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Dear colleagues,

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

Interview:

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.

 
SIMON KIREMERWA
Replied at 1:14 PM, 21 Jul 2012

What is the relationship between malaria (positive slide) and lymphopenia
as shown by CBC report

Terrie Taylor
Replied at 1:24 PM, 21 Jul 2012

I'm not aware of a relationship between peripheral parasitemia and lymphopenia, but there is a well recognized association of parasitemia and thrombocytopenia (Chimalizeni Y, Kawaza K, Taylor T, Molyneux M. The platelet count in cerebral malaria, is it useful to the clinician? Am J Trop Med Hyg. 2010 Jul;83(1):48-50.PMID: 20595476.)

SIMON KIREMERWA
Replied at 2:45 PM, 21 Jul 2012

Had observed it in 20cases and had normal wbc count,HIV negative.
When some of them came back for review, lymphocyte count where normal,
smears negative.
Other cases smears negative,lymphopenia and 2 or 3 days later came back
same complaints but on repeating blood slide its positive
Interesting considering malaria lifecycle
Anyone explanation?

Idongesit Ukpe
Replied at 2:07 PM, 22 Jul 2012

"And yet the same number of children with cerebral malaria are still
presenting to the hospital every year".
What about mortality from cerebral malaria in the children, has it changed
from what it was 25 years ago?

Terrie Taylor
Replied at 11:56 PM, 22 Jul 2012

Regarding the mortality rate - - ours hasn't really changed a lot over the years, but that may be because we are pretty assiduous in terms of managing convulsions, hypoglycemia and evolving anemia. Using artesunate instead of quinine should know the mortality rate down a few percentage points ,but Malawi hasn't jumped on that bandwagon yet. We are close to figuring how what actually kills kids with CM - - once we know that, we may be able to come up with improved interventions.

Terrie Taylor
Replied at 11:59 PM, 22 Jul 2012

Excuse the typo!
"Using artesunate instead of quinine should BRING the mortality rate down...."


;-)

TT

Sophie Beauvais
Replied at 11:44 AM, 23 Jul 2012

Hi everyone,

Great start to the discussion with Terrie Taylor.

Terrie is with us all week to discuss her work and that of her team at the Blantyre Malaria Project Queen Elizabeth Central Hospital in Malawi. In addition to the interview I posted earlier, Terrie talked with me this morning about their needs in human resources (only entomologist in the country!) and community health workers. Listen to Terrie in this short video: http://bcove.me/u8czfs5l and ask questions or share your thoughts now.

Thank you, Sophie

P.S. Remember to invite colleagues to join the discussion!

Clare Hanbury
Replied at 7:37 AM, 24 Jul 2012

Hi there, I am especially interested in health messaging for children which they can pass on to other children. Lately -I have been working on Malaria prevention. I woud like to know what messages you and others use to advise people what to do between dusk and bedtime when mosquitos are actively biting but before people are ready to sleeep under their bednets? Thansk

Attached resource:

Terrie Taylor
Replied at 1:23 PM, 24 Jul 2012

Good question, Clare - - we have not developed any messages for this particular issue - - - let's see if others have!

Violet Chaka
Replied at 4:14 PM, 24 Jul 2012

Hi Terry,
You mentioned that you are rolling out RDTs. Are the end users only nurses in the clinics or are you also training Community Health Workers? What is the general perception of clinicians regarding malaria RDTs versus the peripheral blood smear?

Best,
Violet

Terrie Taylor
Replied at 4:27 PM, 24 Jul 2012

Hi, Violet - -


The National Malaria Control Programme in Malawi are rolling out the RDTs, and for now, they are only being used in health care facilities. The clinicians are loving the SPEED, and they seem to be trusting the positive results - - but it is hard to convince them (sometimes) to believe the negative results!

TT

Mary Nnankya
Replied at 6:52 PM, 24 Jul 2012

Dear Dr.Terri, (foreseeable independent research development) Can you please give details of the funding you have available and how the programme you are currently overseeing will continue to be sustainable in Malawi with further independent collaborative inclusion of other African Led Malaria control Programmes after the current funding is expired. Also please Kindly advise on what training/ new skills that is not already available or acquired knowledge has been provided and implemented permanently (technology and equipment) to community Health Care workers/ Doctors/Research Scientists/ Clinical research experts/ admin personnel etc.... to enable the institution hosting you to subsequently be in a position to compete for international positioning including grants/ peer reviewed publications/ international recognition and continuing the work you are mow being hosted to do being transfered independently with assurance towards acceptable independent Research and development and acceptable sustainability for this work to continue. I look forward to your kind response. Dr. Mary Nnankya

