Presentation on theme: "Introduction to Malaria Prevention 2"— Presentation transcript:
1Introduction to Malaria Prevention 2 Malaria Prevention and Control
2Session Learning Objectives: 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.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.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 InitiativePeace Corps’ Stomping Out Malaria in Africa initiativethe National Malaria Control Program at their post
3High Risk Groups HIV Positive Pregnant mothers “Though every human is capable of being infected by the malarial parasite, a few groups are in much greater danger if they happen to catch it. When individuals from these groups get malaria, there is a much higher risk of death. These especially vulnerable groups are small children (typically under the age of five), pregnant women, people living with compromised immune systems (usually due to HIV), and foreigners (who have no built-up or innate immunity). People living in endemic zones have some immunity to malaria, either from prior exposure during childhood, or through genetics.”Non-immune foreigners such as Peace Corps Volunteers…Children (especially <5)
4Diagnosis Microscopy Rapid Diagnostic Tests Clinical Diagnosis The gold standardRequires trained clinicians, electricity, equipmentMeasures BOTH presence AND severity of malariaRapid Diagnostic TestsRDTs 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 malariaIMPORTANT!“There are three primary diagnostic tools used to detect cases of malaria – clinic diagnosis (this means directly observing the symptoms), Rapid Diagnostic Testing, and microscopy. These tools are used by clinicians to determine firstly, whether a patient has malaria, and (in the case of clinical diagnosis and microscopy) the level of severity of the infection.The ‘gold standard’ for malaria diagnosis is examination of blood under a microscope. Microscopy can both distinguish between malaria and other febrile diseases (presence or absence of Plasmodium in the bloodstream) and quantify the severity of the infection (number of parasites). Unfortunately, to achieve this a microscope, electricity and a trained professional are required which can be difficult in isolated rural settings. Many patients have no access to microscopic diagnostics.New developments in rapid diagnostic testing (RDT) are improving access to malaria diagnostics. RDTs can be used by people with limited training and do not require cold chain or electricity. RDTs are inexpensive, and their use can cut down on the (significant) prescription of malaria drugs for other febrile illnesses that can lead to drug resistance in the parasite.“In extremely isolated areas where neither microscopy nor RDTs are available, clinical diagnosis (using the symptoms to diagnose) is possible for cases of severe malaria. Severe malaria tends to cause a signature hemorrhaging of the retina and jaundicing of the eye generally which is not seen in other febrile diseases. Clinical diagnosis is NOT very effective at distinguishing between simple malaria and other tropical febrile diseases with similar symptoms. For this reason, historically, in malaria endemic areas all fevers were treated as malaria. While this is still true in many areas (particularly for children under 5) many countries are trying to increase the use of RDTs to diagnose malaria before treatment because the tests are less expensive than the treatment and not all fevers are malaria.”Clinical DiagnosisLooking for occular whitening, retinal hemorrhaging, jaundice, splenomegalyA viable alternative in places where there are no advanced diagnostics available
5Treatment and Resistance Drug combinations are better than monotherapyIncorrectly taking drugs increases the chance of resistance development – there’s a BCC goal here…Significant resistance to chloroquine and sulfadoxine-pyremethemine. Artemisinin resistance negligible but growingResistance does not necessarily mean 100% resistanceCurrent WHO-approved treatmentsACTs are the WHO-recommended treatment for uncomplicated malariaComplicated malaria is beginning to be treated with IV ACTs though the use of IV quinine is still common“Artemisinin combination therapy (ACT) is currently the medicine of choice and the only treatment for uncomplicated malaria recommended by the World Health Organization. Complicated cases of malaria are increasingly being treated with ACTs as well, though the use of IV quinine is still common.The use of combination therapies (drug cocktails with 2 or more active ingredients) is important since the malaria parasite has shown an ability to evolve resistance to anti-malaria drugs given as monotherapy, such as chloroquine and sulfadoxine-pyremethemine (SP).“Using combination therapies cuts down the selective pressure for the parasite to develop resistance to any of the drugs used in the therapy.“It’s important to understand that when discussing resistance, a measure of resistance in the parasite population does NOT mean that a drug is 100% ineffective. Though there is a measure of artemisinin monotherapy resistance in some locations, given in the right dose, artemisinin is still capable of clearing malaria.“Though ACT is the WHO standard, sub-standard or fake ACTs and older artemisinin monotherapies therapies are still available in many pharmacies in Africa. Pharmacies and drug vendors also often sell chloroquine and SP, in spite of the evidence that these are increasingly less effective against malaria.The Dark SideA Global Fund study in 2011 found over 50% of all malaria drugs taken in Africa were NOT WHO recommended – monotherapies or counterfeitsEncouraging people to seek real ACTs is vital!
