Treating Malaria by Health Extension Workers: A Case Study from Ethiopia

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For many years the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) have been promoting an Integrated Management of Childhood Illness (IMCI) training package to ensure that nurses and doctors are capable of treating sick children at health facilities.  Over the years, with the realization that many children did not have access to health facilities and therefore were not being ttreated, the two organizations published a Joint Statement on Managing Pneumonia in Community Settings (2004)[1].  This groundbreaking document calls on countries to bring treatment of childhood illness – pneumonia as well as malaria and diarrhea closer to communities that need it, by empowering trained community health workers to identify and manage these problems. Many countries have followed this advice with excellent results.  Here is a story from Ethiopia.

Aminata is a health extension worker (HEW) at the Tebisa health post, located in a rural, hilly area of East Amhara, some 400 kilometers away from Addis Ababa, the capital city of Ethiopia. Aminata received training on integrated community based management of common childhood illnesses (iCCM) in early 2011. After the training, she carried the essential materials and supplies with her back to the health post, and started treating children suffering from pneumonia, malaria, diarrhoea and/or severe acute malnutrition.  In the last two months, she has treated 35 children under five.

HEW Ethiopia
A Health Extension Worker (HEW) with Almaz and her family. Photo: Dr. L. Pearson

One of the children suffering from malaria is a five year old girl, Almaz (which means diamond in Amharic). She developed fever one night in April. Her mother took her to the health post and she was seen immediately. Aminata checked her temperature (39.0 OC), and respiratory rate (children sometimes have pneumonia and malaria at the same time) and pricked her finger to obtain a drop of blood to perform a Rapid Test for Malaria (RTM) to look for malaria parasites [Ed: Rapid Diagnostic Tests, or RDTs, are another, more general term for these tests].

Almaz did not have rapid breathing, an indication of pneumonia, but she did have falciparum malaria (the most severe and deadly of the types of malaria found in humans, and caused by the Plasmodium falciparum parasite).  She was given Coartem (Arthemeter-Lumefentrine) treatment by mouth for three days.  Aminata gave the first dose of medicine and gave the mother the rest of the tablets, explaining when to give them. Aminata made a point to discuss how important it is to feed a sick child so they do not lose weight, and to be alert to certain ‘danger signs’ in case the child is not getting better, in which case they should return immediately to the health post.

On the second day of treatment her mother brought her back to the health post for a follow up check.   Almaz’s mother expressed her gratitude. “If the HEWs are not providing treatment for sick children, I would have to carry Almaz to the health center some 4 hours away by foot. I would also have to pay for the treatment.  We were frustrated before iCCM started because we were not able to help children with malaria and pneumonia”.

malaria medicines at health post Ethiopia
Malaria medicine available, for free, at the Tebisa health post in Ethiopia. Photo: Dr L. Pearson

“The communities trust and support us even more now”, said Aminata. “Now the mothers are so happy, they even bring the children for immunization without us having to push them”.

In the next two years, about 20,000 HEWs will be trained and supported to provide iCCM in 10,000 rural villages. Hundreds and thousands of young children in Ethiopia will benefit from the iCCM programme jointly supported by the government of Ethiopia, Catalytic Initiative of Canada, UNICEF and other development partners. Program implementation will focus on remote and harder to reach villages and households, to ensure every child is covered, no matter where they are and who they are.

The iCCM is be an important opportunity to further improve quality of care provided at the health posts, and accelerate toward the achievement of Millennium Development Goal 4, to reduce deaths of children under 5 by two-thirds by 2015.

[1] Management of Pneumonia in Community Settings (PDF)

EDITORIAL – Reflections on World Malaria Day 2011

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How far have we come in the last four years?

Four years ago, it was estimated that a child died every 30 seconds from malaria, and that more than a million people each year were killed by this devastating and debilitating disease. Four years ago, the malaria advocacy partnership Roll Back Malaria organized the first World Malaria Day, and published the Global Malaria Action Plan (GMAP), which set comprehensive goals for the control of malaria world-wide, with the ultimate aim to eradicate malaria completely. [Read more…]

From the Editor

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Welcome to the re-launch of Malaria.com, a member driven website encompassing the global malaria community.

Malaria.com is designed to be dynamic and user-driven.  It is a place where, to name a few examples, researchers will have the opportunity to connect and collaborate on projects, field practitioners can blog about their adventures on the front lines of malaria control, and where the public has an opportunity to engage directly with personnel in the forefront of malaria treatment and research. Questions asked online will be answered by our team of experts. [Read more…]

Of Macaques and Men

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Plasmodium knowlesi —a new challenge in the Roll Back Malaria Program?

