Written by Super User Category: Malaria Information
Published on 04 June 2015 Hits: 2592
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Introduction

Malaria Advocacy Communication and Socio Mobilisation is a key component that supports all the strategic interventions for malaria control as contained in the Kenya Malaria Strategy. They include:

  • Promotion of the use of LLINs and other vector control methods.   
  • Access to prompt and effective case management.
  • Malaria epidemic preparedness and response.

ACSM aims at imparting knowledge and skills to the general public so that they can make informed decision and participate in malaria prevention, treatment and control activities. It also enhances malaria profile through continuous advocacy activities.

The ACSM main objective is to increase utilisation of all malaria control interventions by communities in Kenya to at least 80% by 2018.

ACSM will used the following strategies.

  1. Strengthen structures for the delivery of ACSM interventions at all levels.
  2. Strengthen program communication for increased utilisation of all malaria interventions.
  3. Advocate for inter-sector collaboration for malaria ACSM.
  4. Strengthen community based social and behaviour change communication activities for all malaria interventions.

 

  • Has trained CHMTs on malaria socio-behaviour change communication in 8 lake endemic counties.

  • Commemoration of World Malaria Day.

Challenges

Inspite of high knowledge level on malaria transmission, prevention and treatment, utilisation of recommended malaria interventions still remained low. This was due to:

  1. Limited focus on household inter-personal and interactive communication approaches: These approaches are able to identify barriers to increased utilisation of malaria interventions while developing innovative approaches to address barriers for positive behaviour change.
  2. Inadequate funding: This has limited the opportunity to exploit the use of community health structures for reaching households.
  3. Inadequate coordination and resource mobilisation for SBCC activities at county level: Counties rely entirely on resources provided at national level and are yet to mobilise resources locally.
  4. Non-health sector being passively engaged in advocacy of malaria within their sector: This enables malaria remains a health issue as opposed to a socio-economic burden which requires wide sector participation.
  5. Weak mechanism to monitor and report on ACSM activities thus lacking specific indicators to measure ACSM specific outcomes.

Malaria ACSM is the key in increasing utilisation of malaria control interventions.

komesha Malaria

 
Written by Super User Category: Malaria Information
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Strategic intervention: Malaria Case Management

The main objective of the case management strategic intervention is the provision of good quality, safe and effective treatment for malaria patients. It's objective as outlined in the Kenya Malaria Strategy 2014 – 2018 is to have 100% of all suspected malaria cases presenting to a health provider managed according to the national malaria treatment guidelines by 2018.

This objective will be achieved through the following strategies:

  1. Capacity building of health workers in malaria diagnosis and treatment at health facilities.
  2. Access to affordable malaria medicines and diagnostics through the private sector.
  3. Strengthening  community case management of malaria using the community strategy through Community Health Workers (CHW).
  4. Ensuring commodity security of anti-malarials and diagnostics in the public sector.

Kenya changed her treatment policy to the more effective ACTs in 2004 in line with the WHO recommendations for the management of uncomplicated malaria. The policy was implemented in June 2006. The table below shows a summary of the treatment policy.

Table 1: Summarized Malaria Standard Treatment Guidelines

Condition Medication Strength Formulation
Uncomplicated malaria Artemether-Lumefantrine tablets packed differently for the different weight categories 20mg Artemether + 120mg Lumefantrine Tablets single dose packed for the different weight categories
Severe malaria   Artesunate 120mg Vials
Artemether Vials
Quinine 300mg Ampoule
Quinine dihydrochloride 300mg tablets
Quinine bisulphate 300mg tablets
Quinine Sulphate 300mg tablets
Quinine hydrochloride 300mg tablets
Intermittent Preventive Treatment Sulphadoxine/pyrimethamine 500mg Sulphadoxine + 25mg pyrimethamine Tablets
Prophylaxis non-immune visitors Mefloquine hydrochloride 250mg Tablets
Atovaquone – Proguanil adult 250mg Atovaquone + 100mg Proguanil
Atovaquone – Proguanil pediatric 62.5mg Atovaquone + 25mg Proguanil
Doxycycline hydrochloride 100mg
Prophylaxis for sickle cell disease patients and persons with splenomegaly Proguanil hydrochloride 100mg Tablets
Pre-referral treatment Artemether injection

80mg/ml adult

20mg/ml pediatric

Vials
Artesunate injection 60mg/ml
Artesunate rectal caps 100mg or 400mg Suppositories
  • The ministry ensures that national guidelines for malaria diagnosis and treatment are distributed free of charge to both government and private sectors health facilities in order to ensure effective management of patients at all levels.

