PROJECTUPDATE
The Blantyre Integrated Malaria Initiative: a model for effective malaria control MJ Hamel, C Mkandala,N Chizani, N Kaimilla, JG Kublin, R Steketee The Blantyre Integrated Malaria Initiative (BIMI) is a district-wide malaria-control effort, supported jointly by the Government of Malawi and the United States Agency for International Development (USAID). BIMI was established in Blantyre District, Malawi in 1998 to promote sustainable and effective strategies to manage and prevent malariarelated morbidity and mortality. The goal of BIMI is to reduce malaria-related deaths among children under fiveyears of age by 30Voby meeting the four main objectiveslisted in table 1. The key BIMI interventions and their expected beneficial outcomes are described in table 2.
Table 1: Objectives of the Blantyre Integrated Malaria Initiative
t . Improve management of pediatric fever and anaemia by health
Table 2: Key interventions and associated benefits of the Blantyre Integrated Malaria Initiative
Key interventions to reduce malaria-related mortality
Established benefits
Conect treatment of children u n d e r - 5i n h e a l t hl a c i l i t i e s
Decreasedmotality (2) and and anaemia(3).
Early correct treatment of febrile c h i L d r ew n i t h a n e f f e c t i r ea n t i m a iarial drug at a health facility or
Decreasedmortality (2,4).
in the community.
Protective intemittent treatment of pregnant women with an elfectiveantimularialdrug.
Decreasedmatemalanaemi and neonatal Iow-birthweight (5,6,7).
Regularuseof insecticide-
Decreasedmortality in children under-5(8, 9, 10), and decreased matemalan-
impregnated bednets for children under 5 years of age and pregnant women.
aemia and neonatal lowbirth-weight (11).
workers at the health facilities and by caretakersin the home.
2, Improve accessand demand for presumptive intermittent treatment of pregnant women with antimalariat therapy.
3 . Increase demand for, accessto, and appropriate use of affordable insecticide impregnated bed nets.
t . Use human and materiai resourcesmore effectively through improved colleclion of data and use of health management information systems.
The origin BIMI is part of a larger effort, the African Integrated Malaria Initiative (AIMD, launchedin 1996 in four countries:Malawi, Kenya, Zambia and Benin. Programme evaluation is a key element to all AIMI programmes. Lessonslearned,including the successesand challengesencounteredwhile implementingkey strategies and the financial and human resources needed for implementation, are shared with national malaria control proand with international health organizationsto promote _qrammes rational expansionof the AIMI interventions beyond the level of district demonstrationprojects. Malawi was selectedas an AIMI programme site becauseof the long-standing national expertise and experienceof using researchfindings to direct malaria control activitiesand policy (1).
\lalau i Medical Joumal
The structure BIMI is located within the Blantyre District Health Office, where the District Health Management Team (DHMT) has primary leadership responsibility for the design and implementation of BIMI, and where BIMI activitiesare included as an integral parl of the annual District Health Plan. Guidance,review and oversight of the programme is provided by the BIMI steerfrom the ing committee,which is comprisedof representatives National Malaria District Ministry of Health, the Central and Elizabeth Central Program, Lilongwe and Control Queen Assembly, USAID, and the Blantyre City Hospitals Staff, (Wellcome The Malaria Trust, researchand donor organizations Project,PopulationServicesInternational(PSI), and the United States Centers for Disease Control and Prevention (CDC)). National and international consultants provide technical assistance for research activities, programme development and programme evaluation. The aims Initial BIMI efforts focused on measurementof baseline data at health facilities and in the community. The information gathered was used to identify gaps in malaria control activities, to guide strategiesfor implementation of interventions, and to provide baselinemeasurementsso the successof programmeinterventionscould be monitored. A descriptionof the baselinestudies and initial interventions implemented are described on page 24 (Table3).
PROJECTUPDATE to date Table 3: Blantyre Integrated Malaria Initiative baselinestudiesand interventions Objective
Studiesand surveillance
Interventrons
Improved malaria ff eatment at the health facilitY
Health facility survey,Patientflow study Microscopy study,In vivo P.falciparum efficacy study comparingSP to cotrimoxazole.
IMCI training, supervision, and mentoring of clinicians, Reorganization of clinics to improve patient flow and distribution of workload, health facility Q A P p r o b l e m s o l v i n g w o r k s h o p sa t . t h e supervlslon. microscopy Montfrly level.
l m p r o v e d i d e n t i f i c a t i o na n d prompt treatment of fever as maiana
Ethnographicsurvey,Householdsurvey' Active surveillanceof severecutaneous reactionsto SP.
lnformation and education strategiesare being developed to improve prompt care-seeking and treatment ior febrile children'
lmproved accessto affordable insecticide treated bednets
surveyStudyof long-lasting Household insecticideefficacy during routine bednetuse.
Subsidized bednet distribution in antenatal and under-5 clinics.
Improve accessto and demand for p r o l e c t i v ei n t e r m i t t e n tt r e a t m e n lw i l h SP during pregnancy
Drug supply evaluationand in-depth interviewswith nurses in antenatalclinics.
To be determinedwhen resultsof studiesare available'
Use human and material resources more effectively through imProved collection of data and use of health management information systems
Monitoring of all ongoing BIMI projects. Active surveillancefor severe cutaneousreactionsto SP
providedandDHMT HMIS in the process Computers of being Computerized. Comprie, lireracyinstructionprovidedto the DHMT'
Preliminary surYey A survey conductedit 1999 to measurethe level of care provided to sick children at all district government health facilities demonstrated that Blantyre District health workers followed national guidelines by providing protective antimalarial treatment to febrile children (187oof children with fever or a history of fever were appropriately treated with an antimalarial drug)' However, health workers tended to focus on the child's chief complaint and thereby failed to diagnose secondary illnesses, (for example, malaria and pneumonia, anaemiaor malnutrition)' Also, less than half of the sickest children, those with signs of severe disease, were identified and managed according to national guidelines. Unfortunately, time constraints, whether self- or externally-imposed,made a complete evaluation of these sick children nearly impossible - total time spent taking a histoless than 2 minutes' ry and examining each child was usually IMCI training The findings from this survey led to the training of Blantyre District clinical officers and nursesin the WHO/UNICEF guidelines for the Integrated Management of Childhood Illnesses (IMCI). The IMCI guidelines provide a means to use a limited number of signs and symptoms to identify and treat sick children presenting to outpatient health facilities. IMCI encourages Lealth workers to always check for the presenceof danger signs and four key signs or symptoms that may indicate the presence of a serious illness, regardlessof the chief complaint' However' the high patient volume and low number'of clinicians impeded regular use of IMCI at the health facilities. The DHMT responded in severalwaYs: By providing on-site mentor-supervisionof IMCl-trained 1. health workers for 3- 5 days at each health facility and by assistingwith the division of IMCI tasks among existing health facility staff, including Health Surveillance 2.