****************IMPORTANT--PLEASE READ*******************
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> Subject: Re: [Malaria Treatment & Prevention] Lessons learned from Malawi: Discuss with Terrie Taylor
> From:
> To:
> Date: Tue, 24 Jul 2012 16:27:43 -0400
>
> Terrie Taylor replied to the discussion "Lessons learned from Malawi: Discuss with Terrie Taylor" in the Malaria Treatment & Prevention community.
>
> Reply contents:
> "Hi, Violet - -
>
>
> The National Malaria Control Programme in Malawi are rolling out the RDTs, and for now, they are only being used in health care facilities. The clinicians are loving the SPEED, and they seem to be trusting the positive results - - but it is hard to convince them (sometimes) to believe the negative results!
>
> TT"
>
> --
> View this post online:
> <http://www.ghdonline.org/malaria/discussion/lessons-learned-from-malawi-discu...>
>
> Unsubscribe or change your email notification settings:
> <http://www.ghdonline.org/users/mary-nnankya/edit/>
>
> Contact the GHDonline team:
> <http://www.ghdonline.org/contact/>
>
> You can reply to this discussion by responding directly to this e-mail; it will be shared with all community members and posted as is. Files cannot be added via email attachment and must be uploaded directly to GHDonline.

Terrie Taylor
Replied at 7:10 PM, 24 Jul 2012

Hi, Mary - -

Great question.

We are working on a couple of different fronts.

To enhance the sustainability of the research work, we are nurturing Malawian investigators, and we've been able to use a number of different mechanisms (training grants, on-the-job training, co-investigator status, advising on grant submissions). It takes awhile, and it is important that the local institution develops the capacity to manage external grants. The EDCTP has been a great partner in terms of enhancing research capacity, and one of the BEST learning experiences are the visits of the clinical montors!

To enhance the sustainability of the surveillance activities, the 'research grant' is supporting the training of lab aides, and we are working with individuals in established cadres in various health facilities to collect the data. The data management system is based in Malawi, and the capacity to store, retrieve and use large amounts of data is also increasing with the support of the ICEMR grant (which is from the NIH).

Much of the leadership is Malawian already, and even more of the leadership will be Malawian as the ICEMR grant unfolds.

Our hope is that the ICEMR data will prove to be so useful that the National Malaria Control Programme will assume the responsibility of maintaining the data collection if/when the research support ends.

Does this address your question? If not, let me know and I will try again.

Mary Nnankya
Replied at 8:19 PM, 24 Jul 2012

Dear Terri, Would you kindly elaborate on what is inclusive in "nurturing Malawian investigators" as you point out it is good to know that leadership is already Malawian is this on economic /political level. What equipment have you Installed locally for potential local analysis of Data and subsequent acceptance by the international Malaria control investigators. Personally I do not believe that their can be ANY long-term sustainability or Independent Research Development unless at least 70% of all work is initiated, conducted, and performed locally by African local Experts who shouls also be in a position to give feedback at international level. This is a very serious and important issue!!!!All international grants should favour local capacity building investigators with peripheral collaboration grant collaborators from non-malaria endemic regions. Have you published or in the process of publishing the work in Malawi with a Malawian lead author and supervisory author. It would also be good experience and inclusion if this panel of discussion did have a Malawian Principal investigator or lead supervisor to help answer some of the questions.
Yes transferring Technical knowledge "How to use biotech equipment and the installation of equipment to sustain the research for all parties to benefit does take time, and the question following this your statement is how long? Expertise is already in place!!! With kindest regards, Mary
****************IMPORTANT--PLEASE READ*******************
If this electronic message contains a zipped attachment and you do not have
a decompression tool, you can download unZIP (for free) from:
http://www.mk-net-work.com/us/uz/unzip.htm. Alternatively, request
that the attachment be resent in an uncompressed format. This electronic message,
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and may contain PROPRIETARY or LEGALLY PRIVILEGED information. If you are
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in it is unauthorized and strictly prohibited. If you have received this
message in error, please immediately notify the sender by reply e-mail and
permanently delete this message and its attachments, along with any copies
thereof. Thank you. 2.2
************************************************************************


