MSc: CONTROL OF INFECTIOUS DISEASES
PROJECT REPORT TITLE
STRATEGIES FOR CONTROLLING MALARIA AND HUMAN AFRICAN TRYPANOSOMIASIS IN ANGOLA
SUPERVISOR: PROFESSOR MICHAEL MILES
CANDIDATE: 49 11 83
WORD COUNT: 9976
Submitted in part fulfilment of the requirements for the degree of MSc on Control of Infectious Diseases
1 of 73 ACKNOWLEDGEMENTS
I would like to express my gratitude to almighty God for the ability to undertake a Masters
Degree course on Control of Infectious Diseases, at the London School of Hygiene and
Tropical Medicine. I would like to thank Professor Michael Miles, very much for giving me the opportunity to do this project and for sending me to the field, supervising this project and for all his support and guidance throughout the project.
I would like also to thank Professor Schofield, Dr. Matthew Yeo from LSHTM for support and advice on the project, all lecturers, and seminar leaders and fellow students from LSHTM for encouragement and support.
I am very grateful to the Ministry of Health in Angola Dr. Jose Van-dunem, Dr. Nilton
Saraivo, D.r Filomena Forte, Professor Josenando Theophile, Dr. Kiasekoka Miguel, Dr.
Vatunga, Dr. Amadeus, Dr. Morgado, Dr. Adao Castelo Antonio, Dr. Eduardo, Dra Marilia,
Dr. Jose Samuel, Dra Maria Rita, Dr. Zinalda, Dr. Rafael, Dr. Nicolau Mfinda, Mr. Felix and health personnel of the national control programme of malaria in Angola and Instituto de
Combate e Controlo de Trepanosomiases, Hospital Jorgina Machel, Clinica de Bom Deus,
Hospital Geral de Benguela, Centro de Internamento e Investigacao de Doencas de Sono, director provincial de saude no Kuanza Sul for hosting me in fieldwork and encouraging me and assisting me to do interviews with health personnel and patients.
Many thanks to my wife Dr. Lando Vita and my two sons Ebenezer Vita and Emmanuel Vita thanks to my father Filipe Luvumbo and Rosita Lubondo and my sister Tete, Nsimba, Lufua, and my uncle Dr. Domingos Vita for support.
Thanks to Apostle Simao Lutumba and Mama Sofia for providing me a place to stay during the fieldwork in Angola.
Many thanks to members of Southampton and London International Evangelical Church, for spiritual support in prayer. Thanks to all people who supported me directly or indirectly to do the course and this project.
2 of 73 ABBREVIATION
ACT Artemisinin Combination Therapy
ASDI Swedish Agency for International Development
CATT Card Agglutination Test for Trypanosomiasis
DNPM Direccao National Do Programa da Malaria
DR Doctor
DRC Democratic Republic of Congo
EPCM Estratégico Plano de controle de malaria
GDP Gross Domestic Product
GFM Global Fund malaria
HAT Human African trypanosomiasis
IPTp Intermittent preventative therapy for pregnant
IPTi Intermittent preventative therapy for infant
IEC Information education communication
IRS Indoor residual spraying
ICCT Instituto de Combate e Controle de Tripanossomíase
LAV Luta Anti Vetorial
LLIN Long Lasting Insecticide Treated Net
LSHTM London School of Hygiene and Tropical Medicine
MDGs Millennium Development Goals
MMCM Manual de Manejo de Casos de Malaria
MCT Missão de Combate a Tripanossomíase
MPLA Movimento Popular para libertação de Angola
NCPM National Control Programme for Malaria
NCP National Control Programme
PNCM Programa Nacional de controle de Malaria
PMI President‟s Malaria Initiative
RBM Roll Back Malaria
RCB Republic of Congo Brazzaville
3 of 73 SP Sulfadoxine-Pyrimethamine
UNITA União Nacional para Independência Total de Angola
UNICEF United Nations International Children Emergency Fund
WHO World Health Organization
4 of 73 ABSTRACT
This study is concerned with the strategy for controlling malaria and human African trypanosomiasis in Angola. Malaria results in the premature death of children under five years old and pregnant women in Angola. Malaria is classified as one of the major killing diseases in Angola with higher prevalence and incidence in the provinces of Luanda and
Huambo. War in Angola was one of the principal factors that influenced the higher prevalence and incidence of malaria and human African trypanosomiasis. Morbidity and mortality of malaria and trypanosomiasis in Angola affected the economy of the country in decreasing the gross product domestic (GDP).
Methods: Qualitative and quantitative method of systematic review to gather data for this project was used. Interviews and questionnaires with Angolan public health personnel and patients at the National Direction of Malaria and Instituto de Combate e Controle de
Tripanosomiase, hospitals and visits to some endemic foci in Angola.
Results: Malaria infects any one and both genders in Angola. The disease is distributed to all provinces. Prevalence and incidence of malaria is higher in the province of Huambo and
Luanda. Auto medication and lack of completing therapy are problems associated with treatment. African trypanosomiasis is classified as a neglected disease. People were dying with disease without notification. Active men, women and children under three years old are more vulnerable to disease.
Conclusion: Malaria and human African trypanosomiasis causes serious problems to public health. Active control of malaria and human African tripanosomiasis in Angola will help to decrease morbidity and mortality rate. Identifying people who are affected and treating them, controlling vectors by using LLIN, IRS, pulverization and capture of tsetse are effective strategies for controlling malaria and human African trypanosomiasis in Angola.
5 of 73 Contents ACKNOWLEDGEMENTS ...... 2 ABBREVIATION ...... 3 ABSTRACT ...... 5 List of Tables ...... 8 List of Figures ...... 9 1.0. INTRODUCTION ...... 10 1.1 MALARIA IN ANGOLA ...... 11 1.2 INCUBATION PERIOD OF MALARIA ...... 11 1.3 TRANSMISSION ...... 11 1.4 CLINICAL PRESENTATION OF MALARIA ...... 12 1.5 DIAGNOSIS OF MALARIA ...... 12 1.6 TREATMENT OF MALARIA ...... 12 1.7 STRATEGIES FOR CONTROLLING MALARIA IN ANGOLA ...... 12 1.8 HUMAN AFRICAN TRYPANOSOMIASIS ...... 15 1.9 CLINICAL MANIFESTATION ...... 16 1.10 DIAGNOSIS OF HUMAN AFRICAN TRYPANOSOMIASIS ...... 16 1.11 TREATMENT ...... 16 1.12 CONTROL OF HUMAN AFRICAN TRIPANOSOMIASIS IN ANGOLA ..... 17 1.13 HISTORY OF TRYPANOSOMIASIS IN ANGOLA ...... 17 1.14 EPIDEMIOLOGICAL DATA...... 19 1.15 GENERAL DESCRIPTION OF ANGOLA ...... 21 1.16 HISTORICAL PERSPECTIVE ...... 21 2.0. OVERAL AIM OF PROJECT:...... 22 2.1. SPECIFIC OBJECTIVES OF PROJECT ...... 23 3.0. METHODS: ...... 24 3.1 INTRODUCTION ...... 24 3.2 LITERATURE SEARCHES ...... 24 3.3 INCLUSION CRITERIA ...... 25 3.4 EXCLUSION CRITERIA ...... 25 3.5 INTERVIEWS AND QUESTIONNAIRES ...... 25 3.6 VISIT TO ENDEMIC FOCI ...... 26 3.7 DATA ANALYSIS ...... 26 3.8 ETHICAL CONSIDERATIONS ...... 26 4.0 RESULTS, OF LITERATURE REVIEWED IN ANGOLA ...... 27 4.2 MALARIA, RESULTS OF LITERATURE REVIEWED IN ANGOLA ...... 27 4.3 PREVALENCE AND INCIDENCE OF MALARIA IN ANGOLA ...... 28 4.4 TREATMENT OF MALARIA IN ANGOLA ...... 29 4.5 CONTROL OF MALARIA IN ANGOLA ...... 30 4.6 HUMAN AFRICAN TRYPANOSOMIASIS, RESULTS OF LITERATURE REVIEWED IN ANGOLA ...... 31 4.7 PREVALENCE AND INCIDENCE OF HAT IN ANGOLA ...... 31 4.8 TREATMENT OF HAT IN ANGOLA ...... 32 4.9 CONTROLLING HAT IN ANGOLA ...... 32 4.10 SUMMARY OF LITERATURE REVIEWED IN ANGOLA ...... 32 5.0 RESULTS OF FIELD WORK ...... 34 5.1 INTERVIEWS AND QUESTIONNAIRES ...... 34 5.2 RESULTS FROM INTERVIEWS AND QUESTIONNAIRES ABOUT MALARIA IN ANGOLA ...... 34 5.3 INTERVIEWS AND QUESTIONNAIRES ABOUT HAT IN ANGOLA...... 38 5.4 SUMMARY ...... 42 6.0 DISCUSSION ...... 43 6.1 PRINCIPAL FINDINGS FOR MALARIA IN ANGOLA ...... 43 6.2 FINDING FOR HUMAN AFRICAN TRYPANOSOMIASIS IN ANGOLA ...... 45
6 of 73 6.3 LIMITATIONS OF THE PROJECT ...... 47 6.4 RECOMMENDATIONS ...... 47 7.0 CONCLUSIONS ...... 49 8.0 REFERENCES ...... 50 9.0 APPENDICES ...... 54 APPENDIX 1: DEATHS WITH MALARIA IN ANGOLA FROM 1999-2009 ...... 54 APPENDIX 2: PERCENTAGE OF CASES OF MALARIA IN PROVINCES (PNCM, 2010) ...... 55 APPENDIX 3: PERCETAGE OF DEATH WITH MALARIA IN PROVINCES (PNCM, 2010) ...... 56 APPENDIX 4 : QUESTIONS CONSIDERED THROUGH LITERATURE RESEARCH AND DISCUSSIONS WITH AUTHORITIES IN ANGOLA ...... 57 APPENDIX 5: CARE FORM ...... 62 APPENDIX 6: CONTACT LETTER ...... 73
7 of 73 List of Tables Table 1: ENDEMIC PROVINCES WITH HAT IN ANGOLA (ICCT, 2010) ...... 19 Table 2: PROVINCES WITH GLOSSINA IN ANGOLA (ICCT, 2010) ...... 20 Table 3: YEARS AND NEW CASES OF HAT IN ANGOLA (Josenando et al.2001) . 21 Table 4: GEOGRAPHIC DISTRIBUTION OF MALARIA IN ANGOLA (PNCM, 2007) ...... 27 Table 5: LLINs DISTRIBUTED IN ANGOLA FROM 2006-2009 (PMI, 2006) ...... 28 Table 6: YEAR OF FERENCE AND NUMBER OF CASES OF MALARIA IN ANGOLA FROM 1999-2009 (PNCM, 2009) ...... 29 Table 7: TREATMENT OF MALARIA WITH ARTEMETER+LUMEFANTRINE IN ANGOLA AND PRINCIPAL FACTORS TO CONSIDER (PNCM,2009) ...... 30 Table 8: CATEGORY OF PEOPLE AND NUMBER INTERVIEWED IN ANGOLA .... 34 Table 9: FOCI FOR MALARIA AND HAT VISITED IN ANGOLA ...... 34
8 of 73 List of Figures Figure 1: Demonstration of IPT ...... 13 Figure 2: Demonstration of how to use LLIN. (WHO, 2009) ...... 14 Figure 3: Larva elimination and pulverization ...... 15
9 of 73 1.0. INTRODUCTION
This project aims to find out the status of malaria and human African trypanosomiasis control programmes in Angola, and consider relevant control strategies to reduce the prevalence, incidence and mortality and the prospects for implementing them. Therefore, the project will involve information gathering on the history and status of control of malaria and human African Trypanosomiasis in
Angola and the prospects for future implementation of control strategies. There is evidence of high prevalence, incidence, morbidity and mortality rates resulting from malaria and Human African trypanosomiasis in developing countries, although some preventable measures are being put in place to help make improvements to the present situation.
