Malaria program supply chain management - continuous professional development course

Malaria program supply chain management - continuous professional development course

1. Chapter 5: Malaria Program Supply Chain Management

2. Brainstorming Questions: How significant is malaria as a public health problem in Ethiopia? What are the peak periods for malaria transmission in Ethiopia? 5.1 Epidemiology of malaria in Ethiopia

3. World malaria report (WHO, 2021) 241 million malaria cases  and  627 000 deaths  worldwide in 2020 14 million more cases compared to 2019, and 69 000 more deaths Most of the increase were registered in WHO African, Ethiopia included Between 2000 and 2019, case incidence in the WHO African Region reduced from 368 to 222 per 1000 Increased to 232 in 2020, main reason? COVID-19 pandemic 5.1 Epidemiology of malaria in Ethiopia

4. Malaria transmission in Ethiopia occurs below 2000m elevation; occasionally it occurs up to 2300m elevation The peak periods of malaria incidence: September to December Minor transmission season: March to May Most malaria cases are observed in persons over five years of age Children under five years of age and pregnant women are most vulnerable 5.1 Epidemiology of malaria in Ethiopia

5. Malaria is also a significant impediment to social and economic development in Ethiopia affects the population during planting and harvesting seasons cutting down productive capacity loss of earnings low school attendance high treatment cost 5.1 Epidemiology of malaria in Ethiopia

6. Malaria is caused by five species of Plasmodium parasites Plasmodium falciparum Plasmodium vivax, Plasmodium malariae Plasmodium ovale , and Plasmodium knowlesi (not common, recently known) In Ethiopia P. falciparum and P. vivax are the dominant parasites (77 and 23% respectively) P. malariae and P. ovale are rare, account for <1 percent of all confirmed cases 5.1 Epidemiology of malaria in Ethiopia

7. Trend of malaria in Ethiopia M alaria cases have shown significant reduction since the last decade T here was no large-scale epidemic reported in Ethiopia, due to T he scaling up malaria interventions such as vector control, diagnosis and treatment Malaria products availability at HF Reduction in the number of cases is not happening in recent years 5.1 Epidemiology of malaria in Ethiopia

8. Malaria Stratification and Mapping Question: What are the bases used for stratification of malaria risk? 5.1 Epidemiology of malaria in Ethiopia

9. Risk of malaria in Ethiopia is classified into five distinct malaria strata based on annual parasite incidence (API) per 1,000 population 5.1 Epidemiology of malaria in Ethiopia Malaria endemicity Classification Population (2020) Number of districts High API>=50 4,929,814 (4.8%) 68 Moderate API>=10&<50 13,480,217 (13.1%) 177 Low API>5 &<10 4,999,818 (4.9%) 80 Very low AP>0 &<=5 30,168,016 (29.3%) 485 Free API=0 49,272,928 (47.9%) 236 Total   102,850,793 (100%) 1,046

10. Figure 5.2: Malaria Stratification Map, June 2020 NMEP

11. Brainstorming questions: What do you know about the current malaria program in Ethiopia? Can you list priority diagnosis and treatment interventions targeted in the national malaria strategic plan ? 5.2 Overview of the National Malarial Program

12. Ethiopia has revised its national malaria program from prevention and control to “ elimination program” in 2021 National malaria elimination roadmap was developed to guide activities for elimination of indigenous malaria by 2030 Elimination activities have been started in 239 districts National Malaria Elimination Program, under disease prevention and control directorate at MOH NMEP develops, updates, and disseminated policy and strategies 5.2 Overview of the National Malarial Program

13. It produces, disseminates, and monitors malaria related guidelines NMEP is also involved in building the capacity of program managers at regional, zonal, district and HF level It provides leadership to all stakeholders and implementing partners working on malaria Regional Health Bureaus (RHB), Zonal, and District Health Offices have malaria team 5.2 Overview of the National Malarial Program

14. At primary health care level, the malaria program is integrated into the health system via the Health Extension Program (HEP) HEP is serving as the core of the health system Health Posts are linked to health centers through the primary health care unit, and they are linked to District Health Office at the woreda level 5.2 Overview of the National Malarial Program

