1. Reducing the Malaria Burden in Community Settings: Synergism across varying transmission settings
ASTMH 2018
Dr Elizabeth Chizema Kawesha
National Malaria Elimination Program
ZAMBIA

2. Background
Post 2000, Zambia made deliberate efforts towards reducing the burden of malaria in the country
Focus of the national malaria strategic plans;
: Scale up of malaria interventions
2006 – 2010 : Continued scale up of malaria interventions
2011 – 2016 : Consolidating the gains made
2017 – 2021 : Malaria elimination
Vision of malaria free Zambia
Mission is to provide equitable access to cost effective, quality health services as close to the family as possible
Malaria incidence thresholds to guide the intervention package deployment

3. Engaging communities 1: MaMaZ Against Malaria Project
12-month pilot project (July 2017 – July 2018)
Implemented in Serenje District, Central Province, Zambia
In 8 HF (33% of operational HFs in district) with target population of 54,000 (~40% of district population)
Focus on severe malaria in children aged 6mths to 6yrs
Implemented in partnership with funding and technical support from Medicines for Malaria Venture

4. Baseline
8% of recorded cases of severe febrile illness resulted in death
Many other household and community barriers & delays to service use
Poor and incomplete knowledge of severe malaria danger signs among trained CHVs
Low awareness at community level of severe malaria symptoms and severity, leading to delays in accessing appropriate treatment
RAS was not available in public health facilities
Although adopted in national policy
Very few HWs trained in use of injectable Artesunate & drug not used below district hospital level
Zambia adopted policy change- 2014
Phased approach starting with third and second level hospitals followed by district hospitals
Severe malaria cases under-reported in HMIS
Baseline studies included:
Statistical baseline study
Facility audit
Rapid qualitative assessment at community level of knowledge, attitudes and practices

5. Intervention Community Level Health Facility Level
MAM built on two earlier projects, MAMaZ & MORE MAMaZ
CHVs were trained to mobilise communities on severe malaria & child health (477, 225)
Community systems established to reduce access/affordability barriers and delays (e.g. food banks, emergency savings schemes)
Strengthen referral by Community-based emergency transport system
Community monitoring system, managed by CHVs
Health Facility Level
Health providers trained in effective severe malaria case management, including use of injectable artesunate
Linkages between health facilities and communities strengthened (mentoring and supportive supervision & data review)
District, Provincial, National Level
Emphasis on building sustainable capacity for RAS programming at district level
Sharing experience and results with provincial and national level

6. Community based approaches – integration with other programs
Leveraging existing community based volunteers and training them to provide malaria services
SMAGS (targeting maternal health) and training them to test and treat simple malaria, recognize danger signs for malaria , provide pre-referral treatment and facilitate referral (using bicycle ambulance ORIGIALLY meant for maternal referral)
Communities can be mobilized to work together – Bicycle ambulance maintained, management of service etc
Source : MAMAs RAS study

7. (children < 1 to 5 years)
When CHWs provide pre-referral treatment with Rectal Artesunate (July 2017-July 2018) (MAMAs RAS Study)
Severe Malaria Case Fatality
Malaria Incidence
Timeframe
Malaria cases
(adults and children)
(children < 1)
(children 1-5 years)
Total
(children < 1 to 5 years)
Severe malaria cases
(children < 1 )
Baseline
Nov 16-Mar 17
17,529
1,434
6,166
7,600 34
156
190
End line
Nov 17-Mar 18
14,686
1,615
4,911
6,526
189
430
619
Net change
-2,843
217
-1,255
-1,074
155
274
429
Source: HMIS records
Source: HMIS
Data covers November 2017 – end Jan 2018.
SM case fatality rate fell from 8% at baseline <0.5% at end line
This is equivalent to >95% reduction in the SM case fatality rate
Total malaria cases (adults & children) fell 16% by end line
Malaria cases in children < 1y/o increased by 12%, ?? better reporting in this age group
Reported cases of severe malaria increased for children (p<0.05), most likely indicating better identification of these cases

8. CHWs have demonstrated ability for successful referral
Indicator
Progress by EOP
Children who received RAS in community and were referred to a HF providing SM treatment
100%
RAS beneficiaries who were referred to a HF and received a counter referral form
72%
Children given RAS by CHV who were followed up for adverse events in 30 days post-exposure
Children with suspected severe malaria transported to HF by ETS
71%
RAS verification exercise confirmed that children with SM were treated with Inj AS at facilities
Notes
Many of the project targets were reached / exceeded
The data on follow-up doesn’t give a clear picture of what happened in the intervention communities. However, in the end line survey 92.4% of CHVs said that they followed up RAS cases upon their return from the HF.
Source: Community Monitoring System
Children given RAS were followed-up by CHVs, with multiple follow-up visits in some cases
RAS verification exercise confirmed that children with SM were treated with Inj AS at facilities

9. Engaging communities 2: CHWs provide additional points of contact with communities
Access to health care services for malaria has been a major barrier to progress
Addition of CHWs has drastically altered travel distances for case management
Source: C. Bever, Institute for Disease Modelling

10. 3: Growing proportion of confirmed cases seen by CHWs when service is provided at community level (HMIS)
This is the summary of what has happened in the study areas (all areas) for reported confirmed malaria in health facilities (brown), confirmed cases seen by community health workers (yellow), and added cases found during household investigation of individual cases (red). Note that blue represents unconfirmed cases ( no diagnostic test done to confirm the case) who were treated; these essentially disappeared by 2014 because all facilities and CHWs had stocks of rapid diagnostic tests (RDTs) and drugs (ACTs). Finally, the blue line shows the growing proportion of confirmed cases that were reported by CHWs…as most of the care and treatment moved into villages.
The rainy seasons for 2012, 2013, 2014, 2015, and 2016 are shown with their spike of malaria cases typically coinciding with the rains. The arrows show when the MDA or fMDA was given and you can see that the expected peak for 2015 was much reduced even though more cases were seen in the villages due to the outreach. And, by 2016, there were very few cases – >87% reduction compared to 2014.

11. 4: Declining Burden of Malaria
Parasite Prevalence by RDT:
Active Case Detection 2008 to 2013
Macha Hospital Pediatric Malaria Admissions
Passive Case Detection
Active Case Detection
Phil Thuma, Harry Hamapumbu, Tamaki Kobayashi and MRT team

12. Moving forward CHWs have a key role for malaria and its elimination
First point of contact in any given community & present in ALL epidemiological settings
Service provision – diagnosis, treatment, pre-referral treatment & referral
Community mobilization and awareness raising
Enhanced surveillance – real time reporting, update community registers
Distribution of LLINs &Simple entomology focused on breeding site identification
Zambia’s CHW need is ~15,000
7,500 would have been trained by end of 2018
Also training “Community health Assistants”
Trained for 1 year & cover more health conditions
Provide supervision/mentorship to CHWs in addition to HWs

13. Acknowledgements

14. Thank you