Issue 8: January December National Malaria Control Programme (NMCP) Box KB 493 Korle - Bu Accra Ghana Contents Page Editorial and Report Highlights 1 Malaria Burden 2 Key Activities Undertaken in 2 Malaria Statistics 7 Indicator Definition 15 References 15 Editorial This is the 8th 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 DHIMS data, representing malaria burden, case management and coverage of malaria interventions for. 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 GHS: Regional and District Directors of Health Services Policy Planning Monitoring and Evaluation Division (PPMED) 1 P a g e
Regional Malaria Focal Persons Partners (WHO, Global Fund, USAID/PMI, DFID, CDC, Noguchi etc.) Malaria Burden In, the country recorded 10.4 million suspected malaria cases at the OPD. This represented a 2.5% increase of cases reported during the same period in 2015. Averagely, 28,606 suspected malaria cases were recorded daily in the country s health facilities. There was a reduction in the number of admission and deaths attributed to malaria from 409,947 to 379,986 and 2,137 to 1264 in 2015 and respectively. This represents a percentage decrease of 7.3% and 40.9% in admissions and deaths respectively. Out of these malaria attributable deaths, 590 occurred among children under 5 years in as compared to 1,037 in 2015. Malaria under five Case Fatality Rate (CFR) also decreased from 0.51 in 2015 to 0.32 in. There is a steady significant reduction in deaths attributable to malaria in the country especially among children under 5 years. Key Activities Undertaken In In, 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 2020. Case Management Case management training, Clinical Outreach Training and Supportive Supervision (OTSS) were conducted in five Regions (Brong Ahafo, Greater Accra, East, West, Volta and 2 P a g e
Western Regions) with a total of 12,159 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 Regions in collaboration with Systems for Health, a USAID/PMI supported project. Malaria in Pregnancy The Malaria in Pregnancy (MIP) working group held three meetings in and carried out two monitoring and supportive supervisory and one advocacy visits to 472 facilities implementing IPTp but do not report 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. At the end of, 1,286,638 home visits have been conducted across the country through CHPs. Measures were taken to ensure availability of SP which was out of stock in the first quarter of. NMCP also participated in the Roll Back Malaria RBM MIP working group meeting in Nairobi, Kenya, developed MIP job aids for Health facilities and conducted a research on impact assessment of IPTp in Kintampo (On-going). Malaria Diagnostics In, the Programme finalised the National Guidelines for Laboratory Diagnosis (NGLD) on Malaria. NMCP and its partners also developed a Malaria Diagnostic Quality Assurance (MDQA) manual for RDTs and Microscopy within the period under review. The programme trained five (5) Microscopist for WHO accreditation for competence. The Programme trained 410 laboratory scientists from public, private and quasi health facilities on malaria diagnostics. The programme also trained 1,797 pharmacy auxiliary staff and over the 3 P a g e
counter medicine sellers (OTCMS) on malaria diagnostic in. The programme participated in the development of a global standards of practice for malaria RDTs in Johannesburg, South Africa. Integrated Vector Control Under vector control, NMCP continued the distribution of LLINs in the country using multiple channels. Point mass distribution of LLIN was conducted in Greater Accra, Northern, East, West and Eastern Regions ; Pakro (Durability study). A total number of 4,888,772 out of 5,054,846 LLINs allocated were distributed in the five (5) Regions. This represented 96.7% of the LLINs distributed. A total number of 688,660 LLINs were also distributed through Continuous Distribution (CD) at health facilities for pregnant women and children under five years. A total of 936,357 LLINs out of a target of 1,014,300 were