Holly A. Williams

Malaria Control during Mass Population Movements and Natural Disasters

Admittedly, the world and the nature of forced migration have changed a great deal over the last two decades. The relevance of data accumulated during that time period can now be called into question. The roundtable and the Program on Forced Migration at the Mailman School of Public Health of Columbia University have commissioned a series of epidemiological reviews on priority public health problems for forced migrants that will update the state of knowledge. Malaria Control During Mass Population Movements and Natural Disasters -- the first in the series, provides a basic overview of the state of knowledge of epidemiology of malaria and public health interventions and practices for controlling the disease in situations involving forced migration and conflict.

Reproductive health services for Syrian refugees in Zaatri Camp and Irbid City, Hashemite Kingdom of Jordan: an evaluation of the Minimum Initial Services Package

BackgroundThe Minimum Initial Services Package (MISP) for reproductive health, a standard of care in humanitarian emergencies, is a coordinated set of priority activities developed to prevent excess morbidity and mortality, particularly among women and girls, which should be implemented at the onset of an emergency. The purpose of the evaluation was to determine the status of MISP implementation for Syrian refugees in Jordan as part of a global evaluation of reproductive health in crises.MethodsIn March 2013, applying a formative evaluation approach 11 key informant interviews, 13 health facility assessments, and focus group discussions (14 groups; 159 participants) were conducted in two Syrian refugee sites in Jordan, Zaatri Camp, and Irbid City, respectively. Information was coded, themes were identified, and relationships between data explored.ResultsLead health agencies addressed the MISP by securing funding and supplies and establishing reproductive health focal points, services and coordination mechanisms. However, Irbid City was less likely to be included in coordination activities and health facilities reported challenges in human resource capacity. Access to clinical management of rape survivors was limited, and both women and service provider’s knowledge about availability of these services was low. Activities to reduce the transmission of HIV and to prevent excess maternal and newborn morbidity and mortality were available, although some interventions needed strengthening. Some planning for comprehensive reproductive health services, including health indicator collection, was delayed. Contraceptives were available to meet demand. Syndromic treatment of sexually transmitted infections and antiretrovirals for continuing users were not available. In general refugee women and adolescent girls perceived clinical services negatively and complained about the lack of basic necessities.ConclusionsMISP services and key elements to support implementation were largely in place. Pre-existing Jordanian health infrastructure, prior MISP trainings, dedicated leadership and available funding and supplies facilitated MISP implementation. The lack of a national protocol on clinical management of rape survivors hindered provision of these services, while communities’ lack of information about the health benefits of the services as well as perceived cultural repercussions likely contributed to no recent service uptake from survivors. This information can inform MISP programming in this setting.

The contribution of social science research to malaria prevention and control

Social science has had an integral role in defining strategies against malaria as affirmed by the growing number of articles in scientific journals and the forging of international partnerships. In spite of this numerous factors impede the integration of social science knowledge and practice into malaria research and programs. First many malaria control personnel physicians and epidemiologists overlook the different complementary disciplines of social science and may only have a superficial knowledge of this type of research. A second factor contributing to the less than optimal contribution of social science research to malaria control is that in many cases those who carry out behavioral research for control programs may have had some training in rapid assessment techniques but limited or no training in social science theory and methodology. The final factor is the expectation that employing a social scientist for a rapid assessment will be sufficient to ensure greater acceptance of whatever intervention is being provided. It is suggested that social scientists need to be more proactive in challenging current orthodoxies and in identifying new intervention methods such as longer periods of ethnographic fieldwork and sharing of experiences working on different diseases of poverty.

Responding to the Syrian crisis: the needs of women and girls

Women and girls are disproportionately affected by conflict because of a lack of access to essential services as learnt from humanitarian crises in recent years. Poor access to sexual assault treatment and emergency obstetric care can contribute to negative health outcomes. In Syria women and girls are strongly affected by the recent conflict and according to the UN Population Fund about 1.7 million women and girls might need access to reproductive health services. Because women often have an essential role I post-conflict reconstruction their basic needs should be met so they can emerge from this ongoing crisis as essential stakeholders in the recovery process. [excerpt]

Discourse on malaria elimination: where do forcibly displaced persons fit in these discussions?

