By: Christopher Wahlfeld
The Frist Global Health Leaders (FGHL) program affords young health professional students, residents, and fellows the opportunity to serve and train abroad in underserved communities for up to one semester. In doing so, they will bolster capacity in clinics in need of support as well as offer training to community health workers to promote sustainability upon their departure from these communities. As part of the program, they blog about their experiences here. For more information, visit our program page.
I have found myself thinking regularly about malaria, and malaria prevention, in recent weeks. This is not only due to my daily consumption of the antimalarial Malarone (atovaquone-proguanil), which I take without fail every day at 6 pm Kenya time. Nor is it a result of my recent training on the community case management of malaria. Rarely a day goes by that I am not reminded of malaria’s place in the fabric of health, and illth, in North Kamagambo.
An ancient disease, malaria is endemic to Kenya, with seasonal peaks tied to the rainy seasons. Malaria effects the entire community and is, by default, linked to Lwala’s Thrive Thru Five initiative and HAWI program, as pregnant women, children under 5 years of age, and individuals living with HIV are at considerably higher risk of becoming infected due to suppressed, or lowered, immune systems. In my previous blog post, I mentioned that there had been an uptick in the number of lab confirmed cases of malaria in children under-five soon after my arrival. Though these numbers have diminished since that time, malaria remains a common diagnosis.
Malaria is known to be caused by parasites from the genus Plasmodium, the most common and virulent of which, P. falciparum, accounts for the overwhelming majority (99%) of malaria cases in Kenya.* Plasmodium parasites are transmitted to humans by the female Anopheles mosquito, which actively feeds between dusk and dawn. Therefore, like many people living in Kenya, I sleep under a bed net in an attempt to reduce the chances of getting bitten.
The use of insecticide treated bed nets (ITNs) is one of the primary approaches to combating malaria in endemic regions of the world, along with indoor residual spraying (IRS). However, many homes in North Kamagambo have not been sprayed since 2012, and not everyone has a bed net. Lwala helps to fill this gap by providing a new bed net to all households enrolled in their Thrive Thru 5 program. Though the insecticide in ITNs is meant to last for approximately five years, the bed nets themselves can break down more quickly, acquiring holes long before the five-year mark.
Walking around North Kamagambo, it is not unusual to see bed nets with holes of various sizes being repurposed as fencing for small kitchen gardens. Though such alternative uses of bed nets are often spoken about in public health classes, it is eye-opening to see the practice in person. Community health care workers play an important role, verifying that their clients are using bed nets properly and checking to see that the nets are generally in good condition.
When used properly, bed nets work quite effectively, however, nets are only protective when a person, or persons, are safely underneath them. As the female Anopheles mosquito begins feeding around dusk, there is a period of several hours when individuals may remain exposed to potential mosquito bites. Anecdotes from community health workers suggest that it is this time period, between dusk and bed time, when young children are especially susceptible to malaria transmission. I suspect that the same would hold true for pregnant women, and individuals living with HIV.
Working to reduce the breeding sites used by Anopheles mosquitos is another approach to combating malaria. Anopheles mosquito lay their eggs in small pools of standing water. Such pools can be found scattered throughout North Kamagambo, occasionally in the form of borrow pits. These manmade pits are created when material is removed from the earth. Around North Kamagambo, the material being removed is clay which is shaped and dried for use as bricks. Left unattended, these shallow excavations leave an exposed pocket in the ground, which when filled with water after a rain, create an ideal spot for the female Anopheles mosquito to lay its eggs. Thankfully, there is a simple solution. And, though open borrow pits can be found throughout the region, it is not uncommon to see many pits filled with plant material. This effectively prevents water from pooling, thus impeding the mosquito from laying eggs at that particular location. Of course, this is only one location and other opportune locations exist where female Anopheles mosquitos may lay their eggs.
As part of Lwala’s malaria intervention, community health workers have become even more involved in the fight to prevent and manage malaria. Led by members of the county Ministry of Health, Lwala staff are working to empower community health workers to identify and respond to cases of uncomplicated malaria in North Kamagambo at the household level. To date, approximately twenty-nine community health workers have been trained on the community case management of malaria. This two-day training session educated CHWs to identify the signs and symptoms of malaria, and to perform a rapid diagnostic test (RDT) in the field when malaria is suspected. These CHWs were also trained to dispense antimalarial medications at the household level and/or refer to the patient to a health facility as necessary, based upon test results.
On July 6 th , Lwala launched the first community case management of malaria outreach in Minyenya, one of the ten areas within Lwala’s catchment. The outreach provided CHWs with an opportunity to practice administering a rapid diagnostic test for malaria to members of the community, under the supervision of Lwala’s head lab technician. Focusing on children under 5, a total of 62 individuals were screened, 34 of whom tested positive for malaria.
In the coming weeks, CHWs from 3 of the 10 areas in Lwala’s catchment area will begin administering rapid diagnostic tests at the household level when a suspected a case of malaria has been identified. This pilot will help to inform the eventual training and rollout of community case management of malaria to CHWs in all 10 areas served by Lwala. I look forward to hearing how the intervention has affected the number of inpatient cases of malaria in children under-five this time next year.
*2016. USAID. President’s Malaria Initiative: Kenya, Malaria Operation Plan FY 2016.