> Subject: Re: [Malaria Treatment & Prevention] Lessons learned from Malawi: Discuss with Terrie Taylor
> From:
> To:
> Date: Tue, 24 Jul 2012 19:11:10 -0400
>
> Terrie Taylor replied to the discussion "Lessons learned from Malawi: Discuss with Terrie Taylor" in the Malaria Treatment & Prevention community.
>
> Reply contents:
> "Hi, Mary - -
>
> Great question.
>
> We are working on a couple of different fronts.
>
> To enhance the sustainability of the research work, we are nurturing Malawian investigators, and we've been able to use a number of different mechanisms (training grants, on-the-job training, co-investigator status, advising on grant submissions). It takes awhile, and it is important that the local institution develops the capacity to manage external grants. The EDCTP has been a great partner in terms of enhancing research capacity, and one of the BEST learning experiences are the visits of the clinical montors!
>
> To enhance the sustainability of the surveillance activities, the 'research grant' is supporting the training of lab aides, and we are working with individuals in established cadres in various health facilities to collect the data. The data management system is based in Malawi, and the capacity to store, retrieve and use large amounts of data is also increasing with the support of the ICEMR grant (which is from the NIH).
>
> Much of the leadership is Malawian already, and even more of the leadership will be Malawian as the ICEMR grant unfolds.
>
> Our hope is that the ICEMR data will prove to be so useful that the National Malaria Control Programme will assume the responsibility of maintaining the data collection if/when the research support ends.
>
> Does this address your question? If not, let me know and I will try again."
>
> --
> View this post online:
> <http://www.ghdonline.org/malaria/discussion/lessons-learned-from-malawi-discu...>
>
> Unsubscribe or change your email notification settings:
> <http://www.ghdonline.org/users/mary-nnankya/edit/>
>
> Contact the GHDonline team:
> <http://www.ghdonline.org/contact/>
>
> You can reply to this discussion by responding directly to this e-mail; it will be shared with all community members and posted as is. Files cannot be added via email attachment and must be uploaded directly to GHDonline.

Mary Nnankya
Replied at 10:30 PM, 24 Jul 2012

Dear Terri, Hope all is well, I can understand that you must be exhausted with all these questions. Looking forward to hearing from you at your earliest convenience.

With kindest Regards, Mary****************IMPORTANT--PLEASE READ*******************
Namba Biotech (uk) Ltd: If this electronic message contains a zipped attachment and you do not have
a decompression tool, you can download unZIP (for free) from:
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permanently delete this message and its attachments, along with any copies
thereof. Thank you. 2.2
Namba Biotech (uk) Ltd is a trading name of Namba Limited registered in England and Wales4************************************************************************


> Subject: Re: [Malaria Treatment & Prevention] Lessons learned from Malawi: Discuss with Terrie Taylor
> From:
> To:
> Date: Tue, 24 Jul 2012 20:19:35 -0400
>
> Mary Nnankya replied to the discussion "Lessons learned from Malawi: Discuss with Terrie Taylor" in the Malaria Treatment & Prevention community.
>
> Reply contents:
> "Dear Terri, Would you kindly elaborate on what is inclusive in "nurturing Malawian investigators" as you point out it is good to know that leadership is already Malawian is this on economic /political level. What equipment have you Installed locally for potential local analysis of Data and subsequent acceptance by the international Malaria control investigators. Personally I do not believe that their can be ANY long-term sustainability or Independent Research Development unless at least 70% of all work is initiated, conducted, and performed locally by African local Experts who shouls also be in a position to give feedback at international level. This is a very serious and important issue!!!!All international grants should favour local capacity building investigators with peripheral collaboration grant collaborators from non-malaria endemic regions. Have you published or in the process of publishing the work in Malawi with a Malawian lead author and supervisory author. It would also be good experience and inclusion if this panel of discussion did have a Malawian Principal investigator or lead supervisor to help answer some of the questions.
> Yes transferring Technical knowledge "How to use biotech equipment and the installation of equipment to sustain the research for all parties to benefit does take time, and the question following this your statement is how long? Expertise is already in place!!! With kindest regards, Mary
> ****************IMPORTANT--PLEASE READ*******************
> If this electronic message contains a zipped attachment and you do not have
> a decompression tool, you can download unZIP (for free) from:
> http://www.mk-net-work.com/us/uz/unzip.htm. Alternatively, request
> that the attachment be resent in an uncompressed format. This electronic message,
> including its attachments, is CONFIDENTIAL
> and may contain PROPRIETARY or LEGALLY PRIVILEGED information. If you are
> not the intended recipient, you are hereby notified that any use, disclosure,
> copying, or distribution of this message or any of the information included
> in it is unauthorized and strictly prohibited. If you have received this
> message in error, please immediately notify the sender by reply e-mail and
> permanently delete this message and its attachments, along with any copies
> thereof. Thank you. 2.2
> ************************************************************************
>
>
> > Subject: Re: [Malaria Treatment & Prevention] Lessons learned from Malawi: Discuss with Terrie Taylor
> > From:
> > To:
> > Date: Tue, 24 Jul 2012 19:11:10 -0400
> >
> > Terrie Taylor replied to the discussion "Lessons learned from Malawi: Discuss with Terrie Taylor" in the Malaria Treatment & Prevention community.
> >
> > Reply contents:
> > "Hi, Mary - -
> >
> > Great question.
> >
> > We are working on a couple of different fronts.
> >
> > To enhance the sustainability of the research work, we are nurturing Malawian investigators, and we've been able to use a number of different mechanisms (training grants, on-the-job training, co-investigator status, advising on grant submissions). It takes awhile, and it is important that the local institution develops the capacity to manage external grants. The EDCTP has been a great partner in terms of enhancing research capacity, and one of the BEST learning experiences are the visits of the clinical montors!
> >
> > To enhance the sustainability of the surveillance activities, the 'research grant' is supporting the training of lab aides, and we are working with individuals in established cadres in various health facilities to collect the data. The data management system is based in Malawi, and the capacity to store, retrieve and use large amounts of data is also increasing with the support of the ICEMR grant (which is from the NIH).
> >
> > Much of the leadership is Malawian already, and even more of the leadership will be Malawian as the ICEMR grant unfolds.
> >
> > Our hope is that the ICEMR data will prove to be so useful that the National Malaria Control Programme will assume the responsibility of maintaining the data collection if/when the research support ends.
> >
> > Does this address your question? If not, let me know and I will try again."
> >
> > --
> > View this post online:
> > <http://www.ghdonline.org/malaria/discussion/lessons-learned-from-malawi-discu...>
> >
> > Unsubscribe or change your email notification settings:
> > <http://www.ghdonline.org/users/mary-nnankya/edit/>
> >
> > Contact the GHDonline team:
> > <http://www.ghdonline.org/contact/>
> >
> > You can reply to this discussion by responding directly to this e-mail; it will be shared with all community members and posted as is. Files cannot be added via email attachment and must be uploaded directly to GHDonline."
>
> --
> View this post online:
> <http://www.ghdonline.org/malaria/discussion/lessons-learned-from-malawi-discu...>
>
> Unsubscribe or change your email notification settings:
> <http://www.ghdonline.org/users/mary-nnankya/edit/>
>
> Contact the GHDonline team:
> <http://www.ghdonline.org/contact/>
>
> You can reply to this discussion by responding directly to this e-mail; it will be shared with all community members and posted as is. Files cannot be added via email attachment and must be uploaded directly to GHDonline.

