycline, doxycycline, and primaquine11.

Most importantly, effective treatment must not be delayed in pregnant women. Given the disadvantages of quinine, i.e. the long course of treatment, and the increased risk of hypoglycemia in the second and third trimesters, ACTs are considered suitable alternatives for these trimesters. In practice, if first-line treatment is an artemisinin combination if this is all that is immediately available to treat in the first trimester of pregnancy, pregnant women who have symptomatic malaria, should be given the first line drug.

Current WHO Guidelines on the use of artemisinin-based products for the treatment of malaria in pregnancy (WHO Guidelines for Treatment of Malaria, 200612) recommend that in uncomplicated malaria, artemisinin-based combination treatment should be used in the second and third trimester, but should be used in the first trimester only if it is the only effective treatment available. In severe malaria, artemisinins are preferred over quinine in the second and third trimester because of the hypoglycemia associated with quinine. However, in the first trimester until more evidence becomes available on the risk benefit ratio of artemisinins, both artesunate and quinine may be considered as options. In severe malaria treatment should be started without delay and whichever medicine is immediately available should be used.

During the past decade, the burden of malaria-associated anemia for the pregnant woman (risk for death) and the fetus (LBW) has been increasingly recognized. Anemia need not be symptomatic to pose appreciable risk during pregnancy. Consequently, case management guidelines should provide advice on appropriate screening and therapy for maternal anemia in malaria-endemic areas. P. falciparum parasites may be present in the placenta and contribute to maternal anemia even in the absence of documented peripheral parasitemia. Therefore, a pregnant woman with severe anemia from a malaria-endemic area must be treated presumptively 11 Guidelines for the treatment of Malaria – World Health Organization, 2006 - http://www.who.int/malaria/docs/TreatmentGuidelines2006.pdf12 http://www.who.int/malaria/docs/TreatmentGuidelines2006.pdf


http://www.who.int/malaria/docs/TreatmentGuidelines2006.pdf


with an effective antimalarial, whether or not peripheral parasitemia is present or whether or not she has a history of fever.


In all malaria endemic areas (high and low transmission) communities and women need to be educated on the increased risk of malaria during pregnancy, and consequences to the mother and child.

In the majority of stable malaria transmission settings in Africa, more than 70% of pregnant women attend ANC at least once during their pregnancy, making ANC an optimal platform to deliver MIP prevention. However, these women often come late in their pregnancy, which leads to lower uptake of IPTp and low likelihood that the pregnant woman will receive an ITN early in pregnancy. Communities and facilities can work together to ensure pregnant women use ITNs and are accessing ANC early in their pregnancies.

In areas of high malaria transmission:

Encourage all pregnant women to seek antenatal care during pregnancy and take intermittent preventive treatment (IPTp) beginning after quickening.

ITNs, preferably LLINs, should be provided to all pregnant women as early in pregnancy as possible, and their use should be encouraged throughout pregnancy and during the postpartum period. If necessary, retreatment with insecticide of all nets should be encouraged and taught.

Assure prompt and effective case-management for pregnant women showing signs and symptoms of malaria.

In areas of low malaria transmission:

ITNs, preferably LLINs, should be provided to pregnant women as early in pregnancy as possible, and their use should be encouraged throughout pregnancy and during the postpartum period.

Assure prompt and effective case-management for pregnant women showing signs and symptoms of malaria.

In some malaria-endemic areas, ANC programs may not be well developed and attendance will be low. To accelerate the delivery of services to pregnant women, non-governmental organizations and community-based health providers can deliver some components of the proposed malaria control package. However, it is important to link these community based initiatives (from training to supervision and supply/logistics support) as much as possible with the public health system to ensure a collective response that leads to the delivery of comprehensive services for pregnant women and their families. Traditional birth attendants may be effective at promoting the use of antenatal clinic services, the use of ITNs and, with appropriate training and logistic support, could deliver IPTp in areas where antenatal services are not available. Programs are encouraged to explore innovative opportunities in the community for program delivery both to extend ANC-based programs and to serve women where clinic-based programming is underdeveloped. Within the community, the woman’s partner and family


(e.g., mother and/or mother-in-law), in addition to other local groups, are important resources that can influence decision-making towards healthy choices. These resources should be fully tapped in order to take complete advantage of the range of opportunities to develop effective and sustainable approaches for prevention and control of malaria during pregnancy, as well as for other diseases posing an undue burden for the pregnant woman and her unborn child.

Health Facility

In all malaria-endemic areas (high and low transmission), it is important to ensure the availability of a “comprehensive package” of antenatal care. This package needs to include access to early diagnosis and quality case management of malaria; access to micronutrient supplementation to prevent anemia (iron/folate tablets for all pregnant women); access to early diagnosis and effective treatment for anemia; education for women about the increased risk of malaria during pregnancy; as well as tetanus toxoid immunization, screenings for hypertension and syphilis, and other important activities following the national Focused Antenatal Care (FANC) protocol. The logistics for using directly-observed therapy (DOT) to administer IPTp should also be in place, including clean cups and drinking water, so that the health care provider can observe the pregnant woman taking the IPTp.

The underpinning of MIP program implementation is the partnership between national RH programs and national malaria control programs. RH programs, which support all maternal and newborn health efforts, play a vital role in the management of MIP program implementation, and malaria programs play a vital role in providing technical oversight throughout implementation. Health care workers, particularly in entry-level facilities, should be trained in the recognition and management of febrile illness and suspected malaria. The training should point out that many cases of malaria in pregnancy may present with very mild or no symptoms but that even women with asymptomatic cases are at increased risk of complication, including a low birth weight child. Collaboration with staff responsible for Integrated Management of Pregnancy and Childbirth (IMPAC) as well as those responsible for Integrated Management of Childhood Illnesses (IMCI) will be particularly effective in developing systematic management protocols and drug supply logistics. These treatment protocols need to be based on the pattern of drug resistance for both children and adults.

At present there are no fully effective (fail proof) and feasible approaches to prevent malaria in non-immune pregnant women in endemic or epidemic-prone areas. Non-immune pregnant women exposed to malaria require prompt access to treatment of febrile illness. Essential elements of the antenatal care package should include malaria diagnosis, where available and needed, and treatment with antimalarial drugs which have an adequate safety and efficacy profile for use in pregnancy.

Special attention needs to be paid to high-risk groups, such as first and second pregnancies, and HIV-positive women (as HIV-infected pregnant women require more frequent intermittent treatments). As noted earlier, HIV-positive women may be taking cotrimoxazole according to national policy. These women should not receive IPTp, and vice versa—if a HIV-positive woman is receiving IPTp, she should not receive cotrimoxazole.


Health System

The strategy of WHO’s Making Pregnancy Safer (MPS) initiative is to work with the health sector, focusing on effective evidence-based interventions that target the major causes of maternal and newborn morbidity and mortality. The target is the reduction of maternal and infant morbidity and mortality. Interventions should be aimed at both strengthening the local health systems and to identify actions at the community level needed to ensure that women and their newborns have access to and utilize the care they need, when they need it. Particular importance is placed on skilled attendance at delivery and the provision of an appropriate and effective continuum of antenatal and perinatal care.

Countries that develop policies on malaria control during pregnancy and actively participate in RBM and MPS will be assisted in accelerating program development. This early phase of programming partnership will involve partners that have a commitment to maternal and child health (e.g., UNFPA, World Bank, UNICEF, USAID, DFID…) and will build on the unique program infrastructure and partnerships in place in individual countries and communities. PVOs/NGOs can play a role in assuring that the household and community are included in the definition of the health system, and that e.g. IPTp under supervision of a community provider is considered during the policy debate.

Expanding coverage of programs requires the careful monitoring of program implementation and evaluation of impact. This will assist to develop a firm basis to invest in malaria prevention and in more effective antenatal services for pregnant women. Operational research related to improved control of malaria during pregnancy is also required to assist in improving program implementation.

For more information, see also the WHO/AFRO publication: A Strategic Framework for Malaria Prevention and Control during Pregnancy in the Africa Region. www.who.int/malaria/rbm/Attachment/20041004/malaria_pregnancy_str_framework.pdf.

For more information on intervention strategies for pregnant women according to endemicity or transmission intensity, see also Annex 4



Insecticide-Treated Nets

The RBM Partnership targets

By 2010, through targeting universal coverage:

80% of people at risk from malaria are using locally appropriate vector control* methods such as long-lasting insecticidal nets (LLINs), indoor residual spraying (IRS) and, in some settings, other environmental and biological measures;

* Locally appropriate vector control should be based on scientific evidence whenever possible.

There can be no doubt about the effectiveness of ITNs. They have been shown to reduce the incidence of malaria episodes by half and in malaria-endemic areas the widespread use of ITNs can be expected to reduce all cause child mortality by about one fifth. Recent data on ITNs for pregnant women indicate that they can also have a significant impact on maternal anemia, preterm delivery and low birth weight.

