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Annex D: Briefing Paper on PVO Malaria Control Activities in Child Survival Projects

Control of Malaria

Plasmodium falciparum, the parasite responsible for most malaria-associated deaths, affects children in three ways: acute malaria illness; chronic or persistent malaria parasitemia with anemia; and perinatal malaria infection in the mother, which can cause low birth weight and increased infant mortality and potentially increased risk for vertical HIV transmission. Malaria interventions are appropriate for areas where the disease makes a substantial contribution to under-five mortality, either directly or indirectly, as in some areas of South and Southeast Asia, where the disease has an impact on the adult population but the economic burden hurts the entire family. The goal of the malaria intervention is to reduce malaria-associated mortality and morbidity, especially in children and pregnant women. PVOs implementing a malaria intervention may include any or all of the following approaches to malaria control in their programs:


Activities that are beyond the scope of the PVO Child Survival Grants Program include large-scale insecticide-spraying operations or environmental engineering measures, and communitywide administration of antimalarial drugs, including mass chemoprophylaxis for children. Environmental measures for manipulating mosquito larva breeding sites have only limited effectiveness in Africa.

Malaria Case Management

Malaria case management (MCM) is an essential component of an effective malaria control program. The requirements for a successful MCM intervention are the same as those for pneumonia case management:

Facility-based health personnel should

Chloroquine-resistant strains of Plasmoduim falciparum are becoming increasingly prevalent throughout Africa. Studies in Senegal show that this increase can have a significant impact on mortality, and so resistance status and strategies for alternate drugs should be addressed in case management programs.

The overlapping clinical presentation of malaria and pneumonia is an important consideration in all areas where children are treated for malaria. Epidemiological studies conducted in several settings in Africa indicate that a substantial proportion of children with fever will also meet a pneumonia case definition (cough or difficult breathing, and fast breathing or chest in drawing) and that almost all children meeting a pneumonia case definition also have fever or a history of fever. Treatments for malaria alone may result in death from pneumonia. Thus, all malaria protocols for children at the level of the community, drug retailer, and health facility should incorporate case management for pneumonia (unless it is not possible to do so). Alternative strategies for incorporating pneumonia into malaria protocols include:


Antenatal Prevention and Treatment

Antenatal prevention and treatment of malaria may increase birth weights and reduce maternal and fetal morbidity and mortality. There is also newer evidence that placental malaria may increase risk of vertical HIV transmission and that HIV-positive women do not respond as well to malaria prophylaxis. Women who are pregnant for the first time are at greatest risk for complications arising from malaria. They also might not attend antenatal services as frequently as other pregnant women, especially if they are unmarried or very young. If they get chloroquine, compliance is sometimes a problem. In addition, weekly chloroquine prophylaxis is no longer effective in many countries because of the increasing prevalence of chloroquine-resistant strains of P. falciparum. Where there is widespread drug resistance, an alternative treatment protocol should be selected in consultation with the ministry of health. The pattern of drug resistance should be specified for both children and adults. For example, in Malawi the Ministry of Health now recommends the administration of a full course of treatment with pyrimethamine-sulfadoxine (Fansidar) twice during pregnancy.

Insecticide-Treated Materials (ITMs)

Trials of ITMs (especially bednets and to a lesser extent curtains) in east and west Africa have demonstrated that this simple technology can reduce all-cause mortality in 1 to 59- month-old children. The ITM trials were mainly controlled trials in which nets and insecticide were distributed free. How effective ITMs are under conditions of voluntary acquisition and use is less clear. Experience has shown that to be successful, ITM programs must create conditions for sustained public demand for, access to, and appropriate use of affordable nets and insecticides to treat them. Also, sustained insecticide retreatment programs are more difficult to implement than the supply of nets themselves:

Public demand: At present, public demand for bednets and other insecticide-treated materials varies throughout Africa. Mosquitoes are often not recognized as the cause of malaria. Bednets may have high acceptability in many communities as a defense against nuisance bites but not as a malaria prevention. Insecticide treatment of bednets and curtains is the critical point but not yet widely disseminated.

Access: Bednets are generally available only in urban areas, if they are available at all, and no organized public or private systems exist for delivery of public health insecticide services, although there may be systems for agricultural insecticides.

Affordability: In many places, bednets now cost $10 to $25, and insecticide treatments
$1 to $2 per year. The typical household may require up to three bednets (which should last 2-4 years), but the initial cash outlay may be beyond the reach of most households.

