|Year : 2019 | Volume
| Issue : 1 | Page : 56-59
Comprehensive case management of malaria: Operational research informing policy
MM Pradhan1, Anupkuamar R Anvikar2, P Grewal Daumerie3, S Pradhan1, A Dutta4, NK Shah5, PL Joshi6, J Banerji3, S Duparc3, K Mendis7, S Murugasampillay8, N Valecha2
1 National Vector Borne Disease Control Programme, Government of Odisha, Bhubaneswar, Odisha, India
2 ICMR–National Institute of Malaria Research, New Delhi, India
3 Medicines for Malaria Venture, Geneva, Switzerland
4 Indian Institute of Public Health, Bhubaneswar, Odisha, India
5 Independent Malariologist, Ganiyari, India
6 Independent Malariologist, New Delhi, India
7 Independent Malariologist, Colombo, Sri Lanka
8 Global Public Health, Geneva, Switzerland
|Date of Submission||26-Mar-2018|
|Date of Web Publication||7-May-2019|
Dr Anupkuamar R Anvikar
Scientist ‘F’, ICMR-National Institute of Malaria Research, Sector-8, Dwarka, New Delhi–110078
Source of Support: None, Conflict of Interest: None
In 2013, the Odisha state Vector Borne Disease Control Programme led a five year operational research project, under programmatic conditions, in close collaboration with several partners. This Comprehensive Case Management Project covered a population of 900,000 across paired control and intervention blocks in four districts, each with different transmission intensities. Key gaps in access to malaria services were identified through household surveys and a detailed situation analysis. The interventions included ensuring adequate stocks of rapid diagnostic tests and antimalarial drugs at the village level, the capacity building of health workers and ASHAs, setting up microscopy centres at the primary health care level, and conducting mass screening and treatment in poorly accessible areas.
The programme strengthened the routine health system, and improved malaria surveillance as well as the access to and quality of care. Initially, the programme led to increased case reporting due to improved detection, followed by a decline in malaria incidence. Lessons from the project were then scaled up statewide in the form of a new initiative—Durgama Anchalare Malaria Nirakaran (DAMaN).
Keywords: ASHA, CCMP, DAMaN, malaria, Odisha
|How to cite this article:|
Pradhan M M, Anvikar AR, Daumerie P G, Pradhan S, Dutta A, Shah N K, Joshi P L, Banerji J, Duparc S, Mendis K, Murugasampillay S, Valecha N. Comprehensive case management of malaria: Operational research informing policy. J Vector Borne Dis 2019;56:56-9
|How to cite this URL:|
Pradhan M M, Anvikar AR, Daumerie P G, Pradhan S, Dutta A, Shah N K, Joshi P L, Banerji J, Duparc S, Mendis K, Murugasampillay S, Valecha N. Comprehensive case management of malaria: Operational research informing policy. J Vector Borne Dis [serial online] 2019 [cited 2019 Jun 16];56:56-9. Available from: http://www.jvbd.org/text.asp?2019/56/1/56/257776
| Introduction|| |
The State of Odisha, traditionally the highest burden state for malaria in the nation given a large at-risk population and favourable ecotypes, is now the poster child for control registering a sharp decline in malaria burden between 2013 to 2018. This success is attributed to several factors including: leadership at the state control programme, political support from the Health Secretary and his office, and support from the National Vector Borne Disease Control Programme (NVBDCP). These forces mobilized public resources, helped develop new solutions through operational research, and scaled up finding to achieve impact.
In 2013, the Odisha state NVBDCP started an operational research programme in collaboration with the National Institute of Malaria Research and NVBDCP with support from Medicines for Malaria Venture and the World Health Organization (WHO). The Comprehensive Case Management Programme (CCMP) aimed at improving patient access to malaria case management, strengthening surveillance, and exploring the impact of improved diagnosis and treatment on transmission against the backdrop of prevailing vector control measures and under routine programmatic conditions.
