Issue 6: January - June 2016 National Malaria Control Programme (NMCP) Box KB 493 Korle - Bu Accra Ghana

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1 Issue 6: January - June 2016 National Malaria Control Programme (NMCP) Box KB 493 Korle - Bu Accra Ghana Contents Page Editorial and Report Highlights Page 1 Malaria Burden Page 2 Key Activities undertaken in the first half year 2016 Page 2 Malaria Statistics Page 6 Indicator Definition Page 12 References Page 13 Editorial This is the 6th issue of the Ghana Malaria Control Programme Periodic Bulletin. The aim of this bulletin is to inform all stakeholders on progress achieved and challenges encountered in malaria control in Ghana. Most importantly, it is to encourage use of this information at all levels in order to foster improvement of our efforts and to highlight achievements and create awareness for increased resource mobilization & allocation in order to maintain the gains we have achieved. In this issue, we present HMIS data, representing malaria burden, case management and coverage of malaria interventions for the first half of We would be pleased to receive comments from you regarding this publication, and we welcome your contributions to subsequent issues. Thank you. We hope this will inform decision making at all levels. ACKNOWLEDGEMENT Programme Manager and staff of NMCP PPMED GHS, Regional and District Directors of Health Services Partners (WHO, Global Fund, USAID/PMI, DFID, CDC and Noguchi etc.) 1 P age

2 Malaria Burden In the first half of the year 2016, the country recorded 4,940,270 suspected cases of malaria. Thus on the average, approximately 26,922 suspected cases of malaria were recorded daily in the country s health facilities during the period. During the semester under review, deaths attributed to malaria by clinicians in the health facilities were 685. Out of these malaria attributable deaths, 290 occurred among children under-5 years in 2016 compared to 385 in 2015.There is therefore a steady significant reduction in deaths attributable to malaria in the country. Even though, suspected malaria cases increased by 6.9% as compared with the previous year, admission and deaths attributed to malaria however decreased by 6.3% and 24.6% respectively. Malaria under five case fatality rate also dropped from 0.44 in the first half of 2015 to 0.35 at the end of the semester in Key Activities undertaken in the First Half year 2016 In the first half of 2016, NMCP undertook the following activities to help achieve the targets set for the year, with the ultimate aim of reducing malaria morbidity and mortality by 75% (using 2012 as baseline) by the year Case Management Case management training and clinical outreach training and supportive supervision OTSS were conducted in five regions (Ashanti, Brong Ahafo, Eastern, Upper East and Upper West region) with a total of 11,083 health staff trained. Trainer of Trainers (TOT) was conducted for eighteen regional coordinators of Ghana Registered Midwives Association (GRMA). Case management refresher training was carried out for 5,781 health workers in Greater Accra, Northern, Volta and Western region in collaboration with Systems for Health, a USAID supported project. The NMCP coordinated case management training for health staff and Pharmacy Auxiliary staff, during sentinel site review meetings and Strengthening Health Outcome through the Private Sector (SHOPs) training. Malaria In pregnancy 2 P age

3 The Malaria in pregnancy (MIP) working group meetings held two within the period and carried out monitoring and supportive supervisory visits to 307 facilities implementing IPTp but are not reporting in DHIMS. Desk review on barriers and determinants of IPTp uptake in Ghana was done and issues of concurrent administration of 5mg folic acid and SP was tackled. Integrated Community Case Management has been integrated into Community Health Planning Services (CHPS) system. At the end of the period 538,311 home visits have conducted across the country. Plans were put in place to ensure availability of SP which was out of stock during the first quarter of the year. Malaria Diagnostics In the first half of 2016, the National Guidelines for Laboratory Diagnosis (NGLD) on Malaria was finalised. Also during the same period NMCP and partners develop a Malaria Diagnostic Quality Assurance (MDQA) manual for stakeholders review. The Program trained 410 Laboratory scientists from public, private and quasi health facilities on malaria diagnostics. NMCP also monitored the supply and use of RDT in 106 private facilities; 24 Pharmacies, 57 Over the Counter Medicine Sellers (OTCMS) and 25 Private Clinics / hospitals. The programme also trained 342 Pharmacy Auxiliary staff in Eastern, Volta, Central, Brong Ahafo, Ashanti, Greater Accra regions on malaria diagnostic. Integrated Vector Control Under vector control, NMCP continued the distribution of LLIN in the country using multiple channels. Point mass distribution of LLIN was conducted in Upper East and Northern Regions. A total number of 695,061 out of 712,300 LLINs allocated and 1,762,811 out of 1,814,467 LLINs allocated were distributed in the two (2) regions respectively. This represents 98% and 97% coverage of LLINs distributed in the two regions respectively. A total of 936,357 out of the targeted 1,014,300 LLINs were distributed to children in public and private basic schools in 6 regions; Ashanti, Brong Ahafo, Central, Western, Eastern and Volta regions representing 92.3% of the target group covered. A total number of 337,207 LLINs were also distributed through Continuous Distribution (CD) at health facilities for pregnant women and children under five years. 3 P age

