Malaria elimination using the 1-3-7 approach: lessons from Sampov Loun, Cambodia.

BACKGROUND: Cambodia has targeted malaria elimination within its territory by 2025 and is developing a model elimination package of strategies and interventions designed to achieve this goal. METHODS: Cambodia adopted a simplified 1-3-7 surveillance model in the Sampov Loun operational health district in western Cambodia beginning in July 2015. The 1-3-7 approach targets reporting of confirmed cases within one day, investigation of specific cases within three days, and targeted control measures to prevent further transmission within seven days. In Sampov Loun, response measures included reactive case detection (testing of co-travelers, household contacts and family members, and surrounding households with suspected malaria cases), and provision of health education, and insecticide-treated nets. Day 28 follow up microscopy was conducted for all confirmed P. falciparum and P. falciparum-mixed-species malaria cases to assess treatment efficacy. RESULTS: The number of confirmed malaria cases in the district fell from 519 in 2015 to 181 in 2017, and the annual parasite incidence (API) in the district fell from 3.21 per 1000 population to 1.06 per 1000 population. The last locally transmitted case of malaria in Sampov Loun was identified in March 2016. In response to the 408 index cases identified, 1377 contacts were screened, resulting in the identification of 14 positive cases. All positive cases occurred among index case co-travelers. CONCLUSION: The experience of the 1-3-7 approach in Sampov Loun indicates that the basic essential malaria elimination package can be feasibly implemented at the operational district level to achieve the goal of malaria elimination in Cambodia and has provided essential information that has led to the refinement of this package.

The U.S. President's Malaria Initiative's Support for Improving the Quality of Malaria Case Management Services: Fifteen Years of Progress and Learning.

Since its launch in 2005, the U.S. President's Malaria Initiative's (PMI) investment in malaria case management has evolved based on lessons learned from its support to countries. An initial focus on updating malaria treatment policies to adopt artemisinin-based combination therapies achieved limited success, in part because of the poor quality of diagnostic and treatment services in targeted countries. In response, the PMI supported the development, refinement, and expansion of Outreach Training and Supportive Supervision (OTSS), a quality improvement approach that combines structured, competency-based supervision with corrective measures, including on-the-job training, coaching, troubleshooting, action planning, and timely follow-up. With 15 years of experience, the OTSS approach has been adopted by more than a dozen countries, and its effectiveness in improving the quality of malaria case management services has been documented. Through the PMI Impact Malaria Project, launched in 2018, the OTSS approach was expanded beyond case management of uncomplicated malaria to support quality improvement of inpatient management of severe malaria and malaria in pregnancy services delivered through antenatal care clinics. The OTSS platform also enabled targeted countries to respond rapidly to the COVID-19 pandemic by adding modules related to clinical management and laboratory diagnosis of suspected cases. The OTSS approach has been established as an effective approach to improve the quality of clinical malaria services and can be expanded to cover other health priorities. Further innovations to improve the quality of inpatient and community-based services, and further integration and institutionalization of OTSS into country health systems are needed.

How Outreach Training and Supportive Supervision (OTSS) Affect Health Facility Readiness and Health-Care Worker Competency to Prevent and Treat Malaria in Niger: A Secondary Analysis of OTSS Data.

The quality of health services is key to the goal of averting morbidity and mortality from malaria. From July 2020 to August 2021, PMI Impact Malaria supported the implementation of four rounds of Outreach Training and Supportive Supervision (OTSS) in 12 health districts in the two regions of Niger: Dosso and Tahoua. Through OTSS, trained supervisors conducted onsite visits to observe an average of 174 healthcare workers (HCWs) per round in 96 public primary health facilities, managing persons with fever or conducting antenatal care (ANC) consultations, and then provided instant and individualized feedback and onsite training. Data from health facility readiness, case management, and malaria in pregnancy (MiP) checklists across the four rounds were analyzed using Wilcoxon's and the χ2 tests. These analyses highlighted improved facility readiness, including an increased likelihood that HCWs had received classroom training, and facilities had increased availability of guidelines and algorithms by round 4 compared with round 1. Median HCW performance scores showed an improvement in the correct performance and interpretation of malaria rapid diagnostic tests, in classification of malaria as uncomplicated or severe, and in the management of uncomplicated malaria across the four rounds. For MiP services, malaria prevention and the management of pregnant women with malaria also improved from round 1 to round 4. These findings provide further evidence that OTSS can achieve rapid improvements in health facility readiness and HCW competency in managing outpatients and ANC clients.

Impact of the Severe Malaria "Champions Program" on the Management of Severe Malaria Cases in 12 Hospitals of the North and Far North Regions of Cameroon.

