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CDC Activities in Tanzania

CDC/IHRDC Malaria Program in Tanzania

Tanzania

CDC conducts operational and implementation research and provides technical input to the national malaria control programs for mainland Tanzania and the islands of the Zanzibar archipelago. These activities are hosted in country by the Ifakara Health Research and Development Centre (IHRDC). Tanzanian and U.S. scientists collaborate on a variety of projects aimed at improving the delivery of malaria prevention and treatment interventions.

The CDC /IHRDC Malaria Program in Tanzania is supported primarily by the U.S. Agency for International Development, Bureau for Global Health, with additional financial support from CDC's Antimicrobial Resistance Working Group, Wellcome Trust, and the National Malaria Control Program. Tanzanian and U.S. scientists collaborate on a variety of projects aimed at improving the delivery of malaria prevention and treatment interventions.

Interdisciplinary Monitoring Project for Antimalarial Combination Therapy in Tanzania (IMPACT-Tz)

A health worker at Jaribu Mpakani Dispensary uses a preprinted dosing envelope to explain the antimalarial combination treatment (ACT) to a patient and her care-taker. The dosing envelopes were developed by IMPACT-Tz project staff and have been shown to improve the patient’s ability to complete the multi-drug treatment. (Courtesy Tanzania Ministry of Health)

IMPACT-Tz is a large-scale implementation project that explores the effect of artemisinin-containing combination therapy on limiting the spread of antimalarial drug resistance in communities with high levels of malaria transmission. IMPACT-Tz includes partners at the National Institute for Medical Research and Muhimbili University College of Health Sciences. In addition, collaborators from the London School of Hygiene and Tropical Medicine's Health Economics and Financing Programme and Pathogen Molecular Biology Unit contribute additional technical expertise. The project also has strong links to the Swiss Tropical Institute, which is collaborating on an initiative to improve access to malaria treatment in Kilombero and Ulanga Districts.

IMPACT-Tz scientists are collaborating with health officials in 5 districts to evaluate whether a new approach to treating malaria – combining the usual treatment with a highly effective new class of drug – can help check the problem of drug-resistant malaria. The implementation research evaluation involves health care providers, patients, community leaders, and scientists from laboratory and applied fields.

Through IMPACT-Tz the Rufiji District Council Health Management Team has offered highly effective combination treatment to more than 1,000,000 malaria patients at health facilities. In addition to tracking the effect that the new treatment has on antimalarial drug resistance, the project has also concentrated on gleaning information about how new treatments for malaria can be implemented through existing health systems in Africa. Early lessons include improving drug supply and delivery, exploring the market for malaria treatment outside formal-sector health facilities, documenting the process and consequences of malaria treatment policy change, implementing new systems for pharmacovigilance, and improving complete adherence to recommended treatment regimens.

Artemisinin-Containing Antimalarial Combination Therapy for Intermittent Preventive Treatment of Malaria in Pregnancy (ACT-IPTp)

The ACT-IPTp project is evaluating a new approach to preventing the adverse health effects associated with malaria in pregnancy. Pregnant women may be infected with malaria parasites even if they have no symptoms. Frequently these silent infections can have devastating effects on the development of the unborn child. Malaria infection in pregnancy increases the risk that a child will be born too soon, or that he/she will suffer from anemia or low birth weight. These problems limit the child's chances of survival right from the first year of life. More than a decade ago, CDC scientists demonstrated that malaria treatments given at regular intervals during pregnancy could limit these problems for women who are repeatedly exposed to malaria infections. Unfortunately the drugs used for these treatments are becoming less effective as malaria parasites develop resistance and newer drugs have not yet been tested in pregnancy. The ACT-IPTp project is comparing safety and effectiveness of several new treatment regimens for pregnant women and their unborn children.

ACT-IPTp researchers collaborate closely with the Kilombero District Council Health Management Team and clinical staff at the St. Francis Designated District Hospital and the Kibaoni Health Centre. Another important partner in the ACT-IPTp project is Axios Foundation, International, a nongovernmental organization assisting local health officials in providing HIV prevention and care to the same women.

Studies on Availability and Use of Retail Providers for Malaria Treatment

Like their neighbors in other African countries, Tanzanians commonly seek treatment for malaria when they or their children develop fever. People can obtain modern medicines to treat these illnesses from public and non-government health facilities, or from pharmacies, specialist drug stores, and general retailers. In such a pluralist setting, changing the malaria treatment available in health facilities can be expected to affect the availability and use of medicines in the retail sector. Since 2000, CDC/IHRDC investigators and their partners have carefully traced the availability of antimalarial treatment drugs in both rural and urban settings. In rural areas, specialist drug stores have increased in numbers but seldom sell effective drugs for malaria, even when the drugs are in stock. Our work has also demonstrated that patients with fever who seek treatment at specialist drug stores are just as likely to be infected with malaria as those who seek treatment for fever at health facilities. IHRDC is currently working to examine how pharmaceutical retailers can be used to help improve access to treatment for childhood malaria and pneumonia in underserved rural communities.