This study is relevant because malaria and trypanosomiasis are known to be serious public health issues in Angola. 270 million of the world‟s population are currently infected with Plasmodium and the prevalence is high in developing countries including Angola. Malaria is one of the major killer diseases that affect the economy of a country because of the morbidity, mortality and high cost of the treatment of the disease. The prevalence, morbidity and mortality rates of malaria increase as result of damage to health infrastructures, such as has occurred due to the war in Angola
(WHO, 2006).
Angola is the second country in the world in terms of the number of new cases of human African trypanosomiasis (HAT) notified, despite the country‟s weak surveillance system for HAT. The true epidemiological situation in the country is unknown due to the civil war, which has been ongoing periodically since 1975 and has limited the number of functional mobile teams to implement relevant strategies for controlling trypanosomiasis. Angola is taking steps to reach rural and remote populations. It is necessary to know that Angola is composed by 18 provinces or cities. During the civil war most of the cities in Angola became weak and the health
10 of 73 system is weak, therefore “many health staff have only basic training and health facilities are in need of repair”(Unicef and WHO, 2005).
1.1 MALARIA IN ANGOLA
Malaria is caused by four species of Plasmodium parasites, which are Plasmodium falciparum, Plasmodium malariae, Plasmodium vivax and Plasmodium ovale (WHO,
20008). Malaria in Angola is one of the major killer diseases, especially for children under 5 years and pregnant women. More than 2.610.070 people were affected in
2005 in Angola and 12.702 people died from malaria (PNCM, 2006).
Angola emerged from three decades of civil war in 2002 that severely damaged infrastructure of the country, particularly the health sector. Angola has an approximate population of 17.5 million people in 18 provinces and 164 municipalities
(Districts).
Malaria is defined as a parasitic disease caused by infection with one or more of four species of intracellular protozoan parasite (Heymann, 2008).
1.2 INCUBATION PERIOD OF MALARIA It is relevant to understand that the period of incubation of malaria depends on the type of parasite. That means each parasite has different periods of incubation such as Plasmodium falciparum for which the incubation period is approximately 9 to 14 days, Plasmodium vivax and Plasmodium ovale 12 to 18 days and 18 to 40 days for
Plasmodium malariae (Heymann, 2008). The incubation period of Plasmodium malariae is therefore longer than other parasites (WHO and UNICEF, 2004).
1.3 TRANSMISSION Malaria infection is usually acquired by the bite of an infected female Anopheles mosquito. The primary vectors in the high transmission areas are Anopheles gambiense and Anopheles funestus, which prefer to bite humans and feed and rest indoors (EPCMA, 2009). Most female Anopheles species feed during the night. The
11 of 73 infection begins when an infective female mosquito injects Plasmodium sporozoites into the bloodstream while feeding (Heymann, 2008).
1.4 CLINICAL PRESENTATION OF MALARIA Malaria is manifested by many classical symptoms, but the most known are „malaise, headaches, high fever, rigors, vomiting, diarrhoea, abdominal pain, back pain and arthritis (Kassianos et al, 1994, Pp156).
1.5 DIAGNOSIS OF MALARIA Malaria is identified by parasitogical and serological tests.
Parasitological exams are based on microscopy of fresh blood of people. The objective of testing fresh blood is to find out the types of Plasmodium that cause malaria in Angola (Jenkinson, 1997). Serological tests are based on rapid diagnostic tests (RDTs) which help to identify parasite especially in large populations by screening those who visit health centres and people suspected of having to malaria in the community (WHO, 2008).
1.6 TREATMENT OF MALARIA The drugs used to treat malaria are: Artemisinin based Combination Therapy (ACT)
„‟quinine sulphate, fansidar, amodiaquine, mefloquine‟‟etc. Research shows that antibiotics such as sulphonamides, doxycycline, sulfadoxine etc must accompany treatment of malaria. These antimalarials are administrated via oral, intramuscular and intravenous routes (PNCM, 2009).
1.7 STRATEGIES FOR CONTROLLING MALARIA IN ANGOLA It is relevant to know that we have many methods of controlling malaria in Angola but the most known are:
Identification of parasite by surveillance, parasitological and serological
Treating patients identified with Artemisinin based Combination Therapies
(ACTs)
Use of intermittent preventative therapy for pregnant women (IPTPs)
12 of 73 IPT FOR PREGNANT WOMEN
Source: UNICEF, 2002 Figure 1: Demonstration of IPT
Vector control
-Use of long lasting insecticide treated net (LLIN)
.
13 of 73
Figure 2: Demonstration of how to use LLIN. (WHO, 2009)
14 of 73 -Use of indoor residual spraying (IRS)
-Larva elimination
-Pulverization intra and extra domiciliary
Figure 3. Larva elimination and pulverization
)
Figure 3: Larva elimination and pulverization
Information education communication (IEC) (PMI, 2006).
1.8 HUMAN AFRICAN TRYPANOSOMIASIS
Human African Trypanosomiasis is also known as sleeping sickness. It is important to understand that Human African Trypanosomiasis is a vector borne parasitic disease with a geographical distribution limited to the African continent where the disease is predominant. The parasites concerned are protozoa belonging to the genus Trypanosoma (WHO, 2008). The disease is transmitted by the bite of tsetse fly, which have acquired their infection from human beings or from “animals harbouring the human pathogenic parasites” (WHO, 2008).
It is important to know that human African trypanosomiasis occurs only in sub
Saharan Africa in regions where tsetse flies are localised, without tsetse flies, the disease cannot be transmitted. For the disease to be transmitted it is necessary to have the presence of someone infected or infected animals in the community and tsetse fly (WHO, 2008).
15 of 73 1.9 CLINICAL MANIFESTATION In the first stage of human African trypanosomiasis people do not recognise that there are affected. In the second stage, they present with some signals and symptoms similar to malaria and in the last stage, the patient presents with mental perturbation. From stage two patients present with fatigue, headache, recurrent fever, sweating, pain in the joints and stiffness (Theophile, 1994).
1.10 DIAGNOSIS OF HUMAN AFRICAN TRYPANOSOMIASIS Diagnosis of human African trypanosomiasis requires confirming the presence of the parasite in any body fluid, usually in the blood and lymph system. This method is called parasitological surveillance. Serological tests are only used for screening T.b. gambiense infections and establishing suspicion of infection. In this case, confirmation of infection requires the performance of parasitological tests to demonstrate the presence of trypanosomes in the patient. The parasites can be present in any body fluid. However, the number of parasites can be so low, especially in the gambiense form of the disease, that available parasitological methods may not be sensitive enough to find them. Thus, a negative parasitological result in the presence of a positive serological test does not necessarily indicate absence of infection, and tests may have to be repeated over time to achieve diagnosis (WHO, 2008).
1.11 TREATMENT The disease is treated by four drugs such as pentamidine, suramin, melarsoprol and eflornithine (WHO, 2008).
16 of 73 1.12 CONTROL OF HUMAN AFRICAN TRIPANOSOMIASIS IN ANGOLA There are several stages to follow in controlling human African trypanosomiasis in
Angola, the most known are:
Detecting the patient
Treating the patient
Follow up of the patient
Vector control
Information education and communication
Epidemiological surveillance
1.13 HISTORY OF TRYPANOSOMIASIS IN ANGOLA Trypanosomiasis in Angola has been known since 1871 to 1872 in the region of
Quiҁama, which is located in south of Luanda a Long the river Kwanza. However, the struggle against this endemic disease started in 1901 with the arrival of a mission directed by Dr. Anibal Beltencourt. The aim of his visit to Angola was to analyse the disease that used to destroy people in the Quiҁama Park, which is located in province of Bengo. In 1926, they created services for medical assistance to the indigenous people and to combat sleeping sickness. Therefore, they introduced microscopy for parasitological tests. In this case, many people were screened and the numbers of positive cases were approximately 10.000 patients (Theophile,
1994).
In 1946, a mobile team under the dynamic management of Dr. Luis Pinto Fonseca was introduced to provide curative and prophylactic services (Stanghellini et al,
2001).
In 1952, a Brigade for Pentamidinization was created and 26 health sectors established in the endemic zones such as (Zaire, Uige, Bengo and Kwanza Norte).
The mobile team was composed of one medical doctor in charge and two nurses,
17 of 73 three drivers and twenty-one laboratory-qualified technicians, experienced to work with microscopy (Theophile, 1994).
In 1963, by Decree number 45:177 (B.O.n 33 of 17-08-63) and the set up of a
Brigade for Pentamidinization created the mission for fighting trypanosomiasis in
Angola, with technical autonomy and administration depending on the authority from the Government of Angola. Regarding this Decree, the mission for combating trypanosomiasis was divided into different divisions such as medicine, entomology and veterinary. In 1967 by decree 47:657 of 28 / April / 1967, the fourth division of investigation was begun (Theophile, 1994).
As result of introduction of the brigade, microscopy and organised team, this helped to decrease the prevalence of trypanosomiasis in Angola to 45 patients, including only three new cases. In 1978 for the first time after national Independence, services were reorganised with elaboration of a national programme for vigilance and control of human African trypanosomiasis, based on classical techniques for diagnosis. The national programme created in 1978 never became operational due to the political situation of the country, lack of qualified health professionals, distortion of roads, lack of materials; equipment, vehicles and health facilities dedicated to trypanosomiasis were destroyed.
In 1980, the National Programme for surveillance and Control of human African trypanosomiasis, signed a trilateral agreement between the Angolan Government,
World Health Organization (WHO) and Swedish Agency for International
Development (ASDI). In this case, the role of ASDI was to provide financial support,
WHO was controlling the project, and the Government of Angola was implementing the project.
18 of 73 Support of the Swedish Agency for International Development (ASDI) from 1982 to
1992 allowed resumption of activities against the endemic, but the working capacities of the program were again destroyed during the post electoral civil war.
After the signing of the Lusaka Protocol in 1994, screening and treatment activities began again in certain zones of endemic transmission (thanks to the presence of
Medicins sans Frontieres, France and Belgium, Caritas, Norwegian peoples Aid and
Medecins du Monde Catalunya) The headquarters of National Programme was supported in its efforts of restructuration by the French Cooperation since 1997 and became the Instituto de Combate e de Controle das Tripanossomiasis in the year
2000 (Stanhellini, et al, 2001).
Since June 1998, a new flare-up of armed conflict, especially in the zones of trypanosome transmission, has again been endangering all efforts of disease control and its overall results from 1949 until today.
1.14 EPIDEMIOLOGICAL DATA It relevant to understand that the population of Angola is over 12 million habitants, 4 million of this population live in endemic areas such as Uige, Bengo, Kwanza Norte,
Zaire, eastern Malange and northern Kwanza Sul.