ITNs reduce human-vector contact by acting as a barrier or by repelling mosquitoes, driving them away from the vicinity of sleepers resulting in preventing vector mosquitoes from biting, but also in killing or shortening the lifespan of mosquitoes who land on ITNs. High levels of ITN coverage (50 to 60%) provide protection both to the individuals sleeping under ITNs and to other community members.

Because of their documented effect in several studies on reducing malaria-related illness and death, ITNs should be promoted for use through public and private outlets throughout malaria-endemic African countries.

To be successful, ITN programs must create conditions for sustained

public demand for, access to, and appropriate use of affordable ITNs. The success of reducing malaria morbidity and mortality is contingent upon a reliable logistics system for ITNs, correct net retreatment over time for those nets that require re-treatment, as well as the proper and consistent use of nets by the most vulnerable members of the household.

Technology now exists to produce a mosquito net treated with insecticide at the point of manufacture. These LLINs retain their effective mosquito-repelling properties and require no


further treatment during their expected lifespan of 3 to 5 years or for about 20 washes.13 This technology obviates the need for retreatment (unlike conventional ITNs, LLINs resist washing) and reduces both human exposure (at any given time, most of the insecticide is hidden and not bioavailable) and the risk of environmental contamination. At a current price, LLINs are already more cost-effective than conventionally treated nets. Efforts are being made to scale up production capacity to meet demand, which is already high.

Between the GFATM and PMI, there has been a massive scale-up in the deployment of LLINs over the past few years. Nevertheless there remain inequities in urban vs. rural and rich vs. poor. There is also the critical issue of appropriate use. In some countries without a traditional culture of nets, a great deal of BCC/IEC is required to ensure the nets are hung and used every night, this might include door-to-door “Hang up, Keep up” campaigns, as well as mass communication strategies. There are a variety of distribution methods for LLINs, including mass free distributions through immunization campaigns, subsidized sales through clinics, vouchers, employer-based schemes and straight commercial sales. A central place to look for information on ITNs and LLINs is the NetMark website: www.netmarkafrica.org.

LLINs are recommended as a key vector control intervention to protect all populations at risk of malaria, and are particularly effective in areas where vectors primarily stay indoors. They provide both personal protection with the net and the insecticide, and community protection by reducing the vector population when implemented at very high coverage. Since 2003, a global consensus has been building towards the scaled up distribution of LLINs at no cost to the end-users. WHO endorses this approach and recommends that all targeted populations are 100% covered with LLINs to exploit the community protective effect of insecticide-treated nets (ITNs) that is observed at high coverage levels. For this purpose, distribution to all populations at risk (not only vulnerable groups) with free LLINs is generally considered to be the most rapid and cost effective way to reach universal coverage.

RBM GMAP - http://www.rollbackmalaria.org/gmap/index.html.

The need to periodically retreat conventional nets by dipping them in insecticide is a major impediment in implementing effective and sustainable ITN programs. Sustained insecticide treatment and retreatment programs are also more difficult to implement than are net supply programs. Those are some of the reasons why most programs now exclusively promote the use of LLINs. However, these nets are not always available and projects might still consider treating existing nets where they are available and in use.

Synthetic pyrethroids are the only insecticides that can be used on mosquito nets. For a current listing of approved chemicals and treated netting, refer to the website of the WHO Pesticide Evaluation Scheme (WHOPES) http://www.who.int/whopes/en/. Projects should consider the relatively new field treatment, KO Tab 123, which does not produce “long lasting” nets (i.e. retaining efficacy up to 20 washes), but does appear to retain efficacy up to 15 washes14.

Note on InsecticidesOnly WHO – approved pyrethroid insecticides are used on nets and curtains. At the doses used on nets these chemicals do not bio-accumulate and are safe for humans, although they can be toxic to fish and other aquatic

13 As technology is improving and new methods come on line, this field is changing rapidly. As far as we can tell right now, best indications are that 3 years is the most likely average lifespan for a polyester net, regardless of its type. The Olyset®, polyurethane nets, however, appear to last much longer, up to 9 years.14 See also http://www.who.int/whopes/en/.


http://www.who.int/whopes/en/


http://www.rollbackmalaria.org/gmap/index.html

http://www.netmarkafrica.org/

organisms. However, some of the pyrethroids, especially the commonly used deltamethrin, alphacypermethrin and lambda-cyhalotrhin can cause mucosal irritation and “tingling” sensations on the skin when treating nets or when sleeping under a net that was freshly re-treated. It is sometimes advisable to air out a freshly treated net or an LLIN right out of the package for a day or two before using. Detailed information on the safety of these pyrethroids can be found at the USAID Africa Bureau: http://www.encapafrica.org/documents/Pest_Management/ITM%20PEA.DOC


At present, public demand for mosquito nets varies widely. Mosquitoes are often not recognized as the cause of malaria and nets may have high acceptability in many communities as a defense against nuisance bites, but not as a means for malaria prevention. While programs can take critical advantage of the “nuisance factor” and build an intervention on it, it is also important to (re)educate the community on malaria transmission. For example, Culex mosquitoes, which do not transmit malaria but are certainly a nuisance, can develop resistance to insecticides faster than Anopheles mosquitoes can. Net owners could thus be under the false impression that the net “doesn’t work anymore,” while they are still protected from malaria when faithfully using the treated net. Demand creation is a very large area to concentrate on, but care must be done so that the communication strategy is based on a clear message that mosquitoes transmit malaria as well as on real factors that motivate a family to acquire and appropriately use an ITN.

ITN promotion activities must be based on comprehensive formative research to fully understand the behavioral, market and social environment in which one works. There are essentially two interventions associated with ITNs—building a net culture and promoting retreatment behaviors when other mosquito nets than LLINs are in use (in this case, insecticide treatment and retreatment of nets is a critical point for health impact and is often not widely practiced). This must be kept in mind when conducting baseline investigations during the design of programs. Some of the issues to explore are net, type of net and insecticide use (current use in the community, latent demand, and barriers to net acquisition, use and treatment); household sleeping patterns (who sleeps with whom, where do targeted at-risk children sleep until what age and with whom); net preferences (type, size, color, durability, etc); net purchasing and use-in-the-home decisionmakers; pricing; preferred sources of purchase; and all the KAP factors related to malaria and net/insecticide use.

To be effective, ITN programs should be designed in accordance with local beliefs and social patterns to encourage ITN use, especially by young children and pregnant women. ITN programs cannot be successful unless a number of ingrained behavioral and social patterns change. For example, young children may not have priority for use of mosquito nets within households15. Without such changes, it is unlikely that the right populations will use the nets and have them treated correctly.

Using the results from formative research, clear and consistent key messages that are convincing and persuasive to the target community on the basis of their own belief systems need to be developed. Participatory message development (asking the community how they themselves

15 A key determinant of net use by children <5 is the number of nets in the household. Eisele, T. and Root, B. Insecticide-treated net use among children and pregnant women in sub-Saharan Africa: systematic review of the evidence. Prepared for JHU CCP, January 9, 2009.


http://www.encapafrica.org/documents/Pest_Management/ITM%20PEA.DOC

would communicate the key messages) or the use of a creative ad agency has been employed successfully.

Target populations need to know how to use their ITN appropriately, such as how it should be hung. If the net needs to be retreated then the number of times the net must be re-treated per year/per season, and the importance of re-treatment after extensive washing, need to be clear. People will make better use of nets if they know what the peak biting times of the day are (this can change by geographic region; i.e., Latin America versus sub-Saharan Africa, etc).

Sleeping arrangements can vary in different areas of one country or intervention area, and children in one household can also sleep in a different place from one night to the other. This can mean that there is not only a potential need and market for different sizes and colors of nets, but that there is probably also a need for innovative methods of net placement and hanging. Methods need to be devised so that when children move from one room to another or from one place in the same room to another “sleeping corner” the net can easily be deployed in that new area.

To promote the appropriate communitywide use of insecticide-treated mosquito materials, programs need to target users (pregnant women, mothers and children), and the community at large (families, community leaders, health workers, shopkeepers, traditional healers and all other influential persons) using a range of communication channels that might include media (radio, television, print), community health workers, social groups, and local theater (see also BCI module of the TRMs.)

An ITN television spot can be viewed on the NetMark Web site http://www.netmarkafrica.org/Communications/Television/Video_1_Buzz_Zambia.mpg.

For the development of specific malaria radio messages, a tool had been developed by the Change project and can be accessed at http://www.changeproject.org/pubs/spotonguide.pdf.

Facility and Health System

In some areas, mosquito nets are made available at health facilities, health posts, or community pharmacies. Antenatal clinics are also used as sites for distributing and promoting ITNs to pregnant women. In some countries, however, mosquito nets are still not widely or consistently available.