4 Advocacy, Communication and Social Mobilization (ACSM) NMCP staffs were involved in 41 Radio and Television discussions programme on selected stations to sensitize the public on malaria control interventions in the first half of These discussion programmes included news interviews and health programmes in both English and local languages. Two press briefings were held to update the media on Malaria Control interventions. We launched the LLIN point mass distribution campaign in Greater Accra during the period. The developed television and radio adverts on test, treat and track: compliance, use and improve provider confidence in the use of RDTs and SP (TV adverts) have been translated into seven local (Akan, Dagbani, Dagaare, Ewe, Ga, Gurini and Hausa) languages. On April 25 th, people across the country took part in different activities to mark the World Malaria Day. The theme for 2016 World Malaria Day was Invest in Malaria: End malaria for good. Research, Surveillance, Monitoring and Evaluation The Surveillance, Monitoring and Evaluation Technical Working Group (SM&E TWG) held one meeting during the period to discuss pertinent issues bothering data quality in the country. Public and private supervisory visits were conducted in selected districts across the country. The districts were selected based on their performance on IPT 3 coverage. A total of 380 facilities in 178 districts were visited. Activities for the first data quality assessment commenced towards the end of the half year. Monthly validation of routine data reported through DHMIS was carried out within the period. All 10 regions were also supported to conduct quarterly data reviews with the focus on completion of consulting room register and timely reporting of monthly data. Sentinel site visits were also conducted in all 30 sites. As part of the visits, on the job coaching was provided for lab personnel as well as data management staff in the facilities. Reported malaria deaths were verified and those found not to be due to malaria were changed and reports updated accordingly. Other research activities and finalization of the report on the impact of seasonal malaria chemo-prevention were some of the key activities under Research, Surveillance, Monitoring and Evaluation for the first half of Procurement Supply Chain Management (PSM) 4 P age

5 The NMCP received anecdotal reports on decreasing demand for ACTs and the growing preference for Artemether Lumefantrine (AL) to Artesunate Amodiaquine (ASAQ). These were also observed in the monthly stock reports from the regions. Based on these observations, the programme revised the respective proportions of ASAQ to AL for both adults and children and subsequently revised the shipment plan for 2016.Some shipments originally scheduled to be delivered in 2016 were reschedule to 2017 to avoid overstocking. In the period under review, the following commodities were received in country, the USAID RDTs were received at the end of March and was not captured in the first quarter report, it has been captured in the current report, Table 1: Malaria Drugs and commodities stock level, Jan Jun 2016 DESCRIPTION mrdts Injection Artesunate 60 mg/vial QUANTITY DATE SOURCE OF RECEIVED FUNDING 3,093,450 11/2/2016 DFID 2,096,925 31/03/2016 USAID/PSM 248, /04/2016 The Global Fund 524,415 13/05/2016 USAID/PSM Artemether Lumefantrine 20/120 mg 24 s 1,520,640 3/5/2016 The Global Fund AL 24 s /05/2016 USAID/PSM 949,800 17/04/2016 USAID/PSM Rectal Artesunate 50mg 3,612 12/1/2016 USAID/PMI/Deliver Sulpadoxine Pyrimethamine 25/500 mg 9,000,000 tablets 3/6/2016 USAID/PSM Artemether lumefantrine 20/120 mg 24s (adults) 223,020 25/01/2016 USAID/PMI/Deliver Artemether Lumefantrine 20/120 mg 6 s 199,800 17/04/2016 USAID/PSM LLINs 2,124,210 4/02-11/03/2016 The Global Fund Source: NMCP PSM, August, 2016 Resource Mobilization/Private Sector Partnership (RM) As part of efforts to generate domestic funds for malaria control, the NMCP Resource Mobilization Working Group under the Malaria Inter-Agency Coordinating Committee (MICC) in collaboration with Stakeholders has developed a Resource Mobilization Plan to guide the generation of domestic resources. As part of the plan, Ghana malaria foundation has been 5 P age