Table 1: ENDEMIC PROVINCES WITH HAT IN ANGOLA (ICCT, 2010) ENDEMIC PROVINCES WITH HAT IN ANGOLA
Zaire
Uige
Bengo
Kwanza Norte
Eater Malange
Northern Kwanza Sul, Bie and Luanda
19 of 73
Table 2: PROVINCES WITH GLOSSINA IN ANGOLA (ICCT, 2010) PROVINCE WITH GLOSSINA IN ANGOLA
Cabinda
Zaire
Uige
Kuanza Norte
Bengo
Malange
Lunda Norte
Lunda Sul
Kuanza Sul
Benguela
Bie
Moxico
Kuando Kubango and Luanda
20 of 73 Table 3: YEARS AND NEW CASES OF HAT IN ANGOLA (Josenando et al.2001) YEARS OF REFERENCE NEW CASES
1949 4318
1955 1015
1960 63
1970 26
1974 3
1975 126
1976 83
1977 118
1979 170
1980 306
1990 1,498
1991 2,094
1992 2,406
1993 1,796
1994 1,274
It is relevant to understand that human African trypanosomiasis is considered as one of the neglected disease in Africa. Table 3 show how the disease increased from
1990 to 1994.
1.15 GENERAL DESCRIPTION OF ANGOLA Angola is one of the countries of Africa which is located on the south west coast of
Africa. It extends about 800 miles (nearly 1300km) from east to west, and is bordered by the republic of Congo (through the exclave of Cabinda), the Democratic
Republic of Congo, by Zambia and Namibia; it is divided into 18 provinces, with a total area 481335 square miles.
1.16 HISTORICAL PERSPECTIVE In 1975, Angola achieved independence after centuries of Portuguese colonial rule.
21 of 73 The Popular Movement for the Liberation of Angola (MPLA) has governed since then, the country being engaged from the earliest days of independence in civil conflict with competing political movements, in particular the national Union for the
Total independence of Angola (UNITA). Despite various peace agreements between the Government of MPLA and UNITA over the years, the country has been plagued by a brutal and nearly constant civil war.
During the time that Angola had war the prevalence, incidence, morbidity and mortality rate of malaria was increased gradually. The reason for increase is the damage of health infrastructures in some villages of Angola (PMI, 2006).
Health professionals were concentrated in Luanda, which is the capital of Angola.
Therefore the majority of health professionals were exercising their profession in the capital because (UNITA) was present in the villages. All health staff were members of MPLA and the Government was paying them. Everywhere that UNITA found health professionals in the villages it was killing them. In this case, health professionals were at risk of death because UNITA realised that all health system infrastructures belonged to the government in power, which is MPLA led by
President Jose Eduardo do Santos. This situation affected health of people in
Angola and increased mortality caused by human African trypanosomiasis and malaria especially among young children under five and pregnant women. War is also one of the factors that caused poor conditions of basic sanitation and poverty, which is in one of the issues of public health in Angola (PNCM, 2007)
2.0. OVERAL AIM OF PROJECT: To find out the current status of malaria and trypanosomiasis control
programmes in Angola, and consider relevant strategies to reduce the
prevalence, incidence and mortality and the prospects for implementing them.
22 of 73 2.1. SPECIFIC OBJECTIVES OF PROJECT To gain an understanding of the history of the public health problems of
malaria and human African trypanosomiasis in Angola and the relevant
control programmes.
To gain an understanding of the current status of malaria and human African
trypanosomiasis in Angola
To consider which interventions might be applicable in Angola
To include brief consideration of the status of malaria and trypanosomiasis in
Angola in comparison with neighbouring regions.
23 of 73 3.0. METHODS:
3.1 INTRODUCTION This chapter will show how the researcher collected information for this project by describing the step by step process used to conduct the project. The author used a qualitative and quantitative method of systematic review to gather data for this project.
Systematic literature review is defined as information reviewed and examined from previously published literature (Knee, 2008). The aim of systematic literature reviews is to review information and discuss a particular issue bringing together the opinion, findings and conclusions from a range of previous reports (Fink, 2005).
It is relevant to understand that systematic literature reviews have many advantages and disadvantages. The most known advantage is the collection of a large quantity of information, which is analysed before findings are considered. The disadvantages of systematic reviews include; the findings are not always consistent with the findings of large scale high quality trials, and reviews may make it difficult for practitioners to apply the results to the situation in which they find themselves (Knee, 2008).
3.2 LITERATURE SEARCHES To investigate the strategies for controlling malaria and human African trypanosomiasis in Angola it was necessary for the author to review some of literature in the public health domain and local publications and unpublished reports in Angola. Further literature research to include briefly some contextual information on the status of malaria and trypanosomiasis in countries neighbouring Angola has been used. The author also investigated some documents, electronic material from the World Health Organization (WHO), United Nations International Children
Emergency Fund (UNICEF). In addition, the author used some books with the key words communicable diseases epidemiology and control. It was relevant to use databases such as Medline, Science direct, channel Pub Med, with key words
24 of 73 strategies of controlling malaria and human African trypanosomiasis in Angola, prevalence, incidence, diagnostics, species of vectors, different types of
Plasmodium, treatment of malaria and trypanosomiasis, and strategies for controlling communicable disease in Angola. The researcher also used the London School of
Hygiene and Tropical Medicine library and Instituto de controle e Combate a
Tripanosomiases em Angola, to find journals and reports regarding this project.
3.3 INCLUSION CRITERIA The researcher used full articles on the chosen topic
The researcher used articles from 1990 to the present date
The author used articles that included themes that he identified
The articles used were written in English, Portuguese and French
The author used articles from developed and developing nations
3.4 EXCLUSION CRITERIA The researcher did not use articles that were not full text
The researcher did not use articles that were not peer reviewed
The researcher did not use articles not written in English, Portuguese and
French.
3.5 INTERVIEWS AND QUESTIONNAIRES Interviewees were informed clearly of the purpose of the work. Interviews and questionnaires were with Angolan public health personnel and patients in Angolan hospitals, and some of the interviews with the chairman of malaria in Angola were recorded. Interviewees were able to curtail the interview at any time and to request that content of the interviews remains anonymous or even off the record. Answers to specific questions in the interviews were analysed qualitatively and comparatively to look for particular themes, consensus and different perspectives.
25 of 73 3.6 VISIT TO ENDEMIC FOCI The author visited some endemic areas of malaria and human African trypanosmiasis in Angola such as Luanda, Benguela and Kwanza Sul. In Luanda the researcher visited the general hospital which is located in district of Maianga, CIinica de Bom Deus (district of Kilamba kiaxi) and Centro de Investigacao e Internamento de Doenca de Sono em Viana (district of Viana). In Benguela and Kwanza Sul the researcher visited only general hospitals. The visit to foci helped the researcher to gain understanding of the history of malaria and human African trypanosomiasis in
Angola and strategies for controlling malaria and trypanosomiasis in Angola.
3.7 DATA ANALYSIS The data from interviews and questionnaires were written directly into a notebook and later were typed, tables produced by computer in the field. The confidential information from the chairman of malaria and from other health officers in Angola was recorded to the DVD.
3.8 ETHICAL CONSIDERATIONS To collect data in the field on strategies for controlling malaria and trypanosomiasis in Angola, it was necessary to have ethical clearance. In this case, the ministry of
Health of Angola gave authorisation to the London School of Hygiene and Tropical
Medicine to send the author of this project to the field. Also, the ministry of health of
Angola authorised the author to work directly with malaria national programme and institute for controlling and combating trypanosomiasis in Angola.
Meetings were held with the Ministry of health, coordinators of malaria and trypanosomiasis, directors of hospitals and clinics, public health personnel and patients. The persons interviewed were informed clearly the purpose of the project and a consent form was presented for signature and return to the author. The
London School of Hygiene and Tropical Medicine and ethical committees granted ethical approval
26 of 73 4.0 RESULTS, OF LITERATURE REVIEWED IN ANGOLA
4.1 INTRODUCTION
The information will be presented in text and tables, as a result of malaria and human African trypanosomiasis literature reviewed in Angola.
4.2 MALARIA, RESULTS OF LITERATURE REVIEWED IN ANGOLA Literature reviewed clarified that malaria is identified as one of the principal cause of morbidity and mortality rate in Angola. The whole country is affected by malaria and malaria affects all ages and both genders. But the vulnerable group that malaria affect and kills with high prevalence and incidence in Angola is children under 5 years old with 35% of mortality of infected children per year and 26% mortality of infected pregnant women per year (PNCM, 2009).
Literature shows that malaria is caused by four different types of Plasmodium such as P. faliciparum, P. vivax, and P. ovale and P. malariae. However, faliciparum is predominant in Angola. In fact, 90% of cases of malaria in the whole country are caused by P. faliciparum (PNCM, 2007).
Angola is divided into 18 provinces and 164 municipalities or districts. Literature shows that some provinces in Angola are hiperendemic in terms of malaria transmission and some are mesoendemic and epidemic prone (PMI, 2006)
Table 4: GEOGRAPHIC DISTRIBUTION OF MALARIA IN ANGOLA (PNCM, 2007) HYPERENDEMIC MEOSENDEMIC EPIDEMIC PRONE AREAS
Cabinda Zaire Namibia
Uige Luanda Kunene
Malange Benguela Huila
Lunda Norte Bengo Cuando Cubando
Lunda Sul Kuanza Sul Moxico
Huambo
Bie
27 of 73
According to the literature the population in Huambo is approximately 1.3 million and
Huambo is considered as a second province with high prevalence of malaria in
Angola (PMI, 2006).
Literature shows that about 80% of women in Angola attended antenatal clinics.
IPTp and roll out of ACT were implemented in May 2006 in Angola (PNCM, 2007)
Literature confirms that LLIN was distributed in Angola. From 2006-2009, the principal donors were PMI, Global Funds, GRA, and other partners. (PMI, 2006)
Table 5: LLINs DISTRIBUTED IN ANGOLA FROM 2006-2009 (PMI, 2006) Donors 2006 2007 2008 2009
PMI 540,949 294,200 734,198 411,000
GlobalF.GRA, 285,707 662,978 737,002 2,100,00 and other partners
Total 826,656 957,178 1,471,200 >2.5million
Literature shows that 30% of the population outside of Luanda has access to public health services and routine distribution of LLINs to children under five years old through immunization centres can reach only a small proportion of the target children
(PMI, 2006).
Literature reviewed shows that more than 470,376 pregnant women received IPTp between 2006 and April 2009 (PNCM, 2009).
In September 2004, the National Malaria Control Programme (NMCP) adopted malaria control as a national policy.
4.3 PREVALENCE AND INCIDENCE OF MALARIA IN ANGOLA Literature shows that three million clinical cases of malaria occur in Angola per year and 12,702 deaths (WHO, 2008)
28 of 73 Table 6: YEAR OF FERENCE AND NUMBER OF CASES OF MALARIA IN ANGOLA FROM 1999- 2009 (PNCM, 2009) 1999 3027514
2000 2080348
2001 1249767
2002 1862662
2003 3246258
2004 2489170
2005 2329316
2006 2283097
2007 2726530
2008 3428567
2009 3126241
Total 27849470
4.4 TREATMENT OF MALARIA IN ANGOLA Literature reviewed in Angola shows that malaria is treated by antimalarial drugs such as Artemether + lumefantrine (AL), Artemisinin based Combination Therapy
(ACT) quinine, sulphate, fansidar, amodiaquine and mefloquine (PNCM, 2009).