6The Four Pillars of Malaria Prevention Early Care SeekingIRSIPTpLLINs“Once someone has malaria it’s a matter of treatment, but ideally we’d like to stop malaria before it even gets to a person, and there are some very basic things that we can do to make that happen.The pillars of malaria prevention are early care seeking, indoor residual spraying (IRS), intermittent presumptive treatment for pregnant women (IPTp), and the use of long-lasting insecticide-treated bed nets (LLINs) - all of which is built on a foundation of a functioning system of community health workersWell TrainedCommunity Health Workers
7Early 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!“Malaria, especially cerebral malaria, can be astonishingly fast acting. There are cases of people being dead within 4 hours of first showing symptoms. Though there are many cases of simple malaria in which a patient can exhibit cyclical fever for days and ultimately recover without treatment, it is difficult to tell at the onset of first fever whether the malaria will be a simple case or the more deadly severe or cerebral malaria. Severe prolonged anemia and its aftereffects caused by malaria are also a major cause of mortality, particularly in children.“The first onset of fever is the first point in the lifecycle of Plasmodium falciparum within the human body at which the malaria can be transmitted to a mosquito. The longer a patient remains febrile without seeking treatment, the greater the chance that he or she will pass the malaria to a mosquito who could, in turn, infect someone else.
8Indoor Residual Spraying/Covering Kills mosquitoes where they like to restChemicals are safeResistance is an issueIRS is expensive: $5 - $30 per household depending on the chemical usedRequires well-trained techniciansImpregnated wall coverings are a new solution“Remember how the female Anopheles mosquito likes to rest on the upper third of interior walls to digest after they’ve taken a blood meal? Well Indoor Residual Spraying (IRS) coats the interior walls of living spaces with insecticide.“IRS is expensive, complicated, and requires a trained technician to apply. The effectiveness of an IRS intervention is directly related the technicians’ ability to evenly coat the walls with an appropriate amount of insecticide. Too little, and the insecticide will not last very long. It may not contain enough toxins to kill the mosquito and could lead to resistance among the mosquito populations”The issue of resistance is especially important in rural agricultural areas because the most commonly used IRS chemicals are also used in agriculture, leading to increased resistance forming pressure.“In addition to spraying walls with insecticide, a recent development in malaria prevention is the use of wall hangings treated with insecticides. Similar to the way nets are impregnated with chemicals, these wall hangings can last up to three years in normal usage – far longer than the 4-6 months a dose of IRS lasts.”
9Indoor 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: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.
10Intermittent Presumptive Treatment for pregnant women - IPTp “Pregnant women are especially susceptible to malaria because their immunity is decreased and malaria parasites can be sequestered in the placenta (so the women could test negative for malaria even though the parasite is present). Malaria during pregnancy can have devastating effects on the woman and the baby (anemia, low birth weight, infant death) and should be avoided at all costs.Pregnant women are particularly susceptible to malariaMalaria parasites may “hide” in the placenta making testing for malaria difficultMalaria in Pregnancy (MiP) can cause anemia, low birth weight and infant death
11IPTp Preventative measures At the Antenatal Clinic (ANC) Sleep under an LLINPresumptive Treatment (IPTp) of sulfadoxine-pyrimethamine (SP) – at least two doses given at least a month a part starting at quickeningAt the Antenatal Clinic (ANC)In addition to IPTp, micronutrient supplements (iron/folate) are providedKey service provider to pregnant women.“In addition to sleeping under an LLIN, it is recommended that all pregnant women in malaria endemic areas receive at least two doses of Sulfadoxine Pyrimethamine (SP) during pregnancy (after quickening-when the baby starts moving- and at least 1 month apart between doses).“You may recognize SP as one of the drugs cited in the discussion of drug resistance. 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!These interventions in addition to anemia prevention and micronutrient deficiencies (iron/folate supplements) are part of focused antenatal care (FANC) services offered 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!