15. Control, elimination and eradication Malaria control  is the reduction of disease incidence, prevalence, morbidity, or mortality to a locally acceptable level as a result of deliberate efforts. Continued intervention is required to sustain control. Malaria elimination  is the interruption of local transmission (that is, reducing the rate of malaria cases to zero) of a specified parasite in a defined geographic area. Continued measures are required to prevent the reestablishment of transmission. Malaria eradication : permanent reduction to zero of the worldwide incidence of malaria infection and does not require intervention after attaining eradication. 5.2 Overview of the National Malarial Program

16. The Ethiopian national malaria strategic plan (NMSP) 2021 -2025, was developed after conducting malaria program review (MPR) for the preceding NMSP The NMSP is fully aligned with policies, guidance, and evidence at global, regional, and national levels and considers recent developments The purpose of the NMSP is to provide direction and implementation strategies so that efforts by all partners are harmonized towards sustaining universal coverage and putting Ethiopia on track for malaria elimination It also provides indicative figures resources required for implementation of planned activities 5.2 Overview of the National Malarial Program

17. National Malaria Strategic Plan Goals By 2025, reduce malaria morbidity and mortality by 50 percent from baseline of 2020. By 2025, achieve zero indigenous malaria in districts with annual parasite incidence less than 10 and prevent reintroduction of malaria in districts reporting zero indigenous malaria cases 5.2 Overview of the National Malarial Program

18. Strategic Objectives By 2025, achieve adoption of appropriate behavior and practices towards antimalarial interventions by 85% households living in malaria endemic areas By 2021 and beyond, conduct confirmatory testing for 100% of suspected malaria cases and treat all confirmed cases according to the national guidelines. By 2021 and beyond, cover 100% of the population at risk of malaria with one type of globally recommended vector control interventions.

19. 4. By 2021 and beyond, conduct cases or foci investigation, classification and response in districts currently having API less than 10 and prevent reintroduction of malaria into areas reporting zero indigenous malaria cases. 5. By 2021 and beyond, generate 100% evidence that facilitates appropriate decision-making. 6. By 2021 and beyond, build capacity of all levels of the health offices to coordinate and implement malaria elimination interventions.

20. Implementation Strategies Enhancing community engagement, empowerment and mobilization Ensuring early diagnosis and prompt treatment Strengthening vector control Improving malaria surveillance and response system Improving malaria supply chain and quality of antimalarial commodities Ensuring human rights and gender equality in accessing malaria services Strengthen engagement of all stakeholders, including civil society organizations (CSOs) and private sector Strengthening malaria programme management, operational research and M&E.

21. Key national strategic interventions related to supply chain management Ensuring early diagnosis and prompt treatment Effective treatment requires effective diagnosis of malaria, well-trained health workers in health facilities, and uninterrupted availability of products required for diagnosis and treatment.

22. Interventions used to implement diagnosis and treatment. Provide universal access to appropriate and quality malaria parasitological diagnosis to all suspected malaria cases. Sustain universal coverage of effective and efficacious treatment as per the national guidelines. Generate evidence on suitability of chemoprophylaxis or seasonal chemoprevention targeting special population group (seasonal migrant laborers) to protect them from malaria and reduce the risk of carrying parasites to their hometown. Establish a quality assurance system for malaria microscopy and RDTs. Support integrated community malaria case management activities .

23. Treatment of uncomplicate malaria Patients with uncomplicated malaria are treated with Artemether-Lumefantrine plus single dose primaquine or Chloroquine plus 14 days of Primaquine depending on the parasite involved Parasite Health post (RDT) Health center/Hospital (microscopy) P.vivax CQ+PQ (radical cure) CQ + PQ (radical cure) Uncomplicated P.falciparum AL+PQ(single dose) AL+ PQ (single dose) Uncomplicated mixed infection AL+PQ(single dose) AL+ PQ (radical cure)

24. Treatment of severe malaria Treat adults and children with severe malaria with IV or IM artesunate for at least 24 h and until they can tolerate oral medication. Complete treatment with 3 days of ACT (add single dose primaquine).

