Malaria Implementation and Evaluation

Revised Intervention 

A current intervention in the Congo is to provide ITNs to it's people but less than 10% of resources are used on ITNs meaning the presence of ITNs is very little. Even the World Health Organization says that "In most high-burden countries, ITN coverage is still below agreed targets." I would like to have even more ITNs provided than is currently provided. Currently, over 50% of materials are used on insecticides and spray materials. I propose that half of the resources used on insecticides and spray materials be moved to buy and give out ITNs.

Implementation

Contact producers of Long Lasting ITNs and make a deal with them to buy ITNs in bulk for a very small price. After communicating our cause to the Congolese people, spread out all over the Congo and take with us as many ITNs as needed (from what we know of the population) and distribute them to as  many families as we can reach. We will also provide easy to understand pamphlets explaining how to properly use the ITNs (such as not sharing one between communities, etc.) and how to maintain them.

Barriers to implementation are getting the Congolese people to trust in our cause and follow our instructions on use and maintenance of the ITNs. Another barrier is in getting the government to lessen resources in one area of their intervention and move it to fund our intervention.

Communication

Contact various stakeholders and explain out intervention to them. We will also explain the purpose of our intervention and how effective we predict our intervention will be.

Use telephones, the television, radio broadcast stations and the internet to reach those we can and inform them of the intervention and of the places we will be giving out ITNs. For those we couldn't reach electronically, we will create easy to understand posters (made up of words and mostly pictures of illiterate people) to hang in various high risk communities.

Evaluation

Desired Outcomes

• A decrease in the number of Malaria cases.
• A decrease in the number of deaths caused by Malaria.
• Greater awareness of the effectiveness of ITNs in preventing Malaria.
• Congolese people approaching us for free ITNs.

Process Measures

• How many ITNs are bought.
• How many ITNs are distributed.
• What percentage of the population has ITNs.
• How many Congolese people know about the free ITNs and the purpose of our intervention.

Outcome Measure

• If the percentage of resources used for ITNs has increased and the percentage for insecticides and spray materials has decreased.
• Most if not all of the desired outcomes are fulfilled.

References

"WHO Global Malaria Programme: Position Statement on ITNs." World Health Organization. Web. 26 Apr. 2013. <http://www.who.int/malaria/publications/atoz/itnspospaperfinal.pdf>.

Malaria Interventions

Problem Definition
Increasing Malaria cases and deaths in the people of the Democratic Republic of the Congo between 2000 and 2011.

Current Interventions

• Intervention - Key Determinant it addresses
• Educating the public about Malaria - Many people are unaware of Malaria transmission and prevention.
• Insecticide Treated Nets (ITNs) - Anopheles mosquitoes only bite at night. Untreated bed nets are not very effective in keeping away mosquitoes at night. 
• Effectively diagnosing and treating patients with Malaria - Health personnel are usually not trained well enough to treat patients' Malaria symptoms. They also have to deal with huge amounts of patients suffering from other equally dangerous diseases.
• Insecticides and Spray Materials - Malaria can only be contracted from a female Anopheles mosquito.
• Indoor Residual Spraying (IRS) - When done feeding, mosquitoes usually rest on the nearest surface available to them.

My Interventions

Primary - Insecticide Treated Nets (ITNs). Humans are only able to contract Malaria at night but night time is also when people are asleep and their guard is down. Bed nets are only useful to a certain degree since mosquitoes can still get past them. With insecticide treated nets, even when the mosquito has gotten past the net, it will die from the insecticide it's had to get through.

Secondary - Indoor Residual Spraying (IRS). Exophilic Anopheles mosquitoes rest indoors after biting to digest their meal. If the indoor surfaces are sprayed they will eventually die before biting anyone else and spreading the malaria.

Tertiary - Educating the Public about Malaria. Since many do not know how malaria is transmitted and how to prevent it, they do nothing to protect themselves from contracting it. If more people understand these things, they can be better prepared to protects themselves before getting malaria. 