WHO/GMP’s recent statement signifies a change in position16: “The WHO/GMP calls upon national malaria control programs and their partners involved in insecticide-treated net interventions to purchase only long-lasting insecticidal nets (LLINs). LLINs are designed to maintain their biological efficacy against vector mosquitoes for at least three years in the field under recommended conditions of use, obviating the need for regular insecticide treatment. In order for their full potential to be realized, LLINs should be deployed as a vector control intervention. WHO/GMP, therefore, recommends full coverage of all people at risk of malaria

16 WHO/GMP: Insecticide-treated Mosquito Nets: a WHO Position Statement: http://www.who.int/malaria/docs/itn/ITNspospaperfinal.pdf, p.1


http://www.who.int/malaria/docs/itn/ITNspospaperfinal.pdf

http://www.changeproject.org/pubs/spotonguide.pdf

http://www.netmarkafrica.org/Communications/Television/Video_1_Buzz_Zambia.mpg

in areas targeted for malaria prevention with LLINs.” The statement also stipulates that “The way in which full coverage should be achieved may vary with particular epidemiological and operational situations. Where young children and pregnant women are the most vulnerable groups, their protection is the immediate priority while progress is made towards achieving full coverage. In areas of low transmission, where all age-groups are vulnerable, national programs should establish priorities on the basis of the geographical distribution of the malaria burden.” In addition, “In most high-burden countries, ITN coverage is still below agreed targets. The best opportunity for rapidly scaling-up malaria prevention is the free or highly subsidized distribution of LLINs through existing public health services (both routine and campaigns). LLINs should be considered a public good for populations living in malaria-endemic areas. Distribution of LLINs should be systematically accompanied by provision of information on how to hang, use and maintain them properly.”

Until systems to support free mass distribution of LLINs are established, in order to increase and improve access, a focus on supply and distribution systems is needed. This may include improving local production and packaging, and promoting distribution through pharmacies and local shops, as well as public sector sites. The “manufacturer’s model” works with the private sector to reduce production and distribution costs, so as to provide cheaper, unsubsidized nets. Social marketing uses the private sector to supply a subsidized product affordable to families with a low income.

The mass distribution of highly subsidized or free LLIN will most likely inhibit the unsubsidized commercial markets, because people who would have bought from them receive o free or buy a subsidized net instead. However well-developed commercial distribution systems are much more likely to be sustainable over the long term, and some social marketing programs have reached large enough numbers so that they are quite efficient in terms of costs per net.

Subsidies must be targeted in order to ensure that they have the maximum possible health impact, and there is an urgent need to identify effective mechanisms. The target group must be clearly defined. Targeting pregnant women through antenatal clinics is an attractive option, as it may also protect the newborn child for several years. Similarly, the form of the subsidy must be considered. It is also important to improve economic access; correct pricing (full-price-subsidized-donated) is a key factor in improving access and creating demand. A number of options are available such as including creative financing for net production and distribution, including cross-subsidization of costs, and providing incentives for distributors and retailers.

Environmental Approaches

Environmental approaches such as modification of human habitations, e.g. changes in location or construction of housing are complex, but humans have long practiced this form of malaria prevention by locating houses away from breeding sites. Mosquito-proofing of dwellings by covering windows, eaves, and doors with netting may reduce human/vector contact and has been shown to be efficacious in reducing malaria risk. These are however no simple, nor easy ways to reduce malaria morbidity and mortality.


Application of environmental approaches must be based upon identification of the malaria vector and its breeding sites. Before getting engaged in environmental approaches to vector control (other than mosquito nets), implementing organizations such as NGOs and PVOs will need to assure that they can access the necessary technical (entomological) expertise. While there are three main environmental approaches to malaria control (larval management, chemical control of malaria vectors, and modification of human habitations), none can currently be funded by the CSHGP. However, PVO matching funds or other sources may be used, and PVOs are encouraged to implement parallel projects or activities in the same program site.

As with treatment and prevention, community and household participation is important. Communities can identify their own rationale for vector control; for example, the reduction of nuisance mosquitoes is an acceptable motivation for applying these methods. Any of the environmental approaches and consequential efforts should have significant public involvement and support.

Larval management approaches require substantial information about vector ecology, distribution of larval habitats, and local environmental conditions. Also, they tend to be effective only under certain conditions, and successful control in one location may not be predictive of results elsewhere. Environmental modification involves a physical change to potential mosquito breeding sites by drainage, land leveling, and filling. Environmental manipulation aims at reducing larval breeding sites through temporary changes. Some examples include water management activities such as changing water levels in reservoirs, flushing streams or canals, and providing intermittent irrigation to agricultural fields (particularly rice). If the breeding sites cannot be eliminated, there are also several biological and chemical options available including larvivorous fish, microbial control or chemical larvicides.

Chemical control of malaria vectors (adult mosquitoes) includes indoor residual house spraying (IRS), which has a long history of efficacy – for more on IRS see below. There are a number of chemicals available for IRS and for larval control and all of these products come with significant environmental concerns; they must meet WHO product specifications and necessary safety precautions must be applied for their use and disposal. In addition, all use of pesticides for malaria control (including ITNs) must conform to the current USAID-approved safe use and practices for that country.

These practices will be documented in the Pesticide Evaluation Report and Safe Use Action Plan (PERSUAP) which must be filed by the USAID mission with the Regional Bureau Environmental Officer. Copies of the current PERSUAP can be requested from USAID/Washington, and most can be found at the Web Site http://encapafrica.org/resources.htm#Resources-USAID_regs by using the Search feature. If a mission does not currently have a valid PERSUAP for the malaria intervention proposed, it is not difficult to assist the mission to write one. Templates and details can be obtained from Mr. Brian Hirsch in the Africa Bureau at USAID/Washington. Email him at: [email protected].

The following decision tree can help in deciding which approach to take:



http://encapafrica.org/resources.htm#Resources-USAID_regs

Are Breeding Sites Manageable?

YES NO

Larval Management Mosquito Management

Water management

Biological management

Chemical management

Mosquito nets and other ITM

House improvement

Chemical spraying/IRS

Note on M&E: If you plan to undertake this type of activity, success can be measured in three relatively simple ways—percent reduction of positive anopheline breeding sites, person-bites (per hour), and entomological inoculation rates.

Indoor Residual Spraying

Indoor Residual Spraying (IRS) was widely used in Asia, the Americas and countries with seasonal transmission in the southern part of Africa and in Ethiopia. More recently, IRS has been reintroduced in all PMI countries17. IRS is implemented by the application of residual insecticides (to which Anopheles female mosquitoes have been demonstrated to be susceptible) to the interior walls of houses and other structures. The insecticide remains on the treated surfaces upon which mosquitoes will rest, sometimes before, but usually after taking a blood meal. Several formulations of insecticides are available for this purpose. The residual effect of the insecticide is sufficient to kill resting mosquitoes for a period ranging from three to twelve months, depending on the insecticide, the surface on which it is applied, and local conditions.

The objective of the IRS program is to reduce the mean life-span of the female mosquito population below the duration required for development of the malaria parasite life phases (the sporogonic cycle) that occur in the mosquito and, thereby, to substantially reduce the mosquito population’s ability to sustain malaria transmission. IRS is most effective in areas with seasonal malaria transmission. It is typically implemented by teams of spray operators who spray houses in at-risk localities prior to the rainy season, because heavy rains prompt increases in the Anopheles vector population. The spray operators who implement IRS use compression sprayers to apply a measured amount of insecticide on the interior walls of houses and structures. To be

17 Angola, Benin, Ethiopia, Ghana, Kenya, Liberia, Madagascar, Malawi, Mali, Mozambique, Rwanda, Senegal, Tanzania, Uganda, and Zambia


effective, IRS must attain coverage rates of at least 85% of the houses in a target area. IRS programs in South Africa, Mozambique, Malawi, Ghana and Zambia as well as Bioko Island in Equatorial Guinea have substantially reduced the malaria burden in targeted communities.

Prior to the spraying of houses, communities must be educated about the purpose of the spraying and their roles and responsibilities during the spray campaign. IRS requires homeowners to move household goods out of their houses, to evacuate sick persons from the household, to stay out of the house for an hour after spraying, and sweep out homes upon return to the household and not to wash or re-plaster their walls after the spray application. NGOs can contribute to IRS programs by conducting IEC campaigns that discuss these roles and responsibilities with community members. At the same time, NGOs can also contribute to the community’s general knowledge about malaria and, as IRS is often used in conjunction with ITN programs, promote the use of ITNs as additional protection against mosquitoes.

