Photo: PAHO/WHO

AmAzon mAlAriA initiAtiveQuarterly Bulletin • November 2015

Volume 2, Issue 4

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Global Malaria NewsFrom October 5–9, 2015, the Pan American Health Organization (PAHO/WHO) organized a series of regional consultation meetings on the Strategy and Plan of Action for Malaria in the Americas 2016–2020 in Punta Cana, Dominican Republic. The meetings were opened by the Dominican Minister of Health, Altagracia Guzmán Marcelino, the PAHO/WHO Country Representative in the Dominican Republic, Alma Morales, the Director of the World Health Organization’s Global Malaria Program, Pedro Alonso, and Marcos Espinal, the Director of Communicable Diseases and Health Analysis for PAHO/WHO. Commentary on the draft strategy was provided by participants from 20 malaria-endemic countries, five non-endemic countries, as well as 18 partners and research institutions. All AMI technical partners were represented at the consultation meeting. The stakeholders’ input helped to inform the strategic direction of malaria control and elimination in the region for the next five years, in alignment with the WHO’s Global Technical Strategy for malaria and the Sustainable Development Goals (SDGs). The consultations concluded with the inaugural meeting of PAHO’s Technical Advisory Group (TAG) for malaria as the principal advisory group to PAHO on matters related to malaria in the Americas.

International Partner HighlightsFrom September 21–October 2, 2015, AMI partners from Belize, Brazil, Honduras, Nicaragua, Panama, Peru, USAID, PAHO/WHO and Links Media participated in the regional edition of the Science of Eradication: Malaria course in São Paulo, Brazil. The course was administered to approximately 100 program managers and members of the research community in malaria-endemic countries. It was hosted at the University of São Paulo’s School of Public Health and co-sponsored by the Harvard T.H. Chan School of Public Health, Swiss Tropical and Public Health Institute (Swiss TPH), and ISGlobal — Barcelona Institute for Global Health, with additional support from PAHO/WHO,

FAPESP — the São Paulo Research Foundation, the Bill & Melinda Gates Foundation, and the CAPES Foundation. The participation of AMI country representatives was coordinated by PAHO in close collaboration with the São Paulo School of Public Health.

Pan American Health Organization (PAHO/WHO) Coordinated by PAHO’s Regional Malaria Program, an External Quality Assurance Program (EQAP) was established in 2011 with the national laboratories of Honduras and Peru as supranational reference laboratories that prepare standardized panels of slides for distribution to participating laboratories. The aim of this program is to improve the quality of malaria diagnosis across countries. Four rounds of evaluation have been undertaken from 2011 to 2015, with 21 national reference laboratories participating in the fourth round. Microscopy performance in 2015 compared with the previous rounds showed that there has been satisfactory improvement and achievement of concordance percentage in diagnosis and parasite morphology, but much less so in parasite density estimation and species identification. Evaluation serves to standardize processes and protocols across countries in the microscopic diagnosis of malaria. With decreasing malaria cases, countries need to prioritize the quality of diagnosis in order to detect each and every case. Given different treatment regimens for P. falciparum and P. vivax throughout the Americas, countries should focus on species identification and parasite density in order to move towards malaria elimination. In October 2015, PAHO/WHO presented a poster on EQAP for Malaria

Photo: Jaime Chang

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Microscopy Diagnosis in the Countries of the Americas at the 64th Annual Meeting of the American Society of Tropical Medicine and Hygiene (ASTMH) in Philadelphia, USA.

PAHO/WHO continues to provide technical assistance for the monitoring of therapeutic efficacy of antimalarial medicines. Currently, all AMI countries using artemisinin-based combination therapies (ACT) for P. falciparum implement Day 3 surveillance on all P. falciparum positive patients as an early warning system to detect any possible loss in sensitivity to first-line treatments. Following this approach, the Central American countries supported by AMI follow a routine surveillance system for all positive P. falciparum cases, using molecular markers for the detection of possible resistance to chloroquine as the first-line treatment.

The joint procurement of antimalarial medicines for the region is moving forward. A long-term agreement to procure antimalarials is now available as a result of a tender process completed in collaboration with UNICEF/WHO. The 24/7 strategic stock warehouse in Panama acquired new antimalarials, such as ACTs for imported cases coming from areas where resistance to chloroquine is known, as well as antimalarials for severe cases that can be mobilized rapidly to save lives.