    • Artenether-Lumefemtrine (AL) drugs are provided at no cost to the patients in the public and mission health facilities.

      • Given the high cost of the AL drugs, it has been found prudent to ensure that there is confirmatory diagnosis of all suspected malaria cases, hence the government aims at improving diagnostics and using Rapid Diagnostic Tests (RDT) in peripheral health facilities without microscopy facilities.


Training of health workers on malaria case management

  • At the National level, treatment guidelines, training modules and reference materials on malaria diagnosis and treatment have been updated and are issued to health workers during training.

  • Training of health workers has been carried out targeting both government and private sectors.

  • NMCP and CHMT support supervision visits is regularly done to monitor the effective trainings of malaria case management. This is done by standard checklist which was developed by the National trainers.

  • The caretakers’ of febrile children common action is to seek care from private and OTCs. Private pharmacy and OTC staffs have been trained on malaria case management, recognition of severe malaria signs, referral advices and appropriate drug storage in order to improve prescriber practices among the outlets.



Access to effective care

  • In order to improve effective case management, it is important that care-seeking behaviours are changed. The care givers need to promptly seek care for febrile illness from a health facility or in a registered pharmacy and recognise the danger signs of severe febrile illness.

  • Due to this, the NMCP has made various efforts such as training health workers in both public and private health facilities in order to increase access to effective malaria case management.

  • In the endemic regions such as Nyanza and Western, CHW have been trained on the malaria case management and is currently being practiced in those regions.

 


Drug regulation, supply and effectiveness

  • Kenya Medical Supplies Agency (KEMSA) purchases drugs used in the public sector. It has its own quality control mechanisms. The ongoing liaison between the NMCP and KEMSA will ensure a continuous supply of high quality anti-malarial drugs to public health facilities.

  • The commodities once purchased are supplied to health facilities based on a distribution list generated by the NMCP. The system operates on a pull basis. The health facilities have been issued with tools for consumption reporting on a monthly basis. They record each dose dispensed and at the end of the month give a summary of stock status, consumption, stock out days and early expiries.

  • County pharmacists have been supported to do intra county re-distribution by moving the drugs from overstocked facilities to stock-outs facilities.

  • Pharmacovigilance, described as the science and activity relating to the detection, assessment, understanding and prevention of adverse effects or any other medicine-related problem has also been implemented by the Pharmacy and Poison's Board in Kenya. The NMCP which is keen on closely monitoring the safety of all anti-malarials in the country especially AL drug has been actively involved in the implementation of the system.

  • The main achievement includes training of the health workers in public and private health care workers on malaria case management.

  • The NMCP together with research organisation continues to monitor the efficiency of currently used and alternative anti-malarial treatments drugs every two years.

  • The NMCP undertakes annual surveys on the quality of anti-malarials in circulation as part of Post Market Surveillance in conjunction with the PPB, WHO, HAI Africa and NQCL and partners.



Diagnostics

  • Many health workers in the public and private sectors do the diagnosis of malaria on a clinical basis. In order to increase diagnostic capacity the NMCP has introduced RDTs at health facilities without microscopy in order to ascertain diagnosis. Microscopy has also been strengthened through supply of microscopes along with the training of health workers on microscopy.

  • Quality control mechanism for laboratory diagnosis is currently being implemented through trainings and regular support supervision visits at facilities with laboratory services in order to improve the performance of laboratory services to support the correct management of malaria cases and to detect malaria treatment failures.