In support of improving pesticide management associated with the IRS Programs, USAID and its partners conduct “Supplemental Environmental Assessments”, or SEA in the countries where they work. Information on the SEA can be found in the overarching Programmatic Environmental Assessment for Integrated Vector Management, on the PMI website: http://www.fightingmalaria.gov/news/docs/pea_03-14-06.doc


http://www.fightingmalaria.gov/news/docs/pea_03-14-06.doc

Going to Scale

The last years have seen a remarkable increase in funding available for National Malaria Control Programs. By December 1 2008, Global Fund for AIDS, Tuberculosis and Malaria (GFATM) had disbursed more than $6.8 billion dollars for control of the three diseases in 137 countries. (http://www.theglobalfund.org/en/). In April 2005 the World Bank launched the “Booster Program”, pledging to commit $500 million of International Development Association (IDA) resources by July 2008 (http://www.worldbank.org/). The third important development in the global malaria effort was the launch of the U.S. President’s Malaria Initiative (PMI) in June 2005 (http://www.pmi.gov/.) PMI pledges to increase US malaria funding by more than $1.2 billion over five years with the goal of reducing deaths due to malaria by 50 percent in 15 African countries. In December 2006, the Malaria Communities Program (MCP) was announced. The MCP is a $30 million initiative created under the PMI to support the efforts of community, faith-based and indigenous organizations to combat malaria in Africa. The MCP will identify and enable groups to become new partners in the effort to extend the coverage of malaria prevention and control activities to reach a larger proportion of those most affected by malaria, particularly children under age 5 and pregnant women. (http://www.pmi.gov/about/mcp/aboutmcp.html)

This massive flow of new resources, as national malaria control programs (NMCP) reorient themselves in this era of health sector reform, decentralization, and going to national scale make the role of NGOs and their focus on malaria in the health center, the home, the community and the marketplace, more important than ever. There is a new emphasis on collaborative relationships between NGOs and the NMCPs as well as National Reproductive Health Programs, recognizing that malaria in pregnancy is a reproductive health issue, in each country. The WHO “Roll Back Malaria” (RBM) strategy emphasizes collaborative relationships between stakeholders, focused on the RBM Country Partnership. NGOs should actively seek out and organize participation in the RBM country partnerships to ensure they can benefit from, and make substantial contributions to, the national process of scaling up malaria control interventions.


http://www.pmi.gov/about/mcp/aboutmcp.html

http://www.pmi.gov/

http://www.worldbank.org/

http://www.theglobalfund.org/en/

References and ResourcesIntroduction

Many of the references listed below are now Web-based and contain their highlighted (in blue) “hyperlinked” Web site address. To access them, use an electronic copy of this document (which you can access from our Web site: http://www.childsurvival.com/documents/usaid.cfm). Simply click on the blue highlighted Web site address of the reference that you want to find in this document, and you will automatically be connected to that site/reference online. Another option is to be online using your browser, and manually cut and paste/or type in the Web site address for the reference you want to find from this document.

Some of the references still remain available only in hard copy, and an attempt has been made to provide information on how to obtain them. All documents published under USAID-funded projects can be obtained from USAID’s Development Experience Clearinghouse (DEC), http://www.dec.org. The order number of each document begins with PN- or PD- and appears in parentheses at the end of the citation.

This reference and resource list of the TRMs is by no means the last word on any of the interventions or cross-cutting strategies and cannot possibly be exhaustive, but rather can help steer the user in the right direction when researching these areas.

This is a dynamic list, as are the TRMs in general. We ask that throughout the year you provide us with information on the availability and usefulness of each entry, as well as additional resources that you think should be added to this list, as appropriate, so that next year we can continue to update it. Please send comments and recommendations to Michel Pacqué at CSTS+ mailto: [email protected].


mailto:mailto:%[email protected].

http://www.dec.org/

http://www.childsurvival.com/documents/usaid.cfm

Suggested sources for baseline information

CORE Group’s Surviving Malaria Decision Guide is a tool that seeks to assist NGOs and other organizations implementing malaria activities to decide on what malaria interventions are most relevant for improving the early detection and appropriate treatment of malaria among the most vulnerable groups in their specific program context. The tool can be downloaded at http://www.coregroup.org/working_groups/Surviving_Malaria_Field.pdf. The Decision Guide presents 10 key behaviors that are critical to ensuring the appropriate case management of malaria in infants and young children beginning from the time a child becomes sick with malaria to the return of the child’s health. Program guidance is provided for each key behavior including:

Explanation of why the behavior is important. Explanation of the levels at which behaviors affect outcomes. Assessment questions to be considered in relation to each behavior. Assessment tools available to help seek answers to questions being asked. Decisions needed/program considerations after the assessment information is collected.

PMI has detailed information on the 15 “focus countries” accessible through the www.pmi.gov site, World Bank, WHO/RBM, DHS data, literature such as medical journal articles (PubMed (http://www.ncbi.nlm.nih.gov/) and for historic and more obscure malaria-related articles, the Armed Forces Pest Management Board (http://www.afpmb.org), the National Malaria Control Programs (NMCP), the NetMark Project (http://www.netmarkafrica.org/research), hospital data, student dissertations, and many more. Epidemiological data can also be found in map form from the web-site Mapping Malaria Risk in Africa (MARA http://www.mara.org.za/). The USAID Environmental Project Malaria Bulletin is a monthly electronic bulletin providing abstracts and information on recent malaria publications in the “gray” as well as peer-reviewed literature. One can subscribe to this service at: http://www.ehproject.org/ehkm/malaria.html.

To gather baseline indicators, a multitude of resources and tools are available. All CSHGP grantees are required to gather a minimal set of baseline indicators, and most use the KPC 2000+ Questionnaire. The latest version, the KPC2000+, includes new and updated modules, as well as the Rapid CATCH (Core Assessment Tool on Child Health). The malaria and other specific KPC 2000+ modules can be downloaded in either Adobe Acrobat (PDF) or Microsoft Word formats, from the following link: http://www.childsurvival.com/kpc2000/kpc2004.cfm. The KPC provides indicators on malaria (fever) case management in the community; health facility care seeking for fever; Intermittent Preventive Treatment in pregnancy (IPTp); household mosquito net possession and child mosquito net use.

Both the household questionnaire and the women’s questionnaire from RBM’s Malaria Indicator Survey can be downloaded from the RBM Monitoring & Evaluation Reference Group (MERG) Web site (http://www.rbm.who.int/merg.html). The Malaria Indicator Survey (MIS) Package represents the scope of needs for assessing coverage of insecticide-treated mosquito nets, antimalarial treatment among children under five with fever, and IPTp among pregnant women including a standard set of well defined indicators, recommended questionnaire and data tabulation plans for calculation of indicators, and guidance on conducting surveys, designing sampling frames and calculating sample sizes. References for


http://www.rbm.who.int/merg.html

http://www.childsurvival.com/kpc2000/kpc2004.cfm

http://www.ehproject.org/ehkm/malaria.html

http://www.mara.org.za/

http://www.netmarkafrica.org/research

http://www.afpmb.org/

http://www.ncbi.nlm.nih.gov/

http://www.pmi.gov/

http://www.coregroup.org/working_groups/Surviving_Malaria_Field.pdf

Malaria indicators can also be found in the Malaria corner of the Demographic and Health Surveys: www.measuredhs.com/topics/malaria/start.cfm

Additional data collection tools can be found on and downloaded from the NetMark Web site (http://www.netmarkafrica.org/research/index.html#instruments). From the Roll Back Malaria (RBM) Web page (http://www.rbm.who.int/) NGOs can also easily obtain other detailed data collection forms (including some 20 data collection instruments for use at national, district, provider and community/household level) and suggested indicators. Another helpful indicator resource is the document “Guidelines for Core Population Coverage - Indicators for Roll Back Malaria, which can be downloaded at: http://www.rbm.who.int/partnership/wg/wg_monitoring/docs/GuidelinesForCorePopulationFINAL9-20_Malaria.pdf. RBM is putting together a document on household level coverage indicators. There is slightly more prescriptive information available from the GFATM M&E toolkit (http://www.theglobalfund.org/documents/me/M_E_Toolkit_lores_en.pdf). The RBM MERG activities site (www.rbm.who.int/merg) points to specific recommendations.

NGOs interested in conducting a health facility assessment to assess quality of care at the provider level should consult the Health Facility Assessment tool developed by BASICS (also on the web): http://www.basics.org/publications/abs/abs_hfa.html, which outlines key steps for planning and conducting an integrated health facility assessment at outpatient health facilities. Alternatively NGOs can use the Rapid Health Facility Assessment (R-HFA) tool, which was originally specifically designed for use by NGOs within the Child Survival and Health Grants Program (CSHGP), but as the Malaria Booster Initiative experience has shown, it is quite suitable for use by District Health Medical Teams (DHMTs). The tool can be downloaded at:http://www.childsurvival.com/rhfa_1.cfm

NGOs interested in conducting formative research on care seeking behavior should also consult the BASICS site for the following documents Comparing Care-seeking for Childhood Malaria: Lessons from Zambia and Kenya (83 pages) and A Guide to Research on Care-seeking for Childhood Malaria (129 pages) http://www.basics.org/publications/index.html#integrated.


http://www.basics.org/publications/index.html#integrated

http://www.childsurvival.com/rhfa_1.cfm

http://www.basics.org/publications/abs/abs_hfa.html

http://www.rbm.who.int/merg

http://www.theglobalfund.org/documents/me/M_E_Toolkit_lores_en.pdf

http://www.rbm.who.int/partnership/wg/wg_monitoring/docs/GuidelinesForCorePopulationFINAL9-20_Malaria.pdf

http://www.rbm.who.int/partnership/wg/wg_monitoring/docs/GuidelinesForCorePopulationFINAL9-20_Malaria.pdf

http://www.rbm.who.int/

http://www.netmarkafrica.org/research/index.html#instruments

http://www.measuredhs.com/topics/malaria/start.cfm

Suggested URL bookmarks for further reading

(Adapted from Michael Macdonald, USAID Malaria Advisor, [email protected] - 26 November 2008)

Biology, Geography and Burden

For general information on malaria control strategy, see the WHO Global Malaria Program website: http://www.who.int/malaria/ and the related Roll Back Malaria website http://www.rollbackmalaria.org/. We sometimes differentiate that WHO is the “What” and RBM is the “How”.

