BAMM: April is Blog About Malaria Month. That being the case, I thought that my blog would be a good forum to share excerpts from my Public Health Analysis (major culminating paper for Tulane) which I wrote on the subject of “Malaria Prevention and Control in Senegal” as I was preparing to leave for Peace Corps.
As a health volunteer in Senegal, malaria prevention will be a major part of my work. Kedougou, the region where we will be serving has the highest prevalence of malaria in Senegal (more on our short visit there in the next post). Plus, I have heard that Masters International students will be focusing on the Stomping Out Malaria in Africa Initiative in a health system strengthening capacity, which I’m very excited about. There is a malaria team among health volunteers that I am hoping to join (they do extra training called Malaria Boot Camp and seem to serve as point-people for all health volunteers). Whatever role I end up playing in the fight against malaria during my service, I think that choosing this topic for my Public Health Analysis will have provided very good preparation. Here are some snippets from my paper, condensed, reorganized and interspersed with commentary based on my personal experience in Senegal.
Malaria in Senegal:
(We will be serving in Kedougou, which is in the very Southeastern corner of the country.)
Source: World Health Organization, 2010.
Malaria has historically been and continues to be a serious health issue in Senegal, one of 43 malaria-endemic countries in Africa. In Senegal, the disease is responsible for 32% of all outpatient visits and 20% of deaths in children under five (Roll Back Malaria, 2010). However, malaria is highly preventable, and these under-five deaths could be avoided. For example, insecticide treated bednets (ITNs) have been shown to reduce clinical episodes of malaria by 50% and all-cause mortality by 17%. When a community-level coverage of greater than 60% is attained, non-users receive a similar protective effect as those who use bednets (Thwing et al., 2011). As stated by the Roll Back Malaria Partnership, “Malaria prevention and control measures work, and they produce remarkable results when they are implemented with adequate human and financial resources” (2010).
The fight against malaria in Senegal has come a long way in the past fifty years. In the 1960s, nearly 50% of children here died before the age of 5 (as shown in the figure below from Trape et al., 2012). Immunization campaigns and access to chloroquine treatment for malaria during the 70s and 80s drove a large decline in child deaths. In the 1990s, chloroquine resistant malaria emerged, which created a period of stagnation in the pattern of decline. An outbreak of meningitis in 1998 created a large spike in mortality. According to Trape et al., the continued decline of under-five mortality in the 2000s can almost entirely be attributed to anti-malarial activity:
“After a decade of stagnation in the 1990s, a new dramatic decrease in child mortality has been observed during the past few years. This decrease was temporally related to the deployment of new malaria control policies, suggesting that malaria has both a direct and an indirect effect on overall morality and that MDG 4* can be achieved primarily through malaria control and vaccination in poor rural areas of Africa” (Trape et al., 2012, p 672).
*MDG 4 refers to Millennium Development Goal 4, which is to reduce child mortality by two thirds by 2015
Under 5 mortality in the Niakhar region of Senegal (Source: Trape, et al., 2012)
Prior to 1997, the antimalarial activities were implemented by the National Department of Major Endemic Diseases, who had a budget of only $10,000 per year from the World Health Organization. The National Malaria Control Programme (NMCP) was created in 1995. In 1997, Senegal was granted $185,000 from the WHO as part of the first Accelerated Malaria Action Plan. Following initial success with these monies, Senegal was selected as a pilot country for the Roll Back Malaria Partnership.
Senegal obtained its first major malaria-control grant from the Global Fund in 2003. However, this Round 1 grant received a negative evaluation in 2004, primarily due to weakness in the management of the National Malaria Control Program. As a result, the NMCP underwent a major reorganization and increased its human resources from 5 to 32 staff members. A second grant from the Global Fund was then obtained in 2005, and the 2006-2010 strategic plan was created (Roll Back Malaria, 2010). Since the major reorganization of the National Malaria Control Programme (NMCP) in 2005, Senegal’s Ministry of Health has shown itself to be a committed and effective partner in the global fight against malaria. Recent policies and interventions have included distribution of Long Lasting Insecticidal Nets (LLINs), Indoor Residual Spraying (IRS), Intermittent Preventive Treatment (IPT) for pregnant women, Home-Based Care, and Rapid Diagnostic Testing (RDT).
The following table depicts the timeline of malaria prevention and control programmatic activity in Senegal from 2006-2010 (Source: Roll Back Malaria, 2010).
