1	Christian Response to Malaria Adam Wolkon, Malaria Branch, CDC: AWolkon@cdc.gov Global Missions Health Conference, November 7, 2003 All of the yellow countries have at least some areas with endemic malaria transmission.
2	What is Malaria? Parasitic infection of human red blood cells 4 species can infect humans Plasmodium falciparum Plasmodium vivax Plasmodium malariae Plasmodium ovale
3	Plasmodium falciparum Most dangerous form of malaria Risk of cerebral malaria, renal failure, acute respiratory distress syndrome, severe anemia Prompt treatment is essential Untreated infection in a non-immune person would likely be fatal Once person is treated and cured, there is no risk of relapse (but you can get infected again…) P. falciparum has no dormant liver stage (hypnozoite)
4	P. vivax and P. ovale Less likely to be life threatening than P. falciparum Symptoms (especially fever) can still be dramatic Different drugs are used to treat blood and liver stage parasites
5	Symptoms of Malaria Fever is by far the most common symptom, but is by no means the only one Often can have constellation of symptoms described as “flu-like” Other symptoms can include: chills, fatigue, weakness, headache, nausea, vomiting, diarrhea, muscle aches, mental status changes
6	What is the Malaria Vector? Spread by bite of infected female Anopheles mosquitoes Night-biting mosquitoes Indoor-biting mosquitoes
7	Malaria Lifecycle
8	Malaria Mortality 2 main ways it kills: Anemia Parasites destroy red blood cells Associated with increased mortality Cerebral malaria Damages brain and other vital organs Fatality rate of 15% or more
9	What’s the Bad News? 1 million deaths per year Most deaths in African children
10	What’s the Good News? (part 1) Every one of these deaths is preventable!!! No stigma associated with malaria No morality debates No “Save the Mosquito” groups
11	Roll Back Malaria (RBM) Founded by: World Health Organization (WHO), United Nations Development Program (UNDP), United Nations Children's Fund (UNICEF) and World Bank Includes national governments, civil society and non-governmental organizations, etc. Provides framework for coordination between Ministries of Health and various organizations
12	Roll Back Malaria (RBM) The goal of Roll Back Malaria, established as a health initiative by WHO and its partners in 1998, is to halve the world's malaria burden by 2010. At the Africa Summit on RBM, April 2000, Heads of State or senior representatives from 44 malaria-afflicted countries in Africa agreed to a series of interim goals to be attained by 2005. Global program with clear strategies Provides framework for Action Touts prevention and treatment
13	Roll Back Malaria (RBM) Goals - At least 60% At least 60% of those with malaria should be able to access and use correct, affordable and appropriate treatment within 24 hours. At least 60% of those at risk of malaria, particularly children under five years of age and pregnant women should use insecticide treated mosquito nets. At least 60% of pregnant women at risk of malaria should have access to chemoprophylaxis or intermittent presumptive treatment.
14	Malaria Interventions Many Partners Many Roles
15	Malaria Interventions Intermittent Preventive Treatment (IPT) Insecticide-Treated Bednets (ITNs) Case Management (Treatment)
16	ANC attendance
17	Malaria During Pregnancy Malaria during pregnancy in sub-Saharan Africa is estimated to account for: 400,000 cases severe anemia in pregnant women ~ 35% preventable low birth weight ~ 5% infant mortality (est. 75,000 - 200,000 infant deaths annually)
18	Malaria During Pregnancy: Opportunities for prevention in areas with high malaria transmission Drugs Intermittent preventive treatment (IPT) Chemoprophylaxis (no longer recommended) Insecticide Treated Nets (ITNs)
19	Malaria During Pregnancy: Chemoprophylaxis Most regimens require weekly or more frequent dosing Chloroquine most commonly used drug Usefulness severely limited by: Difficulty in delivering intervention Poor adherence to regimen Side effects of chloroquine (especially itching) Rising levels of P. falciparum resistance to chloroquine
20	Malaria During Pregnancy: Intermittent Preventive Treatment Most commonly adopted regimen: two treatment doses of sulfadoxine-pyrimethamine (SP) (3 tablets/treatment): one second trimester, one third trimester Very inexpensive (< 20 cents per treatment) Therapy easily delivered and may be directly observed (avoids issues of adherence to regimen) Generally well-tolerated with few side effects Trials demonstrating efficacy have been conducted in Malawi, Kenya (2 studies), and Mali (not yet published)
21	Intermittent Preventive Treatment: Summary World Health Organization recommends that in areas with high malaria transmission: Currently, the best available drug for IPT is sulfadoxine-pyrimethamine (SP or Fansidar) Women receive at least 2 doses of IPT after quickening (i.e.after the first trimester) Doses should be at least one month apart More than 2 doses is likely beneficial and not harmful
22	Insecticide Treated Bednets (ITNs) Why ITNs? Mosquito nets or bednets have been used for a long time for personal protection High household coverage of insecticide treated nets also reduces vector populations (‘community effect’) Personal and community level effects work best at high coverage. ITN use will reduce all-cause infant mortality by more than 20%
23	Insecticide Treated Bednets (ITNs) Coverage counts!!!! Insecticide is extremely important Different shapes and sizes – rectangular, conical Different Materials – cotton, nylon, polyester, polyethylene Different Types – conventional, long lasting/long duration Different Pyrethroid Insecticides - Permethrin (Peripel), Deltamethrin (KO Tabs), Alphacypermethrin (Fendona)
24	Use of Nets
25	PC USA in Malawi Central Church of Africa, Presbyterian (CCAP) Presbyterian Church USA (PC USA) and the Reformed Church in America (RCA) collaborating with CCAP Christian Women’s NetWorkers Program (CWNP) activities in 2 Synods Synod of Livingstonia 1.2 million people Malaria is leading cause of morbidity and mortality Infant Mortality Rate = 17.7% (1992 national estimate)
26	Presbyterian Church in Malawi Facilitating health programs since 1894 Major partner in Christian Hospital Association of Malawi (CHAM) Began malaria prevention education and ITN activities in 1996
27	PC USA and CDC in Malawi 3-year collaboration Technical assistance meetings in Blantyre and Kampala survey development strengthening linkage between CCAP and National Program
28	Objectives of Christian Women’s NetWorkers Program 50% pregnant women under ITNs 50% children <5 sleeping under ITNs 60% pregnant women receive 2 doses of IPT 50% ITN retreatment within 12 months
29	Christian Women’s NetWorkers Program in Malawi Select specific start-up congregations based on location, year-round risk of malaria Selection of women within congregation (all CCAP) because women historically have been more active in church (con’t . .)
30	Christian Women’s NetWorkers Program in Malawi (con’t) Selected women: Have history with and are trusted by congregation Read and write local language Trained for a week in selling, dipping, recordkeeping, and adult education House-to-house sales and redipping ANC and <5 clinics (con’t . .)
31	Christian Women’s NetWorkers Program in Malawi (con’t) Census through village leadership Nets procured through PSI and US-based congregations Follow Malawi government training protocol Sell nets at government set rate Focus on pregnant women and young children (natural fit)
32	What’s Been Achieved To Date? High levels of ITN retreatment – 46% Increasing coverage Pregnant women sleeping under ITN – 34% Children <5 sleeping under ITN – 53% IPT – ~80% receiving at least two doses Increased community awareness
33	What’s the Good News? (part 2) IPT is simple and effective ITNs are simple and effective Both require working closely with people The result is saving lives of children!!!
34	Mother’s Day Cards