CONSTANCE BART-PLANGE DR
Replied at 6:58 AM, 25 Jul 2012

Hi
Ghana is facing this same dilemma: the Clinicians trust the positive results from RDTS but they dont always accept the Negative results. But can we blame them for this stance? There has been a long period in our clinical practise when we were trained, under the IMCI strategy, " to treat fever cases as malaria, in the absence of any other symptom". We are also told, depending on the parasite density, RDTs may not show positive results. It is therefore important that, clinicians combine their clinical expertise ( very good history taking, very thorough examinations for signs and symptoms) and RDT or microscopy results.


(Dr Constance Bart-Plange, Malaria Program Manager, Ghana

On 24 Jul 2012, at 08:28 PM, "GHDonline (Terrie Taylor)" <> wrote:

> Terrie Taylor replied to the discussion "Lessons learned from Malawi: Discuss with Terrie Taylor" in the Malaria Treatment & Prevention community.
>
> Reply contents:
> "Hi, Violet - -
>
>
> The National Malaria Control Programme in Malawi are rolling out the RDTs, and for now, they are only being used in health care facilities. The clinicians are loving the SPEED, and they seem to be trusting the positive results - - but it is hard to convince them (sometimes) to believe the negative results!
>
> TT"
>
> --
> View this post online:
> <http://www.ghdonline.org/malaria/discussion/lessons-learned-from-malawi-discu...>
>
> Unsubscribe or change your email notification settings:
> <http://www.ghdonline.org/users/constance-bart-plange-dr/edit/>
>
> Contact the GHDonline team:
> <http://www.ghdonline.org/contact/>
>
> You can reply to this discussion by responding directly to this e-mail; it will be shared with all community members and posted as is. Files cannot be added via email attachment and must be uploaded directly to GHDonline.

Terrie Taylor
Replied at 11:54 AM, 25 Jul 2012

This is TT, responding to Mary (comments 14 and 15 above) - -

Thanks again, Mary, and don't worry - - this is a very enjoyable exchange and I am not finding it exhausting at all. Your posts arrived during the wee hours of the morning (I'm in Michigan at the moment) and I'm just seeing them now.

I'll use the ICEMR (International Centers of Excellence for Malaria Research) as an example of how internationally funded research can build capcity.

When the RFA was released in April of 2009, a group of investigators gathered in Malawi to consider a proposal. I was the only 'mzungu' in the group. We met weekly over the course of 2 months to plan the proposal. We decided on our hypotheses, we chose the research sites, and we identified Malawians to lead each of the projects (epidemiology, urban malaria, entomology and gametocytes). and one of the three cores (data). An expatriate was unanimously tapped for the molecular parasitology core as there weren't any Malawians with the requisite expertise. The RFA stipulated that the leader of the admin core be the overall PI of the proposal.