distributed through the school-based distribution channel during the year. The second phase of insecticide resistance monitoring was carried out in 5 Regions in the southern sector. Advocacy, Communication and Social Mobilization (ACSM) The Programme believes that communication plays a vital role in changing or improving knowledge, creating positive attitudes and improving practice of desired health behaviors. In, the Programme aired 7,439 and 196 radio & TV adverts respectively on test, treat and track; compliance, use and improve provider confidence in RDT, SP uptake and LLIN use in English and seven (7) local languages ; Akan, Dagbaani,Dagaare, Ewe, Ga, Gureni and Hausa. These adverts were transmitted and broadcasted in 39 and 7 radio and TV stations across the 10 Regions. Additionally, 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. On April 25 th, people across the country took part in different activities to mark the World Malaria 4 P a g e
Day. The theme for World Malaria Day was Invest in Malaria: End Malaria for Good. This placed emphasis on the need for continued investment in malaria. Research, Surveillance, Monitoring and Evaluation The Surveillance, Monitoring and Evaluation Technical Working Group (SM&E TWG) held two meetings in to discuss pertinent issues on data quality in the country. Monthly DHIMS data verification and validation of routine data reported through DHIMS was carried out in all the 10 Regions. A total number of 1,308 out of 6,768 facilities were visited in. The NMCP in collaboration with Policy Planning Monitoring and Evaluation Department (PPMED) conducted two rounds of data quality audit in selected health facilities nationwide. The purpose of the Data Quality Audit (DQA) was to verify and assess the quality of the data recorded in source documents and reporting system, in relation to the Standard Operating Procedures (SOPs) of the Health Information Management System (HMIS) used in Ghana. NMCP in collaboration with the Noguchi Memorial Institute for Medical Research (NMIMR) monitored the malaria parasite prevalence of thirty sentinel sites across the country. The RSM&E carried out a number of research during the year under review. Some of the research includes ATM Mortality Trend Analysis, Impact evaluation of BCC interventions, Desk review: Low IPTp uptake, End User Verification of LLINs, Rapid Impact Assessment (this was carried out in 2015 but analysis and report writing was completed in ). Procurement Supply Chain Management (PSM) In, the Programme revised the respective proportions of ASAQ to AL for both adults and children and subsequently revised the shipment plan for. This was backed by the Monthly Stock Report which disclosed that generally, there was a decreasing demand for ACTs. However, 5 P a g e
there was a growing preference for Artemether Lumefantrine (AL) to Artesunate Amodiaquine (ASAQ) as a drug of choice for the treatment of uncomplicated malaria. A quantification exercise was also done in September to project the commodity needs for the years 2017 to 2020 and revised the supply plan for 2017 and 2018. The Programme also retrieved and redistributed left-over school distribution LLINs from one district to another. Table 1: Malaria Drugs and commodities stock level, Ghana, DESCRIPTION QTY ORDERED QTY RECVD VARIANCE ASAQ 25/67.5 mg 547,914 111,600 436,314 ASAQ 50/135 mg 1,018,075 0 1,018,075 ASAQ 100/270 3 S 442,100 151,200 290,900 ASAQ 100/270 mg 6 S 1,308,950 1,308,950 0 AL 6 s 781,560 199,800 581,760 AL 12 s 436,320 0 436,320 AL 18 s 145,438 0 145,438 AL 24 s - - - 600,000 600,000 0 Injection Artesunate 60 mg 680,810 248,014 432,796 524,430 524,430 0 SP 3,000,000 500,000 2,500,000 9,000,000 9,000,000 0 7,929,306 7,929,306 0 RDT 3,093,450* 3,093,450 0 6,199,925 6,199,925 0 1,159,450 1,159,450 0 LLIN 1,824,209 1,824,209 0 2,689,100 2,689,100 0 RECT. ART 50 MG 3,612 3,612 0 SPAQ 75+250/12.5 mg 1+3 489,933 0 489,933 SPAQ 150+500/25mg 1+3 TAB QUININE SULFATE 300MG Source: NMCP PSM, February, 2017 114,400 114,400 0 744,667 0 744,667 558,280 558.28 0 1,900,000 1,900,000 0 6 P a g e
