Action Meningitis in Malawi


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Dr Rachel Perrin's presentation at Meningitis Research Foundation's 2014 Meningitis Symposium

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  • Hi.
  • Edith, who’s five, lives in Mpemba District of Blantyre, Malawi’s second largest city.
    She was just 2 when her meningitis was misdiagnosed as malaria
    Edith is now 5
    No longer see, no longer hear, no longer sit upright
    Why am I telling you about the story of Edith?
    Edith is a case study from MRF-funded research carried at Malawi Liverpool Wellcome Trust
    This study, conducted in 2010 explored health seeking pathways for patients with bacterial meningitis.
    It found that there are barriers to recognition and treatment of meningitis.
    Both at Primary Health Clinics, and within communities
    And these contribute to the high mortality from meningitis in Malawi ..........
  • Barriers to recognition and treatment of meningitis identified at primary level include:
    1. Misdiagnosis of meningitis, commonly with malaria (as in case of Edith)
    2. Unsystematic and informal triage (prioritising the patients in most need of attention) – adults and children sitting together and seen on a first come first served basis rather than prioritised systematically.
    High numbers of patients on a daily basis in busy PHCs create additional burdens on healthcare workers, which
    further exacerbates an erratic consultation system
  • The study also identified barriers to seeking timely treatment for meningitis, including:
    Negative perceptions of health services in Blantyre - appropriate HSB discouraged by long wait times, and expectation of poor care at Primary level
    Low recognition of meningitis and its symptoms within communities
    Cultural decision making practises within households in Malawi. For example Gender and age-based decision making in community
    Financial constraints in community
    The research very much pointed to the need for an intervention to focus on the recognition of and response to severe illness, both within community and at primary care level.
  • Action Meningitis is MRF’s health initiative to improve outcomes from meningitis in children in Malawi.
    This project is a direct follow on from the MRF-funded barriers study. This initiative began early 2012.
    2 arms of the project:
    The first targetted to primary health level:
    - Improving recognition of severe illness by HCW at primary clinics and making appropriate decisions on referrals.
    TRIAGE SYSTEM Improving patient pathway through the clinic
    The community level arm aims to promote positive health seeking behaviour complements the primary health level intervention.
    The community health education aspect improves the recognition of child illness by parents and guardians & encourage timely HSB
    Concentrate on Primary Level intervention today, but just briefly explain work MRF is doing in communities. Primarily through radio and theatre.....
  • Partnered with MLW and Malawi Broadcasting Corporation - ‘Health Talk’ weekly radio programme on national radio, covered health topics, and MLW research.
    Broadcast to general public & Radio Listening Clubs. Include panel discussions and opportunities for general public to ask questions, via text or phone in
    8 episodes focusing on meningitis were Aired in 2013. Of all the topics covered, Meningitis episodes – Generated most interest from public.
    Build on this success and air another 8 episodes this Autumn.
  • Another approach to tackling the barriers to seeking care is through theatre for Dev
    Through partnership with local theatre groups, Theatre performances will be carried out in the 8 communities where the Primary triage system implemented,
    With the aim of improving knowledge and awareness of meningitis in male and female parents and carers.
    Confront some of the cultural norms for health decision-making in communities (getting permission from husbands / within families).
    Also Provide an opportunity to educate about the after-effects of the disease.
    And address some of the stimga’s faced by families and individuals who are left with the life-long impact of devastating disabilities following meningitis.
  • MRF carried out a Situation analysis, visited all primary clinics within Blantyre, (of which there are 17 run by MOH),
    consulting clinicians at QECH,
    health workers at PHCs,
    and MoH officials at national and district level.
  • Found that:
    lack of effective triage at PHCs meant that severe illnesses were regularly missed.
    Limited number of health workers, equipment and supplies
    Health workers explained they were overwhelmed by high patient numbers, so emergency signs are missed.
    Long waits to see a clinician or receive treatment meant some children die waiting in the queue before ever being assessed.
    Mpemba clinic (top 2 photos) which is more rural.
    Zingwanga clinic (bottom left) is urban, in a township, with a higher population and longer queues and wait times. (right photo- weighing child before entering clinic)
    Clinics use similar systems according to MoH and WHO, but the number of personnel and patients differ, and details of processes and services depend on each clinic’s management and resources.
    Basic supplies = stethoscope, thermometer, basic blood lab (malaria, TB, HIV), immunizations, first line drugs and antibiotics
    Lumbar puncture and further treatment/ drugs require referral to hospital
    Clinics have radios and mobile phones to call for ambulance, but ambulance can take up to 2 days to arrive, or delay trip to hospital until there are a few people to transport in 1 trip. When referred, patients/ carers are advised to get their own transport, which they have to pay for.