3.
Assistants. By utilizing the experlise of the Quality Assurance Programme (QAP) to improve patient flow through the clinic, therely decreasingclient waiting time and improving the distribution of workload' By working with the QAP to assisthealth facility staff to develop group problem-solving skills, focusing mostly on increasing patient contact time with clinical staff'
Malaria diagnosis Anotherfacility-basedsurvey,conductedinJune2000,evaluated microscopy capacityand accuracy. Findings from this survey demonstrated that health facility microscopists received little supervisory suppoft, but were reliable in their ability to detect malaria parasitemia (proportion of positive readings by district ='7'77oand prolaboratorytechniciansthat were true positives technicians laboratory district portion of negative readings by frequentclinicians = However, ihut ,""t" true negatives 907o). treated and (in cases) of 257o ly disregardednegative lab results were survey this of based on the clinical presentation. Results monthly and shared with clinicians and laboratory technicians supervision of laboratory technicians was initiated' Clinicians to rely more on negative laboratory findings *"r" "n"ol'rruged and seek other sourcesoffever in patients with a negative blood smear. Malaria KAP An ethnographic survey to understandperceptionsof malaria i11nessandmalariatreatmentandapopulation-basedhousehold survey to measure care-giving behavior, protective intermittent treatmentwith sulfadoxine-pyrimethamine(SP) during pregnanprocy, and householdbednet use,both conductedin early 2000' these' From programme' the vided invaluable information for we learned that caregivers identified malaria as a serious illness among children and pregnant women' but that SP was considered by some to be too strong for use by children' Consequently' for antipyretics were given in the home as first-line therapy could therapy antimalarial of withholding This childhood fever. be risky; blood samplesfrom febrile children in the community showed that most recently febrile children (over 557o) had malaria parasitemia' Further complicating the matter' care-seeking at a health facility was usually delayed beyond the first 2 days of illness, thus most children did not receive prompt correct antimalarial treatment for febrile illness' The household survey results also revealed that although almost all pregnant women (99Vo) attendedantenatalclinic (ANC), few received the recommended 2 doses of SP during their pregnancy (only 11% receivedatleastonedoseandonlyl/3received2doses) Additionally, very few children or pregnant women were sleeping under bednets one Year ago. Malawi Medical Joumal
PROJECTUPDATE Informing the public protective intermittent treatment during pregnancy. Through To addressthese findings, the DHMT and BIMI staff are con- , BIMI, a district-wide active surveillance system to measurethe sidering using radio spots to encourage caregivers to provide frequency of severecutaneousreactions associatedwith SP has prompt cor:recttreatmentto febrile children with the correct dose been established. Also through BIMI, the efficacy of cotrimoxof antimalarials if the child cannot be brought to a health faciliazole compared to SP plus erythromycin for the treatment of ty during the first 1- 2 days of illness. Radio spotswill also be children with malaria parasitemiaand increasedrespiratory rate, used to remind families of the importance of protective inter- consistent with IMCI classifications of malaria and pneumonia, mittent treatment with SP during pregnancy. Plans are under- is being studied. Additionally, BIMI staff are assisting rhe way to conduct interviews with drug sellers,to learn more about Central Ministry of Health to evaluatetrends in malaria morbidprescribing practices. From these interviews, strategieswill be ity and morlality since SP replaced chloroquine as first-line therformulated to improve prescribing practices, perhaps through apy for simple malaria in 1993. pharmacist training courses or single dose packaging of antimalarial drugs by age to improve the administration of correct The way ahead treatmentdosages. Future BIMI activities include exploring ways to fully implement IMCI at health facilities, including introducing job-aids Collaborations and fufiher dividing IMCI tasks among available personnel. Recently, staff from Safe Motherhood, the District Reproductive There will be an evaluation of the district health-facility based Health Unit, and BIMI joined efforts and together, they are referral system to identify obstacles to severely ill patients assessing SP drug supply at ANCs and conducting in-depth reaching refer:ral-level health facilities. BIMI will evaluate interviews with health workers to understand health worker's potential roles for rapid diagnostic tools for malaria and anaemia knowledge, beliefs and attitudes towards providing protective within the rural health facilities. There will be further developintermittent treatment doses of SP to pregnant women at the ment and dissemination of education messagestargetedtowards appropriatetimes during gestation. Using the results of this sur- caregivers, health workers, and drug vendors to improve early vey, strategiesWill be formulated to improve the administration identification and treatment of febrile children. The interaction ofprotective dosesof SP during pregnancy. between malaria and HIV and the potential need for additional As well as providing insecticide treated nets at fullSP doses during pregnancy for HlV-infected women will be product cost recovery through the commercial sector nation- evaluated. An entomologic assessmentof anopheline mosquito wide, PSI is working with BIMI to improve insecticide treated behavior pattems in the urban and peri-urban areas is planned. bednet coverage among the most vulnerable groups by making And, to furlher support the DHMI computerization of the dishighly subsidizedbednetsavailable to pregnantwomen and chil- trict health managementinformation system and computer literdren under 5 years of age at antenataland under-5 clinics. This acy training are underway. strategyhas been highly successful- during the month of March alone over 7000 bednets were distributed using this avenue. Joining in RBIVI After equitable distribution, a major obstacleto optimal bednets Finally, the DHMT and BIMI staff and consultants are looking use is maintaining adequate levels of insecticide on the nets. forward to improving parlnerships to suppofi the national Roll Currently bednetsrequire insecticide re-impregnation every six Back Malaria movement, which incorporatesmany of the stratemonths, but bednet owners do not routinely follow this recom- gies currently being implemented in Blantyre District. We hope mendation. To find alternative options to bi-annual re-impreg- the lessonslearned in Blantyre District will serve as a resource nation, CDC is providing technical assistanceto compare the for the national effort and that the experlise that now exists withpersistenceof insecticidal effect of long-lasting treated nets and in Blantyre District will be useful for expansion of Roll Back traditionally treated nets during usual household bednet use. Malaria activities. Additionally, we have found the integration of local expertise, as provided through the District Health Office, combined with expertise provided by external consultMonitoring progress ants and the administrative support provided by USAID, a BecauseBIMI is designedas a pilot programme from which the rewarding and effective combination, in which local capacity is nation and the international community can leam how best to expanded and efforts are optimally implemented by those who implement effective sustainablemalaria control strategies,mon- know the citizens of Blantyre and are invested in the well-being itoring the successof intervention implementation is an essential of those citizens. We recommend this model to others interestcomponentof the programme. Monitoring data are used to mod- ed in developing similar districrwide or national health efforts. ify and update the BIMI work plan, and lessons learned are sharedat quarterly Steering Committee meetings and at nation- Mary J Hamel MD, Christopher Mkandala MD, Nyson Chizan| Nyokase al and international meetings related to health. More compre- Kaimilla, Jim Kublin MD MPH, Richard Steketee, MD MPH hensive programme evaluations will be conducted at future From the Division ofParasitic Diseases,National Center for Infectious Diseases,Centers for dates to measure change in key BIMI indicators, and the out- Disease Control and Prevention, Public Health Senice, U.S. Department of Health and Human Senices, Atlmta, Georgia, USA (MJH,RS); The Blantyre District Health Office, come measuresfrom those evaluations will be made available. Blantyre (CM, NK); the Blantyre Integrated Malaia Initiative, Blmtlre (NC), and the Research trnaddition to supporting programme activities, and monitoring ind evaluating those activities, the BIMI programme provides :he opportunity to conduct operational research to address ;rrcusedmalaria-control questions that have arisen in Malawi. lJne example of such a question is whether the rate of SP-asso:tated severe cutaneous reactions is increasing with the .ncreased useof SPfor treatment of febrile illnesses and for \hlarvi Medical Jomal
