ACT implementation in a humanitarian emergency: an overview and a case study from the fiel

In the context of a major humanitarian emergency, malaria constitutes a major public health issue, contributing to significant morbidity and mortality. The complex nature of an emergency means that many issues – such as population displacement, the breakdown of health services, lack of housing, clean water and sanitation – are liable to cause high levels of malaria, or to trigger an outright epidemic. This is particularly the case in Sub-Saharan Africa, where limited resources are available to deal with the problem, even in non-emergency settings. At the same time, it has become increasingly clear that older drug regimens are failing to treat malaria effectively. In response, there has been a gradual shift in favour of more effective protocols. This means that, in many emergencies, health workers responding to malaria are having to work in an environment of evolving treatment policy.

Artemisinin-based Combination Therapy (or ACT) is now the first-line malaria treatment recommended by the WHO. This combination involves the use of an artemisinin – a ‘new’ malaria drug that is in fact a chemical extract of the artemesia plant that has been used in Chinese traditional medicine for at least 2,000 years – plus a companion drug such as amodiaquine, sulphadoxine-pyremethamine or lumefantrine (CoArtem). It allows for short and fast-acting treatment, as well as delaying the development of the parasite resistance that has rendered the previous first-line drug, choloquine, ineffective in most parts of the world for the treatment of falciparum malaria. ACT is an integral, but not exclusive, part of a strategy to control malaria. Other components, such as prevention (for instance through the use of bed nets) and vector control (such as indoor residual spraying of an insecticide) also have a place, especially in emergencies. However, the focus of this article is on how ACT can be successfully implemented in a humanitarian emergency.

General points

In order to implement ACT at field level, it is important to deal with several hurdles that may impede progress. These can be present at several levels, and so often require a coordinated and collaborative approach.

At the international level, the international community must recognise the importance of malaria in emergencies. Resources need to be made available and allocated for ACT implementation. This means identifying the relevant drug to use, and procuring sufficient quantities of it within a suitable timeframe. At national level, protocols may not include ACT-based drugs, so getting permission to use these may therefore require advocacy and lobbying. There may also be administrative and bureaucratic hurdles to cross in importing a drug. Logistical capacity is also needed to import and distribute the drug. Finally, at the local level conflict and displacement may make access to health care and the running of health services difficult, while broader public health issues like widespread malnutrition may require alterations in the approach to implementing ACT. Local partners, such as local health authorities and health workers, may be unfamiliar with recent protocol changes at national level, and there may be technical issues around implementation, such as insufficient human resources, inaccurate diagnosis and prescription, and the need to improve adherence to treatment and data collection for monitoring the use of the new treatment.

These problems will need to be addressed concurrently, and in collaboration with national and local authorities, international agencies and NGOs. A step-by-step approach may frequently be too slow to ensure successful implementation in an emergency. This implies that individual NGOs may need to work together, or with UN agencies. Some of these problems may be beyond the capability or mandate of individual actors or NGOs to resolve, and may require a broader political solution.

Technical implementation in the field

The approach to technical implementation in the field will depend on the specific constraints each context presents. Every emergency will be different, in terms of the capacity of health facilities, the human resources that are available, communication and transport links, security and the ability of the population to access health care. Nonetheless, several general points can be made.

First, a clear and sensible diagnosis and treatment protocol is needed. This should ideally follow the national protocol, but may be adapted after agreement with the ministry of health. The priority is to ensure that an efficacious and effective ACT is used as the first-line drug. Where resistance patterns are unknown, or where the national protocol is not yet an ACT, Artemether-Lumefantrine (e.g. CoArtem) is recommended.

Second, the protocol should use sensible case definitions; these can be as simple as considering as eligible cases all patients with a fever in the last 48 hours. This diagnosis should be confirmed through the use of rapid diagnostic tests (RDTs) or microscopy as clinical diagnosis alone can be unreliable and can result in poor estimates of the true disease burden, and inappropriate and ineffective treatment of patients. RDTs are easy to use and, unlike microscopy, can be employed in the most basic health structure. Hence, a combination of having a working case definition backed up by an RDT can prove useful in providing a more sensitive and specific diagnosis, as well increasing the confidence of health workers in the field.

Third, training is essential when introducing the new ACT (and diagnostic test) in the field, to ensure that health workers are confident in using the new tools they are given. Often, there is a temptation is to treat all cases of fever as malaria, and so a list of and refresher on differential diagnosis can also help the health worker to be more discerning.

Data collection is useful primarily for disease surveillance, but can also be used to monitor and evaluate ACT implementation. Furthermore, it will allow for accurate estimates of future needs of drugs and other items. An easy and standardised format, which also covers other key morbidities, should be put in place as early as possible. These often exist at ministry of health level. At health post level, individual health workers often collect very good information; the challenge is to standardise and collect these forms on a regular basis. Many health posts in rural and isolated areas may not be able to send or receive information on a regular basis.

Attention also needs to be given to ensuring that patients adhere to treatment through health education, the training of health staff and the use of blister packets of ACT. Young mothers of infants should be targeted as a priority. Children under five are especially vulnerable to malaria, and it can also be difficult to administer oral medication to this group. While it is difficult to invest time in these areas in a busy health post, ignoring them will not improve adherence, and may significantly reduce the effectiveness and hence the impact of the ACT. It is not sufficient simply to distribute tablets to centres and hope for the best. This is especially the case if the health worker is using new or unfamiliar treatments and protocols.