Specialist drug stores, like this one in Ikwiriri Town, are an important source of treatment for people with fever and malaria in rural Tanzania. CDC/IHRDC researchers documented that clients at specialist drug stores are just as likely as health facility attendees to be infected with malaria parasites. (Courtesy Tanzania Ministry of Health)

Registered pharmacies are largely limited to major urban centers in Tanzania. CDC/IHRDC investigators have tracked the availability and dispensing preferences for new antimalarial treatments at registered pharmacies in Dar-es-Salaam, Tanzania's commercial capital. Since 2003, we have documented the growing availability and affordability of artemisinin-containing treatments at urban pharmacies. More than 30 artemisinin-containing preparations (some contain artemisinin in combination treatments, some as single drugs) are currently registered and sold in the country, The use of single-drug treatment - also called monotherapy - speeds resistance by killing some of the parasites but not all of them. The widespread sale of artemisinin monotherapy at pharmacies in urban areas could undermine plans to introduce more sensible combination therapies. Findings from this evaluation have led to closer contact between the National Malaria Control Programme and Food and Drugs Authority in Tanzania. In addition, the World Health Organization has called on pharmaceutical manufacturers to voluntarily withdraw artemisinin monotherapy products from markets in malaria-endemic countries.

Studies of Improved Diagnosis of Malaria Infection

For many years, health care workers in small resource-poor rural health facilities in countries where malaria is highly endemic have relied exclusively on signs and symptoms of malaria (clinical diagnosis) to guide malaria treatment. In Tanzania, first-line antimalarial drugs are recommended for any child with fever or history of fever. With the introduction of new malaria treatments and the availability of simpler bedside tests for malaria, however, this practice is being reconsidered. Studies have shown that rapid diagnostic tests are sufficiently sensitive and specific to be cost effective for guiding the use of newly recommended treatments. Findings from our sites have also indicated that both patients and health workers value confirmation of a malaria diagnosis and are willing to rely on the results of these simple tests. CDC/IHRDC investigators are working to introduce rapid diagnostic tests for malaria on a wide scale in a rural area with high transmission levels. This activity should help answer questions about how best to deploy rapid tests.

U.S. President's Malaria Initiative in Tanzania

President and Chairman of the Revolutionary Council of Zanzibar, Honorable Amani Abeid Amani Karume, greets U.S. Deputy Chief of Mission, Mr. D. Purnell Delly at the launch of the U.S. President's Malaria Initiative at Mahonda Police Football Grounds, Unguja North B District. (Courtesy Tanzania Ministry of Health)

In June 2005, President George W. Bush announced a new U.S. government initiative aimed at helping African countries confront the public health burden of malaria. Tanzania, Uganda, and Angola were the first 3 countries identified for the initiative. Of the three, Tanzania has the largest population at risk for malaria. Through the President's Malaria Initiative (PMI), CDC is able to make an important contribution to malaria prevention and control and to ensure that our research findings are translated into public health benefits. CDC provides lead technical support to PMI and plans related activities in partnership with the U.S. Agency for International Development (USAID), the Ministries of Health and Social Welfare, and their development partners.

In the first year of the initiative, activities in mainland Tanzania and the Zanzibar archipelago include:

• In collaboration with PMI and the Global Fund to Fight AIDS, Tuberculosis and Malaria, the Zanzibar Malaria Control Program has provided long-lasting insecticidal nets for all 300,000 children under 5 and pregnant women on the isles.
• PMI will make it possible for infants in mainland Tanzania to receive a voucher for a highly subsidized insecticide-treated net (ITN). PMI will develop a plan to eliminate out-of-pocket payment for nets for the poorest and most vulnerable families. The initiative will also work with other partners and ITN manufacturers in the country to scale up production of long-lasting insecticidal nets.
• PMI will support the CDC/IHRDC Malaria Program to develop, implement, and evaluate a package of interventions to improve the management of severe malaria in children at the community, health facility, and hospital levels. This activity will involve introducing new diagnostics and treatments and enhancing the existing systems for referring severely ill children and reducing their risk of a second severe illness.
• PMI partners will revitalize programs for indoor residual spraying to kill adult mosquitoes throughout the isles and in select districts on the mainland.
• The initiative will contribute to an integrated program for urban malaria control in Dar-es-Salaam.
• PMI will help procure highly effective antimalarial combination therapy (ACT) drugs for use in accredited private sector drug stores and for refugee-affected populations in the country. PMI partners will also assist the Medical Stores Department, the Tanzania Food and Drug Authority, and the Ministry of Health and Social Welfare to make ACTs available across the mainland.

In addition to the PMI country plan, CDC's Malaria Branch, through funds made available by the office of CDC's director, also supports JHPIEGO's ACCESS program to deliver enhanced services for prevention and treatment of malaria in pregnancy. JHPIEGO/ACCESS is USAID's primary implementing partner in Tanzania for improving antenatal care services and reducing maternal and neonatal morbidity and mortality. Their program has integrated intermittent preventive treatment for malaria into the national strategy for Focused Antenatal Care. Beginning in 2006, CDC has supported JHPIEGO/ACCESS to begin work with the Morogoro Rural District Council Health Management Team to develop an enhanced intervention for improving maternal and neonatal services from the community and household level all the way up the health system.

Contact Details

Patrick Kachur, M.D.
Ifakara Health Research and Development Centre
National Institute for Medical Research
PO Box 78373
Luthuli Street and Sakine Road
Dar es Salaam, Tanzania
Tel: 255-22-213-2704
SKachur@cdc.gov