Deforestation oil palm Malaysia

Oil palm plantation in Malaysia: Such land-use change may be affecting malaria transmission. Photo courtesy of Yusmar Yahaya (http://www.flickr.com/photos/leafbug/4880638055/sizes/m/)

Mention of malaria often conjures images of infants hospitalized in Africa. Although most deaths from malaria are children under 5 in sub-Saharan Africa, there are many different types of malaria that put over half of the world’s population at risk in subtropical and tropical regions worldwide.

There have historically been four species of Plasmodium parasites that cause malaria humans.  P. falciparum is the most lethal species that infects humans, whereas P. vivax is the most widespread.  P. vivax and P. ovale also cause clinical symptoms and decreased economic potential in certain regions.

[Read more…]

Lariam Legacy

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In 1990, Lariam (mefloquine) became the drug of choice for malaria prevention.  It was endorsed by the Centers for Disease Control (CDC) and prescribed for travelers, government workers, and the U.S. military who were going to regions where malaria was present. It was even given to airline crews who flew to malaria regions.

Mefloquine has been responsible for psychotic breakdowns, suicides and a host of other side effects.  Many people taking it stopped on their own because they were able to realize it was the drug that was causing the problems.

Here is a vignette of my experience with the drug after it was first released in 1990.

I was in charge of the health unit for a film being made in northern Thailand.  I was aware that there was chloroquine resistant malaria in that region.  I contacted the CDC and talked to the head of the Malaria Prevention Department. He told me that the drug of choice was Lariam. I was unable to obtain it in the USA but was able to get a supply in Europe.

I wrote a letter to the crew instructing them to take the drug while in Thailand. I  think now it was fortunate that many stopped taking the drug because they recognized it was causing “ weird” feelings. I myself took the drug and noticed no effects from it.  However about 3 weeks into the “shoot” a camera-crane operator went suddenly berserk.  It took 5 people to hold him down and get him to the hospital, where eventually enough valium calmed him down. He was however still paranoid and irrational, and had to be evacuated back to England.

I had, at the time, no idea what the cause was for his breakdown.  It wasn’t until two years later when reports started appearing about the drug’s side effects that I realized what the cause was.  I shuddered to think about some of the airline pilots and U.S. military who were being given the drug.

I would be interested to hear if anyone has had personal experiences, or friends who have experienced side-effects from the drug.

Malaria Co-infection with Other Diseases of Global Public Health Importance

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Effects of co-infection on human health, the need for further research and steps towards integrated control

Introduction

Standley Adriko malaria Uganda 2010

Claire Standley and Moses Adriko surveying for malaria infections in a community in Uganda. Photo: Courtesy Dr Claire Standley

In large parts of the world, the Plasmodium protozoans that cause malaria co-exist alongside a number of other pathogens and parasites, many of which are also infectious to humans. One of the foremost challenges in tackling the huge burden of malaria around the world, and particularly in developing countries, is understanding the dynamics between malaria and these other infections. For example, researchers are seeking to understand the effects of co-infections on a patient’s health and well-being, while at the same time, deciphering how best to provide treatment and disease control regimes in regions with high co-infection prevalence. Moreover, of course, the effects and intricacies of co-infection may vary between regions, or between the types of infectious found alongside malaria. This blog gives a quick introduction to some of the common diseases often found alongside malaria, and especially in the developing world, where significant research resources are directed but also where treatment and control needs are greatest.

Malaria and HIV

[Read more…]

A Case for Evidence-Based Communication Campaigns in Angola

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Mosquito Nets Angola

A mother carries home LLINs for her family following a net distribution campaign. Source: PSI/Angola

Malaria is one of the largest health concerns in Angola, particularly for pregnant women and young children. Using a long-lasting insecticide-treated net (LLIN) can greatly reduce the risk of malaria. The Ministry of Health is scaling up malaria control activities with expansion of net distribution as well as communication activities for behavior change to encourage the use of a net every night.

With support from the President’s Malaria Initiative and ExxonMobil, the Global Fund to Fight AIDS, Tuberculosis and Malaria, Population Services International (PSI) works with the National Malaria Control Program to develop communication campaigns based on evidence gathered through research to promote healthier behaviors for malaria control.

All communication campaigns are based on in-depth research into behaviors related to malaria control. These results help target communication campaigns to achieve the desired behavior change for malaria prevention and treatment. A recently completed qualitative study supported by Global Fund Round 7 looked at behaviors and beliefs of pregnant women and caregivers of children under the age of 5 years to further understand why mosquito nets are or are not used. In-depth interviews were complemented by a photo narrative of the women’s lives, where study participants took pictures of important factors in their lives that influence their health and the health of their children. Results were analyzed by groups – those who always use a net and those who do not consistently use a net. [Read more…]