In September 2004, Artemether+Lumefantrine (Coartem) was adopted as the new line drug for the treatment of uncomplicated malaria caused by Plasmodium faliciparum (PMI, 2006).
Antimalarial drugs in Angola are administered by oral, intramuscular and intravenous routes (PNCM, 2007).
Literature shows that treatment of malaria must be accompanied by antibiotics such as Sulfonamides, doxycycline, sulfadoxine etc. Literature shows that in treating malaria with the combination of Artemether+Lumefantrine it is relevant to understand the weight, age and both genders (PNCM, 2009)
29 of 73 Table 7: TREATMENT OF MALARIA WITH ARTEMETER+LUMEFANTRINE IN ANGOLA AND PRINCIPAL FACTORS TO CONSIDER (PNCM,2009) Weight Age N: of tablets Total n: of tablets
< 5 Kg < 6 Months Not recommended Not recommended
5-14 Kg 6 Months- 3 years 1 tablets 6 tablets
15-24 Kg >3-8 years 2 tablets 12 tablets
24-34 Kg >8-14 years 3tablets 18 tables
> 35 Kg >14 years 4 tablets 24 tablets
4.5 CONTROL OF MALARIA IN ANGOLA Literature shows that malaria in Angola is controlled by detecting cases and identifying the parasite in the blood by using parasitological tests. The examinations are made by microscopy. Also, parasites are identified by rapid diagnostic test
(RDT). Literature reviewed in Angola shows that rapid diagnostic test only identifies falciparum (WHO, 2008).
Treating all cases identified with antimalarial drugs such as Artemisinin based
Combination Therapy (ACT) and treating people suspected with malaria in Angola is revealed as one of the good ways of controlling disease in the community (WHO and UNICEF, 2006)
Use of long lasting treated insecticide nests in all houses in Angola is a good way of controlling malaria.
Use of indoor residual spraying (IRS) for all houses literature shows that this is one of the methods of controlling malaria in Angola (PMI, 2006).
Literature shows that information, education and communication (IEC) is a potential strategy which is implemented in controlling malaria in all 18 provinces and 164 municipalities of Angola (PNCM, 2009).
30 of 73 4.6 HUMAN AFRICAN TRYPANOSOMIASIS, RESULTS OF LITERATURE REVIEWED IN ANGOLA
Literature shows that Angola is classified as the second country in the world with new cases of human African trypanosomiasis (Theophile et al, 2001).
The first case of human African trypanosomiasis in Angola was identified in northern
Angola, municipality of Quiҁama, province of Bengo in the late 19th century. The
Portuguese colonial Government put emphasis on control and created a national programme in 1949 named Missao de Combate as Tripanosomiase (MCT) (David et al, 1998).
All villages with identified cases of human African trypanosomiasis in Angola were considered to be endemic for the disease. Therefore, all villages located close to endemic villages but without identified cases of human African trypanosomiasis were also considered to be endemic. Villages with no reported cases of human African trypanosomiasis in Angola, but where the vector was present, were considered to be at risk for the disease. All villages where the vector could not be found were considered to be free of disease (Pere et al, 2002).
Literature reviewed in Angola shows that a cases that were identified positive for the parasite were treated (Theophile et al, 2002).
4.7 PREVALENCE AND INCIDENCE OF HAT IN ANGOLA Literature review shows that the prevalence of human African trypanosomiasis in
Angola was 15,296 cases, from 1949 to 1994 (ICCT, 20010)
In 2005 to 2009, literature shows that 6,572 cases were found in Angola (ICCT,
20010).
31 of 73 4.8 TREATMENT OF HAT IN ANGOLA
Literature confirmed that human African trypanosomiasis in Angola is treated with pentamidine. Complete treatment consisted of 10 injections of 4mg/kg body weight/day on alternate days. Nine injections with melasoprol were given to the patients in second stage human African trypanosomiasis in Angola, with in interval of
6 days between series (Josenand at el 2002).
Literature revealed that melarsoprol treatment began on day one and the dose increased progressively with each injection, from 1.8mg/kg body weight to 3.6 mg/kg body weight, to give a total dose of 26.16mg/kg body weight. Prednisolone was administered (1mg/kg body weight, to a maximum of 40 mg) at the same time as melarsoprol. “Administration started the day before the first melarsoprol injection and was also given during the rest periods of melarsoprol treatment (days 8-13 and 17-
22). Administration of prednisolone continued for three days after the melarsoprol treatment had finished, but it was gradually reduced (0.75mg/kg body weight on day
28)” (Theophile, at el 2002).
4.9 CONTROLLING HAT IN ANGOLA Literature shows that control of human African trypanosomiasis in Angola is based on screening people in the community and detecting cases of human African trypanosomiasis (HAT) and providing curative treatment to all people who are affected by the disease, providing health education and also implementing measures for vector control such as capture of tsetse fly (WHO, 2002).
4.10 SUMMARY OF LITERATURE REVIEWED IN ANGOLA This chapter has revealed the prevalence and incidence of malaria and human
African tripanosomiasis in Angola. The chapter has also clarified that malaria is one of the principal cause of morbidity and mortality in Angola, the causes of malaria, the vulnerable groups that malaria affects, most predominant Plasmodium species, and predominant species of Anopheles, geographical distribution of malaria and human
32 of 73 African tripanosomiasis in Angola, treatment of malaria and HAT in Angola. The drugs for first line for treatment of malaria in Angola have been revealed. Also the chapter identified that Angola is the second country in the world in terms of new cases of human African trypanosomiasis. The chapter clarified the principal factors to be considering in treating malaria and human African trypanosomiasis in Angola.
Furthermore, a strategy for controlling malaria and human African trypanosomiasis in
Angola has been clarified in this chapter.
33 of 73 5.0 RESULTS OF FIELD WORK
5.1 INTERVIEWS AND QUESTIONNAIRES From a total of 85 public health personnel intended for interview from three provinces and different settings in Angola, only 61 health personnel and 20 patients were interviewed due to their different occupations and lack of availability.
Table 8: CATEGORY OF PEOPLE AND NUMBER INTERVIEWED IN ANGOLA CATEGORY OF PEOPLE NUMBER OF PEOPLE INTERVIEWED Medical Doctors 17 Nurses 18 Laboratory technicians 12 Entomologists 2 Psychologists 2 Pharmacists 3 Community Workers 4 Hospitals receptionist 3 Patients 20
Table 9: FOCI FOR MALARIA AND HAT VISITED IN ANGOLA FOCUS LOCATIONS Hospital Jogina Machel Luanda Centro de Investigação e Internamento Luanda de Doenças do Sono em Viana Clinica de Bom Deus Luanda Hospital Central de Benguela Benguela Hospital De Kwanza Sul Kuanza Sul
5.2 RESULTS FROM INTERVIEWS AND QUESTIONNAIRES ABOUT MALARIA IN ANGOLA
A deputy of malaria in Angola revealed that the majority of people in Angola live with malaria and the disease becomes chronic for many people.
Medical doctors from the National Control Programme of Malaria confirmed that the morbidity and mortality rate of malaria in Angola is decreasing. Three doctors and 2 laboratory technicians from the general hospital of Benguela disagreed with this opinion.
34 of 73 Two doctors from Jogina Machel Hospital revealed that most people with high social class visit a public health facility such as the Hospital Jogina Marchel when malaria becomes complicating.
A group of nurses from Clinic of Bom Deus revealed that private health facilities, give more care to patients compared to public health facilities.
The chairman of health in Kuanza Sul clarified that reduction of the annual budget for health services in Kuanza Sul is one of the factors that influences increasing prevalence of malaria. The director of the General Hospital of Benguela had the same opinion.
One doctor confirmed that some people with malaria in Benguela start automedication at home without health professional prescription.
The receptionist from Direção Nacional de programa de Malaria revealed that she works with health professionals that deal with malaria in Angola but she do not have any knowledge of how to control malaria in Angola.
A person in charge of information education and communication from Programa
Nacional de Malaria revealed that most of people in Angola do not like to participate in seminar and group work to demonstrate strategies for malaria control in Angola.
The deputy of malaria in Angola revealed that malaria is one of the major killing diseases and is a serious problem of public health. Two laboratory technicians from
Bom Deus Clinic revealed that a diagnostic method for parasitological surveillance of malaria in Angola is based on microscopy. And the serology surveillance, is made by rapid diagnostic test (RDT). They confirmed that rapid diagnostic tests are available and used in Angola.
According to supervisors of laboratories in Angola, the problems associated with diagnosis are insufficient reagents and laboratory equipment. Additional funding would help to improve parasitological and serological diagnosis of malaria in Angola.
35 of 73 Deputy of malaria in Angola revealed that prevalence of malaria in Angola is about 3 million cases annually and the estimated mortality is 12,702 deaths per year. Health personnel in Angola agreed that the economic impact that malaria causes in Angola is decrease of gross domestic product (GDP). Two medical doctors from national programme of malaria confirmed that vulnerable people affected with malaria are children under 5 years old and pregnant women and also malaria affects all of the country and the distribution is based on three different levels, namely hyperendemic, mesoendemic and epidemic prone.
Two Entomologists from the national control programme of malaria revealed that the species of Plasmodium present in Angola are falciparum, vivax and malariae. Also they confirmed that vectors transmitting malaria are different. The perceived trend in incidence is decreasing.
The chairman of health in Kuanza Sul confirmed that malaria is treated by
Artemether + lumefantrina (Coartem) and Artemisinin based Combination Therapy
(ACT) quinine sulphate, fansidar, amodiaquine and mefloquine. Doctors from national control programme of malaria revealed that the drugs to treat malaria are available and free. Plasmodium falciparum in Angola has been shown to be resistant to chloroquine. Doctors from Central Hospital of Benguela contradicted opinion of doctors from national control programme.
Health professionals revealed that the problems associated with treatment of malaria in Angola are auto medication and lack of completing the medication prescribed.
Additional funding would help to improve the treatment of malaria in Angola.
One entomologist from the national control programme of malaria answered the questionnaires and confirmed that there are two groups of Anopheles vector species in Angola the gambiense complex and funestus complex
Anopheles gambiense are present into the national territory of Angola, Anopheles melas are present in littoral areas in Angola, Anopheles arabiensis are present in
36 of 73 provinces such as Benguela, Huila and Huambo in Angola. The funestus complex predominates in the national territory of Angola. And also entomologists from NCPM confirmed that the methods of vector control used in Angola are environmental cleaning, elimination of larva, pulverization, indoor residual spraying (IRS) and long lasting insecticide treated nets (LLIN) and the revealed that problems associated with vector control are based on insufficient materials and attitudes of people in the community. Additional funding would help to improve the quality of vector control in
Angola.
The chairman of malaria programme in Angola revealed that malaria is controlled at all levels such as primary health care, community support, hospitals and national programmes. And malaria control is not integrated with control of other infectious diseases in Angola. There is a national malaria control programme in Angola with the overall strategies of identifying cases and treating existing and new cases with antimalarials and controlling vectors that transmit the disease and also educating people in the community. The available assets for malaria control in Angola are vehicles, funding, personnel, spraying equipment etc.