  • Embarked on a 6-mo pilot.
    Aim = Implement a triage system within 5 PHCs in Blantyre.
    To develop a triage algorithm, specific for Primary Health Clinics
    To implement prioritisation system within each clinic
    To encourage appropriate referral decisions by HCW to tertiary centre & track referrals
    To evaluate triage system – in order to develop and refine it
  • Let’s first take a look at the Triage system itself .....
    This uses the ETAT (Emergency Triage, Assessment and Treatment ) protocol, developed by the WHO (originally developed in Malawi for hospitals in resource-poor settings).
    It is specifically aimed at lower cadre staff.
    It has had a huge impact in hospital settings, where it has cut mortality rates.
    Our triage tool is based on Emergency Triage component of ETAT
    The triage tool, or triage protocol is basically an app on a mobile phone.
    From a practical point of view = its an ideal tool for HCW to quickly navigate around crowded clinics, assessing patient after patient
    Benefits – ensure hcws stick to protocol, don’t skip step. The phone acts as a prompt to the user to identify severely ill children.
    Action Meningitis is the 1st intervention of its kind combining triage and mhealth.
    In close collaboration with MOH, Action Meningitis established a triage system,
    The Action Meningitis ETAT system was sucessfully implemented within 5 PHCs of Urban Blantyre
    Urban and peri-urban clinics with varying catchment populations
  • System for triage – Chipatala Robots
    The intervention was developed using the concept of the Chipatala Robots (Chipatala meaning health centre and robots meaning traffic lights). Chichewa
    We created Chip as a character to guide patients and carers through the system.
    The clinics’ HCWs assess a child’s symptoms on arrival using a mobile phone app. It’s based on a traffic light system of triage developed by the World Health Organisation.
    Patient is triaged through a series of simple questions on the smartphone screen asking about key clinical signs to identify severe illness
    Screenshot of the triage app.
    Each patient is given a unique personal identification number assigned through the phone.
    Helps HCWs quickly and accurately identify severe illnesses, like meningitis - so emergency cases are fast-tracked to hospital.
    Responses to the series of questions lead to an assignment based on the traffic lights system where
    Red depicts an emergency meaning the child is extremely sick and should be seen immediately,
    Yellow ....
    Green ....
    Patient health passports are stamped with a Chip symbol
    And patient provided with a coloured strip which helps to guide them through the system.
  • walk through the system...
    Patient - all children under 15yrs.
    Initial triage by HCW
    Assigned triage classification – Emergency, Priority , Queue
    Clinican triage and consultation
    We expected that the system would encourage appropriate referral decisions to tertiary care (Queen Elizabeth Central in Blantyre)
    We have fieldworkers at referral hosptial - phones. Collect data on all referrals that arrive to hospital, so we can track whole patient pathway, through primary to teriary
    From all of the five primary centres.
    [short video clip]
    In this clip i hope you are about to see,
    Triage system being used at a crowded clinic in Bangwe,
    a healthworker assesses a sick baby girl.
    Guided by a series of questions on his phone
    he quickly identifies her as a ‘Priority’ for the doctor.
  • It improves chances of survival by helping healthworkers quickly and accurately identify severe illnesses, like meningitis - so emergency cases are fast-tracked to hospital. The clinics’ healthworkers assess a child’s symptoms on arrival using a mobile phone app, specially created by the charity. It’s based on a traffic light system of triage developed by the World Health Organisation.
    [Sounds from clinic]
    In this crowded clinic in Bangwe, a healthworker assesses a sick baby girl. Guided by a series of questions on his phone he quickly identifies her as a ‘Priority’ for the doctor.
  • During the 6-month pilot phase, 42,000 children 0-14yrs were triaged.
    Evaluation showed the system improves patient pathways and has increased recognition of severe illness among lower level HCW unfamiliar with triage beforehand.
  • 41,358 children aged between 0 and 14 were triaged through the triage system during the six month pilot period
    Of these Bangwe, clinic we’ve just seen, triaged the most cases and Mpemba the least.
    Bangwe serves a peri-urban population, situated on the outskirts of Blantyre with a large catchment population of 132K.
    Mpemba serves a rural population spread over a large catchment area with a population of only 50K.
  • The majority of triage within each of the 5 clinics was conducted by Health Surveillance Assistants, or HSAs
    These are salaried community health workers. On average receive clinical training of 8 weeks from the Ministry of Health.