Early diagnosis and complete treatment at the village level are the essence of strong case management. It provides individual benefit by reducing the duration of sickness and preventing the progress of the disease to severe malaria. It also has important public health implications, particularly in areas of low-to-moderate transmission intensities, where early termination of infections serves as an important means of curtailing the size of the infectious reservoir. In the State of Odisha, a large part of the population lives in such areas.
CCMP covered a population of 900,000 inhabitants across pairs of control and intervention blocks from four districts, each with different transmission intensities (low, medium, high, and hyper-endemic). The blocks were matched on malaria incidence and were selected by a two-stage stratified sampling method [Figure 1]
Household surveys and a detailed situation analysis revealed the key gaps in access to malaria services. Although communities were largely aware of the, accredited social health activist (ASHA) in their villages, few turned to them in event of fever. Geographic inaccessibility to ASHAs was also a major obstacles. Many villages and hamlets, particularly in high transmission areas, are dispersed across large forested areas with a population too low to merit a resident ASHA based on the National Health Mission plan. These communities should, in principle, be served by an ASHA from a neighbouring village. In practice however, given the travel time due to poor infrastructure, they remain neglected. Patients also do not usually travel to the neighbouring ASHA, given the distance and time required.
The poor coverage of malaria case management services, and consequently the poor surveillance in some areas, resulted in the real malaria burden being underestimated. This is reflected in the annual parasite incidence (API), the primary indicator used by the National Vector Borne Disease Control Programme (NVBDCP) to stratify areas for vector control measures. These areas, thus fall under the radar and get caught in a cycle of limited access to malaria services, under-detection, less intervention, and continued transmission. These underserved, hard-to-reach areas harbour malaria “hot spots”, which are relatively small geographical areas with significantly higher transmission intensity than in surrounding areas. These hot spots are often difficult to access, with high rates of malaria parasitaemia in the absence of fever or a history of fever at the time of survey due to acquired immunity. They represent a significant barrier to malaria control as they fuel its continued transmission in addition to presenting the community with a high burden of morbidity and mortality.
The WHO global technical strategy recommends surveillance as a core intervention and that data be used to inform programmatic activities. While India maintains a long-standing and the world’s largest malaria surveillance system, the routine surveillance data is simply collected, aggregated and used mainly for reporting purposes without inform programme activities at the local level.
In the control areas, malaria services were provided within the constraints of the routine control programme guidelines. In the intervention areas, efforts focused on:
- Ensuring adequate stocks of rapid diagnostic tests and antimalarial drugs at the village level by quantifying requirements based on the number of service providers and minimum stocks rather than caseload, as in the routine system. Buffer stocks were maintained at the block level rather than the district level. Adequate stocks were put in place before the monsoon when malaria transmission peaks and road access can be challenging.
- Improving the quality of malaria case management by providing training and refresher training to frontline health workers and ASHAs and improving supportive supervision. Individual patient treatment cards were introduced to allow the tracking the adherence to treatment and adverse events [Figure 2].
- Improving access to malaria diagnosis by setting up microscopy centres at the primary health care level (PHC) to complement the services at the block level and community health centres (CHC).
- Closing the access gap in hard-to-reach villages and hamlets. Areas with no resident ASHAs, yet close to subcentres with a high burden were identified and alternative providers (ASHA-plus) were engaged and trained. Most of them were Anganwadi workers (AWW) and a few were village volunteers. ASHA-plus providers test all fever cases for malaria, provide confirmed cases with the appropriate treatment, and monitor treatment completion.
- Identifying areas of hidden burden and asymptomatic cases through mass screening and treatment in poorly accessible areas with risk factors for high malaria transmission. The population in these areas were examined by teams of health workers, ASHAs, and ASHA-plus using rapid diagnostic kits. All positive cases were treated, even if they were afebrile or did not report a history of fever (i.e. asymptomatic).