Even if many national protocols have changed to an ACT, this change has often not filtered down to the rural health post. A clear strategy needs to be pursued; relevant actors need to be involved to ensure good coverage; a sufficient and regular supply of drugs and diagnostic tools should be established; training needs to be undertaken; and a workable monitoring system should be put in place. These steps should all be part of a broader malaria surveillance and control strategy. NGOs can often play a key role in addressing these issues in the emergency context.

Lira, Uganda: a case study from Médecins Sans Frontières

Since 1986, the rebel group the Lord’s Resistance Army (LRA) has been mounting attacks on government and civilian targets in Uganda. The attacks, often initiated from bases in southern Sudan, have led to significant death and displacement in the districts of Gulu, Kitgum, Lira, Pader and Apac. Violent incidents and attacks intensified in northern and central Uganda in 2003. In Lira district alone, an estimated 400,000 people were internally displaced by January 2004. An initial survey done by MSF showed that mortality rates in Lira were exceeding emergency thresholds, with around half of these deaths due to violence.

By the end of 2003, MSF had set up an emergency intervention programme based in Lira, with outreach in surrounding camps. The primary focus of the programme was nutrition and basic health care. From the initial assessment, it was clear that malaria was a significant cause of morbidity in the area. At this time, chloroquine (CQ) and sulphadoxine-pyremethamine (SP) were the first line drugs in the national malaria protocol. Given the nature of the emergency and known levels of resistance to CQ and SP, MSF decided to use an ACT. After discussion with national and local authorities, a combination of artesunate (AS) and amodiaquine (AQ) was selected. These drugs were easy to procure, and large quantities could be imported at relatively short notice.

A methodical approach to implementation was followed. A protocol was devised using a rapid diagnostic test (Paracheck) to confirm diagnosis. Training and implementation started first in the Lira therapeutic feeding centre (TFC) and hospital, and then in peripheral clinics. A monitoring system was put in place over the first few weeks of the programme.

Data from the first six months of the programme (Figure 1) revealed that malaria proved to be a far higher cause of morbidity than expected. In the first 33 weeks of the programme, 18,000 cases were treated, of which 80% were in the under-five age group. This was unsurprising, as MSF had chosen as its target population children and pregnant women. Malaria accounted for over 40% of all consultations at the health post level, and 50% of all RDTs done were positive for malaria. Documented cases of malaria increased as the provision of health care expanded to IDP camps around Lira.

Probable adherence to treatment was surveyed, and estimated to be around 78%, showing that further training and education were required. Retreatment of malaria cases remained low at 1%, possibly implying that initial diagnosis and treatment of fever cases were effective.

It soon became clear in Lira that malaria was a significant contributor to the development of malnutrition. Therefore, a greater emphasis was placed on detecting cases of malaria in the health posts, and particularly in the nutrition centres. This included a medical consultation and testing for malaria in all children with moderate malnutrition – in effect ‘medicalising’ the supplementary feeding programmes. Furthermore, the value of using effective diagnosis and treatment (RDTs and ACT) algorithms was made clear through training, which helped to improve staff knowledge and quality of care. It was also shown to be feasible in the context and scale of the humanitarian emergency in Lira.

Conclusions

Malaria is a very important cause of disease and death in humanitarian emergencies, and surveillance and control of malaria and other diseases form a key part of any humanitarian intervention. The use of effective diagnostic and therapeutic tools is essential. ACT is the recommended treatment for malaria, particularly in emergencies. Implementation of ACT should be undertaken in the most responsible and methodical fashion possible, and should be a priority health intervention in malaria-endemic and epidemic-prone areas.

Dr. Manica Balasegaramworks for Médecins Sans Frontières, based in London. He has worked in the field in Sudan, Uganda, Ethiopia and Congo Brazzaville, and has helped to implement ACT in various MSF programmes in Sub-Saharan Africa.

References and further reading

J. P. Guthman et al., ‘Validity and Ease of Use in the Field of Five Rapid Tests for the Diagnosis of Plasmodium falciparum Malaria in Uganda’, Trans. R. Soc. Trop. Med. Hyg., 96, 2002, pp. 254–57.

International Artemisinin Study Group, ‘Artesunate Combinations for the Treatment of Malaria’, The Lancet 363, 2004, pp. 9–17.

J. A. Najera, R. L. Kouznetsov and C. Delacollette, ‘Malaria Epidemics Detection and Control Forecasting and Prevention’, WHO/MAL/98.1084.

WHO AFRO, Malaria Country Profiles, WHO, Zimbabwe, 2003.

WHO/UNICEF, The Malaria Africa Report (Geneva: WHO/UNICEF, 2003).

WHO, WHO Expert Committee Report on Malaria 20th Report (Geneva: WHO, 2004).

A. Attaran et al., ‘WHO, the Global Fund, and Medical Malpractice in Malaria Treatment’, Lancet, 2004, 363; 9404: 237–240.