Year | Activity |
2006 | National coverage of ACT; Close ties between maternal and child health programs and NMCP: 89% of clinics evaluated able to provide IPT and ITNs to pregnant women in 2006 |
2007 | National coverage of Rapid Diagnostic Tests (RDTs) |
2008 | Introduction of home-based care |
2009 | Launch of national mass distribution campaign of ITNs |
2010 | “Redoubling of efforts” · Extension of PECADOM (home-based care) coverage · Availability of free ACTs: All public-sector health centers supplied with ACT and able to use them (free of charge as of 2010) · Universal ITN coverage in 4 south eastern regions · Artemisinin-based monotherapies banned to fight emergence of resistance |
So, where does Peace Corps fit into Senegal’s anti-malaria campaign in 2012? Peace Corps Volunteers have worked on universal bednet coverage campaigns in an effort to protect communities and individuals. As a result, many communities have reached universal coverage (meaning that every sleeping space has a bed net). The next step, however, is ensuring that people use their nets.
Behavior change is a difficult process. While on our volunteer visit, we had a training assignment to do a brief interview about malaria with a family at our site in our local language. When we asked how many beds in the house had nets hanging, we were told, “For every two beds, there should be two nets.” When we probed further and asked how many beds were in the compound and how many of those particular beds had nets hanging, the truth came out that only one person had actually slept under the net the night before. People know they are supposed to use them, but they choose not to for many reasons. First and foremost, it is dang hot here, and the nets make it even hotter. Additionally, malaria in Senegal is highly seasonal (cases spike in October and November, toward the end of the rainy season where there is more water and therefore more mosquitoes). People think they’re safe during the dry season, when they really are at risk year round. This brings about another issue: even though malaria can be deadly, it may not be at the forefront in people’s minds of all of the deadly things that poverty brings. For example, a full stomach today may trump a fever tomorrow. Just today in Mbour, I saw some Talibes (students sent to study at a Koranic school) fishing with mosquito nets. People also use them as netting in their gardens.
Debate exists amongst those working to fight malaria about the best distribution strategies and whether free, subsidized, or full cost distribution contributes to higher rates of net usage. Is it better to ensure that everyone has access via free distribution or should distributors require people to purchase nets thereby ensuring a sense of ownership? In 2009, Senegal’s National Malaria Control Programme staged a nationwide net distribution (targeting children under five and pregnant women, the groups that are most vulnerable to malaria). In an evaluation of the campaign (which distributed vouchers for free nets), Thwing et al., found that 77.5% of children under 5 and 60.5% of pregnant women slept under an LLIN received during the campaign. These lower than desired usage rates may indicate a need for increased behavior change communication and perhaps should lead to review of the effectiveness of the free distribution strategy. However, of households lacking nets of any kind, 37.1% reported having no means to acquire one (in the lowest wealth quintile, this response was given for 83.2% of households). This particular finding supports the free distribution strategy. Regardless of distribution strategy, education and behavior change communication activities are needed to sustainably increase ITN usage.
In their 2010 Focus on Senegal report, the Roll Back Malaria Partnership asserted, “The coming years will be decisive. They will provide Senegal and its partners, if efforts are maintained and well-managed, with a unique opportunity: the chance to roll back malaria on a large scale with unprecedented force. Senegal could then serve as an example to other national malaria control programmes, sharing good practices and helping them to pave their way to malaria eradication.” (Roll Back Malaria, 2010, p 51). It is an exciting time to be preparing to swear in as a Peace Corps volunteer working on malaria!
References
Ministère de la Santé et de la Prévention. Plan stratégique de lutte contre le paludisme au Sénégal 2006-2010.
Roll Back Malaria Partnership. (2008). Global Malaria Action Plan. Retrieved February 29, 2012 from: http://www.rbm.who.int/gmap/index.html
Roll Back Malaria Partnership. (2010). Progress and impact series: Focus on Senegal. Geneva: World Health Organization.
Thwing, J., et al. (2011). Success of Senegal’s first nationwide distribution of long-lasting insecticide-treated nets to children under five - contribution toward universal coverage. Malaria Journal, 10(86).
Trape, JF, et al. (2012). New malaria-control policies and child mortality in Senegal: Reaching millennium development goal 4. Journal of Infectious Diseases, 205, 672-679.
World Health Organization. (2011). Malaria country profile: Senegal.
Anne - thanks for this great post. We commemorated Malaria Sunday today at CtK - the ELCA Malaria Campaign's goal for this week is to raise $200,000 to begin the campaign's work in Liberia. We'll see!
ReplyDeleteI'll be linking this post to the CtK blog and perhaps on facebook, too.
We pray for you and Pat every Sunday - hope you are well!!