Malaria remains a main cause of morbidity and mortality in Cameroon. Since 2021, the U.S. President's Malaria Initiative Impact Malaria Project has supported the National Malaria Control Program to develop the Champions program in two northern regions. We assessed this program's preliminary effectiveness on the performance of hospitals in the management of severe malaria and reduction of malaria-related deaths. We conducted a secondary analysis of Outreach Training and Supportive Supervision (OTSS) data from four rounds (one round pre-Champions program and three rounds post-Champions program and 2020-2022 malaria-related mortality data for 12 hospitals). Using linear regressions, we measured changes in hospital readiness and competency of health workers in the management of severe malaria between baseline and subsequent rounds. There were statistically significant improvements in overall management of severe malaria scores in post-Champions OTSS rounds, with post-Champions round 3 exhibiting an increase of +14% (P = 0.013) over baseline. Overall health facility readiness scores exhibited an increase of +7% (P = 0.006) from baseline to post-Champions round 3. There were no statistically significant findings associated with providing the right treatment, as nearly all patients hospitalized with severe malaria were treated with a recommended severe malaria treatment. Reported inpatient malaria deaths and case fatality rates trended downward from 2020 to 2022, but these differences were not statistically significant. The Champions program resulted in significant improvements in quality of inpatient care for severe malaria. The downward trends in malaria deaths and case fatality rate will require further monitoring to determine whether the Champions program is having the desired impact of reducing inpatient deaths from malaria.

Clinical Outreach Training and Supportive Supervision Quality-of-Care Analysis: Impact of Readiness Factors on Health Worker Competencies in Malaria Case Management in Cameroon, Mali, and Niger.

Improving the quality of malaria clinical case management in health facilities is key to improving health outcomes in patients. The U.S. President's Malaria Initiative Impact Malaria Project has supported implementation of the Outreach Training and Supportive Supervision (OTSS) approach in 11 African countries to improve the quality of malaria care in health facilities through the collection and analysis of observation-based data on health facility readiness and health provider competency in malaria case management. We conducted a secondary analysis of longitudinal data collected during routine supervision in Cameroon (April 2021-March 2022), Mali (October 2020-December 2021), and Niger (November 2020-September 2021) using digitized checklists to assess how service readiness affects health worker competencies in managing patients with fever correctly and providing those with confirmed uncomplicated malaria cases with appropriate treatment and referral. Linear or logistic regression analyses were conducted to assess the effect of facility readiness and its components on observed health worker competencies. All countries demonstrated significant associations between health facility readiness and malaria case management competencies. Data from three rounds of OTSS visits in Cameroon, Mali, and Niger showed a statistically significant positive association between greater facility readiness scores (including the availability of commodities, materials, and trained staff) and health worker competency in case management. These findings provide evidence that health worker performance is likely affected by the tools and training available to them. These results reinforce the need for necessary tools and properly trained staff if high-quality malaria case management services are to be delivered at health facilities.

Broken promise? Taxes and tariffs on insecticide treated mosquito nets.

Seven years ago, the removal of taxes and tariffs on insecticide treated nets (ITNs) was considered one of the easiest resolutions for most countries to implement among the targets agreed upon at the African Summit on Roll Back Malaria in Abuja, Nigeria, on April 25, 2000. However, seven years later, 24 of the 39 Abuja signatories continue to impose taxes and tariffs on this life-saving tool. Taxes and tariffs significantly increase the price of an insecticide treated net, reduce affordability, and discourage the commercial sector from importing insecticide treated net products. Consequently, Roll Back Malaria partners are engaged in advocacy efforts to remove taxes and tariffs on insecticide treated nets in malaria-endemic countries of Africa. This viewpoint summarizes key obstacles to the removal of taxes and tariffs that have been identified through a review of country situations. To achieve the goal of producing and supplying more than 160 million insecticide treated nets needed to reach the revised Roll Back Malaria Partnership targets by 2010, tax and tariff reforms are urgently needed. Such reforms must be accompanied by country-specific systems to protect the poor (e.g., through voucher systems for vulnerable groups and other forms of targeted subsidies).

Introducing malaria rapid diagnostic tests in private medicine retail outlets: A systematic literature review.

BACKGROUND: Many patients with malaria-like symptoms seek treatment in private medicine retail outlets (PMR) that distribute malaria medicines but do not traditionally provide diagnostic services, potentially leading to overtreatment with antimalarial drugs. To achieve universal access to prompt parasite-based diagnosis, many malaria-endemic countries are considering scaling up malaria rapid diagnostic tests (RDTs) in these outlets, an intervention that may require legislative changes and major investments in supporting programs and infrastructures. This review identifies studies that introduced malaria RDTs in PMRs and examines study outcomes and success factors to inform scale up decisions. METHODS: Published and unpublished studies that introduced malaria RDTs in PMRs were systematically identified and reviewed. Literature published before November 2016 was searched in six electronic databases, and unpublished studies were identified through personal contacts and stakeholder meetings. Outcomes were extracted from publications or provided by principal investigators. RESULTS: Six published and six unpublished studies were found. Most studies took place in sub-Saharan Africa and were small-scale pilots of RDT introduction in drug shops or pharmacies. None of the studies assessed large-scale implementation in PMRs. RDT uptake varied widely from 8%-100%. Provision of artemisinin-based combination therapy (ACT) for patients testing positive ranged from 30%-99%, and was more than 85% in five studies. Of those testing negative, provision of antimalarials varied from 2%-83% and was less than 20% in eight studies. Longer provider training, lower RDT retail prices and frequent supervision appeared to have a positive effect on RDT uptake and provider adherence to test results. Performance of RDTs by PMR vendors was generally good, but disposal of medical waste and referral of patients to public facilities were common challenges. CONCLUSIONS: Expanding services of PMRs to include malaria diagnostic services may hold great promise to improve malaria case management and curb overtreatment with antimalarials. However, doing so will require careful planning, investment and additional research to develop and sustain effective training, supervision, waste-management, referral and surveillance programs beyond the public sector.