Best Intervention

Insecticide Treated Nets.

• Effectiveness - The CDC reported a 20% reduction in deaths of children from all causes (all causes - the mortality rate from a specified cause (Malaria) for a specific population (children under 5)). So ITNs are highly effective.
• Feasibility - As long as the government and the people understand the effectiveness of ITNs, they would not be against the use of them. Moderately feasible.
• Sustainability - Long lasting ITNs can last up to 3 years. Considering the large number of deaths it could prevent, I would consider it moderately sustainable.
• Cost - The ITNs would be a huge cost to the government since they would be given out to the people freely. However, the CDC stated that a recent study has found that an estimated $3.8 billion could be saved over 10 years if the lifespan of Long Lasting ITNs could go from 3 to 5 years. So I say the costs are moderate.
• Cost Effectiveness - There's a higher chance of not getting Malaria if a person uses and ITN rather than not. High cost effectiveness.
• Political Acceptability - ITNs would cost the government economically but thousands of lives could be saved from them. Moderate political acceptability.
• Social Will - If people understand that ITNs would help more than hurt them, there would be high social will.
• Potential for unintended risks - I can think of no unintended risks that come with ITNs so low potential for unintended risks.
• Potential for unintended benefits - It is likely that the bed nets would protect against other nocturnal bugs that could be carrying other severe diseases for there is a high potential for unintended benefits.

References

"Insecticide Treated Bed Nets." Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 09 Nov. 2012. Web. 19 Apr. 2013. <http://www.cdc.gov/malaria/malaria_worldwide/reduction/itn.html>.

Rhee, Michelle. "Use of Insecticide-treated Nets (ITNs) following a Malaria Education Intervention in Piron, Mali: A Control Trial with Systematic Allocation of Households." Malaria Journal 4.35 (2005): n. pag. Print.

Malaria Intervention and Stakeholders

Problem Definition

Increasing Malaria cases and deaths in the women and children of the Democratic Republic of the Congo from 2005 to 2011.

Intervention

After using the Strategy Decision Matrix, I have determined that the best course of action was to increase provisions of Insecticide Treated Nets (ITNs) to the people of the Congo. In 2011, over 50% of expenditures went toward insecticides and spray materials while a very small percentage was spent on ITNs. While the number of deaths and cases has become steady from 2005 to 2011, these numbers are till increasing. The CDC has stated that "ITNs have been shown to reduce the death of children under 5 years from all causes by about 20%." About half of the expenditures used towards insecticides and spray materials will be allocated to ITNs. Women and children, as the most vulnerable population, will be shown preference when ITNs are given out.

Stakeholders

Those involved in the Program Operations: 

• Aid organizations like the CDC, WHO, UNICEF, and more who may provide resources (money, ITNs, etc.) to move the program forward.
• Government - In shaping policies to regulate the allocation of ITNs
• The people involved in developing the intervention

Those who the Program affects:

• The women and children who would be using the ITNs
• The different organizations who would be spending their money

Those interested in the evaluation results: 

• The government of the Congo
• The people who developed the intervention
• The Aid organizations (WHO, CDC, etc.) to update their information on Malaria treatments and such.

The stakeholders that may oppose my intervention in the Congo's government and some of the AID organizations. These stakeholders would probably disagree with spending so much money on ITNs since they are generally more expensive than insecticides and spray materials and also because they're not very long lasting. In response to this, I would demonstrate to them the uses of the Long Lasting Insecticidal Mosquito Nets that several companies have developed. I would also help them understand that I expect the ITNs to have a greater effect on the number of cases of Malaria victims.

References

"Insecticide Treated Bed Nets." Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 09 Nov. 2012. Web. 12 Apr. 2013. <http://www.cdc.gov/malaria/malaria_worldwide/reduction/itn.html>.

World Malaria Report 2012. Publication no. 119. World Health Organization, 2012. Web. 12 Apr. 2013. <http://www.who.int/malaria/publications/country-profiles/profile_cod_en.pdf>.

