Blogging as an RPCV: Belated World Malaria Day

Well, as of April 17th, I officially gained the status of Returned Peace Corps Volunteer, and as of 2:40 am on April 29th when Bozeman welcomed us home with a blizzard that made it impossible to land the plane for nearly three hours, I physically became an RPCV. I still have more to write about, however, and I really hope that whatever I end up doing next is interesting enough to keep blogging about, because it turns out I really enjoy it. But for now, being that today is the last day of World Malaria Month only 13 days after my Close of Service date, I'm going to take the opportunity to write about the project that has dominated most of my waking hours over the last year: PECADOM Plus.

In past blog posts, I wrote about a fellow volunteer's idea of paying a small wage to low-level community health workers to conduct sweeps of every household in their village once a week during rainy season to seek out any suspected cases of malaria (typically identified by fever, headaches or vomiting), administer a Rapid Diagnostic Test (RDT) and treat any positive cases on the spot. An existing program called PECADOM had already trained these health care workers known as DSDOMs (French acronym for home-based care providers) in rural villages to administer the tests and treat simple malaria. Ian called his active version of the model, where the DSDOMs actively sought out the patients instead of waiting for them to seek care themselves, PECADOM Plus. In 2012, Ian and his counterparts conducted a pilot of the model in one village and saw amazing results. By the end of the rainy season, the point prevalence of symptomatic malaria in the project village was 88% lower than that of two neighboring villages with the passive PECADOM model.

Rapid Diagnostic Tests were introduced in Senegal in 2007.

With results like that, it was clear that a larger pilot was necessary to see if the same effect could be seen with a larger sample size. As Ian prepared to finish his service around this time last year, he and I started to work with local health officials and the National Malaria Control Program to design a scaled-up pilot of the model. Dr. Youssou Ndiaye (the Chief Medical Officer of the Saraya Health District at the time) and I co-authored a research protocol to submit to the ethics committee of the Senegalese Ministry of Health and prepared to scale up the project to 15 intervention villages with the active sweeps and 15 comparison villages that would retain the original passive model. From the beginning, it was all a bit daunting, but I fortunately had an amazing mentor in Dr. Julie Thwing, the CDC's Technical Advisor to the Senegalese National Malaria Control Program for the President's Malaria Initiative.

The region of Kedougou. Project villages in red, comparison villages in blue, and health posts in green. The Saraya Health District is the most spread out health district in Senegal.

 The 2013 rendition of the project rolled out in early July, a time picked on account of a) the fact that the 2012 pilot had started in late July and the prevalence was already quite high--this year we wanted to start earlier on in rainier season to try to keep the point prevalence from reaching as high, and, b) a ton of Peace Corps Volunteers come all the way down to Kedougou for the 4th of July, and we would need one volunteer to supervise the sweep in each of the villages in the intervention villages.

Training of volunteers for the project launch

The days of July 7-11 were definitely the craziest of my Peace Corps service. We needed to supervise the sweeps in the 30 intervention and comparison villages along with a training of women in the intervention villages on the signs and symptoms of malaria and the importance of early treatment in order to facilitate the sweeps and encourage early treatment seeking.

When those days were all over, I honestly couldn't believe we had managed to pull off the launch. All of the health district's cars/ambulances were having mechanical problems, so I had to beg Peace Corps to send a car, which came through at the last minute.  Right as we were leaving Saraya to disperse to the project villages, they told me that since the DSDOMs had only been trained and not installed, none of them had tests or medications.  Then one of the DSDOMs informed me that he had changed the village he was living and working in (this is ridiculous, since it is the village that selects the person to be trained to care for them). We got that sorted out, grabbed meds to bring to the villages, but of course realized by the time we got to the first health post that we had forgotten the thermometers in my hut. One DSDOM who met us at the post volunteered to ride his motorcycle the 30 km back to Saraya to get them. While we waited, the clouds darkened and darkened: I still had a 25 k bike ride ahead of me, and it started raining right as I left. My phone rang every five minutes with either volunteers or DSDOMs with questions about exactly what was supposed to happen. Then it stopped ringing and I realized it had fallen out of my pocket back on the trail. I had assigned myself supervision of the one village where I hadn't been able to contact the DSDOM since the training several weeks prior, so I had no idea if he was expecting me. But, the beauty of Senegal is that you can show up anywhere with no warning without knowing a soul and they will be thrilled to feed and shelter you. I finally got there at dusk, and if the DSDOM and his family were surprised to see me, they made no sign of it. After supervising the training and the sweep, I started to bike back in to the health post, thinking that any moment the Peace Corps car with Pat in it would meet me to take me back and prepare for the comparison village sweeps of the next three days. It turned out that the car missed the turn onto the tiny bush path where I was and went all the way to another village on the Mali border. I was already back at the fields surrounding the village with the health post by the time they met me.

Photo time with the Satadougou DSDOM after the women's training. This village is waaay out there on the Mali border. 

Satadougou DSDOM training women from the village on how to recognize symptoms of malaria and the importance of early treatment seeking.

