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IMPROVING MALARIA DIAGNOSTICS AND MANAGEMENT SKILLS
Almost three-quarters of the population in Ethiopia are at risk for malaria.
“In many ways, malaria is the central health issue for people here,” said Dr. Bereket Hailegiorgis, the director of the malaria laboratory diagnosis & monitoring project at ICAP-Ethiopia. “With most of the population living in favorable eco-climatic factors for breeding of the mosquito—meaning altitude, rainfall, temperature and humidity—they live with the daily concern of acquiring the disease. It’s a common concern, and it can be very deadly.” Malaria is the leading cause of illness in the country, and responsible for 20 percent of the death among children below five years of age.
One of the largest national malaria epidemics occurred in 2003-2004, with more than two million clinical cases of malaria recorded in 211 districts. This one epidemic killed an estimated 45,000. In 2005, malaria was the leading health problem accounting for 25 percent of inpatient deaths and 47 percent of child mortality. In recent years, Ethiopia has made significant strides in expanding coverage of key malaria interventions throughout the country, through the commitment of the government and national stakeholders as well as through support from the Global Fund to Fight AIDS, Tuberculosis, and Malaria, the U.S. President's Malaria Initiative, and other funders.
Major scale-up efforts began in 2004-2005, with the introduction of artemisinin-based combination therapy as the first line treatment and expanded use of rapid diagnostic tests. At the same time, prevention efforts expanded through vector control of mosquitoes and the wide distribution of long-lasting insecticidal bed nets with indoor residual spraying of insecticides. The 2006-2010 National Strategic Plan aimed to rapidly scale up malaria control interventions to achieve a 50 percent reduction of the malaria burden. In 2007, the U.S. President’s Malaria Initiative (PMI) began in Ethiopia, complementing the focus on the disease.
ICAP partnered with PMI in Ethiopia in October 2008, working primarily with select hospitals, health centers, and health posts in the Oromia Region to improve the quality of malaria laboratory diagnosis. Oromia is the largest of Ethiopia’s 11 regions, and includes the nation’s capital Addis Ababa. The region includes more than 350,000 square kilometers from the western border to the southwestern corner of the country, comprising one third of Ethiopia’s land mass and including roughly 35 percent of its population.
As a first step, ICAP collaborated with Ethiopia’s Ministry of Health, the Ethiopian Health and Nutrition Research Institute (EHNRI), PMI/USAID, and other in-country malaria partners to conduct a planning workshop on malaria laboratory diagnosis and quality assurance in December 2008. Several key objectives were identified: (1) to conduct a baseline assessment of laboratories in the region, (2) to develop laboratory diagnostics quality assurance guidelines, and (3) to create a standard national training manual for malaria diagnosis.
An initial baseline assessment at 70 facilities in Oromia revealed critical shortages in supplies and equipment. “Most facilities lacked basic necessities such as microscopes, laboratory consumables, and centrifuges,” noted Hailegiorgis. PMI/USAID Ethiopia provided funding for necessary materials, equipping the target facilities with at least a year's worth of supplies.
Through the leadership of the EHNRI, ICAP has facilitated engagement of the national technical team that developed National Malaria Laboratory Diagnosis External Quality Assessment Scheme Guidelines, an essential tool for objectively measuring the quality of testing at the facilities. ICAP also assisted in development of standard operating procedures (SOPs) that are critical for standardizing testing practices across the country. The first round of the blinded-rechecking external quality assessment program was initiated at 57 facilities in June 2010. Held three times a year, it will be reinforced by regular onsite supervisions.
ICAP-Ethiopia’s country director, Zenebe Melaku, said, “For these standards to be put into practice, it’s essential that we train and mentor the clinical and laboratory staff that need to live with them.” Additionally, ICAP and EHNRI worked in close collaboration to develop SOPs and job aids for malaria microscopy to assist laboratory staff on an ongoing basis. So far, ICAP has trained 156 laboratory personnel from 57 health facilities.