    At outset of project, HSAs received a 4-day training in triage, and how to use the phone. Included in this was one day in their own clinic, working as a team to find out the best way to implement the system there.
    One way in which we tested the quality of triage done by HSAs, was by correlating their triage classification with the assessment by the clinician.
    We found in general levels of agreement were high overall between triage and clinician assessments with an above chance level of agreement (Kappa value) of 0.71.
    93% of Queue assignments were consistent across triage and clinician assessment, but this was reduced for priority and emergency assessments with75% agreement for priority and only 54.5% agreement for emergency assessments.
    The total figures of 131 are low for Emergency assessments, but we would expect some Emergencies to be recognised immediately, bypassing the triage system. ( 27 patient carers who reached Queens reported that they had not passed through triage due to immediate recognition of severity).
    Their main role is to provide prevention and some basic curative health services at community level.
    However they are increasingly involved in primary level clinics, taking up a range of roles such as HIV testing and ART provision.
    a total of 10,507 HSAs working across Malawi in 2009, each possessing an average clinical training of 8 weeks from the Ministry of Health.
  • Phones automatically record time and date.
    So we can measure the waiting times within the clinic, between the initial triage evaluation by HSA and subsequent evaluation by clinician.
    For all 41,000 patients
    Time taken to be seen by the clinician was on average significantly shorter for emergencies, than priorities and longest for queue cases
    which is what we would expect to see with the introduction of a system that prioritises according to the severity of the illness.
  • We were able to tracked all referrals from each of the five primary centres.
    Fieldworkers based at tertiary referral hospital armed with mobile phone captured data at the A&E department of the tertiary referral hospital (QECH)
    around the clock so were able to capture all patients entering the hospital from all 5 participating clinics.
    Of all patients seen by the primary level clinicians who had been triaged using tool, 644 or 1.6% were referred.
    However only 37% reached hospital.
    Amongst those who reached Queens mean time between initial triage assessment and arrival at QECH was 5.5 hours.
    This 63% is of concern. We do not know what happened to them. and something we would like to investigate further.
    15.5%(100) - Emergency
    74.9%(482) - Priority
    9.6% (62) - Queue
  • Overall the intervention was viewed very positively by primary health staff with a strong perception that it had improved patient pathways through the clinic.
    PJM identified positive changes in patient flows and ssi health care worker satisfaction high.
    One comment that was mentioned time and time again and reflected in this quote is how the intervention brought the hcws together to work as a team.
  • 40 additional HCWs trained in 3 centres
    Data collection for analysis, evaluation, evidence for success and scaling up
  • Since ETAT triage up and running – Dec 2013
    Triaged over 148,000 children
  • mHealth technologies have the potential to improve primary level services with high patient numbers and over burdened staff.
    How best to adapt our ETAT system, originally developed for hospitals, to the primary setting, still needs to be shown.
    Understanding 63% dropout between primary level referral and arrival at tertiary.
    Since we aim to improve pathways this dropout is of concern.
    Understanding the appropriateness of referral decisions through follow up of referrals through QECH system, particularly tracking admission rates from referrals and obtaining detailed symptom profiles of all referral patients, exploring the links between identification of symptoms as severe and referral decisions.
    Building on a successful foundation we aim to provide MOH with evidence that ETAT can be successfully implemented in a sustainable and cost-effective way.
  • So, returning to the story of Edith. When we went back to see her last year her father said that his one wish was for PHCs to improve on recognising symptoms earlier....
    This sudy has shown that mHealth technologies have the potential to improve primary level services with high patient numbers and over burdened staff.
  • There is a trend as can be seen here though not significant especially because the sample sizes were small for Qs and Es.