Public Health Topic: Malaria Determinants

Increasing Malaria cases and deaths in the Democratic Republic of the Congo.


Environmental Determinants
One of the many determinants of Malaria is water. The mosquitoes that transmit the Malaria virus need water to breed so in most places where a body of water can be found, there is a chance that that water carries Anopheles Mosquito Larvae. One more environmental determinant of Malaria is geography. There is a higher prevalence of Malaria in people who live further from towns and closer to rural areas.

Biological Determinants
Infants and children, pregnant women, non-immune, and HIV/AIDS positive people are at the highest risk of being infected with Malaria due to their weak immune systems.

Social and Cultural Determinants
Males are also at a higher risk than women of being infected Malaria. Thais may be due in part to gender and societal norms like males being expected to work to take care of their families.

Economic Determinants
Certain things like bed nets, treated or not, greatly help in warding off Mosquitoes. If many people cannot afford bed nets, their risk in being affected with Malaria rises.

Behavioral Determinants
It was found that individual use of bed nets was highly effective while community use greatly decreased the effectiveness. So communities that chose to share their bed net(s) have a higher chance of infection that in people who chose to use bed nets individually.

References

"Gender Health and Malaria." World Health Organization. N.p., June 2007. Web. 05 Apr. 2013. <http://www.who.int/gender/documents/gender_health_malaria.pdf>.

Messina, Jane P. "Population, Behavioural and Environmental Drivers of Malaria Prevalence in the Democratic Republic of Congo." Malaria Journal. Malaria Journal, 9 June 2011. Web. 05 Apr. 2013. <http://www.malariajournal.com/content/10/1/161>.

Rogier, Christophe. "Environmental Determinant of Malaria Cases among Travellers." Malaria Journal. Malaria Journal, 4 Mar. 2013. Web. 05 Apr. 2013. <http://www.malariajournal.com/content/12/1/87>.

Public Health Topic: Ebola Zaire (Gabon)

The percentage of Ebola deaths has increased from 57% to 74% among the people of Gabonese Republic from January 1996 to January 1997.

Magnitude

From January to April of the year 1996, there was an outbreak of Ebola Zaire in the Mayibout area of the Gabonese Republic. It was found that there were 19 original cases of Ebola-Zaire and all 19 people involved ate a dead chimpanzee they found in the forest. The disease managed to spread to some family members of the 19 people before control and prevention methods were in place. In the end, 37 people (17 females, 20 males) were reported to be infected with the disease. 21 (57%) of these people were reported dead. 

Later on, from July 1996 to January 1997, 60 new cases of humans infected with Ebola Zaire were reported in the Booue area of Gabon. Some patients were transported to a hospital in Libreville, Gabon, and cases started to pop up there as well. Soon after the first few cases, a dead chimpanzee was found in a forest near Booue that was confirmed to have Ebola. There were 44 reported cases of Ebola-Zaire in Booue with 33 deaths and 14 cases in Libreville with 10 deaths. Of these people, 45 (74%) of the people infected were reported dead.

The surveillance that is available can be used to determine what public health actions need to be taken in the case of another outbreak. Surveillance also determines where certain health resources are needed the most. Lastly, the surveillance available can be used to determine how effective control and prevention methods are in several places in Gabon. Using the surveillance above, I can see how the virus traveled from place to place (like from forest to town and from Booue to Libreville). I can also guess at how the humans became infected with the disease in the first place by associating the dead chimpanzees with the outbreaks.

Direct Indicator: (1) Lab tests used to confirm the existence of Ebola in the chimpanzees and the infected people. (2) 57% and then 74% of people in Mayibout and Booue respectively were confirmed dead from an Ebola infection.

Indirect Indicator: (3) A high number of people who are in close contact with each other showing the symptoms of a hemorrhagic fever.

One strength in the statistics I cited is that they are very direct and clear measures of this particular incidence of Ebola Zaire. A weakness is that the statistics available are only from passive surveillance. That could lead to inaccuracies in the actual statistics. 