12Long Lasting Insecticide-Treated Nets (LLINs) “Long lasting insecticide-treated nets (LLINs) are impregnated with insecticide that, under test conditions, retains insecticide efficacy after 20 washes. This is thought to translate to about 3 years of normal use in an African setting, however, field conditions have shown that in some areas nets only last a few months so people are encouraged to replace or repair their nets as soon as it has holes in it.“Older nets (before the LLIN technology became widespread) used an insecticide that wore off in about 6 months requiring periodic re-treatment of the nets with the chemical. This is being phased out in favor of LLINs, though people in your community and health clinic may still be re-dipping older nets.Modern LLIN –Good for roughly 20 washesOlder nets -Required periodic re-treatment
13LLINs – The Community Effect “In addition to creating a physical barrier preventing the person sleeping under the net from getting malaria (peak biting times for Anopheles are at night), the insecticide decreases vector numbers. When LLIN coverage reaches above 80% there is a community-effect, decreasing the overall risk of contracting malaria due to a significant interruption of the transmission cycle. Essentially, they are giant mosquito traps baited with people and when you reach 80% coverage you start to have a significant impact on the vector population – there are less Anopheles in the area to transmit malaria. A study in the Gambia found that LLINs reduced child mortality by 20%. 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 communityBurden on the health postScholastic absenteeismEtc.
14Quiz Show1) 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) communityb) knock-downc) vectord) Lagrange 2) IRS and LLINS cancel each other out and should NOT be used together.a) Trueb) False3) Due to the difficulty of detecting placental malaria and its severe effects, pregnant women are presumptively treated witha) Artemisininb) Dihydro-oxygenc) mefloquined) Sulfadoxine-pyremethemine4) Encouraging Early Care Seeking Behavior is difficult because:a) Many adults have survived multiple cases of malaria and don’t consider it life-threateningb) Adults may not be aware that they are capable of passing on malaria when they are symptomaticc) They may not have the economic means to pay for treatmentd) 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 insecticidesb) It is effective because mosquitos tend to rest on the interior walls of dwellingsc) It is inexpensived) It requires skilled technicians to apply correctly
15Quiz Show1) 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-downc) vectord) Lagrange 2) IRS and LLINS cancel each other out and should NOT be used together.a) Trueb) False✔3) Due to the difficulty of detecting placental malaria and its severe effects, pregnant women are presumptively treated witha) Artemisininb) Dihydro-oxygen ?c) mefloquined) 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-threateningb) Adults may not be aware that they are capable of passing on malaria when they are symptomaticc) They may not have the economic means to pay for treatmentd) 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 insecticidesb) It is effective because mosquitos tend to rest on the interior walls of dwellingsc) It is inexpensive✔d) It requires skilled technicians to apply correctly
16We must all hang together or… Round or “hoop” netsSquare net“Now we’re going to move on to the bread and butter of malaria prevention – bed net usage. Hanging mosquito nets is an essential skill when helping with mosquito net distributions and is an easy and visible activity for PCTs to do at their sites. While hanging nets seems easy, lack of knowledge of how to hang the nets is the highest reported cause of households that own nets not using them.”Baby netNOTE: These are available in many markets but are rarely treated – offering only a physical barrier.
17How 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?TALK BACK“If we want to improve the longevity of the net, what are some things we need to look out for when hanging the nets?”
18How hanging can go wrong Nets hung too high are repeatedly stretchedNets hung too low are stepped on and are more likely to blouse out to the point where they can be burned by nearby candlesNets hung too low can also catch on sharp bamboo or sticks on the bed
19Challenging hangings“To turn a square net into a round (hoop) net, take a plastic lid from any container and put it underneath the center of the top of the square net. Attach it to the net by putting holes in both the net itself and the lid and secure it by running a rope through those holes and knotting it below the lid. The rope now holds up the lid which holds up the rest of the net. Now you can hang the net from a central point instead of the four corners. It may be useful to sew some reinforcement into the net around the center hole to avoid ripping.”“Suspend two strings across the length of the room or hut. Then put key rings (or loops of cord) into the loops on two sides of the square net. Attach these rings to the appropriate string. Demonstrate to the family that the net can easily be pushed against the wall during the day and then slide over the bed again at night. Make sure that the strings are low enough so that the net can be tucked under the mattress. Explain that the strings can be used as clotheslines during the day.”
20Hindrances 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?TALK BACK
22Thank 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)