Doctors from Benguela disagreed that the available assents for malaria control are vehicles, funding, personnel, spraying equipment etc.
The logistic factors that may make it difficult to deliver malaria control in Angola are funding, qualified people, vehicles and equipment. The chairman of health in Kwanza
Sul confirmed this opinion.
A deputy of malaria in Angola confirmed that there are important malaria foci in countries neighbouring Angola such as the Democratic Republic of Congo (DRC),
Republic of Congo Brazzaville (RCB) and Zambia. A deputy revealed that Angola have good collaboration with African countries that fight to control, eradicate and eliminate malaria in Africa. And also in the transnational context of control of malaria,
Angola is collaborating with international organizations such as WHO, UNICEF, PMI,
37 of 73 GFM, RBM, FMA, etc. The internal and external support, which is currently available for parasitological and vectorial control activities for malaria in Angola is financial support and for equipment and qualified people.
5.3 INTERVIEWS AND QUESTIONNAIRES ABOUT HAT IN ANGOLA. Five medical doctors answered questions regarding human African trypanosomiasis in Angola. Four of them agreed that human African trypanosomiasis in Angola is classified as a neglected disease. But one out of five contradicted the idea and opinion saying that from 2002 to current data, human African trypanosomiasis is no more classified as a neglected disease in Angola.
Two Psychologists from ICCT revealed that the families of patients with positive diagnosis of human African trypanosomiasis in Angola also become sick; most of them present symptoms of high blood pressure and stress.
One patient from Centro de Internamento e Investigaҁao de Doenҁa de Sono confirmed that people with trypanosomiasis are neglected in the community and it is difficult to get a good job. Also one patient with human African trypanosomiasis from the municipality of Dondo province of Kuanza Norte revealed that it is difficult for someone with third stage HAT to recover.
A patient with HAT confirmed that he could not visit any health facilities when he started sick. He went to a health facility after health professionals screened all people in the village. Two nurses in Central hospital of Benguela confirmed that many patients visit health facilities only when the situation of their health becomes dramatic.
Two entomologists confirmed that for most people who are affected by tsetse the attack happens on the street or at work. The percentage of people attacked at home by tsetse is low compared to attacks outside. Entomologists are controlling vectors with difficulty.
38 of 73 Health professionals who lead with department of information education and communication revealed that some people in the community believe that the later stage of human African trypanosomiasis is treated only with traditional medication which is based on herbs.
The chairman of ICCT confirmed that human African trypanosomiasis needs more care and attention. Identifying passive and active cases with human African trypanosomiasis in Angola proving treatment for all positive cases, promoting health of people and preventing spread of disease, is one of the strong ways to help decrease disease in Angola. Furthermore it is one of the Alma Ata conference objectives and Millennium Development Goals (MDGs).
The director of the Centro de Investigação e Internamanto de Doenças do Sono em viana confirmed that the negative behaviour of people in the community is one of the factors that influences human African trypanosomiasis to kill people in Angola.
One technician of laboratory from ICCT revealed that the card agglutination test for trypanosomiasis (CATT) is one of the methods used in Angola for surveillance by serological diagnosis of human African trypanosomiasis. Puncture of enlarged cervical lymph nodes and CSF examination are methods used in Angola for parasitological surveillance. The rapid diagnostic tests are available and are in used in Angola. The problems associated with diagnosis of HAT in Angola are lack of equipment in good condition, delays in receiving basic materials and equipment such as chemical reagents that come from outside the country, lack of funding and insufficient qualified people. Four technicians from the laboratory of Centro de
Investigação e Internamento de Doenças de Sono em Viana, agreed. Three technincians from Central Hospital of Benguela disagreed.
39 of 73 The director of Centro de Internamento e Investigacao de Doencas de Sono confirmed that vulnerable people are adults in employment and children under 3 years.
The chairman from ICCT revealed that HAT is distributed in seven provinces which are Bengo, Uige, Zaire, Malange, Kuanza Norte, Kuanza Sul and outside of Luanada such as Viana. However, 14 provinces are characterised as glossina areas with tsetse fly vectors of human African trypanososmiasis in Angola. The recent timescale of cases reported in Angola is between May and September, and the trend in incidence of human African trypanosomiasis is decreasing. One doctor from
Centro de Investigacao e Internamento de Doencas de Sono revealed that the drugs used to treat human African trypanosomiasis in Angola are pentamidine, suramin, melarsoprol and eflornithine.
Two doctors from ICCT confirmed that melarsoprol as been identified as one of the drugs for which trypanosomes infections showed resistance in Angola.
The manager of Centro de Investigaҁao e Internamento de Doentes do Sono em
Viana revealed that problems associated with treatment of human African trypanosomiasis in Angola are automedication with wrong treatment, lack of following treatment schedule and not completing treatment as the professional of health prescribed. One entomologist from ICCT in answering the questionnaires confirmed that the tsetse species in Angola are not yet well discovered. The method used for vector control in Angola is capture of tsetse fly. Entomologist from ICCT clarified that there is no evidence demonstrating resistance of tsetse to insecticide.
Problems associated with vector control in Angola are insufficient tsetse capture material, lack of equipment for pulverization and transport such as vehicles, motorbikes, motorcycles and lack of incentive for community participation. Additional funding would help improvement of services for vector control in Angola and further
40 of 73 research would help to identify more problems associated with vector control in
Angola.
The chairman of ICCT confirmed that animal trypanosomiasis in Angola is a problem and affects the economy of the country. Problems associated with control of animal trypanosomiasis in Angola are lack of good material and equipment, insufficient financial resources and qualified people. Additional funding or further research would help to improve the quality of services in Angola. Human African trypanosomiasis is delivered at the primary health care level and through community support and by the institute for combating and controlling trypanosomiasis.
The manager from ICCT confirmed that control of trypanosmiasis between instituties in Angola is organised by the Instituto de Combate e controle de Tripanosomiase departments and mobile groups. Control of human African trypanosomiasis in
Angola is not integrated with control of others infectious diseases.
The chairman from ICCT and two nurses from Centro De Investigaҁao e
Internamento de Doenҁas de Sono em Viana confirmed that Angola has a national control programme named Instituto de Combate e Controlo de tripanosomiase. The overall strategies are:
Detecting active and passive cases
Treating positive cases
Follow up of patients
Vector control
Training staff and community participation
Epidemiological surveillance.
The chairman of ICCT confirmed that, the currently assets available for trypanosomiasis control in Angola are vehicles, funding for personnel, spraying and equipment. The national budget for trypanosomiasis control in Angola is decided by
41 of 73 the Government. The logistic factors that may make it difficult to deliver human
African trypanosomiasis in Angola are, lack of good material and equipment such as microscopes, CATT, vehicles in good condition, insufficient number of drivers, food etc.
One entomologist confirm that there are important human African trypanosomiasis and animal trypanosomiasis endemic foci in countries neighbouring Angola.
Transnational control of HAT or animal trypanosomiasis is coordinated regionally or across the African continent to some extent. The currently available and expected support internal and external for parasitological and vectorial control activities for human African trypanosomiasis in Angola are money and materials.
5.4 SUMMARY This chapter shows the category of people and the total number of health personnel and patients who participated in the interviews, and also shows the prevalence and incidence of malaria and HAT in Angola. Geographical distribution and predominant species of vectors of malaria and human African trypanosomiasis in Angola was revealed in this chapter. The chapter provided answers regarding problems associated with diagnosis, treatment and control of malaria and human African trypanosomiasis in Angola.
42 of 73 6.0 DISCUSSION The interviews, questionnaires and visits to focus areas were conducted to gain historical understanding of controlling malaria and human African trypanosomiasis in
Angola.
6.1 PRINCIPAL FINDINGS FOR MALARIA IN ANGOLA The project has found that malaria in Angola is considered as one of the major killing diseases that causes serious problems to public health. In Angola malaria infection has been identified as one of the factors that causes poverty among families because many people are affected by episodes of malaria 6 to 9 times in the year.
When the disease affects children they do not go to the play groups, schools and nurseries, mothers stay with them in hospital or at home under medication. In the case of adults affected, they do not go to work. Malaria affects the health and wealth of the nation and its citizens (UNICEF, 2008).
A political conflict between opposition parties was the cause of war, which resulted in higher prevalence, and incidence of malaria in Angola. During the war health infrastructure in Angola was damaged and the national health system was very weak and all health personnel were concentrated in the capital of Angola (Luanda). Now
Angola is under national reconstruction of what the war has destroyed (PNCM,
2009).
Malaria infection is predominant in children under five and pregnant women because of their reduced immunity. Children under five do not have enough antibodies that can fight and protect them against parasites and pregnant women have very weak immunity (WHO, 2008).
The project found that four types of Plasmodium cases malaria in Angola such falciparum, vivax, ovale and malariae. But Plasmodium falciparum was found as the
43 of 73 most common and predominant with a higher percentage of cases compared to other types of Plasmodium. This is due to climate factors and geographical distribution (PMI, 2006).
Literature reviewed shows that many factors that influence the proliferation of the female Anopheles mosquito in Angola because of the poor condition of hygiene, dirty water, stagnant water for long periods in one place and poor conditions of environment hygiene sanitation and also poor housing conditions. These factors increase proliferation of Anopheles in Angola especially when it is the rain season
(WHO, 2008).
Accornding to the deputy of malaria in Angola the disease is decreasing because the
Government in collaboration with international organizations is putting effort into controlling malaria in Angola and also the National Control Programme of Malaria in
Angola (NCPM) is working very hard on data collection on cases for all of the country and providing treatment for positive cases identified, and controlling disease vectors.
Three doctors and technicians of the laboratory from Benguela hospital disagreed with this view because malaria is still one of the major killing diseases in Benguela and they do not understand what the National Control Programme of Malaria does with the money that the government and international organizations offer to support the situation and to control the disease.
People with high social class do not like to go to public health facilities to be treated with malaria because of abandonment that of public hospitals, people can spend all day in the reception or waiting room without of being checked by the doctor. The reason for that is the services are free of charge but in private clinics the services are charged and patients get more care and attention. Also patient families are affected with disease because in public hospital in Angola when someone is interned the family needs to be there as well. But the hospital does not provide room for the
44 of 73 family to sleep. In this case they spend the night outside of the hospital therefore they become sick.
According to the director of health in the province of Kuanza Sul and director of the general hospital of Benguela reduction of the annual budget is influencing prevalence and incidence of malaria because the money is not enough to cover all expenses.
One doctor in Benguela revealed that the majority of people with malaria start automedication without health professional prescription because they know that antimalaria drugs kill the parasite (PNCM, 2009).
People in some provinces in Angola do not like to attend seminar and group discussion for malaria control in the community, because they do not have time and are busy with different things. It is important for them to understand that health is a priority. If you are not well it will be difficult to work.
6.2 FINDING FOR HUMAN AFRICAN TRYPANOSOMIASIS IN ANGOLA
Four doctors agreed that human African trypanosomiasis in Angola is a neglected disease because many people die with the disease without notification and many internationalorganizations support other diseases than human African trypanosomiasis. One doctor disagreed with the opinion because the budget of ICCT is higher than many national control programmes. When the government is spending more money for ICCT that means care for the disease and the disease is not neglected. Four laboratory technicians from Centro dE Investigaҁao e Internamento de Doenҁas do Sono em Viana confirmed that a problem associated with diagnosis is lack of microscopes because many patients attend the hospital but they do not detect the disease on the same day because they do not have enough microscopes. But the laboratory technicians from Benguela contradicted this opinion because the big problem for diagnosis for HAT is a lack of qualified health
45 of 73 professionals not microscopes. You can have a microscope but if you do not understand how to use it, false result will be produced. Patients revealed that for people with HAT it is difficult to get a good job in
Angola because of the interpretation that many people have about the disease.