ICAP also sought to improve fever case management alongside enhancement of malaria diagnostics. Baseline assessments indicated from facilities showed that less than 30 percent of fever cases received a confirmatory laboratory test, leading to potentially unnecessary treatment. “Under conditions where clinicians have little trust on the quality of testing, most of patients coming in with a fever were given anti-malaria medications that they might not have needed,” explained Hailegiorgis. “Now with appropriate training, equipments, consumables, SOPs, job aids, and guidelines given to the laboratories and initiation of the EQA program, we ask clinicians to rely on the test results and manage their patients accordingly.” ICAP has provided training for 117 clinicians from 54 facilities on the approach to diagnosis and management of patients with fever. Training was also provided to an additional 61 clinical staff who provide care for persons with HIV to inform them of appropriate management of patients with HIV and malaria co-infection.
A training event for program managers and supervisors is planned for October 2010. Melaku explained, “We want to improve the supervisory skills of the program managers. We want also to train district malaria program managers and health extension worker supervisors in malaria rapid diagnostic testing and onsite supervisory skills, so they can in turn train those who work at the many health posts in the country where patients with fever often present.”
New Pediatric Provider-Initiated HIV Testing and Counseling (PITC) Guidelines and Training Package for Zambia
In Zambia, an estimated 95,000 children are estimated to be living with HIV/AIDS, yet the majority of children have not been tested for HIV. Pediatric provider-initiated HIV testing and counseling (PITC) services support the routine HIV antibody testing of children as the first step to accessing vital HIV care and antiretroviral treatment. ICAP, in collaboration with Zambia’s University Teaching Hospital Pediatric Center of Excellence, Zambia’s Ministry of Health, and UMDNJ-François Xavier Bagnoud Center, have worked together to develop the national pediatric PITC guidelines and training package. The complete package of materials is being disseminated nationally to support the scale up of pediatric PITC programs. The materials can be accessed here.
Training in Nigeria Teaches Tailors
Mimi Support Group Cooperative Society helps people living with HIV who receive care at General Hospital Adikpo in Benue State (Mimi translates to “truth” in the local language Tiv). The 250-member support group has recently pooled all their savings and with community support, has established a training center in a rented shop within the town of Adikpo. Sewing, embroidery, and weaving machines are now available for the support group members where they learn how to make clothes for sale to the Adikpo community. Seember Steven, peer educator and support group member reflected on the emotional as well as economic benefits of the group. “The support group has helped me to come out from hiding [and allowed] public disclosure of my status.”
El-Sadr Testifies before Congress
ICAP Director Wafaa El-Sadr was invited to testify before the U.S. Congress Committee on Foreign Affairs at a hearing entitled “PEPFAR: From Emergency to Sustainability and Advances Against HIV/AIDS.” Held on September 29, the hearing also featured Ambassador Eric Goosby (the U.S. Global AIDS Coordinator), Thomas Frieden (CDC), Anthony Fauci (NIAID), and Paula Akugizibwe (AIDS and Rights Alliance for Southern Africa). A Real Player webcast of the session is available here (El-Sadr is featured starting at 1:48:27). The video of the hearing is available here. For the transcript of El-Sadr’s testimony, click here.
Elaine Abrams Co-Authors Two Studies that Inform Management of Children with HIV
Elaine Abrams from ICAP, the Mailman School of Public Health, and the Columbia University College of Physicians & Surgeons was a co-author for two recent articles addressing the optimal antiretroviral management of HIV-infected infants and young children. Featured in the October 14 issue of New England Journal of Medicine, “Antiretroviral Treatment for Children with Peripartum Nevirapine Exposure” (available here) by Paul Palumbo (lead author) and the IMPAACT protocol 1060 investigators showed that among children with prior exposure to single-dose nevirapine for perinatal prevention of HIV transmission, initial antiretroviral treatment consisting of zidovudine and lamivudine plus ritonavir-boosted lopinavir resulted in better outcomes than did treatment with zidovudine and lamivudine plus nevirapine. In the September 8 issue of JAMA, the paper, “Reuse of Nevirapine in Exposed HIV-Infected Children After Protease Inhibitor-Based Viral Suppression,” (available here) by Ashraf Coovadia (lead author) and investigators from the Neverest Study, examined an innovative antiretroviral treatment strategy for HIV infected infants previously exposed to nevirapine for perinatal prevention. They demonstrated that approximately 80 percent of children switching to nevirapine-based treatment after viral suppression on an initial ritonavir-boosted lopinavir regimen are able to maintain viral suppression and propose that this strategy may be feasible in settings where viral monitoring is available.
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