For basic information on malaria biology see the CDC website: http://www.cdc.gov/malaria/biology/index.htm. For journal publications, the primary source is PubMed, http://www.ncbi.nlm.nih.gov/pubmed/, but one can find many other full-text papers, including historical documents at the Armed Forces Pest Management Board http://www.afpmb.org/, and in the WHO Library http://www.who.int/malaria/publications.html

Malaria geography and maps can be found at the Malaria Atlas Project http://www.map.ox.ac.uk/ and the Malaria Area Risk Assessment project http://www.mara.org.za/

Malaria burden, including the most recent World Malaria Report: http://www.who.int/malaria/wmr2008/ with more detailed, country specific data though the USAID- supported Demographic Health Surveys: http://www.measuredhs.com/

Control Strategy

The primary USAID malaria efforts are through the President’s Malaria Initiative, PMI (www.PMI.gov ) where we are also close collaborator with WHO and a core member of the RBM partnership. The Global Strategic Frameworks include the Abuja Summit in 2000 http://www.rbm.who.int/docs/abuja_declaration.pdf_, the Millennium Development Goals (http://www.un.org/millenniumgoals/) in September 2000, and most recently in September 2008 the Global Malaria Action Plan, http://www.rbm.who.int/gmap/index.html. Specific information on the technical interventions, diagnosis and treatment, malaria in pregnancy, and Integrated Vector Management can be found on the PMI website: http://www.pmi.gov/technical/acts/index.html . Information on the specific country profiles, operational plans and spending levels can also be found, at http://www.pmi.gov/countries/profiles/index.html

Tactical Developments

Diagnosis and Treatment

Recognition and treatment of malaria in the home, community, market place and primary health care facility, including support to the Malaria Communities Program http://www.usaid.gov/press/releases/2008/pr081023.html ), the CORE group and country NGO coordinating mechanisms (http://www.coregroup.org/start.cfm) and support to Collaborating


http://www.coregroup.org/start.cfm

http://www.usaid.gov/press/releases/2008/pr081023.html

http://www.pmi.gov/countries/profiles/index.html

http://www.pmi.gov/technical/acts/index.html

http://www.rbm.who.int/gmap/index.html

http://www.un.org/millenniumgoals/

http://www.rbm.who.int/docs/abuja_declaration.pdf_

http://www.PMI.gov/

http://www.measuredhs.com/

http://www.who.int/malaria/wmr2008/

http://www.mara.org.za/

http://www.map.ox.ac.uk/

http://www.who.int/malaria/publications.html

http://www.afpmb.org/

http://www.ncbi.nlm.nih.gov/pubmed/

http://www.cdc.gov/malaria/biology/index.htm

http://www.rollbackmalaria.org/

http://www.who.int/malaria/


Agency projects, such as BASICS (http://www.basics.org/) and the C-Change communication project http://c-changeprogram.org/C-ChangeBrochure.pdf

Diagnostics:

Overall information on malaria, TB etc: http://www.finddiagnostics.org/index.shtml Specific PMI collaboration on diagnostics: http://www.sti.ch/health-systems-support/system-performance-and-monitoring/experience/improving-malaria-diagnostics.html and http://www.fightingmalaria.gov/news/pressreleases/imad_project.pdf

An excellent resource for Rapid Diagnostic Tests: http://www.wpro.who.int/sites/rdt

Drug-Resistant Malaria: Southeast AsiaThe ecology of malaria transmission and issues for control in Southeast Asia differ markedly from Africa. In Southeast Asia, particularly what is defined as the Greater Mekong Sub Region (Burma, Thailand, Lao PDR, Cambodia, Vietnam and Yunnan Province China), the malaria mosquito vectors are largely confined to forested regions along the border areas. In addition to the indigenous communities living in these border areas, there is often a significant migrant population, both domestic (e.g. Cambodians moving to the western forests from the non-malarious central part of the country) and international (e.g. Burmese workers moving from Western Cambodia, to Northeastern Burma, to Southwest Thailand). To address this trans-border, regional problem, the USAID Regional Development Mission for Asia, based in Bangkok (http://www.usaid.gov/rdma/about/index.html ) supports the regional “Mekong Malaria Program”.

Components include financial and technical support to coordination through the WHO Mekong Malaria Program (http://w3.whothai.org/EN/Section3/Section113.htm ); drug procurement, resistance and drug quality monitoring http://www.usp.org/worldwide/dqi/), diagnostics and laboratory quality improvement, monitoring and evaluation, (http://www.orcmacro.com/Survey/Demographic/measure.aspx: and http://www.malariaconsortium.org/ ) community-based initiatives http://www.urc-chs.com/projects/health/CambodiaMalariaPreven.html and capacity building for a range of technical and management skills through the Asian Collaborative Training Network for Malaria (ACTMalaria) http://actmalaria.net/ .

Facility-Based Management

The Integrated Management of Childhood Illness, Health Facility Assessment Tool can be found at: http://www.cpc.unc.edu/measure/publications/html/ms-00-08-tool14.html Tools for assessing quality of services, drug supply and many other functions can be found at: http://erc.msh.org/toolkit/

Maternal Reproductive Health

More information on Malaria in Pregnancy can be found at the Liverpool-based consortium: http://www.mip-consortium.org/index.htm Integrating malaria in pregnancy into reproductive


http://www.mip-consortium.org/index.htm

http://erc.msh.org/toolkit/

http://www.cpc.unc.edu/measure/publications/html/ms-00-08-tool14.html

http://actmalaria.net/

http://www.urc-chs.com/projects/health/CambodiaMalariaPreven.html

http://www.malariaconsortium.org/

http://www.orcmacro.com/Survey/Demographic/measure.aspx

http://www.usp.org/worldwide/dqi/

http://w3.whothai.org/EN/Section3/Section113.htm

http://www.usaid.gov/rdma/about/index.html

http://www.wpro.who.int/sites/rdt

http://www.fightingmalaria.gov/news/pressreleases/imad_project.pdf

http://www.sti.ch/health-systems-support/system-performance-and-monitoring/experience/improving-malaria-diagnostics.html

http://www.sti.ch/health-systems-support/system-performance-and-monitoring/experience/improving-malaria-diagnostics.html

http://www.finddiagnostics.org/index.shtml

http://c-changeprogram.org/C-ChangeBrochure.pdf

http://www.basics.org/

and maternal/neonatal health programs and working to strengthen those programs (e.g., the ACCESS program; (http://www.accesstohealth.org/ Intermittent Preventive Treatment of Infants, a strategy like IPTp (for pregnant women) delivers SP to infants and children through the routine EPI programs. See the IPTi consortium at http://www.ipti-malaria.org/ Malaria and HIV information: http://www.who.int/malaria/malariandhivaids.html

Integrated Vector Management (IVM)

Vector control is implemented through the framework of “Integrated Vector Management,” which is defined as “a rational decision-making process for the optimal use of resources for vector control” (http://www.who.int/neglected_diseases/vector_ecology/en/ ) that includes the following key elements: advocacy, social mobilization and legislation; cross-sector collaboration; integrating methods; evidence-based decision making; and capacity building.