References

Known Cases and Outbreaks of Ebola Hemorrhagic Fever, in Chronological Order | CDC Special Pathogens Branch. (n.d.). Centers for Disease Control and Prevention. Retrieved March 30, 2013, from http://www.cdc.gov/ncidod/dvrd/spb/mnpages/dispages/ebola/ebolatable.htm

Waterman, T. (n.d.). Ebola Zaire Outbreaks. Stanford University. Retrieved March 30, 2013, from http://www.stanford.edu/group/virus/filo/eboz.html

Public Health Topic

I still do not know what public health topic I would like to address yet but I am thinking about choosing between Malaria, Ebola, and West Nile Virus. 

Malaria

Malaria is a serious disease that can lead to death depending on how quickly it is diagnosed and treated. It is caused by infection with malaria parasites from the Anopheles Mosquito. There are two types of Malaria that are observed: uncomplicated malaria and severe malaria. Uncomplicated malaria (which is rare) lasts about 6 to 10 hours in which a person goes through the cold stage, the hot stage, and the sweating stage. Symptoms include fever, body aches, chills, and more. Uncomplicated malaria can sometimes be misdiagnosed as a common infection that has similar symptoms. Sever malaria, as the name suggests, is more serious that uncomplicated malaria. Malaria infections become active in the blood so severe malaria occurs when there are abnormalities in a person’s blood or metabolism. It can also occur when the infected person suffers from serious organ failures. The symptoms like low blood pressure, severe anemia, acute kidney failure make it imperative that anyone with sever malaria find treatment as quick as possible.

Problem Definition

There is a breakout of fever, chills and sweats followed by acute kidney failure in areas with a large population of mosquitoes.

Ebola Hemorrhagic Fever

Ebola is a serious disease that causes severe viral hemorrhagic fevers in humans and primates. Humans contract this disease through close contact with the bodily fluids of infected animal and other infected humans. Symptoms include fever, muscle pains and more that lead to diarrhea, internal and external bleeding, impaired liver and kidney functions, and more. The disease has a case fatality rate that varies between 25% and 90%. Ebola can sometimes be misdiagnosed as Malaria, typhoid fever, cholera, and other diseases with similar symptoms. A best way to diagnose Ebola is through testing. As of now, there are no specific treatments or vaccines for Ebola so infected people are usually given intensive supportive care.

Problem Definition

An increase in deaths caused by hemorrhagic fevers has been found in several zoo workers and the monkeys they look after.

West Nile Virus

West Nile Virus is an illness that is contracted from the bite of an infected mosquito which gets an infected bird. This illness can be very serious but usually is not. Serious symptoms include high fever, coma, vision loss and more. The CDC states that only 1 in 150 infected people actually get severe symptoms. More moderate symptoms can appear in about 20% of infected people. These include fever, headache, nausea, and more which can last for just a few days. However, most infected people, approximately 80%, show no symptoms at all of West Nile Virus. People with a mild form of the illness usually do not need medical help since the illness will go on its own but if an infected person shows serious symptoms, they should get medical help as quickly as possible.

Problem Definition

There has been an incidence of high fevers and comas in a small community with a large population of birds and mosquitoes.

All three of these diseases are important public health issues for different reasons; malaria because it is a frequent and sometimes deadly disease, Ebola because it is not so frequent but is very deadly, and West Nile Virus because for those who show signs of illness, it can be a very serious problem.I chose Malaria because I once had it when I was a child and since I became interested in public health, I've been fascinated with how it's treated in different communities. I chose Ebola because I once read about it in a book called Hot Zone and I was curious about how such a deadly disease is treated in the real world. Lastly, I chose West Nile virus for no special reason. I just thought I would get more data from it. At the moment, I'm leaning towards Ebola. 

