Transcript Health - Stomping Out Malaria in Africa

Introduction to Malaria Prevention 2
Malaria Prevention and Control
Office of Overseas Programming &
Training Support (OPATS)
Session Learning Objectives:
1. By the end of the session, participants will list at least three malaria
prevention strategies and explain which strategies are promoted by
the Ministry of Health or National Malaria Control Program in their
host country.
2.
Using what they have learned from their host families and from their
participation in the training session, participants will cite the three
most common post-specific barriers (physical or behavioral) to net
usage, and strategies to overcome these barriers.
3.
By the end of the session, participants will articulate their role in
malaria prevention, elevator speech style, in relation to the goals of:
• the U.S. President’s Malaria Initiative
• Peace Corps’ Stomping Out Malaria in Africa initiative
• the National Malaria Control Program at their post
High Risk Groups
HIV Positive
Pregnant mothers
Non-immune foreigners
such as Peace Corps Volunteers…
Children (especially <5)
Diagnosis
Microscopy
• The gold standard
• Requires trained clinicians, electricity, equipment
• Measures BOTH presence AND severity of malaria
Rapid Diagnostic Tests
• RDTs are highly effective (high 90s% accuracy)
• Don’t require extensive training for the clinicians,
electricity, cold chain, etc.
• ONLY measures the presence, NOT severity, of malaria
Clinical Diagnosis
• Looking for occular whitening, retinal hemorrhaging,
jaundice, splenomegaly
• A viable alternative in places where there are no
advanced diagnostics available
Treatment and Resistance
Resistance
• Drug combinations are better than monotherapy
• Incorrectly taking drugs increases the chance of resistance
development – there’s a BCC goal here…
• Significant resistance to chloroquine and sulfadoxinepyremethemine. Artemisinin resistance negligible but growing
• Resistance does not necessarily mean 100% resistance
Current WHO-approved treatments
• ACTs are the WHO-recommended treatment for uncomplicated
malaria
• Complicated malaria is beginning to be treated with IV ACTs
though the use of IV quinine is still common
The Dark Side
• A Global Fund study in 2011 found over 50% of all malaria
drugs taken in Africa were NOT WHO recommended –
monotherapies or counterfeits
• Encouraging people to seek real ACTs is vital!
The Four Pillars of Malaria Prevention
Early Care
Seeking
IRS
IPTp
Well Trained
Community Health Workers
LLINs
Early Treatment
It takes 2 to tango transmit
Early treatment not only increases the
patient’s chance of a good outcome –
it also REDUCES THE CHANCE OF
TRANSMITTING TO OTHERS!
Indoor Residual Spraying/Covering
•
•
•
•
Kills mosquitoes where they like to rest
Chemicals are safe
Resistance is an issue
IRS is expensive: $5 - $30 per household
depending on the chemical used
• Requires well-trained technicians
• Impregnated wall coverings are a new solution
14.8cm
Evidence of Impact
21
Figure 3. Impact of roof type on ZeroVector® Durable Lining (DL) efficacy
[Mali, 2009]
% Mortality
100
90
80
70
Bioassay using lab-reared Anopheles sp.
2 cones/ wall, 10 min exposure, 24 hour
mortality
Indoor Residual Spraying/Covering
Q: Hey, waaaaaiiiit a minute… Didn’t Al Gore say poison was bad?
A: While no one likes the idea of spraying chemicals in the home,
all chemicals used in IRS must pass a strenuous WHO testing
regimen detailed here: http://www.who.int/whopes
Q: Isn’t there a controversy about the use of DDT
for this application?
A: While DDT has been approved for this use,
almost all countries have moved away from its use
for the simple reason that many mosquitoes are
now resistant to it.
Intermittent Presumptive Treatment
for pregnant women - IPTp
• Pregnant women are particularly susceptible to malaria
• Malaria parasites may “hide” in the placenta making testing for malaria difficult
• Malaria in Pregnancy (MiP) can cause anemia, low birth weight and infant death
IPTp
Preventative measures
• Sleep under an LLIN
• Presumptive Treatment (IPTp) of
sulfadoxine-pyrimethamine (SP) – at least
two doses given at least a month a part
starting at quickening
At the Antenatal Clinic (ANC)
• In addition to IPTp, micronutrient
supplements (iron/folate) are provided
• Key service provider to pregnant women.
Q: Heeeeey… wait a minute… didn’t you say that there was a lot of resistance to sulfadoxine-pyrimethamine (SP)?