Insecticide-Treated Mosquito Nets

USAID, through the NetMark project, pioneered public-private partnerships with commercial ITN manufactures and distributors, to grow a sustainable market for increasing access to ITNs through large parts of Africa (www.NetMarkAfrica.org). Here you can also find protocols and results for both qualitative and quantitative research related to ITNs. Country-specific LLIN activities also supported through Population Services International (http://www.psimalaria.org/)

Indoor Residual Spraying (IRS)

Information on IRS can be found at the PMI website http://www.fightingmalaria.gov/technical/irs/index.html Included as part of the IRS programs is a large effort to improve pesticide management for the safe and judicious use of pesticides according to the standards and regulations of the national regulatory authorities, the USG and International Treaties, in particular the Stockholm Convention (http://chm.pops.int/) in those countries where, under the treaty, malaria control programs continue the use of DDT. Other information on pesticides used in malaria control can be found at the WHO Pesticide Evaluation Scheme: http://www.who.int/whopes/en/

New Tools

Research and development into new tools to fight malaria, including vaccines and new antimalarial drugs can be found at http://www.usaid.gov/our_work/global_health/id/malaria/news/mvdp_brief.html and malaria drugs, http://www.mmv.org/article.php3?id_article=177&recherche=USAID

Collaborations

Agriculture:

The “System-wide Initiative on Malaria and Agriculture” can be found at http://www.iwmi.cgiar.org/sima/. The pesticide manufacturers group who promote safe


http://www.iwmi.cgiar.org/sima/

http://www.mmv.org/article.php3?id_article=177&recherche=USAID

http://www.usaid.gov/our_work/global_health/id/malaria/news/mvdp_brief.html


http://chm.pops.int/

http://www.fightingmalaria.gov/technical/irs/index.html

http://www.psimalaria.org/

http://www.NetMarkAfrica.org/

http://www.who.int/neglected_diseases/vector_ecology/en/

http://www.who.int/malaria/malariandhivaids.html

http://www.ipti-malaria.org/

http://www.accesstohealth.org/%20

pesticide management through “The International Code of Conduct” is known as Croplife: http://www.croplife.org/ and finally, the FAO/ Integrated Pest Management, including “Farmer Field Schools” can be found at http://www.communityipm.org/

School and youth programs:

FRESH: http://www.freshschools.org/Pages/default.aspx

Economic Development and Public Private Partnerships: Close collaboration is developing with the Global Business Coalition on HIV/AIDS TB and Malaria. Corporate Alliance on Malaria in Africa http://www.gbcimpact.org/live/involved/cama/ and “malaria no more” http://www.malarianomore.org/ Refer also to the World Economic Forum, Business and Malaria Report: http://www.weforum.org/pdf/MalariaReport.pdf

On the micro- family level economic development, including micro credit schemes, refer to BizAIDS: http://www.sabcoha.org/projects/bizaids-2.html and the GSK, Freedom from Hunger malaria project: http://www.freedomfromhunger.org/programs/malaria.php

CommunicationsThe example of community radio collaboration is at Oneworld Africa: http://africa.oneworld.net/ and the example of cell phone technology used for surveillance in Zanzibar at: http://www.fightingmalaria.gov/countries/profiles/zanzibar.html


http://www.fightingmalaria.gov/countries/profiles/zanzibar.html

http://africa.oneworld.net/

http://www.freedomfromhunger.org/programs/malaria.php

http://www.sabcoha.org/projects/bizaids-2.html

http://www.weforum.org/pdf/MalariaReport.pdf

http://www.malarianomore.org/

http://www.gbcimpact.org/live/involved/cama/

http://www.freshschools.org/Pages/default.aspx

http://www.communityipm.org/

http://www.croplife.org/

Other useful sources:

Insecticide-treated mosquito net interventions: A manual for national control programme managers—edited by Roll Back Malaria. World Health Organization Geneva, 2003 http://www.who.int/malaria/cmc_upload/0/000/016/211/ITNinterventions_en.pdf

WHO Expert Committee on Malaria Twentieth Report—WHO Technical Report Series 892 http://whqlibdoc.who.int/trs/WHO_TRS_892.pdf.

World Malaria Report 2008: http://www.who.int/malaria/wmr2008/

Malaria in Pregnancy: A Strategic Framework for Malaria Prevention and Control During Pregnancy in the Africa Region.

www.who.int/malaria/rbm/Attachment/20041004/malaria_pregnancy_str_framework.pdf

Management of Severe Malaria: A practical handbook ISBN 92 4 154523 2 WHOhttp://www.rbm.who.int/docs/hbsm.pdf.

Framework for Monitoring Progress & Evaluating Outcomes and Impact WHO/CDS/RBM/2000.25 http://www.rbm.who.int/cmc_upload/0/000/012/168/m_e_en.pdf.

The Use of Antimalarial DrugsWHO Guidelines for the treatment of malaria - World Health Organization.

WHO/HTM/MAL/2006.1108 http://www.who.int/malaria/docs/TreatmentGuidelines2006.pdf

Report of an Informal Consultation—13-17 November 2000, World Health Organization, Geneva,WHO/CDS/RBM/2001.33 http://www.rbm.who.int/cmc_upload/0/000/014/923/am_toc.htm.

Antimalarial Drug Combination TherapyReport of a WHO Technical Consultation—4-5 April 2001, World Health Organization, Geneva

WHO/CDS/RBM/2001.35 http://www.rbm.who.int/cmc_upload/0/000/015/082/use_of_antimalarials2.pdf.

Instructions for treatment and use of insecticide-treated mosquito nets—WHO/CDS/RBM/2002.41 WHO/CDS/WHOPES/GCDPP/2002 4 http://mosquito.who.int/cmc_upload/0/000/016/007/InstructionsITNen1.pdf.

The Prevention and Management of Severe Anemia in Children in Malaria-Endemic Regions of Africa- A Review of Research- May 7-9, 2001 Geneva http://www.rbm.who.int/arusha2002/Referenced_final_anemia_report.pdf

Scaling-up Insecticide-Treated Netting Programmes in Africa : A strategic Framework for coordinated National Action.

http://www.rollbackmalaria.org/partnership/wg/wg_itn/docs/WINITN_StrategicFramework.pdf

A directory of suppliers of insecticides and mosquito nets for sub-Saharan Africa. Updated and available on line from PATH Canada: http://www.pathcanada.org/english/directory.cfm.


http://www.pathcanada.org/english/directory.cfm

http://www.rollbackmalaria.org/partnership/wg/wg_itn/docs/WINITN_StrategicFramework.pdf

http://www.rbm.who.int/arusha2002/Referenced_final_anaemia_report.pdf

http://mosquito.who.int/cmc_upload/0/000/016/007/InstructionsITNen1.pdf

http://www.rbm.who.int/cmc_upload/0/000/015/082/use_of_antimalarials2.pdf

http://www.rbm.who.int/cmc_upload/0/000/014/923/am_toc.htm


http://www.rbm.who.int/cmc_upload/0/000/012/168/m_e_en.pdf

http://www.rbm.who.int/docs/hbsm.pdf


http://www.who.int/malaria/wmr2008/

http://whqlibdoc.who.int/trs/WHO_TRS_892.pdf

http://www.who.int/malaria/cmc_upload/0/000/016/211/ITNinterventions_en.pdf

Malaria, anemia and iron supplementationSafety of Iron Supplementation in Malaria Endemic Regions. INACG/ILSI. Washington DC, USA.

(1998): IDPAS# 330 http://www.idpas.org/pdf/330SafetyOfIron.pdf

Stoltzfus, R., and M. Dreyfuss. 1999 Guidelines for the Use of Iron Supplements to Prevent and Treat Iron Deficiency Anemia. Johns Hopkins University/International Nutritional Anemia Consultative Group. 46pp. http://www.idpas.org/pdf/161Guidelines.pdf

From the CORE Group.

National Malaria Coordination Workshop Facilitators Guide Available on CD ROM Detailed instruction and resources for organizing a national workshop for NGOs and CBOs in

collaboration with Ministries of Health.


http://www.idpas.org/pdf/161Guidelines.pdf

http://www.idpas.org/pdf/330SafetyOfIron.pdf

Annexes

Annex 1.

Indicators of Population Coverage for RBM Technical Strategies18

PMI Indicators

www.pmi.gov/about/mcp/pmi_indicators.pdf

18 Roll Back Malaria, MEASURE Evaluation, World Health Organization, UNICEF. 2006. Guidelines for Core Population Coverage Indicators for Roll Back Malaria: To Be Obtained from Household Surveys. MEASURE Evaluation: Calverton, Maryland.


Useful Web sites

WHO Roll Back Malaria Web site: www.rollbackmalaria.org

Malaria Foundation International: www.malaria.org

The Malaria Consortium: www.malariaconsortium.org

http://www.pmi.gov/about/mcp/pmi_indicators.pdf

http://www.malariaconsortium.org/

http://www.malaria.org/

http://www.rollbackmalaria.org/

Annex 2


Malaria treatment guideline

The most recent malaria treatment guideline from WHO is a 266 page document published in 2006, found at http://www.who.int/malaria/docs/TreatmentGuidelines2006.pdf

Resistance to inexpensive mono-therapies such as chloroquine and sulfadoxine-pyrimethamine (SP) has developed and is spreading rapidly. The widespread resistance of Plasmodium falciparum to conventional antimalarial drugs is a key factor contributing to increasing malaria mortality and morbidity. Multidrug-resistant P. falciparum malaria is widely prevalent in Southeast Asia and South America. Now Africa, the continent with the highest burden of malaria, is also being affected.

The inappropriate and incorrect use of antimalarial drugs during the past century has contributed to the current situation: antimalarial drugs were deployed on a large scale, always as mono-therapies, introduced in sequence, and were generally poorly managed in that their use was continued despite high levels of resistance. Incorrect use like taking half a dose or getting treatment when malaria is not present, as well as the introduction of fake medicines have also contributed to the present situation.

