Presidents Malaria Initiative

1
Presidents Malaria Initiative

• Malaria
• Whats old, whats new
• GH Mini-U
• 12 September 2008
• http//www.pmi.gov/

2
Overview

• PMI Goal, Scope, Strategy and Progress
• Technical Interventions
• Diagnosis and treatment
• Malaria during Pregnancy
• Vector control
• Management Capacity, ME, Communications

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Goal and Targets

• Goal (2010) Reduce malaria-related mortality
  by 50 in 15 focus countries.
• Targets Achieve 85 coverage of vulnerable
• groups with
• Artemisinin-based combination therapies
• Intermittent preventive treatment in pregnancy
• Insecticide-treated bed nets (ITNs)
• Indoor residual spraying (IRS)

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Strategy

• Integrated complement GFATM, WB, et al.
• Strengthen NMCPs build capacity
• Evidence-based (investment in ME)
• Joint USAID and CDC implementation

Funds support

• Commodities (50)
• Implementation
• Technical Support
• Monitoring and Evaluation
• Applied Research

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Scope
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Progress

• By end of 2007
• 10 m people protected by IRS
• 4.2 m LLINs distributed
• 15 m treatment courses ACTs
• 1.5 m IPTp doses
• 14,000 HW trained
• Support for pharmaceutical management, diagnosis
  and case management, IRS, MIP, ME

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Interventions

• Diagnosis and Treatment
• Logistics, diagnostics, facility and
  community-based activities
• Malaria during Pregnancy
• IPTp, ITNs, HIV/AIDS collaboration
• Vector control
• ITNs, IRS and Integrated Vector Management
• Cross Cutting
• Management strengthening, ME and BCC/IEC
  Guidelines

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Diagnosis and Treatment
Artemisinin-based Combination Therapy (ACT)
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Drug resistance

• Multi-drug resistant Malaria first appeared in
  Western Cambodia
• Spread to Burma via migrant workers
• Large numbers of migrants dispersing through
  Thailand and beyond.

?
?
Yellow Success - Red Failure
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Drugs Quality
(genuine fake)
A- genuine B,C,D - fake
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Drug Logistics
Impact of Stock-outs
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Pharmaceutical Management

• Deliver/SPS
• Support procuring, managing, and delivering
  high-quality, safe, and effective malaria
  commodities
• Provide on-the-ground logistics capacity,
  technical assistance, and pharmaceutical
  management expertise and
• Offer technical leadership to strengthen the
  global supply, demand, and financing of malaria
  commodities..

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Diagnostics

• IMaD Diagnostics Project
• Improve MoH laboratory-based diagnostics
• Logistics and supply chain management
• Training health workers performing microscopy
  and RDTs
• Training health care providers for improved
  prescribing using diagnostics

RDT use by CHWs Zambia 2006 (Steve Harvey, URC)
ACT for negative RDT 26.7 (BS 30.4) (Hamer et
al 2007)
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Out-patient management(Ndhlovu, et al. 2004)

• 2004 4 districts, 105 HC, 1523 children, 819
  older children, adults
• Clinical diagnosis sensitive (80) but only 35
  actually had parasites
• 35 of consultation lt 3 min
• 20 asked previous use of antimalarial
• 58.6 children with negative slide treated
• 14.6 mothers told diagnosis 32 how to give
  medication

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Malaria Communities Project

• New partners and networks of community-based
  organizations
• Increase local and indigenous capacity for
  community-based activities
• Build local ownership of malaria control for the
  long-term in partnership with communities and
  NMCPs
• Extend coverage of PMI and NMCP efforts to reach
  a larger beneficiary population

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Home and Community-based Management

• 80 episodes treated outside formal health
  facilities late presentation leads to mortality
• Challenges cost and logistics diagnostics and
  integrated management plethora of drugs in
  marketplace
• Beginning private sector collaboration Nigeria,
  Tanzania and Rwanda
• ACT in Community Mali and Rwanda, Senegal,
  Madagascar, Zambia.