Resource Mobilization/Private Sector Partnership (RM) The Resource Mobilization Working Group in collaboration with the Malaria Ambassador worked together to identify trustees and set up a private sector-led Malaria Foundation to spearhead resource mobilization among corporate Ghana. The identified trustees were on the 25 th February inaugurated into office by the Deputy Director General; Dr. Gloria Quansah of the Ghana Health Service. The Malaria Foundation could not be launched during the World Malaria Day as planned, due to a delay in registering the Foundation. Finance and Administration As at the end of, the programme had absorbed 91% 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 Reporting Rates Generally, reporting rates on the DHIMS2 platform has improved. Reporting on the monthly OPD morbidity form recorded an increase in data completeness from 88.6% in 2015 to 99.0% in, whilst the Monthly Anti-malaria reporting form also increased from 86.2% in 2015 to 98.2% in. Table 4: Number and Proportion of Malaria OPD Cases, Admissions and Deaths in Ghana, Indicator Number Reported Proportion Of Cases Attributable To Malaria 7 P a g e
OUT PATIENT DEPARTMENT (OPD) ADMISSION DEATHS Total OPD Cases 27,011,587 Suspected Malaria Cases 10,441,515 38.7 Tested Malaria Cases 8,075,174 77.3 Confirmed Malaria Cases 4,533,431 43.4 Pregnant Women 382,862 1.42 Total Admissions (All ages) 1,532,839 Malaria admissions (All ages) 379,986 24.8 Under 5 malaria admissions 182,438 46.7 Total deaths (All ages) 30,332 Total malaria deaths (All ages) 1,264 4.2 Under 5 malaria deaths 590 46.7 Under 5 Malaria Case Fatality Rate (CFR) 0.32 MALARIA MORBIDITY AND MORTALITY The country recorded a reduction in under-five malaria deaths from 1,037 in 2015 to 590 in, representing a case fatality rate of 0.51 and 0.32 in 2015 and respectively. In, East Region recorded the highest case fatality rate of 0.51%, even though it recorded a 48.6% point reduction in malaria deaths from 70 malaria deaths in 2015 to 36 in. Northern Region also recorded a case fatality rate of 0.49%, this is the second highest in the country. On the other hand, Ashanti Region recorded the lowest case fatality rate of 0.13% with 51 malaria deaths out of 37,787 admissions. (Figure 1). Figure 1: Malaria Case Fatality Rate for children under 5 years, by Region, 2015-8 P a g e
Case Fatality Rate 0.90 0.80 0.70 0.60 0.50 0.40 0.30 0.51 0.20 0.10 0.32 0.00 Ashanti Brong Ahafo Central Eastern Greater Accra Northern East West Volta Western Ghana < 5 Malaria 2015 0.18 0.45 0.54 0.26 0.49 0.81 0.72 0.57 0.58 0.45 0.51 < 5 Malaria 0.13 0.26 0.36 0.23 0.29 0.49 0.51 0.35 0.39 0.32 0.32 The country recorded a decrease in malaria deaths amongst persons above five years from 1,100 in 2015 to 674 in and a case fatality rate of 0.54 and 0.34 in 2015 and respectively, representing a 38.7% decrease. In, East and Central Regions recorded the highest above five malaria case fatality rates of 0.80% and 0.58 respectively. Comparatively, there has been an improvement in case management in East and Central Regions in to the same period in 2015. Eastern Region recorded the lowest malaria above five case fatality rate of 0.17 with 33 malaria deaths out of 19,009 malaria admissions. (Figure 2). Figure 2: Malaria Case Fatality Rate for persons above five years by Region, 9 P a g e
Case Fatality Rate 1.20 1.00 0.80 0.60 0.54 0.40 0.20 0.34 0.00 Ashanti Brong Ahafo Central Eastern Greater Accra Northern East West Volta Western Ghana > 5 Malaria 2015 0.35 0.52 0.89 0.21 0.65 0.66 0.84 1.03 0.67 0.31 0.54 > 5 Malaria 0.19 0.31 0.58 0.17 0.25 0.45 0.80 0.53 0.48 0.21 0.34 Table 2: Malaria Slide and Test Positivity Rates, All 30 Sentinel Sites, 2015 & Type of Test (All Ages) Number Period Slide/Test Positivity Rate 2015 2015 Microscopy Tested 106,619 124,234 Positive 33,033 32,855 31.0 26.4 RDT Tested 174,499 229,742 Positive 57,611 78,742 33.0 34.3 The malaria slide positivity rate (percentage of positive malaria cases using microscopy), reduced from 31.0% in 2015 to 26.4% in. Test positivity rate using RDTs also increased from 33.0% in 2015 to 34.3% in. 10 P a g e