  • Since 2001 MRF has sought to improve the very severe outcomes from meningitis in Malawi, where half of childhood cases of meningitis are fatal, by funding research into improved treatments
    But these were found to be of no benefit, due to patients late presentation to hospital
  • Action Meningitis in Malawi

    1. 1. MRF’s healthcare and awareness initiative in Malawi MRF Meningitis Symposium 11 June 2014
    2. 2. Barriers to recognition and treatment of meningitis at Primary Health Level Primary health level misdiagnoses High numbers of patients Erratic consultation systems Unsystematic & informal triage Desmond et al 2013 PLOSone
    3. 3. Desmond et al 2013 PLOSone • Negative perceptions of health services • Low level of awareness of meningitis • Gender and age-based decision making in community • Financial constraints Barriers to seeking timely treatment for meningitis at community level Desmond et al 2013 PLOSone
    4. 4. Action Meningitis • Improved recognition of severe illness • Appropriate referral Primary Health Level Community Level • Community recognition & awareness of meningitis and triage system • Initiation of timely treatment Triage system Theatre Radio
    5. 5. ‘Health Talk’ Radio
    6. 6. Theatre for Development • Partnering with local theatre group • Establish a community-level intervention to encourage recognition and response to illness
    7. 7. Primary Health Clinics: Blantyre Primary Health Level Triage system
    8. 8. • Severe illness regularly missed • Limited number of HCW, equipment & supplies • HCW overwhelmed • Long queues Primary Health Clinics: Blantyre
    9. 9. Aims: 1. To develop a triage system, tailored for PHCs 2. To implement this system within 5 PHCs in Blantyre 3. To encourage appropriate referral decisions to hospital & track referrals 4. To monitor, evaluate and refine this system Implementation of Triage System
    10. 10. ‘mHealth’ Triage Tool • Emergency Triage, Assessment and Treatment (ETAT) protocol developed by the WHO. • Designed for hospital settings, in resource-poor countries. • Specifically aimed at lower cadre staff.
    12. 12. Improving patient pathways Patient enters PHC HCW conducts rapid triage Patient assigned E, P, Q Clinician conducts consultation & enters dataAdapted from Sarah Bar-Zeev (2012) Patient follows clinician instructions Patient Triage PHC ClinicianQECH Fieldworker If referred to QECH data entered on arrival
    13. 13. Bangwe clinic
    14. 14. Evaluation
    15. 15. • Measured agreement between HSA triage assessment and clinician triage assessment. • Above chance agreement for concordance between triage and clinician assessment (kappa = 0.71) Accuracy of triage
    16. 16. (Anova P < 0.001) Triage evaluation Time taken (mins) Paediatric cases Emergency 28.3 131 Priority 44.6 13,585 Queue 59.0 26,452 Mean clinic waiting times
    17. 17. • Out of 41,358 children triaged 1.6% (644) were referred to QECH • From the 644 referrals 37.3% (240) arrived at QECH • Overall mean time to QECH 5.5hrs • 62.7% (404) of referrals from PHCS did not reach QECH Referrals
    18. 18. “At Bangwe we are now working together as a team. It is helping us manage the children so much better. We are seeing them far more quickly than before” “At Bangwe we are now working together as a team. It is helping us manage the children so much better. We are seeing them far more quickly than before” Medical Assistant, 2013 Qualitative findings
    19. 19. Chikhwawa District • Rural setting, 2.5hrs outside Blantyre • Chipatala Robot triage system at two additional Primary Clinics • Also in District Hospital • 40 HCW trained
    20. 20. 148,131 children triaged Triage dashboard
    21. 21. Next steps • Continue triage system in 8 centres. - High drop-out between primary level referral and arrival at tertiary (63%). - How best to adapt triage for primary setting? - Provide evidence that triage can be successfully implemented in a sustainable and cost-effective way. Primary Health Level Community Level • Continue to develop theatre and radio interventions.
    22. 22. Mphatso Cheonga, 2012 “I only wish the primary health centres could improve on diagnosis and recognising symptoms quicker...” “I only wish the primary health centres could improve on diagnosis and recognising symptoms quicker...”
    23. 23. Acknowledgments MLW Nicola Desmond Rob Heyderman Deborah Nyirenda Queen Dube Elizabeth Molyneux Rob Heyderman MRF Linda Glennie Chris Head Thomasena O’Byrne Zione Kalvosi Meliya Kwelepeta Bernadetta Payesa MoH Norman Lufesi Dr Owen Malema Dr Amber Manjidu ETAT Registrars Dr Zondiwe Mwanza Dr Thembi Chirwa Dr Yabwile Mulambia Mtisunge Gondwe D-Tree International Dr Marije Geldof Dr Marc Mitchell Phidelis Suwedi Primary Clinics Bangwe: Tinkhani Bophani Chilomoni: Dalitso Namasani Ndirande: Francis Phiri Mpemba: Rodgers Kuyokwa Zingwangwa: Margaret Chingona All photos reproduced by kind permission of participants
    24. 24. Referrals arriving at QECH with mean time taken between primary and tertiary (Anova P = 0.39) mHealth Triage evaluation Time taken (hours) Paediatric cases E 3.5 33 P 5.7 193 Q 6.8 14 Overall mean time 5.5 hours
    25. 25. Background Research • £700K MRF research in Malawi • Late presentation at tertiary level contributes to mortality from acute bacterial meningitis (ABM) • Study into barriers of recognition and action in treating ABM in Malawi…