Maltria Project md Department of Comunity Malawi (JK).
Health, College of Medicine, Blantyre,
Address for conespondence md reprints: Cfuistopher Mkandala, MD Blmtyre District Health Office Box240 Blantyre District, Malawi
This programme was funded by the Africa Integrated Malaria of the United States Agency for International Developm€nt
Initiative
(7921-3W9)
25
PROJECTUPDATE Informing the public protective intermittent treatment during pregnancy. Through To addressthese findings, the DHMT and BIMI staff are con- , BIMI, a district-wide active surveillance system to measurethe sidering using radio spots to encourage caregivers to provide frequency of severecutaneousreactions associatedwith SP has prompt coffect treatmentto febrile children with the correct dose been established. Also through BIMI, the efficacy of cotrimoxof antimalarials if the child cannot be brought to a health faciliazole compared to SP plus erythromycin for the treatment of ty during the first 1- 2 days of illness. Radio spotswill also be children with malaria parasitemiaand increasedrespiratory rate, used to remind families of the importance of protective inter- consistent with IMCI classifications of malaria and pneumonia, mittent treatment with SP during pregnancy. Plans are under- is being studied. Additionally, BIMI staff are assisting the way to conduct interviews with drug sellers,to learn more about Central Ministry of Health to evaluatetrends in malaria morbidprescribing practices. From these interviews, strategieswill be ity and mortality since SP replaced chloroquine as first-line therforrnulated to improve prescribing practices, perhaps through apy for simple malaria in 1993. pharmacist training courses or single dose packaging of antimalarial drugs by age to improve the administration of correct The way ahead treatmentdosages. Future BIMI activities include exploring ways to fully implement IMCI at health facilities, including introducing job-aids Collaborations and further dividing IMCI tasks among available personnel. Recently, staff from Safe Motherhood, the District Reproductive There will be an evaluation of the district health-facility based Health Unit, and BIMI joined efforts and together, rhey are referral system to identify obstacles to severely ill patients assessing SP drug supply at ANCs and conducting in-depth reaching refenal-level health facilities. BIMI will evaluate interviews with health workers to understand health worker's potential roles for rapid diagnostic tools for malaria and anaemia knowledge, beliefs and attitudes towards providing protective within the rural health facilities. There will be further developintermittent treatment doses of SP to pregnant women at the ment and dissemination of education messagestargetedtowards appropriatetimes during gestation. Using the results of this sur- caregivers, health workers, and drug vendors to improve early vey, strategiesrryill be formulated to improve the administration identification and treatment of febrile children. The interaction ofprotective dosesof SP during pregnancy. between malaria and HIV and the potential need for additional As well as providing insecticide treated nets at fullSP doses during pregnancy for HlV-infected women will be product cost recovery through the commercial sector nation- evaluated. An entomologic assessmentof anopheline mosquito wide, PSI is working with BIMI to improve insecticide treated behavior patterns in the urban and peri-urban areas is planned. bednet coverage among the most vulnerable groups by making And, to furlher support the DHMT, computerization of the dishighly subsidizedbednetsavailable to pregnantwomen and chil- trict health managementinformation system and computer literdren under 5 years of age at antenataland under-5 clinics. This acy training are underway. strategyhas been highly successful- during the month of March alone over 7000 bednets were distributed using this avenue. Joining in RBIVI After equitable distribution, a major obstacleto optimal bednets Finally, the DHMT and BIMI staff and consultants are looking use is maintaining adequate levels of insecticide on the nets. forward to improving partnerships to suppofi the national Roll Currently bednetsrequire insecticide re-impregnation every six Back Malaria movement, which incorporatesmany of the stratemonths, but bednet owners do not routinely follow this recom- gies currently being implemented in Blantyre District. We hope mendation. To find alternative options to bi-annual re-impreg- the lessonslearned in Blantyre District will serve as a resource nation, CDC is providing technical assistanceto compare the for the national effoft and that the expefiise that now exists withpersistenceof insecticidal effect of long-lasting treated nets and in Blantyre District will be useful for expansion of Roll Back traditionally treated nets during usual householdbednet use. Malaria activities. Additionally, we have found the integration of local experlise, as provided through the District Health Office, combined with expertise provided by external consultMonitoring progress ants and the administrative support provided by USAID, a BecauseBIMI is designedas a pilot programmefrom which the rewarding and effective combination, in which local capacity is nation and the international community can learn how best to expanded and efforls are optimally implemented by those who implement effective sustainablemalaria control strategies,mon- know the citizens of Blantyre and are invested in the well-being itoring the successof intervention implementation is an essential of those citizens. We recommend this model to others interestcomponentof the programme. Monitoring data are used to mod- ed in developing similar district-wide or national health efforls. ify and update the BIMI work plan, and lessons learned are sharedat quarterly Steering Committee meetings and at nation- Mary J Hamel MD, Chdstopher Mkandala MD, Nyson Chizani, Nyokase al and international meetings related to health. More compre- Kaimilla. Jim Kublin MD MPH. Richard Steketee. MD MPH hensive programme evaluations will be conducted at future From the Division ofPuasitic Diseases,National Center for Infectious Diseases,Centers for dates to measure change in key BIMI indicators, and the out- Disease Control and Prevention, Public Health Service, U.S. Department of Health and Humm Services, Atlanta, Georgia, USA (MJH,RS); The Blmtyre District Health Office, come measuresfrom those evaluations will be made available. Blantyre (CM, NK); the Blantyre Integrated Malaria Initiative, Blantyre (NC), and the Research In addition to supporting programme activities, and monitoring ;nd evaluating those activities, the BIMI programme provides :he opportunity to conduct operational research to address :.rcused malaria-control questions that have arisen in Malawi. Llne example of such a question is whether the rate of SP-asso: r.lted severe cutaneous reactions is increasing with the n"'reased useof SPfor treatment of febrile illnesses and for 1"f:las'i Medical Jomal
Malaria Prcject and Departrnent of Community Health, College of Medicine, Blmtyre, Malawi (JK).