There was a long discussion regarding who should be the PI of the overall proposal and eventually the group decided that I should be the PI and that my home institution, Michigan State University, should be the primary institution. This was a difficult decision because we all were really hoping that the University of Malawi College of Medicine (Malawi's only medical school, and 22 years old, now) could be the primary institution - - -but when we looked at all that would be required to produce the proposal AND to administer it, we decided that we had to go with a US-based institution. However, we stated explicitly that should the award be RE-COMPETED after its initial seven years, the competitive renewal would come from Malawi AND the overall PI would be a Malawian.

As we embarked on writing the proposal, one of the Malawian Project Leaders asked to step down - - he was over committed. The only person who could step in at the last minute was an American with a long track record of working in Malawi.

Six months after the proposal was submitted, we were asked to revise it and resubmit it, trimming the budget by 50% in response to the reviewers' comments. Two of the four projects had not fared well on review, so we absorbed as much of them as we could into the other other projects, and resubmitted it.

Luckily, it was funded in July 2010. That very month, the Malawian who was leading the Data Core was accepted into a PhD program in the US. Serendipitously, we were approached by an American with the right skill set who was eager to work "in the field". We (the ICEMR team) considered her CV, met with her, and hired her.

So now, we have two projects (one led by a Malawian, one led by an American), three cores (one of which has to be led by the PI, and the other two led by Americans because there were not Malawians who could be identified). Aside from 2 support people at Michigan State, the rest of the ICEMR team (50+ in number) are Malawians.

The project is embedded in the University of Malawi College of Medicine - - the grants administration is handled by the Research Support Centre, the Molecular Core is in the Department of Biochemistry (and serves the rest of the College, as well as the ICEMR projects), and the Data Core and project offices are in the Malaria Alert Centre.

All of the data management equipment (the server and the computers) are in the Alert Centre, and are maintained by the IT Department of the College of Medicine.

All of the study protocols were developed in Malawi, both conceptually and actually. All of the work is conducted in Malawi. All data entry, cleaning and analysis happens in Malawi.

We've had to be nimble, and to adapt to lots of different changing circumstances.

We only have two publications so far - - one has a Malawian as its first author, and the other has his mentor (also part of our team) as its first author.

In terms of your question about "how long does it take?" to develop research capacity, I would say "a long time!". Our Malawian collaborators are extremely able - - but they are tugged in so many different directions! It takes time to build enough bench strength to teach medical students, to administer a medical school AND to carry out research!

Let me know if you have additional questions, Mary!

Terrie Taylor
Replied at 11:56 AM, 25 Jul 2012

Hi, TT again - - I completely agree with Constance! It will take awhile for clinicians to learn how to use the RDTs effectively!!

Nana Yaa Boadu
Replied at 12:29 PM, 25 Jul 2012

Dr. Constance Bart-Plange has highlighted a very important issue. Certainly a reliance on clinical diagnosis built from decades of presumptive treatment of fever as malaria will not be wiped away within two years of revising testing and treatment policies for the disease.

Informed interventions to improve healthcare providers confidence in RDT-guided malaria management (in the case of both positive and negative test results) will likely be helpful. 

Then of course that raises the issue of capacity for differential diagnosis, especially in peripheral facilities. If a healthcare provider excludes malaria using an RDT, and then must fall back on clinical algorithms to make an alternative diagnosis, is it possible that this serves to reinforce clinical/symptomatic diagnosis in the long run? 

Nana

 
 
Nana Yaa Boadu
PhD Candidate, School of Public Health
University of Alberta, Edmonton
Canada
Phone: +1780 885 1764
Phone: +233 54 406 4781




________________________________
From: GHDonline (Terrie Taylor) <>
To: Nana Yaa Boadu <>
Sent: Wednesday, July 25, 2012 9:56 AM
Subject: Re: [Malaria Treatment & Prevention] Lessons learned from Malawi: Discuss with Terrie Taylor

Terrie Taylor replied to the discussion "Lessons learned from Malawi: Discuss with Terrie Taylor" in the Malaria Treatment & Prevention community.

Reply contents:
"Hi, TT again - - I completely agree with Constance!  It will take awhile for clinicians to learn how to use the RDTs effectively!!"

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Awash Teklehaimanot
Replied at 1:49 PM, 25 Jul 2012

RDTs are effectively used by Community Health Workers who received less than a day of training.. Is it because clinicians will be unwilling to use the RDTs that it will be a while for them to use the tools effectively?