Some people in Angola think that human African trypanosomiasis is a disease from which the patient will never recover well especially when the disease achieves third stage because it affects the brain and causes mental pertubation ( Theophile et al
2002).
Entomologists are controlling vectors with difficulty because of insufficient of material equipment and transport to endemic areas and they revealed that in some region the disease was not discovered but existed. The reason for this confirmation is the symptoms of mental perturbation that people present in Angola (ICCT
The project found that HAT was identified as a neglected infection because many people were dying in Quiҁama Park in Angola without notification (ICCT, 2001). War was one of the factors that contributed to higher prevalence and incidence of disease in Angola. In 1945 to February 2002, it was difficult to implement control activities in endemic areas due to the political conflict in Angola. Active men and women were affected and children under three being cared for by active parents (Theophile,
2002).
Problems associated with treatment were lack of completing medication given by health professionals. Most of people with Human African Trypanosomiasis visit health facilities only in the second stage of disease because on the first stage people do not understand that the are infected because clinical manifestation is not presented (Theophile et al, 2006).
46 of 73 6.3 LIMITATIONS OF THE PROJECT Time for data collection was insufficient which limited the author from visiting
more endemic foci and from interviewing more health personnel and patients
in Angola.
Project funding was insufficient to investigate fully both diseases such as
strategies for controlling malaria and human African trypanosomiasis in
Angola.
Access to some departments of hospital and public health sectors was not
easy due to attitude of securities and some health professionals in Angola.
Some articles lacked detailed information
The author was required to pay for some articles and copies
6.4 RECOMMENDATIONS
The findings of this project suggest that national control programme for malaria in
Angola need to improve strategies for vector control and malaria infections.
Malaria must be diagnosed before starting treatment with antimalarials to avoid resistance of parasites to medication. It is important for professionals of health in
Angola to understand that symptoms of malaria and human African trypanosomiasis are similar in the second stage of HAT.
Health professionals in collaboration with community health workers must distribute long lasting insecticide treated nets to all people in the community who do not have them. All the damaged LLIN must be collected and replaced with new ones.
Departments of Public Health must send reports of malaria to national control programmes each month. Also national control programmes of malaria need to understand the responsibility for providing training and capacitating staff in all aspects for controlling infection in Angola, contacting funding and writing new proposals with clearer aims and objectives.
47 of 73 The national programme of malaria control in Angola needs to report clearly all the prevalence, incidence, morbidity and mortality of malaria to international organizations for world country statistics.
The results of this study indicate that more work needs to be done in Angola to control human African trypanosomiasis for vector control and to discover the vector different species existing in Angola and their geographical distribution.
The Instituto de Combate e Controle de Tripanosomiase needs to be aided with funding to improve their standard of work.
More health personnel need to be trained and qualified to provide the service of controlling human African trypanosomiasis in Angola.
More equipment and materials need to be replaced in the laboratory of Centro de
Internamento e Investigaҁao de doenҁas de sono em Viana and hospital geral de
Benguela.
Human African trypanosomiasis needs to be diagnosed well and treated well to avoid mental perturbations and people with HAT need more care and attention for one to two years.
People who work in endemic areas need incentives for encouragement because the condition of work in endemic regions in Angola is very difficult.
All new cases of human African trypanosomiasis in Angola most be notified immediately to the Instituto de Combate e Control de Trypanosomiasis.
48 of 73 7.0 CONCLUSIONS After conducting this study the author has realised that all people in Angola are at risk of being infected with malaria because malaria is in all 18 provinces and 164 municipalities. Prevalence of malaria and human African trypanosomiasis is higher in
Angola due to the damage of health infrastructure caused by war in Angola. Human
African trypanosomiasis is identified as a neglected disease. People were dying by disease without notification in Quiҁama Park in Angola (WHO, 2006)
Prevalence and incidence of malaria is higher than human African trypanosomiasis in Angola. A reason that malaria is identified easily but in first stage human African tripanosomiasis it is difficult for the person to understand that they affected by the disease (Josenando et al, 2004).
It is important to understand that malaria and trypanosomiasis are treatable human diseases. Detecting Plasmodium and trypanosomes, identifying people who are affected and treating them with the right drugs, controlling vectors are the key principal strategies for controlling malaria and human African trypanosomiasis in
Angola (PNCM and ICCT, 2009).
49 of 73 8.0 REFERENCES
1. Abel, M. P., Behrend, M., Fleischmann, H., Loa V, Musolf, J., Josenando, T., Kiala, G. and Krishna, S. (2004) Retaking sleeping sickness control in Angola. Int. J. Volume 9.
2. August, S., Walte,r. O., Inacio, A., Zero, B., Teofile, J., Paolo, M. A., and Christopher, J. M, W. (2006) Diagnosing human African trypanosomiasis in Angola using a card agglutination test: Observational study of active and passive case finding strategies.
3. Cuamba, N., Choi, K. and Townson, H. (2006) Malaria vectors in Angola: Distribution of species and molecular forms of the Anopheles gambiae complex, their pyrethroid insecticide knockdown resistance status and Plasmodium. Malaria Journal 2006, 5:2
4. Donzoau,F. and Junior, M. (2008) Actividades do ICCT, e sua Tarefas. Republica de Angola, Ministerio da Saude. Luanda-Angola.
5. Gedeon, V. Maria, O., Caroline, B., Pierre, R., Lynda, P., Bernado, B. and Theophile, J. (2009) Immunophenotypic Lymphocyte Profiles in Human African Trypanosomiasis.
6. Gosoniu, L., Veta, A. and Vounatsou, P. (2010) Bayesian Geostatistical Modelling of Malaria indicator Survey Data in Angola. PLos ONE, March 2010, Volume 5, Issue 3
7. Heymann, L.D. (2008) Control of Communicable Diseases Manual. 19th Edition.
8. Holmes, H. P., Maudlin, I. and Miles, A. M. (2004) The Trypanosomiases. Published by CAB International Wallingford. Uk
9. Instituto de Combate e Controlo de Tripanosomiases (2002) Estatuto e Missao: Politica National de Luta e Controlo das Tripanossomoses.
10. Jorge,P.C., Carrara, C., Santolamazzaf.,Torre, D. (2002) Preliminary data on Anopheline malaria vectors at two sites of Western Angola. Volume I N0 6 Pp 636.
11. Jobin, R.C., LIuberas, M. and Somandjinga, M. (2009) Difficulties in organizing first indoor spray Programme against malaria in Angola under the President‟s Malaria Initiative. Bull WHO,2009;87;871-874.
12. Jenkinson, C. (1997) Asessment and Evaluation of Heath and Medical care.
50 of 73 13. Jose, A. R., Pere, P. S. and Teofilo, J. (2002) Control of human African trypanosomiasis in the Quiҁama focus, Angola. Bulletin of the WHO 2002, 80 (9).
14. Jose, R. A., Pere, P., Theophile, J. (1999) Attitude towards CATT positive individuals without parasitological confirmation in the African Trypanosomiasis (T.b.gambiense) focus of Quiҁama ( Angola). Volume 4 N0 12 Pp 858-861 December 1999.
15. Kassianos, G. C (1994) Immunization. Published by Blackwell in the UK
16. Kiszewski, A. Teklehaimanot, A. (2004) A review of the clinical and epidemiologic burdens of epidemic malaria. Published by the American Society of tropical Medicine and Hygiene.
17. Miller, N., Mihigo, J., Leon, G., Rowe, A., Santelli, A., Van-Dunem, .P (2009) Quality of malaria case management at outpatient health facilities in Angola. Malaria Journal 2009, 8:275.
18. Mihigo, J., Newman, R., Fernandes, A., Ferreira, F., Forte, .F, Oliveira ,A., Thwing, J. (2009) How Much Malaria Occurs in Urban Luanda, Angola? A Health Facility Based Assessment. Am. J. Trop. Med. Hyg.,80(3), 2009,Pp, 487-491
19. Ndongo P, Nguema E, Louis F, Jannin J and Simarro P (2006) The elimination of Trypanosome brucei gambiense sleeping sickness in the focus of Luba, Bioko Island, Equatorial Guinea. Volume II N0 5 Pp 636-646 May 2006.
20. President‟s Malaria Initiative (2006) Country Action plan. Angola. 21. President‟s Malaria Initiative (2006) Helping Bring Effective Malaria Medicines to Angola.
22. Pinto R, (1976) Relatório Nacional da Missão de Combate as Tripanosomíases. Luanda, Ministerio da Saude 23. Porta, M. (2008) A dictionary of Epidemiology: Fifth Edition. Oxford university press in USA
24. Republica de Angola, Ministério Da Saúde, Programa Nacional De Controlo Da Malaria (2009) Manual de Manejo de Casos de Malaria.
25. Republica de Angola, Ministério Da Saúde, Direção Nacional Da Saúde, Programa Nacional de Controlo da Malaria (2007) Plano estratégico nacional para o controlo da malaria em Angola 2008-2012.
26. Republica de Angola, Ministério Da Saúde, Direcção Nacional de Saúde Publica (2007) Estratégia de promoção do controlo da malaria: Plano de informação, educação, comunicação e mobilização Social para o Programa Nacional de Controlo da Malaria em Angola.
51 of 73 27. Roll Back Malaria (1998) Global Partnership Initiated by WHO, UNDP and UNICEF.
28. Saraiva, N. (2010) Curso Básico de Entomologia no Bengo: Malaria em África
29. Stanghellini A and Josenando T (2001) Situation of sleeping sickness in Angola: A calamity. Tropical Medicine and International Health
30. Smith, H. D., Pepin, J., Stich, R.H.A. (1999) Human African trypanosomiasis: An emerging public health crisis
31. Schofield, J.,C., Kabayo, P. J. (2008) Trypanosomiasis vector control in Africa and Latin America
32. Theophile, J. (1994) Manual de Regras para o controle da tripanossomíase humana Africana. 1 Edição. Ministério da Saúde, Luanda, Angola.
33. Teófilo, J. (1994) Doença Do Sono em Angola: Dados de base para um Projeto de Luta e Controle da Tripanossomíase Humana Africana. Ministério da Saúde, Direção Nacional Para a Vigilância e controlo da Tripanossomíase Human Africana
34. UNICEF (2007) Strategic Plan for the accelerated reduction of maternal and children mortality in Angola
35. Webber, R. (2008) Communicable disease epidemiology and control: 3rd edition
36. Worrall, E.A., Delacolette, C. (2004) The burden of malaria epidemics and cost effectiveness of interventions in African
37. World Health Organization (2003). International Statistical Classification of Deseases and Related Health Problems. Tenth revision. Vol.2. Geneva.