6 registered to drive domestic financing to support Malaria control interventions. A private sector board of trustees has been identified and would be inaugurated in October, Finance and Administration As at the end of June 2016, the programme has absorbed 71% of total funds released. A huge proportion of this disbursement was for procurement of commodities (RDTs and ACTs including private sector co - payment). MALARIA STATISTICS FOR JANUARY JUNE 2016 Reporting Rates Generally, reporting rates on the DHIMS 2 platform has improved. OPD Morbidity s reporting form recorded an increase in data completeness from 86.8% in the first half of 2015 to 97.9% in 2016; whilst the Monthly Anti-malaria reporting form also increased from 84.1% in the first half of 2015 to 97.3% in Table 2: Number and Proportion of Malaria OPD Cases, Admissions and Deaths in Ghana, Jan Jun 2016 PROPORTION CASES NUMBER INDICATOR ATTRIBUTABLE TO REPORTED MALARIA Total OPD Cases 13,373,577 Out Patient Suspected Malaria Cases 4,940, % Department (OPD) Confirmed Malaria Cases 2,029, % ADMISSION Total Admissions (All Facilities) 748,218 Malaria admissions 175, % Under 5 malaria admissions 81, % DEATHS Total deaths (All ages) 15,792 Total malaria deaths (All ages) % Under 5 malaria deaths % UNDER 5 MALARIA CASE FATALITY RATE 0.35 Source: DHIMS, 22nd August P age

7 MALARIA MORBIDITY AND MORTALITY The country recorded a reduction in under-five malaria deaths from 385 in the first half of 2015 to 290 in 2016, representing a case fatality rate of In 2016, Northern region recorded the highest case fatality rate of 0.57%, even though it recorded an 8% reduction in malaria deaths from 108 malaria deaths in the first half of 2015 to 94 in Upper West Region also had a case fatality rate of 0.51% which is the second highest in the country within the same reporting period whilst Ashanti Region recorded the lowest case fatality rate of 0.16% with 30 malaria deaths (Figure 1). Figure 1: Under-five Malaria Deaths, by Region, Jan - Jun 2016 As shown in Figure 2, the country recorded a decrease in malaria case fatality rate amongst persons above five years from 523 malaria deaths in the first half of 2015 to 395 representing a case fatality rate of 0.54 and 0.42 respectively. In 2016, Upper East and Upper West regions recorded the highest above five malaria case fatality rates of 0.95% and 0.94 respectively. Comparatively, there has been an improvement in case management in Upper East and Central 7 P age

8 region in the first half of Eastern Region recorded the lowest malaria under-five case fatality rate of 0.21 with 20 malaria deaths out of 9,593 malaria admissions. Figure 2: Number of Malaria deaths for above five years by Region, Jan - Jun 2016 Table 3: Malaria Slide and Test Positivity Rates, All 30 Sentinel Sites, Jan - Jun Type of Test (All Ages) Number Slide/Test Positivity Period Rate Microscopy Tested 45,029 67,338 Positive 13,588 14, RDT Tested 89,499 90,460 Positive 24,126 22, P age