PAHO warehouse activities from July-September 2015 included:

1. ACTs (arthemeter+lumefantrine 6x4) were distributed to 11 countries.

2. Intravenous artesunate and quinine were distributed to 6 countries for severe malaria cases, including to one country in Africa. One positive outcome has been the successful treatment of three severe cases.

As part of surveillance efforts, countries submitted their 2014 malaria morbidity and mortality data to PAHO/WHO to be analyzed and subsequently compiled for the WHO’s World Malaria Report 2015.

Centers for Disease Control and Prevention (CDC) From August to September, the CDC hosted an entomologist from Peru’s National Institute of Health (INS, by its acronym in Spanish) to be trained on molecular detection of insecticide resistance mechanisms in malaria vectors. The CDC also provided technical assistance to Peru’s INS regarding the interpretation of insecticide resistance data to make insecticide recommendations for vector control.

Photo: PAHO/WHO

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In December, the CDC will be hosting two entomologists from Honduras to be trained on biochemical assays to detect mechanisms of insecticide resistance and to provide technical assistance in interpreting insecticide resistance data for vector control decision making. In the same month, the CDC will host a researcher from Instituto Evandro Chagas in Belém, Brazil who is working on characterizing molecular mechanisms of pyrethroid resistance recently detected in Anopheles darlingi in the Brazilian Amazon.

The CDC disseminated the results from an AMI-supported in vivo study on the “Efficacy of Chloroquine and Primaquine in the Treatment of Uncomplicated Plasmodium vivax Malaria, Cruzeiro do Sul, Acre, Brazil, 2014” at an oral presentation during the 64th Annual ASTMH meeting. Two posters about molecular analyses of the kelch-13 (K13) antimalarial resistance marker in South America were also presented at the meeting:

n Molecular surveillance for K13 gene and other Plasmodium falciparum molecular markers associated with antimalarial resistance in Suriname

n Characterization of the K13 propeller domain in Guyana for suspected artemisinin resistance

U.S. Pharmacopeial Convention/Promoting the Quality of Medicines Program (PQM) Guatemala’s Medicines Unit of the National Health Laboratory (OMCL), received ISO 17025 accreditation from ANAB in September 2015, transitioning from a product-based to a method-based accreditation. The expanded scope of this accreditation includes high-performance liquid chromatography (HPLC) testing, as well as spectrophotometry and dissolution tests, strengthening the capacity to ensure the quality of medicines, including antimalarials in-country. PQM’s laboratory support towards the accreditation was initially provided in the context of AMI, and during the last couple of years was financed by the in-country USAID mission.

Management Sciences for Health/Systems for Improved Access to Pharmaceuticals and Services Program (MSH/SIAPS) The USAID-funded SIAPS program continued to support Colombia’s National Malaria Control Program (NMCP) in the completion and validation of a data collection protocol and instruments. During the next quarter, SIAPS will collect the information in three departments in Colombia. In Brazil, the state malaria programs have scheduled a follow-up monitoring exercise using the adequacy approach for February 2016.

Data collection and analysis for the Quarterly Bulletin on Availability and Consumption of Antimalarials showed an increase in the availability of antimalarials in central warehouses, from 71% in Quarter 3 to 86% in Quarter 4.

In working with local counterparts and AMI partners in Peru, SIAPS supported coordination meetings to finalize a plan for the introduction of artesunate+mefloquine fixed-dose combination therapy. It is anticipated that this fixed-dose combination will be introduced in selected counties in the region of Loreto next quarter, to pilot-test operational procedures for scaling up to the rest of the district.

Photo: Links Media

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In Guatemala, SIAPS provided technical assistance (TA) for the introduction of guidelines to support malaria pharmaceutical management in primary health facilities, and to monitor the availability of antimalarials used by primary health volunteers. Trainings for health volunteers will be carried out during the next quarter.

SIAPS will provide TA to Ecuador on a visit to collect primary data on the country’s malaria supply management, and will discuss alternative interventions with national counterparts.

Links Media From October 6–8, 2015, Links Media participated in the 1st Workshop on Education and Social Participation for Malaria Surveillance and Control organized by the NMCP in Brasília, Brazil. The purpose of the workshop was to discuss and present health education and social mobilization actions and strategies for malaria. Participants included state-level malaria program coordinators, professionals from the areas of health education and social mobilization, and representatives from the Ministry of Health, Ministry of Education, Ministry of the Environment, and the Ministry of Cities. Links Media also presented a poster at the 64th Annual ASTMH meeting in Philadelphia, USA, on the role of communication in raising the awareness of key decision-makers and mobilizing resources as more countries in the Americas transition towards elimination.