Address for conespondence and reprints: Christopher Mkmdala, MD Blantyre District Health Office Box 240 Blmtyre District, Malawi
This programe was funded by the Africa Integrated Malaria of the United States Agency for Intemational Development
Initiative
(7921-3079)
25
STATISTICSCORNER
PROJECTUPDATE References 1. R. Steketee,A Macheso, D Heymmn, et al. A decade of progress in malaria policy and program development in Malawi: 1984-1993. United States Agency for Intemational Development md US depafiment of Health md Human Sewices. 1995. 2. TR Cullinan et al. Packaged treatment for firstline cue in cerebral malria meningitis. Bull WHO | 998:16(3):257 -64. 3. BlolandPB,ELackdtz,PKazembe,etal. Beyondchloroquine:implicationsofdrug resistancefor evaluating maltria therapy efficacy and treatment policy in Africa. Journal of Infectious Diseases 1993;167(4):932-7. 4. Kidane G, R Monow. Teaching mothers to provide home treatment of malaria in Tigray, Ethiopia: a rmdomized trial. Lancet 2000;356(9229):550-5. 5. S J Rogerson et al. Intemittent sulfadoxine-pyrimethamine in pregnancy: effectiveness against malaria morbidity in Blantyre, Malawi in 1997 -99. Trans of the Royal Soc of Trop Med and Hygiene. 2000;94:1-5. 6. Greenwood BM, et al. The effects of malaria chemoprophylaxis given by traditional bifih attendants on the course and outcome of pregnancy. Trans R Soc Trop Med Hyg 1989;83:589-94. 7. Steketee RW et al. The effect of malaria and malaria prevention in pregnancy on off spring birth weight, prematudty, md intrauterine growth retardation in rural Malawi. Am J Trop Med Hyg 1996;55(1):33-41. 8. Binka FN, et al. Impact of permethrin impregnated bednets on child mortality in Kassena-Nankma District, Ghana: a randomized controlled trial. Trop Med Interl Health 1996:lQ):141- 54. 9. Nevill CG, et al. insecticide-treated bednets reduce mortality md severe morbidity from malaria mong children on the Kenym coast. Trop Med Interl Health 1996:1(2):139-46. I 0. Alonso PL, et al. A malria control trial using insecticide-treatedbed nets md ttrgeted chemoprophylaxis in a rural rea of The Gambia, West Africa. 6. The impact of the interventions on mortality and morbidity from malaria. Trans R Soc Trop Med Hyg | 993:87tSuppl 2):37-44. 11.Ter Kuile FO, Terlouw DJ, Phillips-Howard PA, et al.. Permethrin-treatedbednets reduce malaria in pregnancy in an area of intense perennial malaria transmission in western Kenya. Abstract 1 1, Amer Soc Trop Med Hygiene 48th Annual Meeting, Nov 28-Dec 2, 1999; Washington DC.
STATISTICSCORNER S White Welcome to this new feature in the JoumaMn this "Corner" we will look at a specific situation and the statistical methods that can be applied to the analysis of data. Consider this scenario: You want to know how well a simple test may diagnose something, and save the need for a more dfficult' invasive or expensivetest that would provide a definitive answer. For example, in a patient with palpable lymph nodes, is the c&usetuherculosis or not? To answer this with confidence you need an invasive procedure, preferably excision biopsy and histology (EBH). But such a procedure is not only invasive but also difficult, expensive and slow. You may therefore want to know how well a non-invasive, quick method would provide the answer. One method (M7) could be whether simple examination finds 'matted' or not, ie whether they seem to be that the nodes are stuck together in groups. Another method could be a Mantoux (tuberculin) test (M). You want to evaluate each of thesetests on its own for usefulnessin diagnosing TB as the cause of the lymphadenopathy. You also want to know if one test is superior to the other. You plan to conduct a study to evaluate and compare these two methods. The best design uses each method, M 1 and M2, independently, as well as the invasive one, on all patients studied who have palpable lymph nodes. In all the calculations that follw, we will assume that Excission Biopsy and History '7old standard' (EBm is l00%o accurate - it will serve as ovr How should you plan to analyse your data? You will need to select statistical tests to: A Evaluate each method; B
Compare the two methods,
We will consider these questionsin turn. To illustrate the statistical tests to be described suppose you have collected data on 100 patients. Some of the data are shown in Table 1 (this only shows 6 patients - the full table would list all 100 cases),which can be summa.risedin a three-way cross-tabulation(Table 2).
le I Datalisting accordingto diagnosticmethod(EBH = excisionUtpsy andhistology,M1 = pa$ation,M2 = mantouxtest)
Patient ITBTBTB 2 3 4TBTBTB 5 (etc): 100
EBH
M1
M2
TB NOTTB
NotTB NOTTB
TB TB
Not TB : Not TB
Not TB : TB
not TB : not TB Malawi Medical Joumal
The Blantyre Integrated Malaria Initiative: a model for effective malaria control MJ Hamel, C Mkandala,N Chizani, N Kaimilla, JG Kublin, R Steketee The Blantyre Integrated Malaria Initiative (BIMI) is a district-wide malaria-control effort, supported jointly by the Government of Malawi and the United States Agency for International Development (USAID). BIMI was established in Blantyre District, Malawi in 1998 to promote sustainable and effective strategies to manage and prevent malariarelated morbidity and mortality. The goal of BIMI is to reduce malaria-related deaths among children under fiveyears of age by 30Voby meeting the four main objectiveslisted in table 1. The key BIMI interventions and their expected beneficial outcomes are described in table 2.