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Written by Super User Category: Malaria Information
Published on 04 July 2014 Hits: 4993
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Overview

  • Malaria is a major public health problem in most countries of Africa. Over the past two decades, epidemics of plasmodium falciparum malaria often with high case fatality rates have been common in areas of unstable transmission in Africa. A large number of epidemics were reported in highland areas in East and Great lakes countries during the period 1985-1995.

  • In 1997-1998 when all countries in the sub-region Africa experienced malaria epidemic due to El Nino, Southern Oscillation (ENSO) now occurs at least yearly in several East Africa and Great lakes countries during the malaria transmission season.

  • Malaria epidemics occur in the western highlands, the arid and semi-arid lowlands of northern epidemiological zones in Kenya. The epidemics are associated with unusual climatic conditions especially rainfall and other factors such as suitable temperatures that favour breeding and longer survival of the malaria vectors.

  • Prediction methods for epidemics to alert implementers to either undertake epidemic prevention measures like Indoor Residual Spraying (IRS) or prepare to control the epidemic are still at developmental stages. Resources are scarce in developing countries finding it difficult to keep buffer stocks especially drugs to respond to outbreaks when routine services are without.

  • Once the epidemic has been detected the only cost effective measure is to institute case management activities. In the highlands, malaria prevalence above the epidemic threshold level last 4-6 weeks. Since the year 2000, major epidemics have been observed in the malaria epidemic prone districts. Malaria epidemics are some of the most serious public health emergencies with which health officials have to deal.

  • Malaria epidemics occur unexpectedly in areas where the health system is often unprepared to deal with the problem. They affect highly vulnerable populations (all age groups) with only limited immunity to malaria. This situation is exacerbated by public outcry and intense political pressure to intervene rapidly and decisively.

  • Epidemic conditions take few weeks to build up allowing time for preventive action. When it occurs, it takes several weeks to reach to its peak, effective control maybe possible if implemented in the early stages of development. The most important factor in reducing the impact of an epidemic is a timely response implementation of effective control measures as soon as it has been detected.

  • The longer an epidemic goes undetected with no measures for its control, the higher the cost of morbidity and mortality (Delacollette, 1999). Control measures are inherently costly. Implementation of control measures within a short delay after the epidemic has been detected might have some benefit. The maximum impact is however, when measures are implemented at the very early stages, usually within two weeks of onset, when deaths can be minimised.

  • Malaria upsurge is an annual event in the western highlands of Kenya which generally occurs between June and August. In some zones, the upsurges outdo the epidemic threshold. Widespread outbreaks of malaria epidemic involving the western highlands occur periodically and have been recorded between 1918 and 1950s when epidemic malaria was a scourge of the economically important Kenyan highlands.

  • Between 1950s and late 1980s the highlands enjoyed a free malaria epidemics period. This was as due to WHO driven eradication programme of the late 1950s which was terminated in the late 1960s (Republic of Kenya, MOH, 2001).

  • The most spectacular observed event in many occasions had been a dry spell preceding the outbreaks. The long rain season starts in April or May but the heat wave prevailing during the dry spell persists up to June or July. This is the most important factor that facilitates massive build up of vector density thus increasing the vectorial capacity.The increased transmission level of malaria in an area of susceptible population usually results in malaria epidemics.

The table below shows the association of anomalous weather conditions with malaria epidemics in Nandi District, Kenya. (Correlation of a 10-year retrospective data study- DOMC/WHO 2002)

Year Epidemic Unusually High Temperature Unusual Rainfall Unusual Humidity
Maximum Minimum    
 1986  **
 1987  Minor  **  **
 1988  Minor  **  **  *
 1989  **  *  *
 1990  Major  **  **  **  **  **
 1991  Major  * **  **  **
 1992  *  *  *  *
 1993  *  *  *
 1994  Major  **  **  **  **  **
 1995  **
 1996  **
 1997  Major  **  **  **  **
 1998  Minor  *  **  **  **
 1999  Minor

 correlation graph malaria outpatients  

  • Kenya northern arid and semi-arid lowlands are low malaria transmission areas. Malaria epidemics occur only during prolonged periods of flooding as observed during the EL Nino in 1998.