Four malaria success stories: how malaria burden was successfully reduced in Brazil, Eritrea, India, and Vietnam.

While many countries struggle to control malaria, four countries, Brazil, Eritrea, India, and Vietnam, have successfully reduced malaria burden. To determine what led these countries to achieve impact, published and unpublished reports were reviewed and selected program and partner staff were interviewed to identify common factors that contributed to these successes. Common success factors included conducive country conditions, a targeted technical approach using a package of effective tools, data-driven decision-making, active leadership at all levels of government, involvement of communities, decentralized implementation and control of finances, skilled technical and managerial capacity at national and sub-national levels, hands-on technical and programmatic support from partner agencies, and sufficient and flexible financing. All these factors were essential in achieving success. If the goals of Roll Back Malaria are to be achieved, governments and their partners must take the lessons learned from these program successes and apply them in other affected countries.

Antibiotic resistance and serotype distribution of Streptococcus pneumoniae colonizing rural Malawian children.

Nasopharyngeal swabs were taken from 906 Malawian children <5 years old visiting rural health clinics. Pneumococcal colonization was high, 84% among all children, and occurred early, 65% of it in children <3 months old. Among pneumococcal isolates 46% were nonsusceptible to trimethoprim-sulfamethoxazole, and 21% were nonsusceptible to penicillin. Trimethoprim-sulfamethoxazole use in the previous month was a risk factor for trimethoprim-sulfamethoxazole and penicillin nonsusceptibility. Forty-three percent of isolates were serotypes included in the 7-valent pneumococcal conjugate vaccine, and 37% were vaccine-related serotypes, particularly 6A and 19A.

Do malaria control interventions reach the poor? A view through the equity lens.

Malaria, more than any other disease of major public health importance in developing countries, disproportionately affects poor people, with 58% of malaria cases occurring in the poorest 20% of the world's population. If malaria control interventions are to achieve their desired impact, they must reach the poorest segments of the populations of developing countries. Unfortunately, a growing body of evidence from benefit-incidence analyses has demonstrated that many public health interventions that were designed to aid the poor are not reaching their intended target. For example, the poorest 20% of people in selected developing countries were as much as 2.5 times less likely to receive basic public health services as the least-poor 20%. In the field of malaria control, a small number of studies have begun to shed light on differences by wealth status of malaria burden and of access to treatment and prevention services. These early studies found no clear difference in fever incidence based on wealth status, but did show significant disparities in both the consequences of malaria and in the use of malaria prevention and treatment services. Further study is needed to elucidate the underlying factors that contribute to these disparities, and to examine possible inequities related to gender, social class, or other factors. To achieve impact and overcome such inequities, malaria control efforts must begin to incorporate approaches relevant to equity in program design, implementation, and monitoring and evaluation.

Efficacy of chloroquine, sulfadoxine-pyrimethamine, and mefloquine for the treatment of uncomplicated Plasmodium falciparum malaria on the north coast of Peru.

As part of an effort to assess antimalarial drug resistance in Peru, we carried out 14-day in vivo efficacy trials of chloroquine (CQ; 25 mg/kg) and sulfadoxine-pyrimethamine (SP; 25 mg/kg of the sulfadoxine component) for the treatment of uncomplicated Plasmodium falciparum infections at three sites on the northern coast of Peru. Mefloquine (MQ; 15 mg/kg) also was evaluated at one site. The results from all three sites were similar. Of the 53 patients treated with CQ, 58.5% had RII/RIII responses. No RIII failures were observed among the 112 patients who received SP, but 4.5% and 1.8%, respectively, had RII and RI responses. All 33 patients treated with MQ showed a sensitive response. Early treatment failures were observed in 27.1% of the CQ patients but in no patients receiving SP or MQ. Late treatment failures were seen in 59.3% of the CQ patients and 6.4% of the SP patients but in none of those treated with MQ. Based on these findings and because of concern about the potential for development of resistance if SP were used alone, the National Malaria Control Program is planning a change in malaria treatment policy to SP-artesunate combination therapy for this region of the country.

A health systems approach to integrated community case management of childhood illness: methods and tools.

Integrated community case management (iCCM) of childhood illness is an increasingly popular strategy to expand life-saving health services to underserved communities. However, community health approaches vary widely across countries and do not always distribute resources evenly across local health systems. We present a harmonized framework, developed through interagency consultation and review, which supports the design of CCM by using a systems approach. To verify that the framework produces results, we also suggest a list of complementary indicators, including nine global metrics, and a menu of 39 country-specific measures. When used by program managers and evaluators, we propose that the framework and indicators can facilitate the design, implementation, and evaluation of community case management.