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Maternal Reproductive Health

• Intermittent Preventive Treatment (IPTp)
• Insecticide Treated Mosquito Nets (ITNs)
• HIV/AIDS and links to PEPFAR

UNICEF/C-55-10/Watson
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Effects on Unborn Babies

• Parasites hide in placenta
• Interferes with transfer of oxygen and nutrients
  to the baby, increasing risk of
• Spontaneous abortion
• Preterm birth
• Low birthweightsingle greatest risk factor for
  death during first month of life
• Stillbirth

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Intermittent Preventive Treatment (IPT)

• Three treatment doses of Sulfadoxine-Pyrimethamine
  (SP) given to all pregnant women in areas of
  high transmission, even without symptoms, after
  first trimester, can significantly reduce the
  negative consequences of malaria during pregnancy

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ITNs and Pregnancy
Pregnant Women in ITN village had

• During Pregnancy
• lt parasitemia 27
• lt anemia 16
• At Delivery
• lt placental malaria 20
• lt preterm delivery 40
• Higher mean birth
• weight 68.8 g

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Summary of HIV-Malaria interactions

• Co-infection
• HIV - increased severity and prevalence of
  placental malaria
• Malaria - increased HIV replication
• Placental malaria increased risk of MTCT
• Drug interactions
• ACTs and PIs (yes) NNRTIs (maybe) and NRTIs (no)
• Sulfonamides and Stevens Johnson Syndrome

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HIV-Malaria Programming

• Diagnosis and Treatment
• Laboratory support (TB)
• Logistics and Pharmacovigilance
• Differential diagnosis of O.I. in PLWHA
• Prevention
• MiP and PMTCT
• Malaria in Adolescent Reproductive Health
• Home-based Care
• ITNs
• Treatment of febrile illness in HBC programs

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Integrated Vector Management

• Rationalization and Optimization of vector
  control, alone or in combination

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Indoor Residual Spraying

• IRS Management Cycle
• Environmental regulations,
• Pesticide management
• Entomological Monitoring, Capacity Building
• Resistance

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IRS Management Cycle
Environmental Assessment
Pesticide Selection and Procurement
Mapping, Targeting and Quantification GIS, GPS
Micro-Planning Timing and Program of spraying
Evaluation Epidemiological Entomological
Environmental
Organization logistics Teams, transport,
supplies, systems
Action Supervision, information management,
environmental compliance
Training Spray teams, supervisors
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Progress

• Zanzibar
• Rwanda
• N.W. Tanzania

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ITNs mixed distribution models

• Free distribution
• Campaign
• Routine distribution (ANC, EPI, lt5 clinics)
• Targeted subsidies (incl. vouchers)
• Facilitate commercial sector

28
Larval Source Management

• Still mostly operations research
  (e.g. Kenya, Mali)
• Support for larval control in Dar
  es Salaam

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Monitoring Evaluation

• For example, core impact indicators
• Outpatient malaria cases for lt5s at sentinel
  sites
• Lab-confirmed outpatient malaria cases for lt5s at
  sentinel sites
• Inpatient malaria cases for lt5s at sentinel sites
• Lab-confirmed inpatient malaria cases for lt5s at
  sentinel sites
• Malaria deaths among lt5s at sentinel sites

30
Zanzibar surveillance system via SMS
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NMCP Rapid Assessment

• Rapid Assessment Tool
• Organizational mandate
• Organizational structure and staffing
• Strategy and planning
• Leadership and management
• Management systems
• Coordination/collaboration
• Keeping up to date technically

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Communication Guidelines
Planning and Strategy Development
Case Management MiP ITNs and IRS
Interventions Objectives, timing, sequencing and
frequency
Monitoring and Process Evaluation
Program Implementation
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PMI ambitious goals, but vast
opportunity and great hope for the future.

• Interventions
• Diagnostics and Treatment
• Pregnancy and HIV
• Vector Control
• Systems
• ME, Management, BCC/IEC,