  • The temperatures are always right for the malaria vectors to breed when water is available and prolonged flooding makes such conditions to prevail. Other periods have short rain spells that do not enable build up of malaria vectors to levels that can result in malaria upsurge reaching the epidemic threshold proportions.

  • The national policy advices IRS in the epidemic prone Western highlands of Kenya in order to prevent the malaria upsurge.

  • Kenya National Strategic Plan of 2014-2018 identifies epidemic preparedness and response as a key approach to the control of malaria in the country. It proposes the development of a cost-effective monitoring system that includes forecasting, early warning and detection.
  • This will either lead to early recognition of epidemics and immediate implementation of control measures or the implementation of preventive measures before the epidemic starts. These efforts will improve the management of epidemics and reduce morbidity and mortality during epidemics.

  • The key to decisive reaction in the prevention and control of malaria is ‘preparedness.’ This means that effective surveillance and case detection will remain key to instituting response measures in the meantime. This is because the development of early warning systems is still in its developmental stages. However, so far this strategy has not worked well for the malaria epidemic response and containment in Kenya.
  • The strategy recommends that 80% of detected epidemics be contained within reasonable time. Due to the current health information systems (HIS) performance, it has been very difficult to detect epidemics as they build up, yet this is the ultimate requirement for effective response so as to significantly affect the magnitude or even avert it.
  • This scenario has made the Ministry of Health to modify its approach to malaria epidemic management. Since 2005, there has been a shift from the “preparedness and response” approach to the epidemic prevention and control approach.
  • The use of Indoor Residual Spraying (IRS) as a lead intervention in averting malaria epidemics in the highlands is a priority for the Ministry of Health. The NMCP, previously the Division of Malaria Control has been implementing well timed and coordinated IRS campaigns in 16 districts viewed to be highland epidemic prone. The counties are tabulated below:

Province County
Rift Valley West Pokot
Trans Nzoia
Uasin-Gishu
Nandi North
Nandi South
Kericho
Koibatek
Bomet
Narok
Buret
Trans-Mara
Western Mt.Elgon
Lugari
Nyanza Nyamira
Kisii Central
Gucha

irsperfomanceDue to the heavy resource needs for the IRS campaigns, the Government of Kenya opted to scale up coverage in the 16 counties. The initial approach was to prioritise high risk areas within the counties and eventually progressively spiral to the entire counties. Due to increased support from the WHO, Global Fund and USAID, tremendous progress in terms of coverage has been realised. This is depicted in the IRS figure alongside.   

  • The success of the malaria epidemic control relies on the choice of intervention to be undertaken at every stage within the epidemic cycle. The preparedness and response strategy requires the retention of buffer stocks of drugs, blood banks and infusions.
  •  

  • However, it is difficult to estimate the resource requirements including the right placement. This is heavily hinged on effective and prompt diagnosis as well as case management.
  •  

  • Long lasting insecticide-treated nets (LLINs) and insecticide-treated bed nets (ITNs) can be useful in containing epidemics among the nomadic communities. The two are effective since they are tools that can be easily carried or used anywhere provided they are used correctly.
  •  

  • Other vector control methods may also be employed. However, due to the acuteness of the epidemics, there is often a very short lead time to enable a credible response to be mounted.
  •  

  • The use of methods such as environmental management, house screening and biological agents of control is practically difficult. The methods may fail to produce the rapid desired effects on transmission in epidemic situations.
  •  

  • Ideally, these vector control options should be implemented on a routine basis as part of the community strategies and as control approaches to reducing malaria causing vectors. It is important to note that these methods have been implemented in Kenya over time.
  • nguli spraying

     

  • However, due to lack of capacity to sustain them, they have yielded limited results in terms of malaria epidemic control. Only one county, Trans-Nzoia county has been able to utilise this strategy widely under a programme referred to a 'healthy villages'.
  •  

  • In other areas such as in lowlands, arid and semi-arid, the prediction of malaria epidemics is very difficult. This also makes the epidemic control difficult. Although vulnerability assessment of factors such as prolonged drought, preceding heavy rainfall and flooding can provide forecast, the expansive nature of the settlements and nomadic nature of the population makes it difficult to institute any epidemic prevention strategy.
  •  

  • The common approach has been to focus on effective diagnosis and prompt treatment of cases. It is important to note that the use of ITNs/LLITNs is also very useful among internally displaced persons during floods.




