Lessons learned in Malawi: Discuss with Terrie Taylor
Terrie Taylor, DO, a Michigan State University Distinguished Professor of Internal Medicine, leads the Blantyre Malaria Project, Queen Elizabeth Central Hospital (QECH), in Malawi. She’s been conducting malaria research and treating patients there six month a year for the past twenty five years. In 2010, Malawi and MSU were named one of ten International Centers of Excellence in Malaria Research (ICEMR) by the U.S. National Institutes of Health.
Next week, July 23 to 26, she will be fielding questions and sharing her vast experience with us. To kick-off the discussion, she shared with me some highlights from her work. Feel free to start asking questions and sharing thoughts today.
Thank you, Sophie
Question: Please give us a brief introduction on the Blantyre Malaria Project at the Queen Elizabeth Central Hospital in Malawi, and how you came to work there.
The Blantyre Malaria Project began in 1987 when the Malawi Ministry of Health identified “severe malaria in children” as a research priority. A red carpet was rolled out by Dr. Ankie Borgstein, then principal pediatrician at the Queen Elizabeth Central Hospital (QECH), which was fortuitous because in 1991, QECH became the first teaching hospital for the new University of Malawi College of Medicine.
Q: What are the main components and goals of BMP's partnership with Malawi's College of Medicine? What are the highlights so far, 9 years into the relationship?
BMP was integrated into the College of Medicine right from the beginning. As a research affiliate of the College, members of the BMP team have been involved in providing patient care, teaching medical students, identifying post-graduate training opportunities, and supporting new investigators. One highlight was being named as one of the ten International Centers of excellence in Malaria Research (ICEMR) by the U.S. National Institutes of Health. Another was receiving a new, 1.5 Tesla Magnetic Resonance Imaging (MRI) machine from General Electric Health care in 2008. Neither of these could have happened without strong partnerships within and outside of Malawi.
Q: Can you talk about the work of BMP in severe malaria? What are the key lessons for other malaria professionals/programs out there?
BMP has been unraveling the pathogenesis of cerebral malaria since 1987. We developed the Blantyre Coma Score, which helps to standardize the assessment of comatose children. Our autopsy study revealed that 23% of children who appear to have cerebral malaria actually do not; they are infected with malaria but die for other reasons. Concomitantly, we identified a characteristic retinopathy, evident on funduscopic examination of the eye – and it turns out that the cerebral malaria patients who have this retinopathy are the ones who truly have cerebral malaria. If a child appears to have cerebral malaria (i.e., they are infected with malaria, they are comatose, they are not post-ictal and they don’t have hypoglycemia or meningitis) but s/he doesn’t have any evidence of malaria retinopathy, the clinician should search for other causes of coma. We are currently working with the MRI findings to identify the actual cause of death in children with true cerebral malaria, in hopes of introducing an intervention which could save lives.
Q: Are you seeing resistance to antimalarial drugs; do you see this as a future threat?
Malawi was the first country to move away from chloroquine in 1993. We reported on the “return of chloroquine sensitivity” in 2006. Now Malawi is using Coartem® (artemether/Lumefantrine, AL) as the first line treatment for uncomplicated malaria. It’s been in use for four years now, and based on informal clinical observations, it continues to be very effective.
Q: Do you see a need for more integration, with TB as well as non-communicable diseases for example?
We routinely offer HIV pre-counseling and testing to the patients and guardians of children admitted to the paediatric research ward. This is an activity which has taken off in Malawi generally. HIV voluntary counseling and testing is offered throughout QECH. We consider it to be a basic aspect of good clinical care. Although many malaria patients are co-infected with HIV, the interactions are fairly subtle.
Q: You’ve been treating patients and researching malaria in Malawi since 1986, most especially children. What has changed and what has not in 25 years?
If we look back 25 years ago and compare “then” to “now” in terms of malaria in Malawi, it’s been a sea change. And yet the same number of children with cerebral malaria are still presenting to the hospital every year. So this is very interesting, especially because all around Malawi many countries have been able to enact changes in their malaria national control programmes and see an impact, and we haven’t yet. Malawi was among the first countries to move away from chloroquine; it was also one of the last countries to introduce artemisinin-combination therapies. Also, although the National Malaria Control Programme has been growing in size and in capacity over the years, it’s still a small band of people who are working hard to get on top of the problem. There have been initiatives like insecticides treated bed nets. Currently we are rolling out RDTs. I think we are on the brink of getting ahead but there’s still a ways to go.
Q: Please tell us more about the ICEMR research project.
The work with ICEMR will allow us to go out into communities and begin to understand the determinants of malaria disease at a more grassroots level. It is one of the most innovative programs ever funded by the NIH. There are 10 centers scattered around the endemic malarial areas of the world. We all have different transmission patterns, disease intensities, and species of parasites. We’re one of the southern African ICEMR, and our whole project is in Malawi (others are spread across several countries). One of Malawi’s attribute is its enormous ecological diversity. It’s a very small country but, within it, there is practically every ecological setting known to malaria.
For this project, we have three different sites within 50 kilometers of Blantyre, including one in urban Blantyre and two rural sites: one in the highlands, one in the lowlands. We’ll focus on the determinants of malaria at six different health centers scattered around highly-urban areas of Blantyre - - this is a case-control study. The clinical epidemiological study will look at transmission and disease: facility-based surveillance at three different hospitals (and one health centre) looking at the patient populations and the seasonality of the disease. We will link the facility-based surveillance data with the intervention studies that are carried out not only by the MOH of Malawi and the NMCP but also by nonprofits. We believe that the health centers and hospitals in Malawi are pretty good proxies for the disease burden in Malawi because the government health care option in Malawi is free.
The epi study is also doing cross-sectional surveys. We’ve mapped out our three different areas and we’ll be going twice a year, during the dry season and the rainy season, to the same areas in each of these three ecologically distinct parts of the country. Our approach to gathering incidence data is to set up cohort studies. Starting at the end of this year, we’ll be following a wide age range of individuals through two successive seasons for two years, cataloging their malaria infectivity and illness. With this we hope to get a handle on transmission which is highly labor-intensive and expensive but we think it’ a good way to capture that information.
ICEMR will transition after seven years to Malawian leadership so we are working carefully with the local team to assume the management of the program. We’ve developed all the activities of ICEMR hand-in-hand with the NMCP, the MOH, and the district level health managers at each of our sites. We realize that data collection has to be integrated. Although it meant that our start-up time took longer, we hope that it will make data collection part of the day-to-day routine.