BackgroundIndividuals forcibly displaced are some of the poorest people in the world, living in areas where infrastructure and services are at a bare minimum. Out of a total of 10,549,686 refugees protected and assisted by the United Nations High Commissioner for Refugees globally, 6,917,496 (65.6%) live in areas where malaria is transmitted. Historically, national malaria control programmes have excluded displaced populations.ResultsThe current discourse on malaria elimination rarely includes discussion of forcibly displaced persons who reside within malaria-eliminating countries. Of the 100 malaria-endemic countries, 64 are controlling malaria and 36 are in some stage of elimination. Of these, 30 malaria-controlling countries and 13 countries in some phase of elimination host displaced populations of ≥50,000, even though 13 of the 36 (36.1%) malaria-elimination countries host displaced populations of ≥50,000 people.DiscussionNow is the time for the malaria community to incorporate forcibly displaced populations residing within malarious areas into malaria control activities. Beneficiaries, whether they are internally displaced persons or refugees, should be viewed as partners in the delivery of malaria interventions and not simply as recipients.ConclusionUntil equitable and sustainable malaria control includes everyone residing in an endemic area, the goal of malaria elimination will not be met.

Malaria in Kakuma refugee camp, Turkana, Kenya: facilitation of Anopheles arabiensis vector populations by installed water distribution and catchment systems

BackgroundMalaria is a major health concern for displaced persons occupying refugee camps in sub-Saharan Africa, yet there is little information on the incidence of infection and nature of transmission in these settings. Kakuma Refugee Camp, located in a dry area of north-western Kenya, has hosted ca. 60,000 to 90,000 refugees since 1992, primarily from Sudan and Somalia. The purpose of this study was to investigate malaria prevalence and attack rate and sources of Anopheles vectors in Kakuma refugee camp, in 2005-2006, after a malaria epidemic was observed by staff at camp clinics.MethodsMalaria prevalence and attack rate was estimated from cases of fever presenting to camp clinics and the hospital in August 2005, using rapid diagnostic tests and microscopy of blood smears. Larval habitats of vectors were sampled and mapped. Houses were sampled for adult vectors using the pyrethrum knockdown spray method, and mapped. Vectors were identified to species level and their infection with Plasmodium falciparum determined.ResultsPrevalence of febrile illness with P. falciparum was highest among the 5 to 17 year olds (62.4%) while malaria attack rate was highest among the two to 4 year olds (5.2/1,000/day). Infected individuals were spatially concentrated in three of the 11 residential zones of the camp. The indoor densities of Anopheles arabiensis, the sole malaria vector, were similar during the wet and dry seasons, but were distributed in an aggregated fashion and predominantly in the same zones where malaria attack rates were high. Larval habitats and larval populations were also concentrated in these zones. Larval habitats were man-made pits of water associated with tap-stands installed as the water delivery system to residents with year round availability in the camp. Three percent of A. arabiensis adult females were infected with P. falciparum sporozoites in the rainy season.ConclusionsMalaria in Kakuma refugee camp was due mainly to infection with P. falciparum and showed a hyperendemic age-prevalence profile, in an area with otherwise low risk of malaria given prevailing climate. Transmission was sustained by A. arabiensis, whose populations were facilitated by installation of man-made water distribution and catchment systems.

Beyond evidence: a retrospective study of factors influencing a malaria treatment policy change in two South African Provinces

There is a growing appreciation that decisions on changing drug treatment policy should be based on robust evidence of drug effectiveness. No published information describing the process of decision making prior to malaria treatment policy changes or subsequent success in implementing treatment policy changes exists in South Africa. This retrospective study of the differential implementation of a policy change from chloroquine to sulphadoxine-pyrimethamine for first-line treatment of malaria in two South African provinces, Mpumalanga and Limpopo Province, sought to explore the change from the perspective of national and provincial policy makers and programme managers. Focus-groups discussions, in-depth interviews, participatory exercises and archival documentary analysis were conducted. Policy makers and programme managers mentioned the need for local efficacy data as a prerequisite for changing malaria treatment policy. However, drug efficacy data alone were not sufficient to ensure effective policy making or implementation in this study. An effective strategy identified for motivating a change in policy was emphasizing the potential negative consequences of failure to implement a treatment change. In both provinces it was recognized that, for a policy change to be successful and applied at peripheral levels, the proposed change had to have official sanctioning from credible sources. Physical removal of all previously recommended medication from public healthcare facilities appeared to be a key factor in ensuring successful implementation. Lessons learnt through this retrospective analysis may be of value to a number of countries in sub-Saharan Africa, considering policy change in response to rapidly increasing anti-malarial drug resistance. However, additional case studies of the process of malaria treatment policy change are urgently needed from other African settings to determine commonalities and optimize the efficiency of formulating and implementing malaria treatment policy changes.