That's just a small taste of the shenanigans of the PECADOM Plus launch. During the five launch days, both the Peace Corps car and the one remaining district cars broke down at different times, and it rained nearly every day, turning the roads into rivers. Two volunteers from outside the Saraya area who were supervising one comparison village walked into a compound where people were burning mercury to process gold, which freaked them out enough that they left the village and we couldn't use the data. Fortunately, due to another mix up involving a nurse inviting way too many DSDOMs to participate, we still had 15 comparison villages. At one point, I was preparing to send a volunteer with a DSDOM to his village to supervise him, and another DSDOM asked me, "Has this guy ever even done a rapid test?" To which he responded, "What's a rapid test?" Turned out that his supervising nurse was in Mecca for the Hajj, so he had never been trained, and was not ever supposed to be a comparison DSDOM. He had somehow just shown up, gone through the orientation and never said a word.

No big deal, just a river in the road.

Taking advantage of cars going to remote villages, the health district sent nets with us for the Universal Coverage distribution that took place soon after our project launch in all villages in Kedougou

This craziness is what makes Peace Corps Peace Corps. The bulk of my job was figuring out how to adapt to unideal situations. But we pulled it off. Sweeps were conducted and supervised in 30 villages. The project was launched. At that point, the prevalence of symptomatic malaria in both sets of villages was approximately 1.1%. Sweeps continued every week after in the intervention villages. For the next five months, I coordinated supervisions of the sweeps, both through the supervision we had set up through the health district and supplemental supervision by Peace Corps Volunteers for research quality purposes. Sweeps were conducted on Mondays in most villages, which meant that I would call each of the DSDOMs on Saturday mornings to check in with them and make sure they had tests and meds for the upcoming sweep. I was worried that checking in each week would annoy them, but in Senegalese culture, calling super often just to greet is a preferred communication technique, and they loved it. Every Monday that I was free, I would bike to a project village to supervise a sweep myself--I really wanted to know intimately how things were going in each village to be able to understand the final data when it was ready for analysis.

DSDOMs hard at work conducting active sweeps

In September and November we went back to the comparison villages to compare the prevalence of symptomatic malaria. Whereas in July, before the program, the point prevalence had been the same in both sets of villages, in September (half way through the rainy season), the prevalence was 2.5 times higher in the comparison villages than in the intervention villages. By the time the program ended in late November, the prevalence in comparison villages was sixteen times higher than that of the project villages. From supervising closely throughout the project and monitoring the data from the sweeps each week, I had sensed that the active model was making a difference, but I was blown away by the difference we saw at the end of the program. In all of the 15 villages, only six cases of symptomatic malaria were found on the last sweep!

At baseline, both sets of villages had relatively low prevalence of symptomatic malaria, except in this village where Pat supervised. It was a tiny village, but they found 19 cases...over 15% prevalence. Fortunately, after that first sweep, the prevalence quickly dropped and stayed low the rest of the rainy season.

Doing this scaled-up pilot showed that this active model really is both feasible and effective. There had been concerns that weekly sweeps for a five month period would be too much for a DSDOM to take on, but our DSDOMs as a whole completed 89% of their possible sweeps. Only ten sweeps total were missed because of gold mining, whereas, when we went out to the comparison villages in November, only 8 of the 15 DSDOMs were in there villages--all the others had left to mine gold (in the intervention zone, nonetheless!). It could be that the active role (and the accompanying payment) provides an incentive for the DSDOM to stay in the village and be accessible to those who need care. The other big concern about the model was that people would wait until the sweep to get seen instead of seeking out the DSDOM when they first got sick. I was delighted to find that the DSDOMs actually consulted the majority of their patients during the week using routine surveillance rather than during the active sweeps. What I observed was this: in doing the sweeps, the DSDOM starts a virtuous cycle in which he proves that a) he was competent as a care provider, b) the medication is effective, and c) the medication, contrary to widespread misconception, is free, all factors which encourage early treatment seeking on behalf of the community.

After the project period, I spent most of my time going to all of the health posts in the district to find the village of origin of every case of malaria in order to look at the incidence of both simple and complicated malaria at the post level. From 2012 to 2013, both simple and complicating cases originating from project villages decreased more than cases from other villages in the catchment area of the intervention health posts. More evidence that this model is really good! For a cost of just over $1 for person protected, it's very cost effective for these kinds of results. There is a debate about whether or nor community health workers should be paid or should work as volunteers. In doing this work, I have come down strongly of the side of: pay them for the work they do! If they have an actual task, like a weekly sweep of their village, they must be paid to complete the task. As I was preparing to leave Saraya, one of the DSDOMs called me and said that he had never known the value of his work as a DSDOM until this year--it was one of the comments that touched me most as I wrapped up my service.

In early February, I was invited to present the findings to the National Malaria Control Program, which was a huge honor. Pat and our friend Karin Nordstrom, who were both huge in leading the implementation of this year's program, came with me, along with the nurse and community health worker who helped design the original pilot and one of the DSDOMs. I was really happy with the presentation--the NMCP members were really engaged and asked great questions. A few weeks later, I got word that they were interested in scaling up the model to the entire region of Kedougou. Right around the time I was leaving, they got funding for the scale-up, and the model will be deployed in approximately 150 villages. I'm so proud of everyone who was involved in this project and so excited to see where it goes. If we want to reach the goal of near zero malaria deaths by 2015, I think this is a really promising approach in high endemic areas, and it has been an honor to work with people at all levels of the Senegalese health system to show the promise of the PECADOM Plus model.

Our team of presenters at the National Malaria Control Program

Definitely the biggest deal presentation I've ever given

Most of the DSDOMs from this year's project. It was amazing to see what these men, most of whom had very little education, were capable of doing in their communities when empowered by this model for malaria detection and treatment.

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