Appropriate use: ITM programs cannot be successful unless a number of ingrained behavioral and social patterns change. Without such changes, it is unlikely that the right populations will use the nets and have them treated correctly. For example, young children may not have priority for use of bednets within households. To be effective, ITM programs should be designed in accordance with local beliefs and social patterns to encourage ITM use by young children and pregnant women.

More difficult than the provision of nets themselves, but of critical importance, are systems for insecticide retreatment. Thus, PVOs should consider implementing insecticide-treated mosquito net activities only when it is likely that a sustainable program of net provision and retreatment can be set up. When nets and insecticide are initially distributed for free, usage may drop dramatically after charges are introduced. There is evidence in Gambia, however, that usage begins to resume after a period of time. PVOs should consider a charge, however nominal, when initiating bednet programs. Nets that are regularly treated with a pyrethroid insecticide have been shown to be far more effective than untreated nets. Therefore, programs should not promote the use of untreated nets. Cotton nets are not suitable for insecticide treatment because the insecticide is absorbed into the interior of the fiber. In countries where use of untreated mosquito nets is already high, programs may only need to introduce insecticide treatment of nets. If malaria transmission is confined to only part of the year, it may be possible to treat the nets once a year instead of every 6 months.


Recommended General References on Malaria Control

Gilles, Herbert M., and David A. Warrell. December 1993. Bruce-Chwatt's Essential Malariology. Third edition. London: Oxford University Press.
Healthlink Worldwide. “Child Health Dialogue.” Issue 6. London.
This 16-page issue with a supplement on malaria contains information on prevention, recognition, and management of malaria in young children and pregnant women. CHD is free to readers in developing countries.

In addition to the international English edition, 11 regional language editions are also produced. An adapted text is available on electronic mail in selected countries via Healthnet. To subscribe to a published version of “Child Health Dialogue,” contact Mary Helena, Publications Secretary, Healthlink Worldwide, 29-35 Farringdon Road, London EC1M 3JB. Tel: +44 171 2420606, Fax: +44 171 2420041, E-mail: info@healthlink.org.uk, Internet: http://www.healthlink.org.uk/. For the electronic version of CHD please contact: hnet@usa.healthnet.org. Healthlink Worldwide produces a range of free publications for health workers in developing countries.        