Country SpotlightResearchers from Brazil’s malaria-endemic and non-endemic areas and international counterparts shared their work at the XIV National Malaria Research Meeting held in São Paulo from October 1–3, 2015. The prospects for eliminating P. falciparum malaria in Brazil were discussed, along with innovations in the fields of parasitology, molecular biology, immunology, and vaccine development. The Brazilian Ministry of Health co-sponsored the event. Separately, Brazil has launched a regional epidemiological bulletin with data collected on malaria cases imported from neighboring countries.

Honduras’ supranational laboratory is currently creating a regional slide bank including over 1,000 slides to date with PAHO’s support. All samples were tested with PCR prior to their inclusion in the slide bank, following standard operating procedures adapted from WHO’s South East Asia Regional Office (WHO/SEARO). Other malaria-endemic and non-endemic countries in the region will be able to borrow panels from the slide bank to sustain their national diagnostic capacity for malaria through trainings and periodic evaluations following quality assurance procedures.

Credit: SIAPS/Links Media

Photo: PAHO/WHO

Es muy importante confirmar el diagnóstico a toda persona que se sospeche que tiene malaria mediante: Un examen de gota gruesa. Si se dispone de la prueba de diagnóstico rápido (PDR), también se debe realizar.

Los medicamentos para curar la malaria se dan solamente si el resultado es positivo.

La malaria se cura tomando el tratamiento completo de cloroquina y primaquina, según el esquema radical de tratamiento.

El tratamiento es gratis.

¿CUÁNDO SOSPECHO QUE UNA PERSONA PUEDE TENER MALARIA?

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Cuando la persona:

-Tiene calentura un día sí y otro no.

-Tiene escalofríos un día sí y otro no.

-Tiene dolor y malestar generalizados.

-Vive en zona malárica y cree que tienemalaria.

SEÑALES DE GRAVEDAD

Mareo Desorientación Convulsiones

¿CÓMO CONFIRMO QUE ES MALARIA?

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MAL

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P. fal

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um C T

-Tomo la muestra para gota gruesa, envuelvo la laminilla en el Formulario E-1 y la entrego al supevisor antes de 72 horas.

-En caso de que el supervisor no llegue todavía, envío la muestra con el personal del puesto de salud, del Centro de Atención Permanente o con un maestro de la comunidad.

-Si tengo PDR, también la realizo y espero el resultado en 20 minutos.

-Solamente si el resultado de la prueba es positivo le doy tratamiento.

¿CÓMO DEBO TRATAR LOS CASOS CONFIRMADOS?

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-Todas las embarazadas y todos los niños menores de 1 año, con diagnóstico positivo deben referirse al hospital o centro de salud.

-Cuando el resultado del examen de gota gruesa o PDR es positivo, doy medicamentos antimaláricos.

-Entrego cloroquina y primaquina, según la ficha de esquema radical de tratamiento.

¿CÓMO DEBO ENTREGAR LOS MEDICAMENTOS ANTIMALÁRICOS?

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-Doy la primera dosis de cloroquina y primaquina y observo al paciente.-Si vomita en los primeros 30 minutos, le doy otra vez la misma dosis de las medicinas; si con la segunda dosis sigue vomitando, entonces referirlo a un centro de salud u hospital.-Oriento al paciente o familiar sobre cómo se deben tomar los medicamentos antimaláricos.-Le entrego tratamiento en tres partes. Por ejemplo, los primeros tres días, y el resto dividido en dos entregas. -Cada vez que regresa el paciente por su tratamiento, lo observo y le pregunto si se siente mejor y si está cumpliendo con el tratamiento.-Lleno un formulario E-1 para cada paciente y anoto en él, la cantidad de medicamentos antimaláricos entregada.-Reporto los tratamientos finalizados de igual manera en el E-1.-Debo hacer las pruebas de control al terminar el tratamiento.

¿CUÁNDO DEBO REFERIR AL PACIENTE AL CENTRO DE SALUD O AL HOSPITAL?

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-Cuando la persona ya tomó los medicamentos antimaláricos y sigue con síntomas.

-Cuando el resultado sea negativo y la persona sigue con síntomas.

-Cuando haya señales de gravedad.

-Cuando el paciente sea un niño menor de 1 año o una embarazada.

¿CÓMO PREVENIR LA MALARIA?

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-Evitar las picaduras usando pabellón cuando están descansando o durmiendo.

-Identificar criaderos que tienen apariencia de lana verde, limpiarlos cada 8 días o drenarlos y rellenarlos.

