The ACT Malaria Treatment Policy Change in Kenya

Objectives of the national Antimalarial treatment policy: •Enable population at risk access safe, good quality, effective, affordable & acceptable antimalarial drugs •Ensure rapid and long lasting clinical cure •Prevent progression to severe disease •Reduce the incidence of anaemia •Reduce consequences of placental malaria infection •Delay development of resistance to antimalarial drugs Key specific issues: •Limited data available on safety of ACTs in young infants (use of coartem <5kgs) •Lack of adequate safety and efficacy data on drug combinations in pregnant women (safety of lumefantrine in pregnancy) •Improving systems of forecasting of drug needs •Strengthening the management and drug supply system (procurement, distribution and use) according to the specificities of the new drugs (shorter shelf life and the course-of-therapy packs) •Complex treatment schedules poses challenge for ensuring compliance •Need for more friendly paediatric formulation

Up-scaling orange-fleshed sweetpotato (Ipomoea batatas (L) Lam) technologies in western Kenya.

Vitamin A deficiency is a major nutritional problem in Kenya, leading to night blindness and high mortality rate in infants. Consumption of orange-fleshed sweetpotato (OFSP) that is high in -carotene (pro-vitamin A), can reduce the risk of the deficiency. The utilization of the OFSP in Kenya despite its nutritional advantage is limited. Efforts by the Government extension service to promote the crop has had limited impact. The Kenya Agricultural Research Institute in collaboration with the International Potato Centre and farmers developed a number of OFSP technologies that can enhance its utilization. The ASARECA/AfDB-supported project “Dissemination of New Agricultural Technologies in Africa” (DONATA) for Orange-fleshed sweetpotato (OFSP) was initiated in Bungoma and Busia counties of Western Kenya in 2008. The project used the Innovation Platforms for Technology Adoption (IPTAs) approach in up-scale the proven OFSP technologies. IPTA acts as the institutional mechanism bringing together different stakeholders for scaling out and scaling-up of OFSP technologies along the value chain. Within three years 29 technologies on seed systems, agronomic practises, postharvest processing and marketing were promoted to 7500 beneficiaries. This was achieved through training of 215 extension agents and 1250 farmers on different aspects of OFSP. Thirteen information products were made available to the users through 15 different uptake pathways. Area under OFSP root production increased by over 600% while productivity per unit area increased from 8 to 16 tons/ha in the project countie

The challenges of changing national malaria drug policy to artemisinin-based combinations in Kenya

Backgound: Sulphadoxine/sulphalene-pyrimethamine (SP) was adopted in Kenya as first line therapeutic for uncomplicated malaria in 1998. By the second half of 2003, there was convincing evidence that SP was failing and had to be replaced. Despite several descriptive investigations of policy change and implementation when countries moved from chloroquine to SP, the different constraints of moving to artemisinin-based combination therapy (ACT) in Africa are less well documented. Methods: A narrative description of the process of anti-malarial drug policy change, financing and implementation in Kenya is assembled from discussions with stakeholders, reports, newspaper articles, minutes of meetings and email correspondence between actors in the policy change process. The narrative has been structured to capture the timing of events, the difficulties and hurdles faced and the resolutions reached to the final implementation of a new treatment policy. Results: Following a recognition that SP was failing there was a rapid technical appraisal of available data and replacement options resulting in a decision to adopt artemether-lumefantrine (AL) as the recommended first-line therapy in Kenya, announced in April 2004. Funding requirements were approved by the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and over 60 million US$ were agreed in principle in July 2004 to procure AL and implement the policy change. AL arrived in Kenya in May 2006, distribution to health facilities began in July 2006 coincidental with cascade in-service training in the revised national guidelines. Both training and drug distribution were almost complete by the end of 2006. The article examines why it took over 32 months from announcing a drug policy change to completing early implementation. Reasons included: lack of clarity on sustainable financing of an expensive therapeutic for a common disease, a delay in release of funding, a lack of comparative efficacy data between AL and amodiaquine-based alternatives, a poor dialogue with pharmaceutical companies with a national interest in antimalarial drug supply versus the single sourcing of AL and complex drug ordering, tendering and procurement procedures. Conclusion: Decisions to abandon failing monotherapy in favour of ACT for the treatment of malaria can be achieved relatively quickly. Future policy changes in Africa should be carefully prepared for a myriad of financial, political and legislative issues that might limit the rapid translation of drug policy change into action