Recommended References on Specific Aspects of Malaria Control

Malaria case management in facilities and drug resistance
Redd, S. C., P. N. Kazembe, S. P. Luby, O. Nwanyanwu, A. W. Hightower, C. Ziba, J. J. Wirima, L. Chitsulo, C. Franco, and M. Olivar. 1996. “Clinical Algorithm for Treatment of Plasmodium Falciparum Malaria in Children.” Lancet, 347(96/January 26), 223–27.
This reference brings up important issues for case management: a new case definition for malaria, the issue of overtreatment with the related risk of resistance. To assess this policy and to find out whether a better clinical case definition could be devised, this paper assessed children with fever in two hospital different outpatient departments in Malawi.
Malaria Case Management and Drug Resistance
Bloland, P. B., P. N. Kazembe, and A. J. Oloo. 1998. “Chloroquine in Africa: Critical Assessment and Recommendations for Monitoring and Evaluating Chloroquine Therapy Efficacy in Sub-Saharan Africa.” Tropical Medicine and International Health, 3(7/July), 543–52.
Gove, S. 1997. “Integrated Management of Childhood Illness by Outpatient Health Care Workers: Technical Basis and Overview.” Bulletin of the World Health Organization, 75(Suppl. 1), 7–24.
Makler, M. T., C. J. Palmer, and A. L. Ager. 1998. “A Review of Practical Techniques for the Diagnosis of Malaria.” Annals of Tropical Medicine and Parasitology, 92(4/June), 419–33.
Ofori-Adjei, D., and D. K. Arhinful. 1996. “Effect of Training on the Clinical Management of Malaria by Medical Assistants in Ghana.” Social Science and Medicine, 42(8), 1169–76.
White, N. J. 1996. “The Treatment of Malaria.” New England Journal of Medicine, 335(11/September 12), 800–6.
WHO/UNICEF. 1995. Integrated Management of Childhood Illness. Child Health and Development. Geneva: World Health Organization. (WHO/CDR/995.14)
The IMCI charts and manuals for health facility clinicians include guidelines for the management of fever in areas of low and high malaria risk, and address the overlap of malaria and pneumonia.
Newton, P. and N. White. 1999. “Malaria: New Developments in Treatment and Prevention.” Annual Review of Medicine, 50( ), 179–92. Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. <Fnnjw@diamond.mahidol.ac.th>
A review paper for those interested in issues of antimalarial resistance. Discusses new drugs and use of bednets. Explains why vaccine is ultimately needed.
Malaria Case Management in the Home and Community
Beales, P. F. 1997. “Anaemia in malaria control: a practical approach.” Annals of Tropical Medicine and Parasitology, 91(7/October), 713–18.
McCombie, S. C. 1996. “Treatment seeking for Malaria: A Review of Recent Research.” Social Science and Medicine, 43(6/September), 933–45.
Ruebush, T. K., M. K. Kern; and C. C. Campbell. 1995. “Self-treatment of Malaria in a Rural Area of Western Kenya.” Bulletin of the World Health Organization, 73(2), 229–36.
Winch, P. J., A. M. Makemba, and S. R. Kamazima. 1996. “Local Terminology for Febrile Illnesses in Bagamayo District, Tanzania, and Its Impact on the Design of a Community-Based Malaria Control Programme.” Social Science and Medicine, 42 ( ), 1057–67.
Antenatal Prevention and Control of Malaria
Intermittent sulphadoxine-pyrimethamine to prevent severe anaemia secondary to malaria in pregnancy: a randomised placebo-controlled trial. Shulman CE, Dorman EK, Cutts F, Kawuondo K, Bulmer JN, Peshu N, Marsh K Lancet 1999 Feb 20;353(9153):632-6 London School of Hygiene and Tropical Medicine, UK. c.shulman@lshtm.ac.uk
This is considered a seminal paper, central to the malaria in pregnancy strategy.
The efficacy of intermittent treatment doses of sulphadoxine-pyrimethamine in preventing malaria and severe anaemia in pregnancy in a double-blind placebo-controlled trial among primigravid women was studied. It was concluded that intermittent presumptive treatment with sulphadoxine-pyrimethamine is an effective, practicable strategy to decrease the risk of severe anaemia in primigravidae living in malarious areas.
Nahlen, B. D., et al. 1998. HIV and Malaria overlap and do interact in sub-Saharan Africa Pregnant Women.” Abstract, 12th World AIDS Conference (Geneva, Switzerland), June 28–July 3.
Menendez, C., E. Kahigwa, and R. Hirt. 1997. “Randomized Placebo-controlled Trial of Iron Supplementation and Malaria Chemoprophylaxis for Prevention of Severe Anaemia and Malaria in Tanzanian Infants.” Lancet, 350(9081/September 20), 844–50.
Menendez, C. 1995. “Malaria during pregnancy: A priority area of malaria research and control.” Parasitology Today 11:178-183.
Steketee, R., B. D. Nahlen, and J. Ayisi. 1998. “HIV and Malaria Overlap and Do Interact in Sub-Saharan Africa Pregnant Women.” Twelfth International Conference on AIDS (Geneva, Switzerland) 12(145). Abstract no. 13298.
(Author is affiliated with the CDC in Atlanta, Georgia, 30333. Contact them for the article.)
Steketee, R., and J. Wirima. 1996. “Malaria Prevention in Pregnancy: The Effects of Treatment and Chemoprophylaxis on Placental Malaria Infection, Low Birth Weight, and Fetal Infant and Child Survival.” American Journal of Tropical Medicine and Hygiene,
Insecticide-Treated Mosquito Nets
Bryce, J., J. B. Roungou, and P. Nguyen-Dinh. 1994. “Evaluation of National Malaria Control Programmes in Africa.” Bulletin of the World Health Organization, 72(3), 371–81.
Curtis C. F., J. Myamba, and T. J. Wilkes. 1996. “Comparison of Different Insecticides and Fabrics for Anti-Mosquito Bednets and Curtains.” Medical and Veterinary Entomology, 10(1), 1-11.
55(1, Suppl.), entire volume (16 articles).