Over the past decade, a new group of antimalarials—the artemisinin compounds, especially artesunate, artemether and dihydroartemisinin—have been deployed on an increasingly large scale. These compounds produce a very rapid therapeutic response (reduction of the parasite biomass and resolution of symptoms), are active against multidrug-resistant P. falciparum malaria, are well tolerated by the patients and reduce gametocyte carriage (and thus have the potential to reduce transmission of malaria). If used alone, the artemisinins will cure falciparum malaria in 7 days, but artemisinin-based combination therapy (ACT) produces high cure rates on just 3 days of treatment. Furthermore, there is some evidence that use of such combinations can greatly retard development of resistance to the partner drug. However, the uncontrolled and widespread use of ACT could lead to resistance and ACT costs for adults can be as high as US$1.50 per treatment, 20 times the cost of chloroquine treatment.

Artemisinin compounds are derived from a raw substance extracted from the plant Artemisia annua. Cultivation of the plant requires a minimum of 6 months, and extraction, processing and manufacturing of the final products require at least 2 to 5 months, depending on the product formulation. In addition, the shelf life of the products is only about 2 years. Reliable forecasting of ACT requirements and use is thus essential.

WHO Recommendations on Malaria Treatment

As a response to increasing levels of antimalarial resistance, WHO recommends that all countries experiencing resistance to conventional monotherapies, such as chloroquine, amodiaquine or sulfadoxine-pyrimethamine, should use combination therapies, preferably those containing artemisinin derivatives (ACTs) to treat falciparum malaria.

WHO currently recommends the following therapeutic options:

1. Artemether/lumefantrine(Coartem®)

2. Artesunate plus amodiaquine

3. Artesunate plus sulfadoxine-pyrimethamine (in areas where SP efficacy remains high)

4. Artesunate plus mefloquine (in areas with low to moderate transmission—not recommended for Africa)

5. Amodiaquine plus sulfadoxine-pyrimethamine, in areas where efficacy of both amodiaquine and SP remains high (mainly in the countries of West Africa). This non-artemisinin-based combination therapy is reserved as an interim option for countries that, for whatever reason, are unable immediately to move to ACT.

Over 50 countries have ACTs included in their malaria treatment protocol and over 30 have adopted ACTs as the first line treatment. For more information about these drugs, Artesunate-sulfadoxine-pyrimethamine and other antimalarials, refer to the WHO Fact sheet on ACTs: http://www.rbm.who.int/cmc_upload/0/000/015/364/RBMInfosheet_9.htm. Consult National Malaria Control Programs for country-specific protocols regarding treatment in the general population, as well as for pregnant


http://www.rbm.who.int/cmc_upload/0/000/015/364/RBMInfosheet_9.htm


women.


A simple clinical triageIf the child…• is fitting (having a convulsion)• is prostrated, meaning that he or she is unable to:

– sit up unaided (if age 1 year or above)* or– drink or breast feed (if age < 1 year)

• has respiratory distress, meaning:– deep, rapid breathing or– in drawing of the lower chest wall**

S/he MUST be brought to the top of the queue for immediate assessment and treatment

Annex 3

Prompt Treatment — Article by Jane Crawley

Reducing deaths from malaria among children:the pivotal role of prompt, effective treatment

Dr Jane Crawley, Roll Back Malaria

Of malaria deaths in hospital, over 50% occur within 4 hours of admission. 1What can the clinician do to improve these horrifying statistics? This article discusses the management of malaria in children, emphasizing that: 1. Children with uncomplicated malaria must be given prompt treatment with an effective antimalarial drug, to avoid subsequent progression to severe malaria.2. Children with clinical features of severe malaria, who have an increased risk of dying, must be rapidly identified, immediately treated, and referred to a health facility where maximal clinical care is possible.

The importance of clinical triage

In clinics throughout sub-Saharan Africa, there may be several hundred patients waiting to see the clinician. It is therefore essential to ensure that those children who are seriously ill are readily identified. Children with severe disease from any cause can deteriorate very rapidly and may die, if not identified and treated appropriately. The rapid recognition of severe malaria and other life-threatening diseases can be extremely challenging in situations where facilities are poor, skilled staff are few, and patient numbers are excessively high. It is therefore essential that clinical triage is not only effective at detecting the sickest patients, but is simple and fast to perform. The clinical triage described in Box 1 can be carried out in less than a minute, and is easily taught to assistants with limited clinical experience.

Resuscitation of the sick child is the immediate priority. It is imperative that a child with any of the danger signs listed in Box 1 receives immediate resuscitation (see Box 2). It cannot be stressed enough that rapid treatment saves lives!

*It is ESSENTIAL that this is actually tested. Remove the child from the mother’s lap, and see whether s/he is able to sit up without support.

**The child’s clothing should be adjusted so that the chest wall can be clearly visualized.


Clinical diagnosis

It is important to remember that the clinical presentation of both uncomplicated and severe malaria is extremely nonspecific. In addition, patients often have more than one underlying disease. Symptoms of uncomplicated malaria include fever, headache, vomiting, diarrhea, cough, and flu-like symptoms (chills, muscle pains).

Children with malaria caused by Plasmodium falciparum, who fail to receive appropriate treatment with an effective antimalarial drug, may deteriorate and develop severe malaria over the course of a few days. The features of severe malaria that may be detected without the need for laboratory investigations are shown in Box 3.

Box 2—The resuscitation of the sick childSign Check If TreatmentConvulsions Duration Lasts >5 minutes Diazepam 0.3 mg/kg i.v. over 2 minutes,

or 0.5 mg/kg per rectumBlood glucose <2.2 mmol/L 10% glucose 5 mL/kg i.v. over 15 minutes

or 5 mL/kg via nasogastric (n.g.) tubeProstration Blood glucose <2.2 mmol/L 10% glucose (as above). Glucose solution or

milk can be given orally if the child is able to drink

Hydration / Circulation

Sunken eyesSlow skin pinch*Cold handsCapillary refill >3 seconds**Weak rapid pulse

Use normal (0.9%) saline or Ringer’s lactate ONLY.Infuse 20 mL/kg i.v. rapidly over 15 minutes.

Reassess patient: if no improvement,repeat 20 mL/kg over 15 minutes

Palmar pallor / assess haemoglobin (Hb) or haematocrit (Hct)

Hb <5 g/dl or Hct <15%

Transfuse whole blood i.v. 20 mL/kg over 4 hours.See below if child has respiratory distress

Conscious level+ Child is unconscious Insert n.g. tube; start treatment for cerebral malaria and meningitis (see text)

Respiratory distress

Hydration / Circulation

As above Normal saline or Ringer’s lactate i.v. as above

Palmar pallor / assess Hb or Hct

Hb <5 g/dl or Hct < 15%

Order whole blood urgentlyTransfuse 20 mL/kg blood RAPIDLY: 10 mL/kg over 30 minutes, then 10 mL/kg over 2 hours (see text)

Listen to chest Fast breathing/crackles

Antibiotics i.v. or i.m. for pneumonia

*Skin pinch Pinch the skin of the abdomen (halfway between the umbilicus and flank) for one second, then release and observe. If the skin takes >2 seconds to return, this indicates dehydration.

**Capillary refill Apply pressure for 3 seconds to whiten the fingernail. Determine the capillary refill time from the moment of release to the recovery of the original nail colour.

+Assessment of conscious level in children aged 9 months and above, apply pressure to sternum using knuckles. If the child is unable to localize this painful stimulus, s/he is unconscious. Children of <9 months are unconscious if they are unable to follow moving objects with their eyes (adapted from Molyneux et al)18.

Laboratory diagnosis

In many situations in Africa, laboratory facilities are not available, and it is therefore necessary to treat patients on the basis of clinical diagnosis alone. This, unfortunately, results in significant over-treatment with antimalarial drugs. When diagnostic facilities are available, a diagnosis of malaria is made in a child with any of


Box 3 Clinical features of severe malaria in African children

a) Danger signs (see Box 1)• Multiple convulsions• Prostration• Coma• Respiratory distress• Shock (weak rapid pulse, cool peripheries, slow capillary refill time)

b) Other features (less common)• Haemoglobinuria• Abnormal bleeding tendency

the symptoms in Box 3 plus detectable malaria parasitaemia. Malaria parasites may be detected by microscopy, or by rapid diagnostic tests (malaria dipstix).

The availability of laboratory tests other than microscopy depends upon the relative sophistication of the health facility. Any health facility in which seriously ill patients are being treated should, as a minimum requirement, have the capacity to measure blood glucose and haemoglobin/haematocrit. The provision of a rapidly available and safe supply of screened blood for transfusion is also highly desirable.

Note that none of these features is unique to severe malaria, but they indicate that the child is extremely ill, andneeds immediate treatment (see Box 2).

The treatment of uncomplicated malaria

The choice of oral antimalarial drug to treat a child with uncomplicated malaria is determined by national antimalarial drug policy and will not, therefore, be discussed in any detail here. It is essential to ensure that the drug is administered at the correct dose, and for the appropriate duration, since inadequate antimalarial treatment compromises the health of the child, and encourages the spread of drug resistance. Resistance to chloroquine is now wide spread in many parts of sub-Saharan Africa and, although sulphadoxine-pyrimethamine (SP) has been adopted as the first-line antimalarial drug in many countries, resistance rates of up to 45% have been recorded in parts of East Africa.2 This poses major economic problems for the majority of African countries, since alternative antimalarial drugs are considerably more expensive. To maximise drug efficacy, and to slow the relentless spread of resistance, countries are now being urged to consider the use of combination therapy, involving concurrent treatment with more than one antimalarial drug. This is discussed further in the article by Peter Olumese—see page 28.