Article Prepared By
J Sang - Division of Malaria Control
Ministry of Health

 

 
Written by Super User Category: Malaria Information
Published on 04 July 2014 Hits: 1434
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DOMC Malaria Research Unit.

  • The Global communities have been renewing commitment towards control and prevention of malaria for more than a decade. The first step towards this effort was to meet all Ministers of health from malaria endemic countries in Amesterdam in 1994. The resolution created malaria control units/structures within the Ministries of Public Health and development of strategic plans of Action.
  • Kenyan government launched her Plan of Action in April 1994. It further renewed its effort with the World Health Organization embalming the Roll Back Malaria initiative (RBM).
  • The RBM movement brought all malaria players together increasing resources toward malaria control and adopting sound and feasible strategies.
  • The formation of technical committee to oversee the implementation of technical sound malaria interventions made recognition of malaria researchers and malaria research institutes.
  • Reviewed research work was strategically positioned in planning for feasible intervention measures. Regular review of meetings, malaria conferences, and presentation during the malaria stack-holders forums become common.
  • The first GOK malaria plan of action was reviewed in 2001 and runs up to 2010 with malaria intervention strategies indicated elsewhere.
  • All the intervention strategic approaches have to be guided by operational research as they must be based on evidence. For examples, in malaria vectors control, insecticide treated bed nets and long lasting insecticide treated nets have been proven by researchers to be one of the most effective methods of preventing malaria infections.
  • Based on these findings, many Africa governments including the Kenyan government have scaled up this intervention which have resulted into low morbidity and mortality.
  • The second example may be drawn from regular change of anti-malaria drug policy. In 1998, studies from eight sites revealed that there was an 85% failure rate in the use of chloroquine drug as first line treatment in areas such as Kisumu.
  • The country adopted SP as replacement for chloroquine drug as the first line of treatment. Within 5 – 6 years of the SP introduction, resistance to SP reached 25% high in some of the eight sites. These again call for yet another policy change in 2004, where the country adopted AL . The life span of AL cannot be predicted but operational research unit is following any possible resistance to this drug in readiness to inform policy.

    Updates

    Activities planned for implementation in 2007/2008 

    Operational research Priority areas
    • Network coordination of partners working in malaria research institution.
    • Evaluation and maintenance of updated records of pesticides which are useful in control of malaria vectors.
    • Coordinated national malaria research agenda.
    • Country specific data on RDTs use available.
    • Specific data on 1st and 2nd line antimalarial drug efficacy.
    • Country specific Data on ACT drug policy implementation and therapeutic effectiveness.
    • Country specific data on piloting ACTs in the informal sector.
    • Provision of evidence base on ITN/LLIN distribution mechanism.
    • Country specific data on public health insecticide, LLIN efficacy and IRS operational performance.
 
Written by Super User Category: Malaria Information
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Surveillance Monitoring, Evaluation  and Operational Research (SMEOR)
The National Malaria Control Programme has the responsibility to monitor the Kenya Malaria Strategy's success toward its stated targets, work in collaboration with national partners to identify ways to measure its intended goal achievement and actively solicit and advocate research to refine strategic approaches. The SMEOR activities are  guided by the Monitoring &Evaluation and the Operational Research Technical Working Groups which comprise various partners. These two groups were actively involved in the revision of the National Malaria Strategy 2009-2017 and monitoring and Evaluation plan and have helped in the development in the revised Kenya Malaria Strategy 2014-2018 and the Monitoring and Evaluation plan 2014-2018
 According to the Malaria Policy
The Government of Kenya shall ensure that:
•    The M&E of malaria activities in Kenya is guided by a comprehensive national Malaria M&E Plan
•    M&E becomes an integral and relevant part of malaria Control and adequate resources are committed to its implementation
•    There is efficient monitoring and evaluation of the strategic approaches to malaria prevention control
•    Joint annual performance reviews of operation plans are conducted
•    Targeted operational research that informs malaria control policy and strategy are promoted and supported
•    Collaborating research partners are engaged to translate research output into policy
•    Effective channels of communication and dissemination of research findings are promoted
The monitoring and evaluation plan contains all the indicators, their source and frequency for their measurement to fulfil the monitoring and evaluation of the malaria control activities in Kenya and thus guide implementing partners what ought to be measured. These indicators are harmonized with guidance from the World Health Organization documents.
In the recent past the Malaria Control Programme has produced several M&E products like the Annual Malaria Reports and the quarterly malaria surveillance bulletins which is circulated quarterly to malaria partners. These products are available for downloading in the resource centre.