Table 1: Objectives of the Blantyre Integrated Malaria Initiative
t . Improve management of pediatric fever and anaemia by health
Table 2: Key interventions and associated benefits of the Blantyre Integrated Malaria Initiative
Key interventions to reduce malaria-related mortality
Established benefits
Conect treatment of children u n d e r - 5i n h e a l t hl a c i l i t i e s
Decreasedmotality (2) and and anaemia(3).
Early correct treatment of febrile c h i L d r ew n i t h a n e f f e c t i r ea n t i m a iarial drug at a health facility or
Decreasedmortality (2,4).
in the community.
Protective intemittent treatment of pregnant women with an elfectiveantimularialdrug.
Decreasedmatemalanaemi and neonatal Iow-birthweight (5,6,7).
Regularuseof insecticide-
Decreasedmortality in children under-5(8, 9, 10), and decreased matemalan-
impregnated bednets for children under 5 years of age and pregnant women.
aemia and neonatal lowbirth-weight (11).
workers at the health facilities and by caretakersin the home.
2, Improve accessand demand for presumptive intermittent treatment of pregnant women with antimalariat therapy.
3 . Increase demand for, accessto, and appropriate use of affordable insecticide impregnated bed nets.
t . Use human and materiai resourcesmore effectively through improved colleclion of data and use of health management information systems.
The origin BIMI is part of a larger effort, the African Integrated Malaria Initiative (AIMD, launchedin 1996 in four countries:Malawi, Kenya, Zambia and Benin. Programme evaluation is a key element to all AIMI programmes. Lessonslearned,including the successesand challengesencounteredwhile implementingkey strategies and the financial and human resources needed for implementation, are shared with national malaria control proand with international health organizationsto promote _qrammes rational expansionof the AIMI interventions beyond the level of district demonstrationprojects. Malawi was selectedas an AIMI programme site becauseof the long-standing national expertise and experienceof using researchfindings to direct malaria control activitiesand policy (1).
\lalau i Medical Joumal
The structure BIMI is located within the Blantyre District Health Office, where the District Health Management Team (DHMT) has primary leadership responsibility for the design and implementation of BIMI, and where BIMI activitiesare included as an integral parl of the annual District Health Plan. Guidance,review and oversight of the programme is provided by the BIMI steerfrom the ing committee,which is comprisedof representatives National Malaria District Ministry of Health, the Central and Elizabeth Central Program, Lilongwe and Control Queen Assembly, USAID, and the Blantyre City Hospitals Staff, (Wellcome The Malaria Trust, researchand donor organizations Project,PopulationServicesInternational(PSI), and the United States Centers for Disease Control and Prevention (CDC)). National and international consultants provide technical assistance for research activities, programme development and programme evaluation. The aims Initial BIMI efforts focused on measurementof baseline data at health facilities and in the community. The information gathered was used to identify gaps in malaria control activities, to guide strategiesfor implementation of interventions, and to provide baselinemeasurementsso the successof programmeinterventionscould be monitored. A descriptionof the baselinestudies and initial interventions implemented are described on page 24 (Table3).
PROJECTUPDATE to date Table 3: Blantyre Integrated Malaria Initiative baselinestudiesand interventions Objective
Studiesand surveillance
Interventrons
Improved malaria ff eatment at the health facilitY
Health facility survey,Patientflow study Microscopy study,In vivo P.falciparum efficacy study comparingSP to cotrimoxazole.
IMCI training, supervision, and mentoring of clinicians, Reorganization of clinics to improve patient flow and distribution of workload, health facility Q A P p r o b l e m s o l v i n g w o r k s h o p sa t . t h e supervlslon. microscopy Montfrly level.
l m p r o v e d i d e n t i f i c a t i o na n d prompt treatment of fever as maiana
Ethnographicsurvey,Householdsurvey' Active surveillanceof severecutaneous reactionsto SP.
lnformation and education strategiesare being developed to improve prompt care-seeking and treatment ior febrile children'
lmproved accessto affordable insecticide treated bednets
surveyStudyof long-lasting Household insecticideefficacy during routine bednetuse.
Subsidized bednet distribution in antenatal and under-5 clinics.
Improve accessto and demand for p r o l e c t i v ei n t e r m i t t e n tt r e a t m e n lw i l h SP during pregnancy
Drug supply evaluationand in-depth interviewswith nurses in antenatalclinics.
To be determinedwhen resultsof studiesare available'
Use human and material resources more effectively through imProved collection of data and use of health management information systems
Monitoring of all ongoing BIMI projects. Active surveillancefor severe cutaneousreactionsto SP
providedandDHMT HMIS in the process Computers of being Computerized. Comprie, lireracyinstructionprovidedto the DHMT'
Preliminary surYey A survey conductedit 1999 to measurethe level of care provided to sick children at all district government health facilities demonstrated that Blantyre District health workers followed national guidelines by providing protective antimalarial treatment to febrile children (187oof children with fever or a history of fever were appropriately treated with an antimalarial drug)' However, health workers tended to focus on the child's chief complaint and thereby failed to diagnose secondary illnesses, (for example, malaria and pneumonia, anaemiaor malnutrition)' Also, less than half of the sickest children, those with signs of severe disease, were identified and managed according to national guidelines. Unfortunately, time constraints, whether self- or externally-imposed,made a complete evaluation of these sick children nearly impossible - total time spent taking a histoless than 2 minutes' ry and examining each child was usually IMCI training The findings from this survey led to the training of Blantyre District clinical officers and nursesin the WHO/UNICEF guidelines for the Integrated Management of Childhood Illnesses (IMCI). The IMCI guidelines provide a means to use a limited number of signs and symptoms to identify and treat sick children presenting to outpatient health facilities. IMCI encourages Lealth workers to always check for the presenceof danger signs and four key signs or symptoms that may indicate the presence of a serious illness, regardlessof the chief complaint' However' the high patient volume and low number'of clinicians impeded regular use of IMCI at the health facilities. The DHMT responded in severalwaYs: By providing on-site mentor-supervisionof IMCl-trained 1. health workers for 3- 5 days at each health facility and by assistingwith the division of IMCI tasks among existing health facility staff, including Health Surveillance 2.