- Enhancing supervision by the appointment of block level managers (BLMs) to enhance routine surveillance and the introduction of district health information system 2 (DHIS2), an electronic health management information system. Automated monthly report cards were issued with key epidemiological indicators to inform programme activities and permit timely action.
|Figure 2: Patient shown holding their CCMP treatment card. Villagers who test positive for malaria are issued health cards that provide a record of their medical history and past treatment regimens. ASHAs monitor the progress of those who have been diagnosed with malaria.|
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Health system: By working through routine health services, CCMP strengthened the health system as a whole and not just malaria. Capacity building of ASHAs resulted in improvement of their ability to diagnose, treat, report and follow-up of malaria. Improved stock management resulted in a nearly uninterrupted supply of RDTs and antimalarial drugs.
CCMP resulted in improved access to early case detection and prompt treatment with more patients seeking treatment from ASHAs. The recruitment of alternative providers in underserved areas and strong support by block managers improved the reach and quality of care. Cases were not just spot treated, but nearly all diagnosed cases were followed up upon using the patient treatment cards in the intervention areas. Patient cards to were scaled up to all the Districts of Odisha.
CCMP highlighted the extent to which routine data underestimates areas of high malaria burden due to poor surveillance. Targeted mass surveys detected large numbers of cases, many asymptomatic, which would have been otherwise been missed. DHIS2, an open source surveillance system, was introduced into the programme based on the importation of monthly Excel spreadsheets of a line-listing of malaria cases from every provider and facility of the public health services. Programmatic activities were then informed by surveillance data. Spikes in caseload, for example, when children returned from boarding schools in high endemic areas to low endemic areas, triggered action.
Improved case management led to a dramatic increase in people seeking diagnosis from the public sector and therefore increased case detection during the intervention period (2013–2016). This was followed by a decline in reported cases during the post-intervention period (2016–2018) while maintain the same level of case detection (marked by the tipping point [Figure 3]). These programmatic indicators and interrupted time series analysis of the data demonstrate a reduction in malaria burden in CCMP intervention areas.
|Figure 3: Monthly blood test and malaria cases in intervention and control areas, 2013–2018.|
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CCMP finding were adopted into a state driven programme—Durgama Anchalare Malaria Nirakaran (DAMaN). i.e. malaria elimination in hard-to-reach villages within high endemic areas. DAMaN scaled-up the CCMP approach of mass screening and treatment to clear the parasite reservoir from communities in underserved villages where many malaria cases were also asymptomatic. CCMP results also provided experience regarding the optimal frequency of surveys. Additionally, DAMaN incorporated additional vector control, as it is a critical tool in high transmission settings. Communities in these areas were simultaneously provided with universal coverage of long lasting insecticide treated nets (LLINs). Mass screening and treatment has also now been incorporated into the National Strategic Plan.
| Discussion|| |
CCMP served as a living laboratory within the state malaria control programme. It revealed the gaps in access to care, malaria diagnosis and treatment through routine health services, and the extent to which the malaria burden is underestimated, particularly in certain foci in all districts. CCMP then developed solutions to close these gaps, increase the utilization of services, and expand the coverage of the routine malaria programme. Improved surveillance, with the effective use of DHIS2, also helped transform surveillance into a core intervention that generated local action. New approaches were tested, modified, and scaled up including in the control blocks if they proved to be useful. These include the supportive supervision, patient cards, and mass screening and treatment. As the project activities were supported by key state leaders, and already implemented through the routine programme, they were easily scaled. The DAMaN initiative, which built on CCMP results has led the Odisha wide decline in the most malarious state in the country.
CCMP demonstrates the tremendous value of programme led operational research, supported by sound technical expertise, and the political will to find pragmatic and innovative solutions. The results have had national and international influence as well. The National Strategic Plan for Malaria (2017–2022) of the Government of India has incorporated the CCMP activity for targeted mass screening and treatment and the associated detection of and management of asymptomatic cases. The WHO also reported on malaria control in Odisha including the CCMP developed patient cards and emphasis on comprehensive case management. Programmatic operational research and interventions within the routine system can be trial in other states, where challenges may be different, in order to improve malaria control though through similar mechanisms.
| References|| |
Pradhan S, Pradhan MM, Dutta A, Shah NK, Joshi PL, Pradhan K, et al
. Improved access to early diagnosis and complete treatment of malaria in Odisha, India. PLoS One
[Figure 1], [Figure 2], [Figure 3]