OPD Malaria cases For the period under review, the number of suspected malaria cases put on ACTs reduced from 5,845,998 in 2015 to 5,752,931 in. This could be attributed to the improvement in adherence to the T3 policy. (Table 2) Figure 3: Number of Malaria Suspected Cases, Malaria Cases Tested, Malaria Cases Test Positive and Cases Put On ACTs in Ghana, 2015 & 12,000,000 10,000,000 8,000,000 6,000,000 4,000,000 2,000,000 0 Uncomplicat ed Malaria suspected 2015 Uncomplicat ed Malaria suspected Uncomplicat ed Malaria Suspected Tested 2015 Uncomplicat ed Malaria Suspected Tested Uncomplicat ed Malaria Tested Positive 2015 Uncomplicat ed Malaria Tested Positive OPD Attendants Treated with ACTs 2015 OPD Attendants Treated with ACTs Ghana 10,186,510 10,441,515 7,502,166 8,075,174 4,319,919 4,533,431 5,845,998 5,752,931 The country recorded an increase in malaria testing rate from 73.6% in 2015 to 77.3% in. Eight Regions; Ashanti, Brong Ahafo, Central, Eastern, Greater Accra, Northern and Volta and Western Regions recorded an increase in testing rate within the period under review. (Figure 3), whilst the other two Regions; East and West recorded a decrease. Figure 4: Testing Rate of all Health Facilities by Region, 2015 & 11 P a g e
Testing Rate 100.0 Testing Rate 2015 Testing Rate 90.0 80.0 77.3 70.0 60.0 50.0 40.0 30.0 73.6 20.0 10.0 0.0 Ashanti Brong Ahafo Central Eastern Greater Accra Northern Region East West Volta Western Ghana INTERMITTENT PREVENTIVE TREATMENT IN PREGNANCY (IPTp) There was there was a stock-out of Sulfadoxine Pyrimethamine (SP) for IPTp throughout the country in the first half of. This affected the uptake of IPTp during the period under review. This shortage was however resolved by the beginning of the second half of. The proportion of IPTp 1 decreased from 69.0% in 2015 to 64.1% in ; there was a decrease in IPTp 2 and IPTp 3 in. Despite the decrease of IPTp 1 to IPTp 3, IPTp 4 and 5 uptake increased from 15.7% (2015) to 16.7% () and 5.8% (2015) to 6.7% in. (Figure 5). 12 P a g e
Proportion Proportion Figure 5: Proportion of Pregnant Women Taking IPT 1-5, Ghana, 2015-80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 % IPT 1 2015 % IPT 1 % IPT 2 2015 % IPT 2 % IPT 3 2015 % IPT 3 % IPT 4 2015 % IPT 4 % IPT 5 2015 Ghana 69.0 64.1 58.0 51.6 41.3 36.7 15.7 16.7 5.8 6.7 % IPT 5 LONG LASTING INSECTICIDAL NETS (LLINs) In the year under review, the distribution of LLINs through the continuous distribution model in health facilities continued. LLIN coverage for pregnant women increased from 32.8% in 2015 to 40.8% in. East Region had the highest coverage of LLIN given to pregnant women with 74.2%; Central Region recorded the lowest coverage with 19.8% (Figure 6). Figure 6: Proportion of ANC Registrants given LLIN by Region, 2015 & 80.0 70.0 60.0 50.0 40.0 30.0 32.8 40.8 20.0 10.0 0.0 Ashanti Brong Ahafo Central Eastern Greater Accra Northern East West Volta Western Ghana 2015 51.0 56.5 23.9 15.2 6.3 63.6 64.6 55.5 10.2 6.2 32.8 29.2 66.0 19.8 48.9 31.9 48.3 74.2 12.6 38.5 51.4 40.8 13 P a g e
Proportion LLIN coverage for children due for measles 2 distributed through CWC increased from 48.2% in 2015 to 53.2% in. In, Brong Ahafo Region had the highest coverage with 79.3%, followed by East Region with 77.7%. Central Region recorded the least coverage with 27.6% (Figure 7). Figure 7: Proportion of under five children given LLIN through CWC by Region, 2015 & 90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 Ashanti Brong Ahafo Central Eastern Greater Accra Northern East West Volta Western Ghana 2015 69.8 67.0 46.0 26.8 23.3 70.2 78.8 76.7 31.7 19.8 48.2 38.5 79.3 27.6 59.8 46.3 65.9 77.7 28.9 54.8 61.8 53.2 48.2 53.2 14 P a g e
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 REFERENCES GHS. District Health Information Management System II. Ghana Health Service, Ghana,. GHS.NMCP NMCP Surveillance data, Ghana,. GHS.NMCP - PSM Malaria drugs and commodities stock level, Ghana,. 15 P a g e