Progress of malaria control in sub-saharan Africa: Case of Kenya

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1 Research, Training & Cooperation for Sustainable Malaria Control 2013 Workshop Targeting the Vector Camerino & Pergugia, Italy July 2013 Progress of malaria control in sub-saharan Africa: Case of Kenya Anne Kamau (DrPH) Department of Sociology Kenyatta University, Nairobi-Kenya Tel: +254(0)

2 Outline Background on malaria in Kenya Achievements and strengths; drawbacks and weaknesses - through a gender lens Key issues to be addressed by the malaria research community Recommendation for health policy makers & National Malaria Programmes

3 Abbreviations ACSM - Advocacy, communication and social mobilisation GOK Government of Kenya IPTp - Intermittent preventive treatment of malaria in pregnancy M&E monitoring and evaluation NML - National Malaria Strategy TWG - Technical working group

4 Background Kenya covers an area of sq kms Estimated population of 39 million people (2009) 25% of Kenya s population are women yrs 17% are children <5 yrs Infant mortality rate (IMR) 52% & Child mortality rate (CMR) 74% per 1000 live births (96 children per day) Malaria a major public health problem in Kenya 70% of Kenya s population live in malarious areas 29% of Kenya s live in malaria endemic zones 24 million Kenyans (ca 61%) at risk of infection each year

5 Malaria burden in Kenya Malaria remains a major cause of morbidity and mortality in Kenya primary cause of ill-health 11.3 million cases are recorded annually Clinically tested malaria responsible for:- - 30% of all out-patient attendance - 19% of admissions % of inpatient deaths Leading cause of death in children <5 yrs Every day 96 children < 5 yrs contract malaria Most vulnerable are pregnant women and children Poor households most affected esp. in rural areas i.e. feminisation of malaria

6 Malaria epidemiology in Kenya Malaria is not homogenously distributed in Kenya Four malaria epidemiological zones i. Endemic Lake stable endemic & Coastal seasonal (risk = > 20%) ii. Highland epidemic prone (risk = 5 - <20%) iii. Arid & semi-arid seasonal low transmission (risk = < 5%) iv. Low risk zones (risk = <0.1%) Targeted interventions based on malaria epidemiology

7 Kenya Malaria Endemicity Map Warmer areas are high endemic areas high levels of transmission in coast and around Lake Victoria Little/no transmission in highlands above 1,500 2,000 meters altitude

8 Kenya s response to malaria GOK has made malaria control and management a high priority Anchored in vision 2030 provide equitable and affordable quality health services to all Kenyans (shift from curative to promotive and preventive health care) Goal of National Malaria Strategy reduce morbidity and mortality associated with malaria by 30% by 2009 and to maintain it to 2017 Government working towards a malaria-free Kenya Key targets: 80% coverage in malaria endemic areas

9 Malaria control & prevention interventions 1. Case management prompt diagnosis and effective treatment at all levels of health care system 2. Vector control integrated vector management Long lasting insecticidal nets Indoor residual spraying 3. Management of malaria and anaemia during pregnancy - Intermittent preventive treatment of malaria in pregnancy (IPTp) 4. Epidemic preparedness and control Surveillance, M&E, Operation Research (OR) 5. Advocacy, communication and social mobilisation (ACSM)

10 Progress in Malaria Control in Kenya

11 Provision of prompt and effective treatment (case management) Overall decline in malaria prevalence Malaria prevalence reduced from 28% in 2001 to 5% in In Central reduction from 15% - <1% Attributed to high net coverage and use Improved case management & reporting rate high) Free malaria treatment in children (GoK facilities) i.e. presumptive treatment among the <5s Treatment policy with Artemisinin combination treatment (ACT) Artimether Lumefantrine (AL) since 2006; subsided ACT at health facilities; 2008> over the counter (OTC) Cerebral malaria decline/eliminated in areas that previously had this e.g. Mwea, Coast

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13 Provision of prompt and effective treatment (case management) From 2012> policy moved from presumptive treatment to diagnosis based treatment Now confirmatory tests done through use of RDTs RDT Kits distributed across all government health facilities Plans to roll-out RDTs to community level so that CHWs can test and treat (discussion stage) Single sourcing of malaria drugs through Kenya Medical Supplies Agency (KEMSA) to ensure quality Budgetary allocation increased (narrowed funding deficit gap)

14 Prevention of malaria during pregnancy Proportion of women using LLINs increased 4.4% in 2003 to 48.2% in Increased Intermittent preventive treatment of malaria in pregnancy (IPTp) Women who received ca. 2 doses [SP -Sulphurdoxine polymethanyme] during ANC visits - 4% in 2002 to 15% in Rolled-out nationally

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16 Vector control using Insecticide Treated Nets Overall aim achieve universal coverage of LLINs/ITNs (at least 2 nets per household) , Free LLINs distributed in malaria endemic areas by 2012 = 26M (Kemri sources). Free distribution addressed inequality among the poor Two approaches used:- Keep up (routine distribution of IPTs) LLINs given to every pregnant woman in one ANC visit Infants below 1 year given LLINs/ ITNs Women are caregivers - in contact with health care system Catch-up (when net coverage is low) Mass nets distribution in endemic areas School children targeted through malaria free schools Social marketing e.g. PSI where nets are subsidised