Survey data
To assess the overall impact of the National Malaria Strategy on the health of the community at large the malaria programmes uses two surveys to inform itself:
1)    the Kenya Malaria Indicator Survey: These surveys are to be conducted every 3 years. The NMCP has conducted two Kenya Malaria Indicator Surveys (KMIS); the first was conducted in  2007 and then followed by KMIS 2010. These surveys have been used to inform strategic direction. The programme is preparing itself for the KMIS 2015 which will inform of progress from 2010 and well as coverage of malaria interventions. The KMIS is conducted every three years, it was supposed have been conducted n 2013 but since the KDHS was planned during that same period the KMIS was postponed to 2014 and then to 2015 because of the KDHS.
2)    Kenya Demographic Health Survey: This is conducted every 5 years in collaboration with the health sector and informs the program on child mortality indicator of 20% is attributed to malaria. The NMCP is usually involved in the KDHS planning, fieldwork and also report writing.

To monitor our malaria out -patient quality of care in public facilities health facility surveys are conducted every 6 months since 2010. It monitors availability of malaria case management commodities and health worker adherence to the national guidelines. The latest report is available on the this website.

Routine Data
The NMCP in concert with the Health Management Informatics Unit has revised the registers used in the health facilities so that variables that satisfy the malaria indicators are captured. Currently the malaria programme uses the District Health Information Software (DHIS) to get its routine information from the outpatient, antenatal Care clinics and the Child welfare clinics. Information on logistics management for the case management commodities (RDTs and ACTs and SPs) are tracked through the Malaria Commodity form that is housed in the DHIS. This assists in the quantification and forecasting of our commodity needs.
For malaria surveillance activities routine information is accessed through the electronic Integrated Disease Surveillance system (e-IDSR). This information assists the epidemic prone areas and seasonal transmission areas in the detection of evolving malaria epidemics. Trainings have been conducted on malaria surveillance including entomological surveillance for health workers in seasonal transmission areas. This is so that they can detect epidemics since in the past it was only the epidemic prone areas that received this capacity building.
Data from the two routine systems is used to produce the quarterly surveillance bulletin which comprises the WHO surveillance graphs and some tables broken down by County. This bulletins are circulated every quarter to the Counties and other partners.


Operational Research
The NMCP has conducted a two malaria fora (in 2012 and 2014 respectively) that brought together policy makers and researchers so that latest information in the malaria field could be shared. The reports of the forums are available in the resource centre. The evidence presented at the forum will be used to revise the Malaria Operational research agenda. The OR TWG will meet annually to revise the research agenda and to discuss progress on the research questions. It will hope to resource mobilize for 3 research questions per year form nay intervention area.
Malaria M&E needs assessment
The NMCP underwent the above activity in 2013 which identified needs of the programme. The same was administered to the Counties and an M&E capacity building plan was formulated from the above results.
The Malaria Information Acquisition System (MIAS)
The M&E unit, with support from USAID, is setting up a Malaria Information Acquisition System (MIAS) that will collate malaria information from HMIS, IDSR, surveys, operational research papers and other sources so that analysis of processes and interventions can be done. It will also have a financial component that will help in the tracking of finances.  The MIAS will also help in generation of reports of various activities that the NMCP has undertaken with its partners.

 

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