25. Pv Suspected Clinical Malaria Case Are there danger signs? (Vomiting, lethargic or unconscious, convulsion/convulsing now, prostration, neck stiffness, respiratory distress? Yes No Do Microscopy and Manage accordingly or refer to higher level Microscopy (Blood film) Manage accordingly or refer Negative for malaria parasites Positive for malaria parasites Look for other causes of fever pf Pf+Pv Treat with AL*+ 0.25mg/kg Primaquine single dose Treat with AL+14 days radical cure Rx with Primaquine(0.25mg/kg) Treat with chloroquine+14 days radical cure Rx with primaquine (0.25mg/kg)

26. Malaria products, particularly Artemisinin-based combination therapies (ACTs) and rapid diagnostic test kits (RDTs) have special characteristics that influence their shelf life, packaging, and cost . Compared to many diseases, malaria and its control have peculiar characteristics, such as Seasonality H eterogeneous transmission Hi story of treatment provided at the community level 5.3. Peculiarities affecting malaria supply chain management

27. 5.3. Peculiarities affecting malaria supply chain management Seasonality : is a big challenge to use the simple AMC rule for inventory replenishment estimates from the most recent months of consumption. During peak malaria transmission periods, demand and use of malaria medicines and tests will increase requiring adjustment in stock quantities and distribution/supply demands. Look-Ahead Seasonality Indices (LSI)—a n approach that operationally involves multiplying the AMC by indices that compensate for seasonality before multiplying by the maximum stock level.

28. 5.3. Peculiarities affecting malaria supply chain management Geography : altitude, h umidity, more dense foliage may provide more hospitable environments for malaria-carrying mosquitoes. This have a direct impact on the malaria product stocks required at facilities in different areas. It also have direct influence on the environmental condition particularly temperature this requires health facilities to give special attention to the storage situation.

29. 5.3. Peculiarities affecting malaria supply chain management Parasite species, treatment, and level of service: For uncomplicated malaria, ACTs are recommended. Complicated or severe malaria is often treated with injectable artesunate or quinine. While treatment of uncomplicated malaria can be administered at all levels of the health system, severe malaria cases are generally referred to a higher level of care (health centers and hospitals).

30. Presentation : Various presentations must be managed separately and are often presented in a single setting. During stock outs, these presentations may be cut or combined to provide treatments. It should be noted that cutting or crushing these tablets would lead to instability and inaccurate dosages. Combining of different weight bands may also make the dose more than double or triple a dose if a caregiver is not careful with dosages being combined. Such practices might also create stock shortages or wastages at different levels. 5.3. Peculiarities affecting malaria supply chain management

31. Shelf life: Most ACT formulations have a relatively shorter shelf life than other essential medicines (24-month shelf life) increasing high risk of expiry both in the supply chain and health facilities thus require more attention during distribution and dispensing (First-Expire-First-Out principle). Manufacturers/Quality: Multiple manufacturers produce ACTs, but only a few offers pharmaceutical preparations approved by a stringent regulatory authority or WHO prequalified creating challenges in accessing quality malaria products. Cost: ACTs have significantly high value relative to most essential medicines and thus potentially more susceptible to pilferage that leads to stockout at health facilities. 5.3. Peculiarities affecting malaria supply chain management

32. Laboratory diagnosis: Ho spitals and health centers: Microscopy H ealth posts: RDT Treatment: U ncomplicated malaria: at all levels of the health system (HP, HC and HL) S evere malaria: higher level of care at hospitals and health centers. Health posts are expected to administer pre-referral treatment Service model and diagnosis and treatment policy: 5.3. Peculiarities affecting malaria supply chain management

33. T he information generated on reported malaria cases is expected to be in line with the quantity of treatment doses of malaria medicines that are distributed/consumed. However, the annual malaria cases reported through the DHIS-2 and the quantity of malaria medicines treatment doses distributed in the same period have shown significant disagreements at the national level. Proper and correct information is key to all aspects of pharmaceutical supply management. Higher quantity of malaria medicines was reported to have been issued or consumed than the number of malaria cases reported at health facilities. Despite this, frequent stock outs were reported from health facilities. Case Study 5.1. Discrepancy between malaria case report and medicines consumption data Why do you think this happen? What are the major possible factors contributing to the discrepancies between the two data sets and what is your recommended which intervention?

34. Thank You!