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18 Epidemic preparedness and response Indoor residual spraying (IRS) to prevent malaria occurrence IRS team comprised of locals Community Resource Persons (CORPS) supervisors & spray operators to acquire acceptance and buy-in Important for Advocacy Communication & Social Mobilisation to promote acceptance of IRS Institutionalised populations given priority in IRS and LLINs/ITNs e.g. Prisons

19 Epidemic preparedness and response Gender aspects in IRS Confirmation of non-pregnancy and not breastfeeding (pregnancy tests needed/ repeated!) sometimes not an acceptable practice (informed consent) Women involvement key in household preparation for IRS Important to consider community seasonal calendar for best results/coverage (planting season, school holidays etc)

20 Information, Education and Behaviour change communication Knowledge about malaria transmission in Kenya 95% Knowledge gap only 10% know that malaria causes anaemia and neonatal and maternal death By 2008 on 40% of service providers were able to accurately state the effects of malaria in pregnancy Malaria communication strategy development to respond to this need

21 Progress in Malaria Control Monitoring and evaluation What get measured get done Malaria programme review conducted prior to coming up with the National Malaria Strategy. Review took stock of what has been going on in Malaria control (right & wrong) Assessed what had been done and how, and identified what more needed to be done and how. Key challenge identified then was lack of data/missing data Emphasize put on M&E for timely and effective decision making

22 Challenges in Malaria Control in Kenya

23 Malaria morbidity still high Lake region burden still high although mortality has declined Low access to prompt treatment especially for children below 5 yrs Inadequate parasitological diagnostic services in the health sector Widespread use of non-recommended monotherapies for malaria treatment self treatment

24 Low uptake of IPTp Observations: more compliance in IPTp in Central Kenya (low malaria zone) than in Nyanza (highly endemic); high use of ACT in Nyandarua than Homabay perception and attitude (lived with malaria so no fear of infection) Potential misuse of drugs in Central (fear of infection) Low use of ANC services?? need to address this Likely to shift with introduction of free maternity care (M&E important) close M&E necessary

25 Alternative uses of nets Alternative uses Flower beds Rice nurseries Lydia Kibe study in Kilifi rearing chicken National Malaria Strategy TWG 3 acknowledges the need to provide technical advice on implementation of IRS and LLIN waste management and disposal Through Ministry of Environment and Natural Resources This remains a challenge particularly on used nets disposal

26 Attainment of IRS universal coverage Ineffectiveness of IRS due to insecticide resistance IRS universal coverage still a challenge - difficult to attain due to high cost Drug failure/resistance Resistance of mosquito vectors to insecticides on ITNs - in 2012 pyrethroid was not effective Technical working group advised change to alternative insecticides The alternative has a shorter lifespan, therefore have to spray twice It also costs more - more expensive than pyrethroid than 3 times - Shooting up costs Additional funding from DFID

27 LLINs use consistency a challenge Net ownership high but usage low During dry season, people do not use net The few bites are more infections for the mosquitoes to have survived the dry season Why low or non-use??? Assumption that there is no malaria because mosquitoes are fewer Behaviour change difficult Net hanging related issues e.g. what provisions? Gender-related socio-cultural issues related to universal coverage of LLINs

28 Consistency a big issue in Kenya Basic rule at least 1 net per household for 2 persons Rural household (HH) with average 5 members = 3 nets (who are these HH members?) Hypothesis 1 father + mother = 1; 2 children same/different gender < 5yrs = 1 net & 2 users; + 1 more = total 3 nets = universal coverage attained Hypothesis 2 father + mother = 1; 2 children same gender aged 5 & 12 yrs = 1 net & 1 user; + 1 more user = total 3 nets but 4 users = universal coverage??? cultural practices

29 Special population groups 5 15 years still a challenge Coverage school health programmes not comprehensive focus on endemic areas National coverage important for this group Highly mobile population Dependent on adults (influenced by household socio-economic status) Social and cultural issues affect boys and girls differently e.g. LLINs use vis-a-vis maturation pathway to adulthood/manhood etc Promote internationalisation of best preventive behaviour/habits (socialization) in addition to BCC

30 Mobile populations Although malaria endemicity is not spread throughout Kenya, the population is highly mobile Discussions (KEMRI) indicated that January & February have many malaria cases are reported in the low income urban areas of e.g. Kibera in Nairobi Attributed to populations mobility during December festive season Need for targeted interventions for mobile populations in policy and programmes i.e. Combined approaches (education, awareness and prevention strategies e.g. LLINs use)

31 Implementation of National policies Implementation of National policies a key challenge Few people know that the policy documents are there Thus, do not use them or attempt to implement

32 Financial & logistical challenges Financial and human resources within the health sector Completeness and timeliness in the reporting of routine monitoring data missing or lacking data? Shift from Districts to Counties DHIS-CHIS

33 Malaria Politics For IRS to be effective there is need for wide coverage and community acceptance Experience that community misconceptions /perceptions can derail control and prevention efforts e.g. talking nets Political interference - sometimes, politics interfere with community acceptance

34 Summary

35 A look at malaria using a gender lens Interrogate the extent to which gender concerns of men and women are included in malaria control and management Are there emerging gender issues? Is gender mainstreamed in conceptualisation, planning and implementation of malaria control programmes?

36 References 1. DOMC, Indoor residual spraying for malaria control: A handbook for the IRS Team. 2. DOMC, National Malaria Communication Strategy DOMC, National Malaria Policy, 1 st Edition. 4. DOMC, National Malaria Strategy

37 Asanteni sana!

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