Costs and cost-effectiveness of delivering intermittent preventive treatment through schools in western Kenya

BACKGROUND: Awareness of the potential impact of malaria among school-age children has stimulated investigation into malaria interventions that can be delivered through schools. However, little evidence is available on the costs and cost-effectiveness of intervention options. This paper evaluates the costs and cost-effectiveness of intermittent preventive treatment (IPT) as delivered by teachers in schools in western Kenya. METHODS: Information on actual drug and non-drug associated costs were collected from expenditure and salary records, government budgets and interviews with key district and national officials. Effectiveness data were derived from a cluster-randomised-controlled trial of IPT where a single dose of sulphadoxine-pyrimethamine and three daily doses of amodiaquine were provided three times in year (once termly). Both financial and economic costs were estimated from a provider perspective, and effectiveness was estimated in terms of anaemia cases averted. A sensitivity analysis was conducted to assess the impact of key assumptions on estimated cost-effectiveness. RESULTS: The delivery of IPT by teachers was estimated to cost US$1.88 per child treated per year, with drug and teacher training costs constituting the largest cost components. Set-up costs accounted for 13.2$ 0.25 per child) whilst recurrent costs accounted for 86.8% (US$1.63 per child per year). The estimated cost per anaemia case averted was US$ 29.84 and the cost per case of Plasmodium falciparum parasitaemia averted was US$5.36, respectively. The cost per case of anaemia averted ranged between US$ 24.60 and 40.32 when the prices of antimalarial drugs and delivery costs were varied. Cost-effectiveness was most influenced by effectiveness of IPT and the background prevalence of anaemia. In settings where 30% and 50% of schoolchildren were anaemic, cost-effectiveness ratios were US$ 12.53 and 7.52, respectively. CONCLUSION: This study provides the first evidence that IPT administered by teachers is a cost-effective school-based malaria intervention and merits investigation in other settings

Evaluating Different Dimensions of Programme Effectiveness for Private Medicine Retailer Malaria Control Interventions in Kenya

BACKGROUND: Private medicine retailers (PMRs) are key partners in the home management of fevers in many settings. Current evidence on effectiveness for PMR interventions at scale is limited. This study presents evaluation findings of two different programs implemented at moderate scale targeting PMRs for malaria control in the Kisii and Kwale districts of Kenya. Key components of this evaluation were measurement of program performance, including coverage, PMR knowledge, practices, and utilization based on spatial analysis. METHODOLOGY/PRINCIPAL FINDINGS: The study utilized mixed quantitative methods including retail audits and surrogate client surveys based on post-intervention cross-sectional surveys in intervention and control areas and mapping of intervention outlets. There was a large and significant impact on PMR knowledge and practices of the program in Kisii, with 60.5% of trained PMRs selling amodiaquine medicines in adequate doses compared to 2.8% of untrained ones (OR; 53.5: 95% CI 6.7, 428.3), a program coverage of 69.7% targeted outlets, and a potential utilization of about 30,000 children under five. The evaluation in Kwale also indicates a significant impact with 18.8% and 2.3% intervention and control PMRs selling amodiaquine with correct advice, respectively (OR; 9.4: 95% CI 1.1, 83.7), a program coverage of 25.3% targeted outlets, and a potential utilization of about 48,000 children under five. A provisional benchmark of 7.5 km was a reasonable threshold distance for households to access PMR services. CONCLUSIONS/SIGNIFICANCE: This evaluation show that PMR interventions operationalized in the district level settings are likely to impact PMR knowledge and practices and lead to increased coverage of appropriate treatment to target populations. There is value of evaluating different dimensions of public health programs, including quality, spatial access, and implementation practice. This approach strengthens the potential contribution of pragmatic study designs to evaluating public health programs in the real world

Patient adherence to prescribed artemisinin-based combination therapy in Garissa County, Kenya, after three years of health care in a conflict setting.