In addition to effective antimalarial therapy, it is advisable to treat a febrile child with uncomplicated malaria with antipyretic drugs, such as paracetamol 15 mg/kg 6-hourly, for the first 48 hours of the illness. Oral fluids should be encouraged. It is essential to check the child for anemia, and to treat anaemic children with oral iron and antihelmintics (see below). Attendance at the health clinic also provides an opportunity to discuss with the mother the advantages of purchasing an insecticide treated mosquito net. These have been shown to reduce the incidence of malaria episodes by 48%, and all-cause mortality in children under 5 years by 17%.3


Anemia: the silent killer

Malaria, nutritional deficiencies, and intestinal helminth infections all predispose to anemia, which is estimated to affect more than 103 million children aged nine years or below in Africa. 4 In malaria-endemic regions of Africa, community surveys have shown the prevalence of anemia in children to be between 49% and 89%. 5–8 It has been estimated that severe malarial anemia causes 190 000–974 000 deaths annually in children under the age of 5 years,9 with the highest mortality observed among infants below the age of 1 year. The current risk of transmitting HIV and other blood-borne infections through blood transfusion (approximately 1% in areas with a high prevalence of HIV among the donor population)10 means that it particularly important to intervene early to avoid the development of severe anemia. Iron supplementation (3-4 mg elemental iron/kg/day for 14 days) should be given to all children with Hb <9 g/dL (Hct <27%). The data suggesting that iron supplementation increases susceptibility to malaria is extremely weak, and a recent consensus statement by the International Nutritional Anemia Consultative Group (INACG) favors the administration of iron to children in malaria-endemic regions.11 The administration of folic acid to anaemic children with malaria should be avoided, particularly in those children who have been treated with SP, a folate antagonist. Anaemic children who have not received antihelmintic treatment in the previous 6 months should be given a single dose of mebendazole or albendazole.

The treatment of severe malaria

Resuscitation

The key to reducing mortality from severe malaria is the rapid recognition of the clinical signs associated with a high mortality, and the immediate resuscitation of these children (see Boxes 1 and 2). Treatment of hypoglycaemia and restoration of normal circulating volume are the immediate priorities. The mortality of children with respiratory distress (deep breathing) and severe anemia (Hb < 5g/dL, equivalent to a Hct of <15%) is extremely high (up to 30%)12 and these children should be transfused rapidly, as indicated in Box 2. This is based on research demonstrating that, in this group of children, central venous pressure is low and is accompanied by a severe metabolic acidosis.13 Rapid transfusion of blood is well tolerated, and leads to rapid clinical improvement in the majority of cases.14

Drug therapy

Parenteral quinine dihydrochloride is the drug of choice. Patients should be given a loading dose of quinine (20 mg salt/kg as a slow intravenous infusion over 4 hours). This should be followed by the administration of a maintenance dose (10 mg salt/kg as a slow intravenous infusion over 2 hours), repeated every 12 hours. If intravenous infusion is not possible, quinine can be given at the same dose by deep intramuscular injection, diluted to a concentration of 60 mg salt/ml. At least three doses of parenteral quinine should be given. Oral treatment (a single dose of SP or, in areas of SP resistance, oral quinine (10 mg/kg three times daily) to complete a total of 7 days of treatment) should be substituted for i.v. therapy once the child is able to drink. Suppositories of artesunate, a rapidly acting and highly effective antimalarial drug, may soon be available in Africa. These are likely to be enormously valuable in situations where parenteral antimalarial treatment is not possible. Concurrent bacteraemia is found in approximately 12% of children with severe malaria, and is associated with a three-fold increase in mortality. 15It is therefore advisable to start parenteral antibiotics (ampicillin 50 mg/kg i.v. every 6 hours and gentamicin i.v. 7.5 mg/kg once daily) in children who remain severely ill following initial resuscitation.

Cerebral malaria

The term ‘cerebral malaria’ is used to describe unconscious children with P falciparum parasitaemia. Management (resuscitation, antimalarial therapy) is the same as for other forms of severe malaria. It is particularly important to detect and treat hypoglycaemia in any child with impaired consciousness. Following admission, a nasogastric (n/g) tube should be inserted, to avoid the risk of aspiration pneumonia. In addition, all children should have a lumbar puncture (LP), to exclude meningitis. A recent study found concurrent bacterial meningitis in 4% of children with cerebral malaria, the proportion rising to 14% in children below the age of 1 year.16 Children with cerebrospinal fluid results suggestive of meningitis, and all children in whom LP is not possible, should be treated for meningitis (benzyl penicillin 60 mg/kg i.v. 6-hourly, plus chloramphenicol 25 mg/kg i.v. 6-hourly for 7 days). Convulsions, which may be prolonged or multiple, complicate the clinical course of up to 80% of cases of cerebral malaria.17 Convulsions lasting for more than 5 minutes should be


treated with intravenous diazepam (see Box 2), or paraldehyde (0.2 ml/kg by deep intramuscular injection, or 0.4ml/kg per rectum). Each drug can be repeated at intervals of 10 minutes, to a maximum of three doses. Multiple (>3) convulsions, or those lasting for more than 30 minutes, can be treated with a single dose of phenobarbitone, 10 mg/kg i.m.

Supportive care and observation

Maintenance intravenous fluids (dextrose 4% saline 0.18% or equivalent) should be changed to 10% dextrose if recurrent hypoglycaemia is a problem. Once the child is able to drink, maintenance fluids and food should be given orally.

The clinical status of any severely ill child is changing continuously, and it is essential that regular clinical observations are undertaken. Pulse, respiratory rate, and an assessment of conscious level (using a standardised score, such as the Blantyre Coma Score)18 should, ideally, be assessed 4-hourly, with any deterioration prompting a search for the cause. It is vital to exclude hypoglycaemia (which is frequently recurrent in severe malaria, despite treatment) or a significant drop in haemoglobin, since these are easily amenable to treatment.

Conclusions

The provision of prompt and effective treatment for children with malaria forms one of the cornerstones of RBM, which aims to halve mortality from malaria by the year 2010. The identification and appropriate treatment of children within the community is the vital first step. It is then the responsibility of the clinician to ensure that those children who do reach the formal health services are given the best possible treatment.

© Dr J Crawley


Annex 4 –

Intervention Strategies for Pregnant Women According to Transmission Intensity

Case Management of Pregnant Women

Intermittent Preventive Treatment (IPT)

Insecticide-Treated Nets (ITNs)

HIGH or MEDIUM TRANSMISSION

PERENNIAL (STABLE)*

Risk for febrile illness and severe malaria limited.

Screen and treat anemia with recommended antimalarial drug and iron supplementation.

Provide pregnant women a standard IPTp**** dose at the first regularly scheduled ANC visit after quickening.

At each subsequent routine visit***** provide an IPTp dose, with a minimum of two doses given at not less than monthly intervals.

Begin use early in pregnancy and continue postpartum.

Emphasize including young children under ITNs.

HIGH or MEDIUM TRANSMISSION

SEASONAL (STABLE)*

Risk for febrile illness and severe malaria limited.


Provide pregnant women a standard IPTp**** dose at the first regularly scheduled ANC visit after quickening.

At each subsequent routine visit***** provide an IPTp dose, with a minimum of two doses given at not less than monthly intervals.

Begin use early in pregnancy and continue postpartum


LOW TRANSMISSION

(UNSTABLE)**

Risk for febrile illness and anemia high.

Promptly recognize and treat all potential malaria illness with an effective drug.


Consider P.vivax infection in East and Northern Africa and parts of Asia. ******

IPTp cannot be recommended in these areas, based on present evidence.

Begin use early in pregnancy and continue postpartum.



Case Management of Pregnant Women

Intermittent Preventive Treatment (IPT)

Insecticide-Treated Nets (ITNs)

EPIDEMIC TRANSMISSION

(UNSTABLE)***

Risk for severe malaria illness high.

Risk for febrile illness and anemia high.

Promptly recognize and treat all potential malaria illness with an effective drug.


Consider P.vivax infection in East and Northern Africa. ******

Not indicated. Begin use early in pregnancy and continue postpartum.


* Adult women have high level of acquired antimalarial immunity.** Adult women have no or very low level of acquired antimalarial immunity.*** Adult women have no acquired antimalarial immunity.**** Presently the most effective drug for IPT is sulfadoxine-pyrimethamine.***** WHO recommends an ideal visit schedule of three ANC visits after quickening, for a total of three IPT doses.****** CQ prophylaxis to decrease the burden of P. vivax in pregnancy may be considered, but no evidence on efficacy/effectiveness of this strategy is presently available.


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