Anti-malaria mass drug administration in the Ebola epidemic in Sierra Leone and Liberia John Pringle, Anna Kuehne, Michel Janssens, Yves Houedakor, Amanda Tiffany, Estrella Lasry, M. Angeles Lima, Jerlie Loko, Jas Mantero, Carolina Nanclares, Chibuzo Okonta, Mathieu Bichet, Olimpia de la Rosa, Samuel Smith, Oliver Pratt

Malaria and Ebola thrive together Malaria is hyper-endemic and left to flourish as sustained Ebola transmission disrupts health systems: Malaria fevers mimic Ebola and overrun Ebola management centres, multiplying Ebola exposure. “WHO recommends MDA [mass drug administration] with ACT [artemisinin-based combination therapies] in areas that are heavily affected by the Ebola outbreak and where malaria transmission is high and access to malaria treatment is very low …” (WHO. 2014, Nov. 13. Guidance on temporary malaria control measures in Ebola affected countries)

Two distribution rounds MSF did two mass drug administrations of 3-day courses of artesunate-amodiaquine (ASAQ) as both treatment and chemoprevention for malaria in Freetown, Sierra Leone and Monrovia, Liberia in collaboration with the ministries of health. (Photo: Anna Surinyach/MSF)

An unprecedented undertaking Monrovia, Liberia: In four administrative zones (population 552,000) Fixed-site family-kit distributions Assessed by phone cohort study (systematic sample) Freetown, Sierra Leone: In the greater Freetown area (population 1.8 million) House-to-house distributions Assessed by serial two-stage cluster surveys The MDA was the largest-ever distribution of antimalarial drugs in Africa, as well as in the context of an Ebola epidemic. Overall, the national campaign is believed to have reached 2.5 million people in Round 1. The MSF-led distribution reached nearly 1.5 million people in Round 1 and more than 1.8 million people in Round 2. The Monrovia assessment was a cohort study (not a coverage survey) which involved a systematic sample of households that received vouchers assessed by phone. Sources: Map 1: http://www.nationsonline.org/map_small/sierra_leone_small_map.jpg Map 2: http://www.therightperspective.org/wp-content/uploads/2012/05/Map_Liberia_Sierra-Leone.jpg

Social mobilization Town criers Leaflets and banners Radio jingles Radio and TV panels SMS via mobile phone Social media Advocacy meetings (Photo: Patrick Robitaille)

Results from Monrovia November 2014: More than 95% of sampled households that received vouchers attended both distribution rounds. Taking at least one dose: 53% (47-59%) first round 22% (17-28%) second round 16.5% of people reported an adverse event (round one), all mild. (Photo: Estrella Lasry)

Results from Freetown Over 90% of those surveyed said they liked the idea of the MDA and would accept ASAQ in a future distribution.   First Round 5-8 December 2014 Adult and Child Second Round 16-19 January 2015 Adult Child Received ASAQ 88% (82-94%) 92% (88-94%) 92% (89-94%) Took correctly 75% (68-81%) 64% (59-68%) 86% (83-90%) Adverse event 66% (60-73%) 54% (49-59%) 39% (34-44%) First round survey sampled 399 people (55% adults and 45% children). Second round survey sampled 453 adults and 451 children. Almost all (96%) of those who received ASAQ took one or more pills.

Adverse events (Freetown, Second Round) In the second round in Freetown, 54% of adults and 39% of children reported one or more adverse events. This graph represent the percentage of all those who took ASAQ, who experienced each adverse event. Adults denominator = 397. Children denominator = 402.

Challenges and limitations Time, logistics and human resources No touch during Ebola (ABC rule) Out-of-date maps, old census Mobilizing communities and building trust Evaluating coverage and impact Pharmacovigilance (adverse events) In terms of evaluating the distributions: two different methodologies (phone cohort and two-stage cluster survey) in relation to contexts. OCBA was a new section in Sierra Leone as was OCP in Liberia. They were setting up from scratch: No national staff, no registration, no office, no warehouse, no supplies or emergency preparedness on the ground, and lack of knowledge of the country and the health systems. (Photo: Patrick Robitaille)

Non-Ebola health needs must be addressed Discussion Scale and scope was unprecedented Monrovia and Freetown differed in context, point in outbreak and methodology MDAs can be feasible, accepted and welcomed Malaria control is a crucial part of Ebola response (Anna Surinyach / MSF) Non-Ebola health needs must be addressed We expect that the intervention significantly reduced the number of febrile patients in the targeted communities and in the holding centers, resulting in a likely decreased risk of transmission of Ebola to malaria patients; and a reduction of “non Ebola” pressure on the health system. In these two contexts, mass distribution of antimalarials proved to be feasible, welcomed by the communities and, despite some reported minor adverse events, relatively well adhered to in terms of dosage.

Thank you Residents of Monrovia and Freetown MSF France, MSF Spain, and Epicentre Field, capital and headquarters teams Ministry of Health partners Liberia and Sierra Leone National Malaria Control Programs MSF Scientific Day Organizers, reviewers, editorial committee, and participants