3.
Assistants. By utilizing the experlise of the Quality Assurance Programme (QAP) to improve patient flow through the clinic, therely decreasingclient waiting time and improving the distribution of workload' By working with the QAP to assisthealth facility staff to develop group problem-solving skills, focusing mostly on increasing patient contact time with clinical staff'
Malaria diagnosis Anotherfacility-basedsurvey,conductedinJune2000,evaluated microscopy capacityand accuracy. Findings from this survey demonstrated that health facility microscopists received little supervisory suppoft, but were reliable in their ability to detect malaria parasitemia (proportion of positive readings by district ='7'77oand prolaboratorytechniciansthat were true positives technicians laboratory district portion of negative readings by frequentclinicians = However, ihut ,""t" true negatives 907o). treated and (in cases) of 257o ly disregardednegative lab results were survey this of based on the clinical presentation. Results monthly and shared with clinicians and laboratory technicians supervision of laboratory technicians was initiated' Clinicians to rely more on negative laboratory findings *"r" "n"ol'rruged and seek other sourcesoffever in patients with a negative blood smear. Malaria KAP An ethnographic survey to understandperceptionsof malaria i11nessandmalariatreatmentandapopulation-basedhousehold survey to measure care-giving behavior, protective intermittent treatmentwith sulfadoxine-pyrimethamine(SP) during pregnanprocy, and householdbednet use,both conductedin early 2000' these' From programme' the vided invaluable information for we learned that caregivers identified malaria as a serious illness among children and pregnant women' but that SP was considered by some to be too strong for use by children' Consequently' for antipyretics were given in the home as first-line therapy could therapy antimalarial of withholding This childhood fever. be risky; blood samplesfrom febrile children in the community showed that most recently febrile children (over 557o) had malaria parasitemia' Further complicating the matter' care-seeking at a health facility was usually delayed beyond the first 2 days of illness, thus most children did not receive prompt correct antimalarial treatment for febrile illness' The household survey results also revealed that although almost all pregnant women (99Vo) attendedantenatalclinic (ANC), few received the recommended 2 doses of SP during their pregnancy (only 11% receivedatleastonedoseandonlyl/3received2doses) Additionally, very few children or pregnant women were sleeping under bednets one Year ago. Malawi Medical Joumal
PROJECTUPDATE Informing the public protective intermittent treatment during pregnancy. Through To addressthese findings, the DHMT and BIMI staff are con- , BIMI, a district-wide active surveillance system to measurethe sidering using radio spots to encourage caregivers to provide frequency of severecutaneousreactions associatedwith SP has prompt cor:recttreatmentto febrile children with the correct dose been established. Also through BIMI, the efficacy of cotrimoxof antimalarials if the child cannot be brought to a health faciliazole compared to SP plus erythromycin for the treatment of ty during the first 1- 2 days of illness. Radio spotswill also be children with malaria parasitemiaand increasedrespiratory rate, used to remind families of the importance of protective inter- consistent with IMCI classifications of malaria and pneumonia, mittent treatment with SP during pregnancy. Plans are under- is being studied. Additionally, BIMI staff are assisting rhe way to conduct interviews with drug sellers,to learn more about Central Ministry of Health to evaluatetrends in malaria morbidprescribing practices. From these interviews, strategieswill be ity and morlality since SP replaced chloroquine as first-line therformulated to improve prescribing practices, perhaps through apy for simple malaria in 1993. pharmacist training courses or single dose packaging of antimalarial drugs by age to improve the administration of correct The way ahead treatmentdosages. Future BIMI activities include exploring ways to fully implement IMCI at health facilities, including introducing job-aids Collaborations and fufiher dividing IMCI tasks among available personnel. Recently, staff from Safe Motherhood, the District Reproductive There will be an evaluation of the district health-facility based Health Unit, and BIMI joined efforts and together, they are referral system to identify obstacles to severely ill patients assessing SP drug supply at ANCs and conducting in-depth reaching refer:ral-level health facilities. BIMI will evaluate interviews with health workers to understand health worker's potential roles for rapid diagnostic tools for malaria and anaemia knowledge, beliefs and attitudes towards providing protective within the rural health facilities. There will be further developintermittent treatment doses of SP to pregnant women at the ment and dissemination of education messagestargetedtowards appropriatetimes during gestation. Using the results of this sur- caregivers, health workers, and drug vendors to improve early vey, strategiesWill be formulated to improve the administration identification and treatment of febrile children. The interaction ofprotective dosesof SP during pregnancy. between malaria and HIV and the potential need for additional As well as providing insecticide treated nets at fullSP doses during pregnancy for HlV-infected women will be product cost recovery through the commercial sector nation- evaluated. An entomologic assessmentof anopheline mosquito wide, PSI is working with BIMI to improve insecticide treated behavior pattems in the urban and peri-urban areas is planned. bednet coverage among the most vulnerable groups by making And, to furlher support the DHMI computerization of the dishighly subsidizedbednetsavailable to pregnantwomen and chil- trict health managementinformation system and computer literdren under 5 years of age at antenataland under-5 clinics. This acy training are underway. strategyhas been highly successful- during the month of March alone over 7000 bednets were distributed using this avenue. Joining in RBIVI After equitable distribution, a major obstacleto optimal bednets Finally, the DHMT and BIMI staff and consultants are looking use is maintaining adequate levels of insecticide on the nets. forward to improving parlnerships to suppofi the national Roll Currently bednetsrequire insecticide re-impregnation every six Back Malaria movement, which incorporatesmany of the stratemonths, but bednet owners do not routinely follow this recom- gies currently being implemented in Blantyre District. We hope mendation. To find alternative options to bi-annual re-impreg- the lessonslearned in Blantyre District will serve as a resource nation, CDC is providing technical assistanceto compare the for the national effort and that the experlise that now exists withpersistenceof insecticidal effect of long-lasting treated nets and in Blantyre District will be useful for expansion of Roll Back traditionally treated nets during usual household bednet use. Malaria activities. Additionally, we have found the integration of local expertise, as provided through the District Health Office, combined with expertise provided by external consultMonitoring progress ants and the administrative support provided by USAID, a BecauseBIMI is designedas a pilot programme from which the rewarding and effective combination, in which local capacity is nation and the international community can leam how best to expanded and efforts are optimally implemented by those who implement effective sustainablemalaria control strategies,mon- know the citizens of Blantyre and are invested in the well-being itoring the successof intervention implementation is an essential of those citizens. We recommend this model to others interestcomponentof the programme. Monitoring data are used to mod- ed in developing similar districrwide or national health efforts. ify and update the BIMI work plan, and lessons learned are sharedat quarterly Steering Committee meetings and at nation- Mary J Hamel MD, Christopher Mkandala MD, Nyson Chizan| Nyokase al and international meetings related to health. More compre- Kaimilla, Jim Kublin MD MPH, Richard Steketee, MD MPH hensive programme evaluations will be conducted at future From the Division ofParasitic Diseases,National Center for Infectious Diseases,Centers for dates to measure change in key BIMI indicators, and the out- Disease Control and Prevention, Public Health Senice, U.S. Department of Health and Human Senices, Atlmta, Georgia, USA (MJH,RS); The Blantyre District Health Office, come measuresfrom those evaluations will be made available. Blantyre (CM, NK); the Blantyre Integrated Malaia Initiative, Blmtlre (NC), and the Research trnaddition to supporting programme activities, and monitoring ind evaluating those activities, the BIMI programme provides :he opportunity to conduct operational research to address ;rrcusedmalaria-control questions that have arisen in Malawi. lJne example of such a question is whether the rate of SP-asso:tated severe cutaneous reactions is increasing with the .ncreased useof SPfor treatment of febrile illnesses and for \hlarvi Medical Jomal