Evans, David, Girma Azene, and Joses Kirigia. 1997. “Should Governments Subsidize the Use of Insecticide Impregnated Mosquito Nets in Africa? Implication of a Cost-effectiveness Analysis.” Health Policy and Planning, 12(2), 107–114.
Healthlink, Worldwide. 1997. Insecticide Treated Nets for Malaria Control. London: Healthlink, Worldwide.
A directory of suppliers of insecticides and mosquito nets for sub-Saharan Africa. Includes practical information on the preparation and use of treated mosquito nets; suppliers of finished nets, bulk netting, insecticides and related products for malaria control; and a list of useful contacts and resource materials. Single copies free of charge. (34 pages)
Lengeler, Christian, Jacqueline Cattani, and Don de Savigny, eds. 1996. Net Gain: A New Method for Preventing Malaria Death. Ottawa: International Development Research Centre/World Health Organization.
(189 pages)
Mills, A. 1998. “Operational Research on the Economics of Insecticide-treated Mosquito Nets: Lessons of Experience.” Annals of Tropical Medicine and Parasitology, 92(4), 435–47.
The following three documents are available from the Malaria Consortium “Converting Expertise and Partnerships Into Operational Realities”; for more information see http://eps.lshtm.ac.uk/~ethestho/MALCON.HTM
Chavasse, D., C. Reed, and K. Attawell. 1999. Insecticide Treated Net Projects: A Handbook for Managers. DfID: Malaria Consortium.
Partnerships for Change and Communication. Guidelines for Malaria Control. Division of Control of Tropical Diseases, World Health Organization. Developed in collaboration with Malaria Consortium U.K.
November 1996. Approaches to Malaria Control in Africa - Part 1. Analysis and Opportunities for Malaria Control Support in Selected Countries in Africa—Ghana, Kenya, Malawi, Namibia, Tanzania, Uganda, Zambia, Zimbabwe. (A Malaria Consortium initiative).
Malaria and Iron Supplementation
Stoltzfus, R., and M. Dreyfuss. 19__. Guidelines For The Use Of Iron Supplements To Prevent And Treat Iron Deficiency Anemia. Johns Hopkins University/International Nutritional Anemia Consultative Group. The purpose of these guidelines is to provide practical, scientifically sound guidance to those responsible for planning and implementing anemia control programs. (Refer to nutrition references for ordering details.)
Shankar, Anu, et al. “Iron Supplementation And Morbidity Due To Plasmodium Falciparum: A Meta-Analysis Of Randomized Controlled Clinical Trials.” Unpublished (as of October 1999. Supported by Johns Hopkins and the USAID OMNI project. Ashankar@jhsph.edu.
Verhoeff, F. H., B. J. Brabin, L. Chimsuku, P. Kazembe, and R. L. Broadhead. 1999. “An Analysis of the Determinants of Anaemia in Pregnant Women in Rural Malawi—A Basis for Action.” Annals of Tropic Medicine and Parasitology, 93(2/March), 119-23. School of Tropical Medicine, Liverpool, England.
Haematological data are presented on 4,104 pregnant women attending the antenatal-care facilities of two hospitals in a ruralarea in southern Malawi. Variables associated with an increased risk for moderately severe anaemia were iron deficiency (RR = 4.2; CI = 3.0-6.0) and malaria parasitaemia (RR = 1.9; CI = 1.3-2.7) in primigravidae, iron deficiency (RR =4.1; CI = 2.7-6.3) and mid-upper-arm-circumference < 23 cm (RR = 1.8; CI = 1.1-3.0) in secundigravidae, and iron deficiency in multigravidae (RR = 3.1; CI = 4.3-6.9).
Malaria and GIS
MARA. 19__. Mapping Malaria Risk in Africa. http://www.mara.org.za/.
This reference gives a good idea of how GIS can be usefully employed in health care. It contains all the essential components for an understanding of disease determinants and spatial scale.

Internet References
The Environmental Health Project Web site with links to several malaria topics, including bednets: <http://www.crosslink.net/~ehp/webliog.html>. EHP Malaria Bulletins: can be assessed at http://www.crosslink.net/~ehp/products.htm Maternal and Newborn Care. Homepage is: <http://www.crosslink.net/~ehp>
Also, the Malaria Foundation maintains a Web site, <http://www.malaria.org/> with links to the WHO “Roll Back Malaria” project, The Malaria Consortium, and the Asian Collaborative Training Network for Malaria (ACTMalaria), among other entities.
PubMed—National Library of Medicine <http://www4.ncbi.nlm.nih.gov/PubMed/>
WHO/World Bank Malaria Network (many good online documents) <http://www.malarianetwork.org>
ACTMalaria: (an intercountry initiative between and among Bangladesh, Cambodia, China [Yunnan Province], Indonesia, Lao People's Democratic Republic, Malaysia, Myanmar, Thailand, and Vietnam) <http://www.beebop.com/actmalaria//>

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