A retrospective analysis of the change in anti-malarial treatment policy: Peru

BackgroundNational malaria control programmes must deal with the complex process of changing national malaria treatment guidelines, often without guidance on the process of change. Selecting a replacement drug is only one issue in this process. There is a paucity of literature describing successful malaria treatment policy changes to help guide control programs through this process.ObjectivesTo understand the wider context in which national malaria treatment guidelines were formulated in a specific country (Peru).MethodsUsing qualitative methods (individual and focus group interviews, stakeholder analysis and a review of documents), a retrospective analysis of the process of change in Perus anti-malarial treatment policy from the early 1990s to 2003 was completed.ResultsThe decision to change Perus policies resulted from increasing levels of anti-malarial drug resistance, as well as complaints from providers that the drugs were no longer working. The context of the change occurred in a time in which Peru was changing national governments, which created extreme challenges in moving the change process forward. Peru utilized a number of key strategies successfully to ensure that policy change would occur. This included a) having the process directed by a group who shared a common interest in malaria and who had long-established social and professional networks among themselves, b) engaging in collaborative teamwork among nationals and between nationals and international collaborators, c) respect for and inclusion of district-level staff in all phases of the process, d) reliance on high levels of technical and scientific knowledge, e) use of standardized protocols to collect data, and f) transparency.ConclusionAlthough not perfectly or fully implemented by 2003, the change in malaria treatment policy in Peru occurred very quickly, as compared to other countries. They identified a problem, collected the data necessary to justify the change, utilized political will to their favor, approved the policy, and moved to improve malaria control in their country. As such, they offer an excellent example for other countries as they contemplate or embark on policy changes.

Perceptions of Health Communication, Water Treatment and Sanitation in Artibonite Department, Haiti, March-April 2012

The international response to Haiti’s ongoing cholera outbreak has been multifaceted, including health education efforts by community health workers and the distribution of free water treatment products. Artibonite Department was the first region affected by the outbreak. Numerous organizations have been involved in cholera response efforts in Haiti with many focusing on efforts to improve water, sanitation, and hygiene (WASH). Multiple types of water treatment products have been distributed, creating the potential for confusion over correct dosage and water treatment methods. We utilized qualitative methods in Artibonite to determine the population’s response to WASH messages, use and acceptability of water treatment products, and water treatment and sanitation knowledge, attitudes and practices at the household level. We conducted eighteen focus group discussions (FGDs): 17 FGDs were held with community members (nine among females, eight among males); one FGD was held with community health workers. Health messages related to WASH were well-retained, with reported improvements in hand-washing. Community health workers were identified as valued sources of health information. Most participants noted a paucity of water-treatment products. Sanitation, specifically the construction of latrines, was the most commonly identified need. Lack of funds was the primary reason given for not constructing a latrine. The construction and maintenance of potable water and sanitation services is needed to ensure a sustainable change.

Participation of African social scientists in malaria control: identifying enabling and constraining factors

ObjectiveTo examine the enabling and constraining factors that influence African social scientists involvement in malaria control.MethodsConvenience and snowball sampling was used to identify participants. Data collection was conducted in two phases: a mailed survey was followed by in-depth phone interviews with selected individuals chosen from the survey.FindingsMost participants did not necessarily seek malaria as a career path. Having a mentor who provided research and training opportunities, and developing strong technical skills in malaria control and grant or proposal writing facilitated career opportunities in malaria. A paucity of jobs and funding and inadequate technical skills in malaria limited the type and number of opportunities available to social scientists in malaria control.ConclusionUnderstanding the factors that influence job satisfaction, recruitment and retention in malaria control is necessary for better integration of social scientists into malaria control. However, given the wide array of skills that social scientists have and the variety of deadly diseases competing for attention in Sub Saharan Africa, it might be more cost effective to employ social scientists to work broadly on issues common to communicable diseases in general rather than solely on malaria.