A: Why yes we did. There is a significant amount of resistance to SP in the parasite population in Africa and it is no
longer recommended for non-pregnant adults. BUT due to the specific nature of malaria in pregnancy – the
tendency for the parasite to sequester itself in the placenta and the specific form the parasite takes in order to do
so – SP is still effective and recommended for pregnant women!
Long Lasting Insecticide-Treated Nets
(LLINs)
Modern LLIN –
Good for roughly 20 washes
Older nets Required periodic re-treatment
LLINs – The Community Effect
In communities with low coverage rates,
mosquitos are deflected from net users.
The users malaria burden goes down but
it only marginally decreases the overall
burden of malaria on the community,
mostly it shifts the burden to those who
don’t have nets.
When a village has Universal Coverage
(defined as 80%), you can actually decrease
the vector population and with it:
• Child mortality of the entire community
• Burden on the health post
• Scholastic absenteeism
• Etc.
Quiz Show
1) Achieving Universal Coverage is vital because when
over 80% of a population sleeps under a mosquito net
they achieve a “ _________ effect” which reduces the
vector population.
a) community
b) knock-down
c) vector
d) Lagrange
2) IRS and LLINS cancel each other out and should NOT
be used together.
a) True
b) False
3) Due to the difficulty of detecting placental malaria
and its severe effects, pregnant women are
presumptively treated with
a) Artemisinin
b) Dihydro-oxygen
c) mefloquine
d) Sulfadoxine-pyremethemine
4) Encouraging Early Care Seeking Behavior is difficult
because:
a) Many adults have survived multiple cases of
malaria and don’t consider it life-threatening
b) Adults may not be aware that they are capable
of passing on malaria when they are symptomatic
c) They may not have the economic means to pay
for treatment
d) All of the above
5) Which of the following is NOT TRUE about Indoor
Residual Spraying (IRS)?
a) Resistance is an issue because of agricultural
use of similar insecticides
b) It is effective because mosquitos tend to rest
on the interior walls of dwellings
c) It is inexpensive
d) It requires skilled technicians to apply correctly
Quiz Show
1) Achieving Universal Coverage is vital because when
over 80% of a population sleeps under a mosquito net
they achieve a “ _________ effect” which reduces the
vector population.
a) community✔
b) knock-down
c) vector
d) Lagrange
2) IRS and LLINS cancel each other out and should NOT
be used together.
a) True
b) False✔
3) Due to the difficulty of detecting placental malaria
and its severe effects, pregnant women are
presumptively treated with
a) Artemisinin
b) Dihydro-oxygen ?
c) mefloquine
d) Sulfadoxine-pyremethemine✔
4) Encouraging Early Care Seeking Behavior is difficult
because:
a) Many adults have survived multiple cases of
malaria and don’t consider it life-threatening
b) Adults may not be aware that they are capable
of passing on malaria when they are symptomatic
c) They may not have the economic means to pay
for treatment
d) All of the above✔
5) Which of the following is NOT TRUE about Indoor
Residual Spraying (IRS)?
a) Resistance is an issue because of agricultural
use of similar insecticides
b) It is effective because mosquitos tend to rest
on the interior walls of dwellings
c) It is inexpensive✔
d) It requires skilled technicians to apply correctly
We must all hang together or…
Square net
Round or “hoop” nets
Baby net
NOTE: These are available in many markets but are
rarely treated – offering only a physical barrier.
How hanging can go wrong
 What are some things to look out for when
hanging nets?
 What are some ways that you’ve seen nets get
damaged?
How hanging can go wrong
 Nets hung too high are repeatedly stretched
 Nets hung too low are stepped on and are
more likely to blouse out to the point where
they can be burned by nearby candles
 Nets hung too low can also catch on sharp
bamboo or sticks on the bed
Challenging hangings
Hindrances to a habit of hanging
 What are the behavioral barriers to net
hanging?
 How about physical barriers that don’t pass
the sniff test – “I don’t have string” – that are
really behavioral barriers?
 How can we overcome them?
Taking it to scale
Thank you
"Our response to this problem will define this
generation. What will you say when your children ask
you, 'How did you let so many women and children
die when you had the ability to save them and you
knew?' Will we say that we didn't care, that we didn't
care enough? This situation is solvable.”
- Cynthia Scharf, UN Office for the Coordination of
Humanitarian Affairs
(Jan. 3rd, 2007)