38. World Health Organization (2005) World Malaria Report
39. World health Organization and UNICEF (2005) World Malaria Report
40. World Health organization (2006) The African Malaria Report 2006
41. World health organization (2006) Malaria vector control and personal protection: Report of a WHO study group. Geneva 42. World Health organization (2010) Human African Trypanosomiasis: Symptoms, diagnosis and treatment
43. World health organization (2006) African trypanosomiasis (sleeping sickness)
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44. World Health Organization, Regional office for Africa (2006) Control of human African trypanosomiasis: A strategy for the African region
45. World Health organization (1995) Planning Overview of Tropical Disease Control. Division of Control of tropical diseases. Geneva
46. Zaramba, S. (2005) Uganda Malaria Control Strategic Plan 2005/06-2009/10
53 of 73 9.0 APPENDICES APPENDIX 1: DEATHS WITH MALARIA IN ANGOLA FROM 1999-2009 (PNCM, 2010)
YEAR OF DEATH WITH CASES OF DEATHS
MALARIA
1999 25572
2000 9510
2001 9473
2002 14434
2003 38598
2004 12459
2005 13768
2006 10229
2007 9812
2008 10249
2009 9624
TOTAL 16,3728
54 of 73 APPENDIX 2: PERCENTAGE OF CASES OF MALARIA IN PROVINCES (PNCM, 2010)
Provinces Percentage of malaria in provinces
Bengo 2%
Benguela 7%
Bie 6%
Cabinda 5%
Cunene 4%
Huambo 14%
Huila 12%
Kuando Kubango 2%
Kuanza Norte 3%
Kuanza Sul 4%
Luanda 17%
Lunda Norte 1%
Lunda Sul 3%
Moxico 2%
Malange 5%
Namibe 3%
Uige 5%
Zaire 3%
55 of 73 APPENDIX 3: PERCETAGE OF DEATH WITH MALARIA IN PROVINCES (PNCM, 2010)
Provinces Percentage of deaths
with malaria in Angola
Bengo 1%
Benguela 27%
Bie 7%
Cabinda 4%
Cunene 6%
Huambo 10%
Huila 10%
Kuando Kubango 4%
Kuanza Norte 5%
Kuanza Sul 5%
Luanda 1%
Lunda Norte 2%
Lunda Sul 1%
Moxico 3%
Malange 4%
Namibe 3%
Uige 5%
Zaire 4%
56 of 73 APPENDIX 4 : QUESTIONS CONSIDERED THROUGH LITERATURE RESEARCH AND
DISCUSSIONS WITH AUTHORITIES IN ANGOLA
Trypanosomiasis
Which methods are used for the surveillance, parasitological and serological diagnosis of human African trypanosomiasis (HAT) in Angola?
Are rapid diagnostic tests available and used?
What are the problems with diagnosis and how might additional funding or further research help?
What are the prevalence and incidence of HAT in Angola? Are particular ages, sexes or occupations affected? What are the estimated mortalities and economic impacts?
What is the geographical distribution of HAT in Angola, and are there particularly important endemic foci?
What is the recent timescale of case reporting?
What is the perceived trend in incidence, increasing or decreasing?
Which drugs are used to treat HAT in Angola and they are readily available and free?
Have drug resistant trypanosome infections been found in HAT in Angola and if so to which drugs?
What are the problems associated with treatment of HAT and how might additional funding or further research help?
What are the tsetse species in Angola and have their geographical distributions been mapped? Which of these species are the vectors of HAT?
Which methods of vector control are used in Angola?
Has resistance to insecticides been found among tsetse in Angola?
57 of 73 What are the problems associated with vector control and how might additional funding or further research help?
Is animal trypanosomiasis a problem in Angola, and if so where and to what extent?
What are the problems associated with control of animal trypanosomiasis in
Angola and how might additional funding or further research help?
To what extent is HAT control delivered a) at the primary health care level and b) through community support?
How is trypanosomiasis control organised between institutions in Angola?
Is HAT control in Angola integrated with control of other infectious diseases?
Is there a national HAT control programme in Angola and if so how would you summarise the overall strategy?
What assets are currently available for trypanosomiasis control in Angola (vehicles, funding, personnel, spraying equipment etc.)?
How is the national budget for trypanosomiasis control decided in Angola?
Which logistic factors may make it difficult to deliver HAT control in Angola?
Are there important HAT or animal trypanosomiasis endemic foci in countries neighbouring Angola?
To what extent are national control programmes for trypanosomiasis collaborating with similar programmes in neighbouring countries?
To what extent is transnational control of HAT or animal trypanosomiasis coordinated regionally or across the continent?
What internal and external support is currently available/expected for parasitological and vectorial control activities for HAT?
Malaria
Which methods are used for the surveillance, parasitological and serological diagnosis of malaria in Angola?
Are rapid diagnostic tests (RDTs) available and used?
58 of 73 What are the problems with diagnosis and how might additional funding or further research help?
What are the prevalence and incidence of malaria in Angola? Are particular ages, sexes or occupations affected? What are the estimated mortalities and economic impacts?
What is the geographical distribution of malaria in Angola, and are there particularly important endemic foci?
Which species of Plasmodium are present and do they have different vectors and geographical distributions?
What is the recent timescale of case reporting?
What is the perceived trend in incidence, increasing or decreasing?
Which drugs are used to treat malaria in Angola and they are readily available and free?
Has drug resistance been found in Plasmodium in Angola and if so to which drugs?
What are the problems associated with treatment of malaria and how might additional funding or further research help?
What are the anopheline vector species in Angola and have their geographical distributions been mapped?
Which methods of vector control are used in Angola?
Are long life insecticide treated nets readily available, free and widely used?
Which insecticides are used and are they readily available?
Has resistance to insecticides been found among mosquitos in Angola?
What are the problems associated with vector control and how might additional funding or further research help?
To what extent is malaria control delivered a) at the primary health care level and b) through community support?
How is malaria control organised between institutions in Angola?
59 of 73 Is malaria control in Angola integrated with control of other infectious diseases?
Is there a national malaria control programme in Angola and if so how would you summarise the overall strategy?
What assets are currently available for malaria control in Angola (vehicles, funding, personnel, spraying equipment etc.)?
How is the national budget for malaria control decided in Angola?
Which logistic factors may make it difficult to deliver malaria control in Angola?
Are there important malaria foci in countries neighbouring Angola?
To what extent are national control programmes for malaria collaborating with similar programmes in neighbouring countries?
To what extent is transnational control of malaria coordinated regionally or across the continent?
What internal and external support is currently available/expected for parasitological and vectorial control activities for malaria?
Recommendations by authorities in Angola
What further information gathering would facilitate control programmes for trypanosomiasis or malaria?
What helpful additional data analyses might be performed?
What are your recommended priorities in terms of improved diagnosis, treatment and vector control?
How might any logistic difficulties in delivery of control be reduced?
What collaborative initiatives might improve delivery of control programmes?
What other information and recommendations are important?
How might further, more focused MSc projects be useful to Angola?
60 of 73
61 of 73 APPENDIX 5: CARE FORM
London School of Hygiene & Tropical Medicine (University of London)
Combined Academic, Risk assessment and Ethics (CARE) approval form for MSc Project Reports
*This form must be completed electronically. For detailed guidance, please refer to the Project Handbook for your course.
SECTION 1 – STUDENT AND COURSE INFORMATION MSc DETAILS AND DEADLINES (deadlines to be communicated by Course Director) Academic Year 2009-10 MSc course (and stream, where applicable) Deadline for Supervisor approval Deadline for Course Director approval Deadline for submission to Ethics Committee Friday 30 April 2010 Target for approved form to be passed to TSO Friday 28th May 2010 STUDENT, SUPERVISOR AND TUTOR DETAILS (to be completed by student) Full name of student Domingos Vita Student email address [email protected] Year of study (part-time students only) First Year Second Year Supervisor name Michael Miles
Supervisor email address [email protected] Supervisor status (at time of this version Confirmed Provisional Still to be identified of the form being completed) Name of personal tutor (where Supervisor Michael Miles is still to be identified)
SECTION 2 – APPROVAL AND SUBMISSION STATUS *Students please note: It is a requirement of your LSHTM degree that you obtain all required approvals before beginning your project work. To comply with legal requirements, your Supervisor and Course Director must specifically give Risk Assessment approval. Ethical approval must also be obtained if required (answers in Section 5 will help determine if so).
STUDENT DECLARATION (to be completed for all projects) I agree to conduct my project on the basis set out in this form, and to consult staff (initially, my Supervisor) if making any subsequent changes – especially any that would affect the information given with respect to ethics approval. I agree to comply with the relevant safety requirements, and will submit a separate request for LSHTM travel insurance where relevant. *Where seeking ethical approval for a study involving human subjects, please also attach copies of any information sheets, consent forms, and other relevant documents. Date of declaration 05-05-2010
*Further note: when submitting your final project report at the end of the summer, you should also include a copy of your approved CARE form (which will be seen by the project markers); but to preserve anonymity, the page above – with your name – should be omitted.
62 of 73 STAFF APPROVAL *Staff please note: Sections 3 and 4 of the form should be completed by the student before you are asked to sign. If you tick ‘no’ to any of the ‘Yes/No’ questions below, or disagree with any of the statements given, or have any other concerns, then you should not give approval – instead, please contact the student immediately to inform them of your concerns and discuss changes which they may need to make before you may be willing to give approval. *Supervisors and Course Directors should also be aware that in the exceptional case of a request to undertake a project in a country or region to which the Foreign & Commonwealth Office advise against travel, the student would need to fill out a separate form which will then need further School- level approval by the Safety Manager and Secretary & Registrar.
SUPERVISOR’S APPROVAL (required for all projects – this approval should be given first) I agree that Section 3 of this form is a reasonable summary of the proposed Yes No project. I agree that responses in Section 4 of this form address the main risks Yes No connected with a project of this nature. Name of Supervisor (if not yet identified, personal tutor Michael Miles or Course Director should approve) Date of approval 17/05/2010
COURSE DIRECTOR’S APPROVAL (required for all projects – should follow Supervisor approval) I agree that the academic content of the proposed project, set out at Section Yes No 3 of this form, is suitable for this MSc. I agree that responses in Section 4 of this form address the main risks Yes No connected with a project of this nature. Name of Course Director (or nominee) Michael Miles Date of approval 17/05/2010
DEPARTMENTAL SAFETY SUPERVISOR’S APPROVAL (only required if project involves working with pathogenic organisms, human blood or radiochemicals – should follow Supervisor approval) I agree that the proposed project, as set out in this form and particularly Yes No Section 4, may proceed. Name of Departmental Safety Supervisor (or nominee) Date of approval
ETHICAL APPROVAL (required for all projects involving human subjects or human data, except for public domain data that cannot enable the identification of living people – NB that Supervisor approval must have been received before the application is submitted to the Ethics Committee) Date application received Ethics Committee application number assigned On behalf of the Ethics Committee, I approve the project proposal Yes No set out on this form. Name of Ethics Committee scrutineer Date of approval
63 of 73 SECTION 3 – APPLICATION FOR ACADEMIC APPROVAL *All students should complete all sub-sections (3.1, 3.2 and 3.3); if particular questions are not applicable to you then please write ‘N/A’.