-Chapear los alrededores y la orilla de los riachuelos para evitar que el agua se estanque.

-Además, trabajar con las autoridades y la comunidad para eliminar criaderos de zancudos.

¿CÓMO DEBO ORIENTAR SOBRE EL TRATAMIENTO?

Explico que: -La malaria se cura únicamente tomando cloroquina y primaquina, según el esquema radical.-Se deben tomar las pastillas cada día, a la misma hora.-Se debe tomar el medicamento antimalárico después de comer, para evitar molestias del estómago.-Se debe cumplir con todo el tratamiento, aunque ya no tenga molestias.-No se debe dar el medicamento antimalárico a otra persona.-Se debe guardar fuera del alcance de los niños.-Si los signos de malaria no desaparecen se debe consultar otra vez.-No se debe automedicar.

Mosquito Anopheles

GUÍA PARA COLABORADORES VOLUNTARIOS/AS:

¿Cómo debo atender a las personas con sospecha de malaria?

Referir al centro de salud

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30 min.

Debo solicitar cantidades adecuadas de medicamentos e insumos antimaláricos para abastecer a los Colaboradores Voluntarios. Si pido pocos medicamentos e insumos, no podré abastecerlos a todos y si pido muchos medicamentos e insumos, no los utilizarán todos y se podrían vencer.

Debo saber cuántos Colaboradores Voluntarios activos tengo a mi cargo que están reportando casos.

Debo solicitar cada medicamento e insumo antimalárico de acuerdo a las cantidades máximas establecidas para distritos clasificados como en fase de control y distritos clasificados pre-eliminación, en el Reporte Consolidado de Control de Insumos Antimaláricos de los Colaboradores Voluntarios.

En este reporte, calculo la cantidad máxima de cada medicamento e insumo antimalárico.

Cantidad máxima que debe tener un Colaborador Voluntario.

Número de Colaboradores Voluntarios que debo abastecer, más (+) un stock de reserva para el supervisor.

El stock de reserva es igual a la cantidad máxima para cubrir 2 Colaboradores Voluntarios.

La cantidad a solicitar la calculo restando a la cantidad máxima el saldo actual que tengo en el reporte:

GUÍA DE GESTIÓN DE MEDICAMENTOS ANTIMALÁRICOS E INSUMOS DE DIAGNÓSTICO PARA SUPERVISORES DE LOS COLABORADORES VOLUNTARIOSE N D I S T R I T O S D E S A L U D

La presente Guía se elabora para orientar al personal que supervisa a los Colaboradores Voluntarios en la gestión de medicamentos e insumos, para el diagnóstico y tratamiento de malaria, a fin de asegurar el abastecimiento y uso racional de los mismos, de acuerdo con las Normas del Ministerio de Salud Pública y Asistencia Social.*

1¿Qué cantidad solicito?

*El encargado de apoyar a los Colaboradores Voluntarios recibe varias denominaciones dependiendo del Área de Salud: Supervisor, Técnico de Campo, Polifuncional, Evaluador, Polivalente, etc.

Cantidad Máxima

Cantidad Máxima por Colaborador

Voluntario

No. de Colaboradores Voluntarios que cubro + stock de reserva

= x

Cantidad a Solicitar

Cantidad Máxima

Saldo Actual (saldo de todos los Colaboradores Voluntarios y el supervisor)

= –

ASPECTOS IMPORTANTES PARA LA GESTIÓN DE LOS MEDICAMENTOSE INSUMOS ANTIMALÁRICOS

La presente guía se elaboró con base en las Normas de Atención del Departamento de Regulación de los Programas de Atención a las Personas. Su objetivo es orientar al personal que gestiona medicamentos en los distritos de salud y al Coordinador de Vectores del distrito, para asegurar el abastecimiento de medicamentos antimaláricos e insumos de diagnóstico para la atención oportuna de los casos que los requieren.

COMO RESPONSABLE DE VECTORES DEL DISTRITO, DEBO: Revisar los reportes consolidados de los supervisores y aprobar la requisición de medicamentos e insumos antimaláricos de cada uno.

Entregar las requisiciones autorizadas de los supervisores al encargado de medicamentos del distrito.

Elaborar la certificación de la información de los supervisores y enviarla al coordinador municipal de salud para su firma.

COMO RESPONSABLE DE LOS MEDICAMENTOS EN EL DISTRITO, DEBO:

Debo tener suficientes medicamentos antimaláricos e insumos de diagnóstico para abastecer a los supervisores, centros y puestos de salud. Si tengo pocos medicamentos no podré atender a todos y si tengo muchos se pueden vencer.