Awash
________________________________________
From: GHDonline (Nana Yaa Boadu) []
Sent: Wednesday, July 25, 2012 12:29 PM
To: Awash Teklehaimanot
Subject: Re: [Malaria Treatment & Prevention] Lessons learned from Malawi: Discuss with Terrie Taylor

Nana Yaa Boadu replied to the discussion "Lessons learned from Malawi: Discuss with Terrie Taylor" in the Malaria Treatment & Prevention community.

Reply contents:
"Dr. Constance Bart-Plange has highlighted a very important issue. Certainly a reliance on clinical diagnosis built from decades of presumptive treatment of fever as malaria will not be wiped away within two years of revising testing and treatment policies for the disease.

Informed interventions to improve healthcare providers confidence in RDT-guided malaria management (in the case of both positive and negative test results) will likely be helpful.

Then of course that raises the issue of capacity for differential diagnosis, especially in peripheral facilities. If a healthcare provider excludes malaria using an RDT, and then must fall back on clinical algorithms to make an alternative diagnosis, is it possible that this serves to reinforce clinical/symptomatic diagnosis in the long run?

Nana



Nana Yaa Boadu
PhD Candidate, School of Public Health
University of Alberta, Edmonton
Canada
Phone: +1780 885 1764
Phone: +233 54 406 4781




________________________________
From: GHDonline (Terrie Taylor) <>
To: Nana Yaa Boadu <>
Sent: Wednesday, July 25, 2012 9:56 AM
Subject: Re: [Malaria Treatment & Prevention] Lessons learned from Malawi: Discuss with Terrie Taylor

Terrie Taylor replied to the discussion "Lessons learned from Malawi: Discuss with Terrie Taylor" in the Malaria Treatment & Prevention community.

Reply contents:
"Hi, TT again - - I completely agree with Constance! It will take awhile for clinicians to learn how to use the RDTs effectively!!"

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Terrie Taylor
Replied at 1:50 PM, 25 Jul 2012

I agree with Nana - - sometimes I wish someone would invent a dipstick that would provide a hint to the clinicians (e.g., "high neutrophil count" to suggest a bacterial infection, "lymphocytosis" to suggest a viral etiology)....


TT

Terrie Taylor
Replied at 2:04 PM, 25 Jul 2012

Awash - - hello! It's been ages since our paths have crossed.

I don't think the challenge is with PERFORMING the RDT - - the challenge lies with the interpretation of the RDT, and the clinical decisions based on the interpretation.

TT

Idongesit Ukpe
Replied at 2:34 PM, 26 Jul 2012

It should be of interest to know why the clinicians don't believe negative
RDT results. Any idea?

IS Ukpe

Edward Kamau
Replied at 3:24 PM, 26 Jul 2012

There are several reasons; some clinicians still trust clinical symptoms more than lab/RDT results.
The options for negative RDT results are limited or non existent in most settings, where antimalarials are the only drugs available. Referral system or availability of alternative drugs (antibiotics) or tests to conform what other diseases the patient may be having are not provided along with RDT. So instead of letting the patient return home without "treatment", they prescribe the only drug available despite indication that the patient does not have malaria!

Edward Kamau
----------------------------------
Sent from a BB terminal

----- Original Message -----
From: GHDonline (Idongesit Ukpe) [mailto:]
Sent: Thursday, July 26, 2012 08:34 PM
To: KAMAU, Edward Mberu
Subject: Re: [Malaria Treatment & Prevention] Lessons learned from Malawi: Discuss with Terrie Taylor

Idongesit Ukpe replied to the discussion "Lessons learned from Malawi: Discuss with Terrie Taylor" in the Malaria Treatment & Prevention community.

Reply contents:
"It should be of interest to know why the clinicians don't believe negative
RDT results. Any idea?

IS Ukpe

-----Original Message-----
From: GHDonline (Terrie Taylor) [mailto:]
Sent: 24 July 2012 10:28 PM
To: Idongesit Ukpe
Subject: Re: [Malaria Treatment & Prevention] Lessons learned from Malawi:
Discuss with Terrie Taylor

Terrie Taylor replied to the discussion "Lessons learned from Malawi:
Discuss with Terrie Taylor" in the Malaria Treatment & Prevention community.

Reply contents:
"Hi, Violet - -


The National Malaria Control Programme in Malawi are rolling out the RDTs,
and for now, they are only being used in health care facilities. The
clinicians are loving the SPEED, and they seem to be trusting the positive
results - - but it is hard to convince them (sometimes) to believe the
negative results!

TT"

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FLORA KALIMBA
Replied at 3:34 PM, 26 Jul 2012

I feek other clinicians prescribe presumptively for fear of being pointed a finger that the patient died because they refused the patient from getting access to ACTs,they would rather wash hands that they did something to the patient than following the drug policy
Sent from my BlackBerry® smartphone provided by Airtel Malawi.