Contagion

In the movie Contagion, a business woman contracts a disease (later named MEV-1) on her travel to Hong Kong and it is not visible until days after she's infected various people on her plane ride back home. This is the beginning of a MEV-1 pandemic that arouses a wave of fear in the people of Minneapolis. The movie also follows the decisions of various government officials and how they deal with the outbreak. Dr. Erin Mears, an Epidemic Intelligence officer, is sent to Minneapolis to investigate the disease when she dies from it, Dr. Leonora Orantes, an Epidemiologist, is sent to Hong Kong to investigate the beginning of the disease when she is kidnapped for the cure, and Dr. Ally Hextall, a CDC scientist, works on a vaccine for MEV-1 which she later discovers. At the end of movie, viewers are taken back to see each step that leads to the outbreak from how the bat and the pig created the virus to when the business woman shakes the hand of a butcher that was cutting up the pig.

The first time I watched this movie, I was in High School and I was just understanding that Health is not just what you see in the hospital. This movie is one of the reasons I got so interested in Public Health, epidemiology specifically. I was really impressed with how realistic the movie was and how well it described the responsibilities of many different Public Health officials from those who work in the government to those who work in the labs and even to those who work in the field. Now that I am taking this class, I am able to understand the importance of the CDC in the event of such a huge outbreak, The first time I watched the movie, I did not know so much about what Public Health officials did and I thought the government should be the one making final decisions on the health of the public. Now, I understand that the government has it's functions and Public Health officials have their functions. In other words, the government should take a step back when an outbreak occurs and let the CDC do their job.

An outbreak occurs when the incidence of a disease (number of new cases) at a specific place and time is greater than what is expected. For example, if one case of smallpox is found anywhere in the US, it would be considered an outbreak since smallpox is not an expected disease. However, if one case of the flu is found during flu season, it would not be considered an outbreak since it is expected that some people get the flu. In the movie, MEV-1 is a new disease so no illnesses were expected, thus it was an outbreak.

An outbreak investigation is, simply put, the investigation of an outbreak. There are 10 steps epidemiologists follow that the CDC says are involved in investigating an outbreak. They are to

1. Prepare for field work
2. Establish the existence of an outbreak
3. Verify the diagnosis
4. Define and Identify cases
5. Describe and orient the data in terms of time, place, and person
6. Develop hypotheses
7. Evaluate Hypotheses
8. Refine hypotheses and carry out additional studies
9. Implement control and prevention methods
10. Communicate findings

In some or most cases, these steps can be followed in a different order and repeated as much a necessary. The epidemiologists and scientist follow different steps of the outbreak investigation as their jobs require. Dr, Mears manages to follow all the steps stated and in the process contracts the disease. Dr. Orantes is in the process of following the steps of the investigation when she is kidnapped. Their jobs are obviously very dangerous is different ways.

Isolation and quarantine are some of the ways step 9 of an outbreak investigation can be carried out. If a person has a disease that is highly contagious, they are usually put in isolation so that other people surrounding them do not acquire the disease. Quarantine is when people who are suspected of having been exposed to a contagious disease are separated from others in case they start to show symptoms of the disease. The difference between isolation and quarantine is that Isolation deals with people who are already sick while quarantine deals with people who have been exposed to a disease. In the movie contagion, Mitch Emhoff is quarantined when his wife dies from MEV-1 and he is suspected of having it. Later on in the movie, the whole city of Minneapolis is quarantined from the rest of the country when the government realizes that too many people have been exposed to the disease. Many of the sick people in the movie are later isolated when the seriousness of the disease is comprehended.

In the movie, several public health agencies could have been better "prepared" for MEV-1. When Dr. Mears was sent to investigate MEV-1, she had to work with local government officials to create a space for the infected people to be treated. However, many the people she was working with were reluctant to help since they did not fully understand what they were dealing with and this slowed down the control and prevention of the disease. They all could have been better prepared if there was more effective risk communication between the different public health agencies and the public. Since they weren't better prepared, Dr. Mears had to take the time to explain to the government officials what could be prevented with their resources when they should have already been informed of the dangers of the disease.