Debo solicitar mensualmente medicamentos antimaláricos e insumos de diagnóstico a la Dirección de Área de Salud para mantener un stock que me permita abastecer a su nivel máximo a los supervisores del distrito, así como a los centros y puestos. Sumo las cantidades máximas estimadas por los supervisores, centros y puestos de salud, reportadas en los consolidados y balances. Esto se lo resto al dato del saldo del mes siguiente del Balance Consolidado de Distrito.

GUÍA PARA LA GESTIÓN DE MEDICAMENTOS ANTIMALÁRICOS E INSUMOS DE DIAGNÓSTICOE N D I S T R I T O S

Para asegurar el buen manejo de medicamentos antimaláricos y el tratamiento adecuado de los casos de malaria, existen cinco preguntas que debo considerar, como responsable de los medicamentos en el Distrito de Salud.

Recibir, revisar y aprobar las requisiciones y balances de medicamentos antimaláricos y productos afines de los centros y puestos de salud.

Preparar los pedidos de medicamentos e insumos antimaláricos, con base en las requisiciones autorizadas, para despacharlos a los supervisores, centros y puestos de salud, en el caso de que en el distrito no sea el coordinador de vectores el que los entregue.

Entregar los medicamentos a los supervisores, centros y puestos de salud.

1¿Qué cantidad debo tener? ¿Qué cantidad debo tener?

La presente guía se elaboró con base en las Normas de Atención del Departamento de Regulación de los Programas de Atención a las Personas. Su objetivo es orientar al personal que gestiona medicamentos en los centros y puestos de salud (encargado de bodega) para asegurar el abastecimiento de medicamentos antimaláricos e insumos de diagnóstico para la atención oportuna de los casos que los requieren.

COMO RESPONSABLE DE LOS MEDICAMENTOS EN EL CENTRO O PUESTO DE SALUD, DEBO:

Tener siempre disponibles los medicamentos antimaláricos: cloroquina y primaquina, e insumos de diagnóstico que no estén vencidos.

Almacenar los medicamentos e insumos antimaláricos de acuerdo a las buenas prácticas de almacenamiento.

Entregar medicamentos antimaláricos solamente a los pacientes con diagnóstico confirmado de malaria, es decir, que tengan resultado positivo del examen de gota gruesa o de prueba rápida.

1Debo estar abastecido con medicamentos antimaláricos e insumos de diagnóstico para atender a casos sospechos de malaria. Si tengo pocos medicamentos e insumos antimaláricos no podré atender a todos los pacientes y si tengo muchos se pueden vencer.

Debo solicitar medicamentos antimaláricos e insumos de diagnóstico mensualmente para mantener mi abastecimiento entre un stock máximo y mínimo de acuerdo a la classificación de mi distrito.

GUÍA PARA LA GESTIÓN DE MEDICAMENTOS ANTIMALÁRICOS E INSUMOS DE DIAGNÓSTICOE N C E N T R O S Y P U E S T O S D E S A L U D

Para asegurar el buen manejo de medicamentos antimaláricos y el tratamiento adecuado de los casos de malaria, existen cinco preguntas que debo considerar.

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DISCLAIMER: Bulletin contents do not necessarily reflect views or endorsements of the United States Agency for International Development or the United States Government.

November 2015143rd American Public Health Association (APHA) Annual Meeting and Exposition, Chicago, USA, October 31–November 4, 2015.

Forum of Malaria Networks and Advocates & Regional Launch of Action and Investment to Defeat Malaria (AIM), Pan American Health Organization Headquarters, Washington, USA, November 5, 2015.

Malaria Day in the Americas, Region-wide, November 6, 2015.

November–December 2015World Malaria Report 2015 Release, TBD.

March 2016AMI/RAVREDA Annual Evaluation Meeting and Semi-Annual Steering Committee Meeting, Colombia, March 14–18, 2016.

Photo: PAHO/WHO

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In September 2015, Peru’s Ministry of Health and the regional government of Loreto contributed additional resources to deploy health brigades to remote areas of the Amazon more frequently in order to address malaria. Thirty health brigades left Iquitos by boat to provide microscopy diagnosis and treatment to riverine populations in light of the ongoing health emergency due to malaria in Loreto. Emphasis was placed on providing timely and efficacious services to communities who live along the Pastaza, Marañón, Tigre and Corrientes rivers.Photo: Jorge Escobedo

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