Charles Llewellyn
Replied at 4:03 PM, 26 Jul 2012

Because the patients think it is malaria, and they have effective treatment
for malaria. Anything else would take time to diagnoisis and they might
not have the treatment, if they could figure it out. Sad but often true.

On Thu, Jul 26, 2012 at 7:34 PM, GHDonline (Idongesit Ukpe) <
> wrote:

> Idongesit Ukpe replied to the discussion "Lessons learned from Malawi:
> Discuss with Terrie Taylor" in the Malaria Treatment & Prevention community.
>
> Reply contents:
> "It should be of interest to know why the clinicians don't believe negative
> RDT results. Any idea?
>
> IS Ukpe
>
> -----Original Message-----
> From: GHDonline (Terrie Taylor) [mailto:]
> Sent: 24 July 2012 10:28 PM
> To: Idongesit Ukpe
> Subject: Re: [Malaria Treatment & Prevention] Lessons learned from Malawi:
> Discuss with Terrie Taylor
>
> Terrie Taylor replied to the discussion "Lessons learned from Malawi:
> Discuss with Terrie Taylor" in the Malaria Treatment & Prevention
> community.
>
> Reply contents:
> "Hi, Violet - -
>
>
> The National Malaria Control Programme in Malawi are rolling out the RDTs,
> and for now, they are only being used in health care facilities. The
> clinicians are loving the SPEED, and they seem to be trusting the positive
> results - - but it is hard to convince them (sometimes) to believe the
> negative results!
>
> TT"
>
> --
> View this post online:
> <
> http://www.ghdonline.org/malaria/discussion/lessons-learned-from-malawi-dis
> cuss-with-terrie-ta/#reply-5314-2?id=17798448&format=text&type=instant>
>
> Unsubscribe or change your email notification settings:
> <http://www.ghdonline.org/users/idongesit-ukpe/edit/>
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> will be shared with all community members and posted as is. Files cannot be
> added via email attachment and must be uploaded directly to GHDonline."
>
> --
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> <
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> >
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>



--
Charles Llewellyn
114 Marsh Street
Beaufort, NC 28516

US Cell 919 599-2147

Awash Teklehaimanot
Replied at 8:46 PM, 26 Jul 2012

Hi Terrie,

Greetings from New York. It has been a while since we saw last. It is good to hear from you. I agree that there is a challenge to the interpretation of RDT and treatment decisions. But as you know we have come a long way from diagnosing fever cases as malaria to the detection of malaria parasites in febrile patients with RDTs. For lack of better tools, we take an RDT positive case to be case that is sick from malaria event hough it is possible that a febrile patient with malaria parasitemia could be sick from other causes.

Best regards,
Awash
________________________________________
From: GHDonline (Terrie Taylor) []
Sent: Wednesday, July 25, 2012 2:04 PM
To: Awash Teklehaimanot
Subject: Re: [Malaria Treatment & Prevention] Lessons learned from Malawi: Discuss with Terrie Taylor

Terrie Taylor replied to the discussion "Lessons learned from Malawi: Discuss with Terrie Taylor" in the Malaria Treatment & Prevention community.

Reply contents:
"Awash - - hello! It's been ages since our paths have crossed.

I don't think the challenge is with PERFORMING the RDT - - the challenge lies with the interpretation of the RDT, and the clinical decisions based on the interpretation.

TT"

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Gashu Zegeye
Replied at 1:46 AM, 27 Jul 2012

Dear all,
The RDTs are intended for use by health care providers
working at community / grassroots level, whose activities focus mainly on
prevention and treatment, which are not too clinical. The problem lies when you
are using RDTs at higher levels (from the health center and more) where the
diagnosis should be the gold standard microscope, which is expected again to
provide treatment for negative cases referred from the community health
providers with further diagnosis with microscopes.
Gashu--- On Wed, 7/25/12, GHDonline (CONSTANCE BART-PLANGE DR) <> wrote:

From: GHDonline (CONSTANCE BART-PLANGE DR) <>
Subject: Re: [Malaria Treatment & Prevention] Lessons learned from Malawi: Discuss with Terrie Taylor
To: "Gashu Zegeye" <>
Date: Wednesday, July 25, 2012, 3:58 AM

CONSTANCE BART-PLANGE DR replied to the discussion "Lessons learned from Malawi: Discuss with Terrie Taylor" in the Malaria Treatment & Prevention community.

Reply contents:
"Hi
Ghana is facing this same dilemma: the Clinicians trust the positive results from RDTS but they dont always accept the Negative results. But can we blame them for this stance? There has been a long period in our clinical practise when we were trained, under the IMCI strategy, " to treat fever cases as malaria, in the absence of any other symptom". We are also told, depending on the parasite density, RDTs may not show positive results. It is therefore important that, clinicians combine their clinical expertise ( very good history taking, very thorough examinations for signs and symptoms) and RDT or microscopy results.