Maltria Project md Department of Comunity Malawi (JK).
Health, College of Medicine, Blantyre,
Address for conespondence md reprints: Cfuistopher Mkandala, MD Blmtyre District Health Office Box240 Blantyre District, Malawi
This programme was funded by the Africa Integrated Malaria of the United States Agency for International Developm€nt
Initiative
(7921-3W9)
25
PROJECTUPDATE Informing the public protective intermittent treatment during pregnancy. Through To addressthese findings, the DHMT and BIMI staff are con- , BIMI, a district-wide active surveillance system to measurethe sidering using radio spots to encourage caregivers to provide frequency of severecutaneousreactions associatedwith SP has prompt coffect treatmentto febrile children with the correct dose been established. Also through BIMI, the efficacy of cotrimoxof antimalarials if the child cannot be brought to a health faciliazole compared to SP plus erythromycin for the treatment of ty during the first 1- 2 days of illness. Radio spotswill also be children with malaria parasitemiaand increasedrespiratory rate, used to remind families of the importance of protective inter- consistent with IMCI classifications of malaria and pneumonia, mittent treatment with SP during pregnancy. Plans are under- is being studied. Additionally, BIMI staff are assisting the way to conduct interviews with drug sellers,to learn more about Central Ministry of Health to evaluatetrends in malaria morbidprescribing practices. From these interviews, strategieswill be ity and mortality since SP replaced chloroquine as first-line therforrnulated to improve prescribing practices, perhaps through apy for simple malaria in 1993. pharmacist training courses or single dose packaging of antimalarial drugs by age to improve the administration of correct The way ahead treatmentdosages. Future BIMI activities include exploring ways to fully implement IMCI at health facilities, including introducing job-aids Collaborations and further dividing IMCI tasks among available personnel. Recently, staff from Safe Motherhood, the District Reproductive There will be an evaluation of the district health-facility based Health Unit, and BIMI joined efforts and together, rhey are referral system to identify obstacles to severely ill patients assessing SP drug supply at ANCs and conducting in-depth reaching refenal-level health facilities. BIMI will evaluate interviews with health workers to understand health worker's potential roles for rapid diagnostic tools for malaria and anaemia knowledge, beliefs and attitudes towards providing protective within the rural health facilities. There will be further developintermittent treatment doses of SP to pregnant women at the ment and dissemination of education messagestargetedtowards appropriatetimes during gestation. Using the results of this sur- caregivers, health workers, and drug vendors to improve early vey, strategiesrryill be formulated to improve the administration identification and treatment of febrile children. The interaction ofprotective dosesof SP during pregnancy. between malaria and HIV and the potential need for additional As well as providing insecticide treated nets at fullSP doses during pregnancy for HlV-infected women will be product cost recovery through the commercial sector nation- evaluated. An entomologic assessmentof anopheline mosquito wide, PSI is working with BIMI to improve insecticide treated behavior patterns in the urban and peri-urban areas is planned. bednet coverage among the most vulnerable groups by making And, to furlher support the DHMT, computerization of the dishighly subsidizedbednetsavailable to pregnantwomen and chil- trict health managementinformation system and computer literdren under 5 years of age at antenataland under-5 clinics. This acy training are underway. strategyhas been highly successful- during the month of March alone over 7000 bednets were distributed using this avenue. Joining in RBIVI After equitable distribution, a major obstacleto optimal bednets Finally, the DHMT and BIMI staff and consultants are looking use is maintaining adequate levels of insecticide on the nets. forward to improving partnerships to suppofi the national Roll Currently bednetsrequire insecticide re-impregnation every six Back Malaria movement, which incorporatesmany of the stratemonths, but bednet owners do not routinely follow this recom- gies currently being implemented in Blantyre District. We hope mendation. To find alternative options to bi-annual re-impreg- the lessonslearned in Blantyre District will serve as a resource nation, CDC is providing technical assistanceto compare the for the national effoft and that the expefiise that now exists withpersistenceof insecticidal effect of long-lasting treated nets and in Blantyre District will be useful for expansion of Roll Back traditionally treated nets during usual householdbednet use. Malaria activities. Additionally, we have found the integration of local experlise, as provided through the District Health Office, combined with expertise provided by external consultMonitoring progress ants and the administrative support provided by USAID, a BecauseBIMI is designedas a pilot programmefrom which the rewarding and effective combination, in which local capacity is nation and the international community can learn how best to expanded and efforls are optimally implemented by those who implement effective sustainablemalaria control strategies,mon- know the citizens of Blantyre and are invested in the well-being itoring the successof intervention implementation is an essential of those citizens. We recommend this model to others interestcomponentof the programme. Monitoring data are used to mod- ed in developing similar district-wide or national health efforls. ify and update the BIMI work plan, and lessons learned are sharedat quarterly Steering Committee meetings and at nation- Mary J Hamel MD, Chdstopher Mkandala MD, Nyson Chizani, Nyokase al and international meetings related to health. More compre- Kaimilla. Jim Kublin MD MPH. Richard Steketee. MD MPH hensive programme evaluations will be conducted at future From the Division ofPuasitic Diseases,National Center for Infectious Diseases,Centers for dates to measure change in key BIMI indicators, and the out- Disease Control and Prevention, Public Health Service, U.S. Department of Health and Humm Services, Atlanta, Georgia, USA (MJH,RS); The Blmtyre District Health Office, come measuresfrom those evaluations will be made available. Blantyre (CM, NK); the Blantyre Integrated Malaria Initiative, Blantyre (NC), and the Research In addition to supporting programme activities, and monitoring ;nd evaluating those activities, the BIMI programme provides :he opportunity to conduct operational research to address :.rcused malaria-control questions that have arisen in Malawi. Llne example of such a question is whether the rate of SP-asso: r.lted severe cutaneous reactions is increasing with the n"'reased useof SPfor treatment of febrile illnesses and for 1"f:las'i Medical Jomal
Malaria Prcject and Departrnent of Community Health, College of Medicine, Blmtyre, Malawi (JK).