9 The malaria slide positivity rate (percentage of positive malaria cases using microscopy), decreased from 30.2% in the first half of 2015 to 21.4% in Test positivity rate using RDTs also decreased from 27.0% in the first half of 2015 to 25.3% in For the period under review, the number of suspected malaria cases put on ACTs reduced from 2,760,652 in the first half of 2015 to 2,651,216 in This could be attributed to the improvement in adherence to test result. Despite this reduction, malaria cases treated with ACTs were more than confirmed malaria cases. (Figure 3). Figure 3: Number of Malaria Suspected Cases, Malaria Cases Tested, Test Positive and Cases Put On Acts in Ghana, Jan - Jun OPD attendants treated with ACTs 2016 OPD attendants treated with ACTs 2015 Malaria cases test Positive 2016 Malaria cases test Positive ,651, ,029,162 1,814,440 Malaria cases tested 2016 Malaria cases tested ,268,448 3,812,692 Suspected malaria cases 2016 Suspected malaria cases ,940,270 4,620, ,000,000 2,000,000 3,000,000 4,000,000 5,000,000 6,000,000 OPD Attendants The country recorded an increase in malaria testing rate from 70.7% in the first half of 2015 to 77.2% in All the regions with the exception of Upper East and Upper West Regions recorded an increase in testing rate. (Figure 4). 9 P age

10 Figure 4: Testing Rate of all Health Facilities by Region, Jan - Jun Testing Rates Testing Rate 2015 Testing Rate 2016 Ashanti Brong Ahafo Central Eastern Greater Accra Northern Upper East Upper West Volta Western Ghana Region INTERMITTENT PREVENTIVE TREATMENT IN PREGNANCY (IPTp) In the first quarter of the period under review, there was a massive stock-out of Sulfadoxine Pyrimethamine (SP) for IPTp throughout the country. This affected the uptake of IPTp tremendously. There was a decrease in the proportion of ANC registrants that took IPTp 1 from 71.0% in the half of 2015 to 59.7% in IPTp 3 uptake also decreased from 41.7% in 2015 to 35.7% in However there was a slight increase in IPTp 5 uptake from 4.9% in the half year of 2015 to 6.5% in 2016 (Figure 5). This is probably due to the increasing acceptance of the change in policy from 3 doses to 5 doses by pregnant women. 10 P age

11 Figure 5: Proportion of Pregnant Women Taking IPT 1-5, Ghana, Jan - Jun IPT IPT IPT IPT IPT IPT IPT IPT IPT IPT Proportion LONG LASTING INSECTICIDAL NETS (LLIN) The Distribution of LLIN through the continuous distribution model in health facilities continued within the period under review. LLIN coverage for pregnant women decreased from 29.1% in the first half of 2015 to 27.5% in Upper East Region had the highest coverage 69.7% of LLIN given to pregnant women; whilst Central Region recorded the lowest coverage of 7.0% (Figure 6). Figure 6: LLIN coverage for Pregnant Women through ANC by Region, Jan - Jun LLIN coverage Ashanti Brong Ahafo Central Eastern Greater Accra Northern Upper East Upper West Volta Western Ghana P age

12 LLIN coverage for children due for measles 2 distributed through CWC also decreased from 53.1% in the first half of 2015 to 45.7% in In the first half of 2016, Upper East Region had the highest coverage of 82.3%; whilst Central Region recorded the lowest coverage of 10.3% (Figure 7). Figure 7: LLIN coverage for Children under five years through CWC by Region, Jan - Jun LLIN coverage Ashanti Brong Ahafo Central Eastern Greater Accra Northern Upper East Upper West Volta Western Ghana Source of data: DHIMS 2, 22 nd August 2016 INDICATOR DEFINITIONS Reporting completeness: Percentage of monthly reports received from health facilities in relation to the number of monthly reports expected. Malaria Case Fatality Rate: Proportion of deaths attributable to malaria out of all malaria admissions. Malaria slide positivity rate: percentage of total malaria microscopy positive test out of all malaria microscopy test conducted. Malaria Test positivity rate: percentage of total malaria RDT positive test out of all malaria RDT test done. Testing Rate: Proportion of suspected malaria cases that received a parasitological test at a facility (RDT and microscopy). IPTp1 5 coverage: Percentage of pregnant mothers who received appropriate dose of SP 12 P age

13 REFERENCES GHS. District Health Information Management System II. Ghana Health Service, Ghana, Half Year,2016. GHS.NMCP - PSM Malaria Drugs and commodities stock level, Ghana, Half Year, P age