(Dr Constance Bart-Plange, Malaria Program Manager, Ghana

On 24 Jul 2012, at 08:28 PM, "GHDonline (Terrie Taylor)" <> wrote:

> Terrie Taylor replied to the discussion "Lessons learned from Malawi: Discuss with Terrie Taylor" in the Malaria Treatment & Prevention community.
>
> Reply contents:
> "Hi, Violet - -
>
>
> The National Malaria Control Programme in Malawi are rolling out the RDTs, and for now, they are only being used in health care facilities.  The clinicians are loving the SPEED, and they seem to be trusting the positive results - - but it is hard to convince them (sometimes) to believe the negative results!
>
> TT"
>
> --
> View this post online:
> <http://www.ghdonline.org/malaria/discussion/lessons-learned-from-malawi-discu...>
>
> Unsubscribe or change your email notification settings:
> <http://www.ghdonline.org/users/constance-bart-plange-dr/edit/>
>
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>
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Terrie Taylor
Replied at 6:01 AM, 27 Jul 2012

Good morning!

The discussion has highlighted the challenges of interpreting both positive and negative RDTs - - - the presence of a parasite antigen, which is what the HRP-2 based tests detect, is one step away from identifying parasites per se - - and even the presence of parasites does not necessarily mean that the parasites are related to the patient's symptoms. This is not a problem limited to RDTs - - it is a limitation of microscopy as well.

The second challenge has to do with the clinician's decision regarding the patient who tests negative for an RDT, and the group has very cogently outlined the myriad reasons why a clinician would go ahead and treat for malaria in the face of a negative RDT.

I see this area as a MAJOR challenge for malaria control programmes, going forward.

At the most basic level, even if malaria is eliminated, the public will continue to experience short-lived febrile (viral) illnesses . . . will the public continue to "blame" malaria for those fevers?

At the next level, the first level of health care, clinicians need to be provided with other diagnostic tests and therapeutic options so that they don't have to "default" to treating patients for malaria.

TT

Awash Teklehaimanot
Replied at 2:58 PM, 27 Jul 2012

I agree with Trrie of the tools limitations. RDT positives or by microscopy are not necessarly related with the illness of the patient. But for lack of better tools at the moment, positive test by RDT is taken to be a malaria case.

If Negative RDTs are to be treated for malaria, then , there is no point of using the RDTs in the first place. The RDT negative cases should be referred to clinics for further evaluation to determine other causes of illness.

Awash
________________________________________
From: GHDonline (Terrie Taylor) []
Sent: Friday, July 27, 2012 6:01 AM
To: Awash Teklehaimanot
Subject: Re: [Malaria Treatment & Prevention] Lessons learned from Malawi: Discuss with Terrie Taylor

Terrie Taylor replied to the discussion "Lessons learned from Malawi: Discuss with Terrie Taylor" in the Malaria Treatment & Prevention community.

Reply contents:
"Good morning!

The discussion has highlighted the challenges of interpreting both positive and negative RDTs - - - the presence of a parasite antigen, which is what the HRP-2 based tests detect, is one step away from identifying parasites per se - - and even the presence of parasites does not necessarily mean that the parasites are related to the patient's symptoms. This is not a problem limited to RDTs - - it is a limitation of microscopy as well.

The second challenge has to do with the clinician's decision regarding the patient who tests negative for an RDT, and the group has very cogently outlined the myriad reasons why a clinician would go ahead and treat for malaria in the face of a negative RDT.

I see this area as a MAJOR challenge for malaria control programmes, going forward.

At the most basic level, even if malaria is eliminated, the public will continue to experience short-lived febrile (viral) illnesses . . . will the public continue to "blame" malaria for those fevers?

At the next level, the first level of health care, clinicians need to be provided with other diagnostic tests and therapeutic options so that they don't have to "default" to treating patients for malaria.

TT"

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Sophie Beauvais
Replied at 8:55 PM, 27 Jul 2012

Dear All,

Thank you very much for a very rich discussion and thank you again Terrie for joining us for this week-long Q&A sharing your experiences with the Blantyre Malaria Project at the Queen Elizabeth Central Hospital in Malawi.

Best, Sophie

Terrie Taylor
Replied at 3:26 PM, 30 Jul 2012

Thank YOU all for your participation -- as a parting gift, here is the pre-print of a very practical paper about the clinical management of severe malaria. It was written as a tribute to my longtime collaborator, Prof. Malcolm Molyneux, on the occasion of his 'stepping down' as the head of the Wellcome Trust unit in Malawi.

cheers,

TT

Attached resource:

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