Address for conespondence and reprints: Christopher Mkmdala, MD Blantyre District Health Office Box 240 Blmtyre District, Malawi
This programe was funded by the Africa Integrated Malaria of the United States Agency for Intemational Development
Initiative
(7921-3079)
25
STATISTICSCORNER
PROJECTUPDATE References 1. R. Steketee,A Macheso, D Heymmn, et al. A decade of progress in malaria policy and program development in Malawi: 1984-1993. United States Agency for Intemational Development md US depafiment of Health md Human Sewices. 1995. 2. TR Cullinan et al. Packaged treatment for firstline cue in cerebral malria meningitis. Bull WHO | 998:16(3):257 -64. 3. BlolandPB,ELackdtz,PKazembe,etal. Beyondchloroquine:implicationsofdrug resistancefor evaluating maltria therapy efficacy and treatment policy in Africa. Journal of Infectious Diseases 1993;167(4):932-7. 4. Kidane G, R Monow. Teaching mothers to provide home treatment of malaria in Tigray, Ethiopia: a rmdomized trial. Lancet 2000;356(9229):550-5. 5. S J Rogerson et al. Intemittent sulfadoxine-pyrimethamine in pregnancy: effectiveness against malaria morbidity in Blantyre, Malawi in 1997 -99. Trans of the Royal Soc of Trop Med and Hygiene. 2000;94:1-5. 6. Greenwood BM, et al. The effects of malaria chemoprophylaxis given by traditional bifih attendants on the course and outcome of pregnancy. Trans R Soc Trop Med Hyg 1989;83:589-94. 7. Steketee RW et al. The effect of malaria and malaria prevention in pregnancy on off spring birth weight, prematudty, md intrauterine growth retardation in rural Malawi. Am J Trop Med Hyg 1996;55(1):33-41. 8. Binka FN, et al. Impact of permethrin impregnated bednets on child mortality in Kassena-Nankma District, Ghana: a randomized controlled trial. Trop Med Interl Health 1996:lQ):141- 54. 9. Nevill CG, et al. insecticide-treated bednets reduce mortality md severe morbidity from malaria mong children on the Kenym coast. Trop Med Interl Health 1996:1(2):139-46. I 0. Alonso PL, et al. A malria control trial using insecticide-treatedbed nets md ttrgeted chemoprophylaxis in a rural rea of The Gambia, West Africa. 6. The impact of the interventions on mortality and morbidity from malaria. Trans R Soc Trop Med Hyg | 993:87tSuppl 2):37-44. 11.Ter Kuile FO, Terlouw DJ, Phillips-Howard PA, et al.. Permethrin-treatedbednets reduce malaria in pregnancy in an area of intense perennial malaria transmission in western Kenya. Abstract 1 1, Amer Soc Trop Med Hygiene 48th Annual Meeting, Nov 28-Dec 2, 1999; Washington DC.
STATISTICSCORNER S White Welcome to this new feature in the JoumaMn this "Corner" we will look at a specific situation and the statistical methods that can be applied to the analysis of data. Consider this scenario: You want to know how well a simple test may diagnose something, and save the need for a more dfficult' invasive or expensivetest that would provide a definitive answer. For example, in a patient with palpable lymph nodes, is the c&usetuherculosis or not? To answer this with confidence you need an invasive procedure, preferably excision biopsy and histology (EBH). But such a procedure is not only invasive but also difficult, expensive and slow. You may therefore want to know how well a non-invasive, quick method would provide the answer. One method (M7) could be whether simple examination finds 'matted' or not, ie whether they seem to be that the nodes are stuck together in groups. Another method could be a Mantoux (tuberculin) test (M). You want to evaluate each of thesetests on its own for usefulnessin diagnosing TB as the cause of the lymphadenopathy. You also want to know if one test is superior to the other. You plan to conduct a study to evaluate and compare these two methods. The best design uses each method, M 1 and M2, independently, as well as the invasive one, on all patients studied who have palpable lymph nodes. In all the calculations that follw, we will assume that Excission Biopsy and History '7old standard' (EBm is l00%o accurate - it will serve as ovr How should you plan to analyse your data? You will need to select statistical tests to: A Evaluate each method; B
Compare the two methods,
We will consider these questionsin turn. To illustrate the statistical tests to be described suppose you have collected data on 100 patients. Some of the data are shown in Table 1 (this only shows 6 patients - the full table would list all 100 cases),which can be summa.risedin a three-way cross-tabulation(Table 2).
le I Datalisting accordingto diagnosticmethod(EBH = excisionUtpsy andhistology,M1 = pa$ation,M2 = mantouxtest)
Patient ITBTBTB 2 3 4TBTBTB 5 (etc): 100
EBH
M1
M2
TB NOTTB
NotTB NOTTB
TB TB
Not TB : Not TB
Not TB : TB
not TB : not TB Malawi Medical Joumal