BACKGROUND: Current day malaria cases and deaths are indicative of a lack of access to both methods of prevention, diagnosis, and treatment; an important determinant of treatment efficacy is adherence. This study is a follow up to the baseline study of adherence to artemether-lumefantrine (AL) carried out in Garissa District in 2010. The study presented evaluates any changes in adherence levels which may have occurred in the area during this period and after nearly three years of sustained use of ACT across the public health sector. METHODS: The study was carried out in Garissa County in the North Eastern Province of Kenya and included patients fitting the suspected malaria case definition and having been prescribed AL, regardless of confirmatory diagnosis. A questionnaire assessed the intake of AL via both self-reporting by the participant and observation of blister packs by the interviewer. On separate occasions exit interviews with patients and observations of prescribers were also carried out. RESULTS: Of the 218 participants enrolled, 195 were successfully followed up. 60% of participants were found to be adherent to the three-day AL regimen, this is 4.7% lower than the proportion of participants adherent in 2010; the result of a two-sided z-test was not significant (p = 0.23). The odds of the patient being adherent to AL increased by 65% with each additional correct statement regarding how to take AL that a patient could recall (between zero and four statements), this was the only variable significantly associated with patient adherence (p = 0.01). CONCLUSION: Sustaining the ACT adherence rates at the 2010 levels, through 2.5 years of insecurity in the study area is an achievement and suggests that if security can be improved barriers to improving health service quality and patient adherence to AL would be removed. This study, by looking specifically at anti-malarial adherence over a prolonged period and in a setting of severe conflict, provides a valuable and rare insight in to the challenges and barriers to ACT adherence in such settings

Silica vesicles increase stability of Salmonella-specific phages isolated from chicken in environments mimicking the gastrointestinal tract

Non-typhoidal Salmonella (NTS) enterica serovar Enteritidis is one of the major causes of foodborne infections worldwide. This NTS serovar is mainly transmitted to humans through poultry products. Bacteriophages (phages) are a promising alternative to antibiotics to reduce NTS incidences in poultry farms. The ability to survive the harsh environment encountered in the chicken gastrointestinal tract (GIT), such as low pH, high temperature and enzymatic digestion, can be valuable in selecting phages with high therapeutic potential. In this study, we characterized 13 newly isolated Kenyan S. Enteritidis-specific phages for their ability to survive in pH-adjusted media, different temperatures, and simulated gastric and intestinal fluids (SGF and SIF, respectively). Furthermore, we evaluated the possibility of using silica vesicles (SV) to increase the stability of these phages in these environments. All phages were relatively stable from pH 4 to 12 and from 25℃ to 42℃ following 12 hours of incubation. At pH 3, phages lost up to 3 logs in viral titres after three hours of incubation. They remained more stable at pH 9, with phage titres 2 logs higher than at pH 3. In SGF, they were stable for 20 minutes; afterwards, they started losing their viability up to 5 logs, while they were relatively stable in SIF for up to two hours. Moreover, significant differences were observed among the different phages in surviving these environments. Encapsulating phages with SV demonstrated a slow but long rate of phage release upon adsorption for 96 hours. Preliminary data indicate that SV 140 C18 can protect phages longer than other silica vesicles tested. In contrast, free phages in SGF had an average reduction of 7 logs PFU/ml after 60 minutes of incubation. These data suggest that a number of these phages can potentially survive through the chicken GIT and that SV can be an ideal technology to prolong the stability of phages in acidic environments

Possible Interruption of Malaria Transmission, Highland Kenya, 2007–2008

Annual insecticide spraying and artemisinin combination therapy may stop transmission