3.1 PROJECT OUTLINE (should not normally exceed 750 words total) Proposed project title: (should not normally exceed 20 words) A review of strategies for controlling malaria and trypanosomiasis in Angola Proposed project type: *See course-specific section of Project Handbook for details of project types permitted for each MSc. Be aware that restrictions may apply for individual courses. Literature review Proposed project length: *For almost all students, this will be ‘Standard’. Long and extended projects are only available for certain ITD courses; they have a different schedule and allow a slightly greater word count. Standard Long Extended Background: (about 200 words) *Indicate why this topic is of interest or relevance. *If the project involves work with a specific organisation please give details. *Please give any other details specifically relevant for consideration by the Ethics Committee, e.g. related to purpose.
This study is relevant because malaria and trypanosomiases are known to be serious public health issues in Angola. 270 million of the world‟s population are currently infected with Plasmodium and the prevalence is high in developing countries including Angola. Malaria is one of the major killer diseases that affect the economy of a country as a result of the morbidity, mortality and high cost of the treatment of the disease. The prevalence, morbidity and mortality rates of malaria increase as result of damage to health infrastructures, such as has occurred due to the war in Angola. UNICEF and WHO (2004) claim that about 1.4 to 2million of cases of malaria were identified in young children in Angola of which, 86% of cases were children under the age of five years. 78 percent of malaria in Angola is caused by Plasmodium falciparum and 22% by other species of Plasmodium. Angola is the second country in the world in terms of the number of new cases of human African trypanosomiasis (HAT) notified, despite the country‟s weak surveillance system for HAT. The true epidemiological situation in the country is unknown due to the civil war, which has been ongoing periodically since 1975, and has limited the number of functional mobile teams to implement relevant strategies for controlling trypanosomiasis. This project will involve information gathering on the history and current status of control of malaria and HAT in Angola and the prospects for future implementation of
64 control strategies. I am an Angolan national and am making arrangements to meet key local public health authorities in Angola to assemble relevant information for the project.
Hypothesis: (about 30 words, where applicable)
Overall aim of project: (about 30 words) To find out the current status of malaria and trypanosomiasis control programmes in Angola, and consider relevant control strategies to reduce the prevalence, incidence and mortality and the prospects for implementing them. Specific objectives of project: (about 70 words)
1)-To gain any understanding of the history of the public health problems of malaria and trypanosomiasis in Angola and the relevant control programmes. 2)-To gain any understanding of the current status of malaria and trypanosomiasis and the control strategies in Angola. 3)-To consider which interventions might be applicable in Angola. 4)-To include brief consideration of the status of malaria and trypanosomiasis in Angola in comparison with neighbouring regions.
Proposed methods: (about 200 words) *Please summarise methods, and include any relevant details for consideration by the Ethics Committee such as numbers of participants and procedures to be performed.
Review of literature in the public domain and of local publications and unpublished reports in Angola. Interviews and questionnaires with Angolan public health personnel. Field visits to local endemic areas (excluding regions of conflict if any) to consider the practical and difficulties in applying interventions and establishing control programmes. Further literature research to include briefly some contextual information on the status of malaria and 65 trypanosomiasis in countries neighbouring Angola. Interviewees will be informed clearly of the purpose of the work. Interviews may be recorded. Interviewees will be able to curtail the interview at any time and to request that content of the interviews remains anonymous or even off the record. Answers to specific questions in the interviews will be analysed qualitatively and comparatively to look for particular themes, consensus and different perspectives. References: (max 150 words) *List any key references which will shape the project, including for methods to be used. It should not normally be necessary to quote more than 5 references.
1-Republica de Angola, Ministério da Saúde, Direcção Nacional de Saúde, Programa Nacional de Controle da Malária (2007). Plano estratégico nacional para o controle da malária em Angola 2008-2012. 2-Strategic Plan for the accelerated reduction of maternal and children mortality in Angola http:www.uniceff.org/ accessed on 26-April 2007. 3-World Health Organization (2005). World Malaria Report 2005. 4-World Health Organization and UNICEF. (2005). World Malaria Report. Report no. 5-Jose A, Pere P and Tiofilo J (2002) Control of human African trypanosomiasis in the Quicama focus Angola. 6-Control and surveillance of African trypanosomiasis. Geneva: WHO, 1998.
Prior work: (only where relevant; max 100 words) *Indicate any previous work you have done related to this project topic, including student work, professional work, or publications. No prior research focused on this topic. However in December/January 2009/10 I was in Angola for preliminary discussions to prepare for the project. I have also sought advice from Professor C. J. Schofield, who has provided names and contact details for public health authorities in Angola who may contribute. I am Angolan and will have no difficulty in working in the country.
3.2 FEASIBILITY (about 100 words total – but can write more or write less if appropriate) What could cause this project to fail, i.e. prevent you from achieving your objectives? *Please indicate any aspects of your proposed approach which could potentially experience difficulties, e.g. delays with permissions, data collection or storage problems, lack of sufficient comparable information, etc. You may also wish to mention any wider matters which could affect your project, e.g. civil unrest, natural disasters, transport availability. Unforeseen outbreak of civil war, accidents and insufficient material on the topics would cause difficulty in achieving the objectives What alternative plans do you have in case you encounter any of the potential problems you have identified? Alternative plans would be to focus on one disease only and use literature review only.
3.3 INTELLECTUAL PROPERTY, COPYRIGHT AND OTHER PERMISSIONS *Please also see Section 5.2 regarding any specific data rights limitations arising from local ethical or research governance requirements If you expect to use existing data, how will you obtain it and what permissions will be required? Local permission might be required to refer to some unpublished Angolan reports, and if this arises permission will be sought on location in Angola.
66
Having considered whether intellectual property rights (IPR) or copyright issues may affect your project, will any specific agreements be required? *Please tick all boxes that apply, and attach copies of any forms/agreements (even if in draft). No specific IPR, Copyright or permissions issues should apply to this project (student retains Copyright and related IPR by default, in line with LSHTM registration declaration) IPR to be retained by LSHTM (specific LSHTM form to be completed) Copyright to be transferred to LSHTM (specific LSHTM form to be completed) IPR, Copyright or other agreements/permissions required with external parties/organisations Please give any further relevant details about IPR, copyright or other permissions. N/A
SECTION 4 – APPLICATION FOR RISK ASSESSMENT APPROVAL *All students should answer all questions in sub-section 4.1; this will make clear which of the following sub-sections you need to complete. Ensuring safety during project work is the responsibility of each individual student, and not of LSHTM or LSHTM staff. *Please see the Project Handbook for further guidance.
4.1 TYPE OF RISK (to be completed by all students) Where will the project be carried out? (please tick all that apply) *Note that work away from LSHTM or outside the UK means any form of work for your project, not just primary data collection. Some courses may have specific restrictions on this. All work will take place either at LSHTM, in libraries in the UK, or at my personal residence in the UK. [If so, you do not need to complete either section 4.2 or section 4.3] Some work will take place in the UK that is away from LSHTM sites in London, is non- Library-based, and is not at my personal residence. [If so, section 4.2 on „Work away from LSHTM‟ must be completed] Some work will take place at my personal residence outside the UK [If so, section 4.3 on „Work outside the UK‟ must be completed] Some work will take place outside the UK that is not at my personal residence [If so, both sections 4.2 and 4.3 on „Work away from LSHTM‟ and „Work outside the UK‟ must be completed] Will the project involve working with or handling any of the following materials? Pathogenic organisms Yes No Human blood Yes No Radiochemicals Yes No [If „Yes‟ to any of the above, Sections 4.4 and 4.5 must be completed] Are any other potentially hazardous activities likely to be carried out during the project? Yes No [If „Yes‟, Section 4.5 must be completed] Do any special requirements (e.g. disability-related issues) or other concerns need to be taken into account for either you as a student, study participants or colleagues? Yes No [If „Yes‟, Section 4.6 must be completed]
4.2 WORK AWAY FROM LSHTM (to be completed if any work will be done away from LSHTM, other than at your home or at libraries elsewhere in the UK) Will the project be based in an established hospital, college, research Yes No institute, NGO headquarters, field station or other institutional site? If „Yes‟, please give the name and location of the site(s); describe approximately what proportions of your project will be spent there; and state name and role of person who has confirmed willingness to support you at each site (indicating extent of correspondence, especially what they have confirmed in writing). 67
Professor Jose Nando Tiofilo, chairman of trypanosomiasis in Angola and Dr. Nilton Saraivo, vice chairman of malaria in Angola and Dr. Adao Castelo Antonio, chairman of health in Kwanza Sul Angola. All have confirmed willingness to support my project either in person or by email. Will you have an ‘external supervisor’, co-supervisor or other main advisor, or Yes No be working with any specific organisation(s), during your work away from LSHTM? If „Yes‟, please indicate the name, role, contact details, and level of support that any such external advisors are expected to provide, and give details about any organisations you will be working with. Professor Jose Nando Tiofilo, chairman of trypanosomiasis in Angola and Dr. Nilton Saraivo, vice chairman of malaria in Angola and Dr. Adao Castelo Antonio, chairman of health in Kwanza Sul Angola. Contact details: [email protected], [email protected], and [email protected] Will the project involve personal visits, interviews or interactions with people Yes No in their homes, workplaces, community settings or similar? If „Yes‟, please give details, including approximately what proportion of your project this will involve. Workplace visits to a few key public health personnel. Will the project involve lone/isolated work or significant travel? If „Yes‟, please Yes No give details, including approximately what proportion of your project this will involve, and state how you can be contacted while working or travelling.
What arrangements are proposed for contact with your main supervisor while you are away from LSHTM? Indicate expected ease and frequency of contact, and communication methods to be used. Regular email or telephone contact with Michael Miles or a nominated proxy. Please tick to confirm: I have read the LSHTM Code of Practice on off-site work.
4.3 WORK OUTSIDE THE UK (to be completed if any work will be done outside the UK) What form of project work will be undertaken outside the UK? (please tick all that apply) Work at my family home or personal residence only Work at an established hospital, college, research institute, NGO headquarters, field station or other institutional site Work away from my personal residence or an established site *Note that for either the second or third options, you should also have completed Section 4.2. Name the country/countries and region(s) in which work will be undertaken: Country or countries: Angola Region(s) : Luanda and Kwanza sul (Angola) But excluding: Cabinda Province and North and South Lunda provinces where travel is inadvisable. Do the Foreign & Commonwealth Office’s (FCO) Travel Advice Notices Yes No (www.fco.gov.uk/en/travelling-and-living-overseas/travel-advice-by-country/) advise against travel to the regions(s), country or countries involved? *Note that if ‘Yes’, the School will not normally permit such travel for project work. In exceptional circumstances only, requests may be considered by the Safety Committee and require approval by the Safety Manager and Secretary & Registrar. Please tick to confirm: I understand that LSHTM travel insurance is required for any international travel as part of my project. *Travel insurance can be applied for using a separate form.
4.4 WORK WITH HAZARDOUS SUBSTANCES (to be completed if the project involves any work with pathogenic organisms, human blood or radiochemicals – NB that this will require approval by the Departmental Safety Supervisor) Name the organism or organisms to be used:
Identify all potential routes of infection:
68
Name the radiochemical or radiochemicals to be used:
List laboratories where work with pathogens or radioisotopes will be carried out:
List disinfectants to be used, and describe arrangements for disposal of used material:
Will or might Health Surveillance be required for you or any staff working with Yes No you? If „Yes‟, please give details.
4.5 PRECAUTIONS AGAINST HAZARDS (to be completed if any potentially hazardous activities are likely to be carried out during the project. Refer to Project Handbook and School safety documentation for further information. Departmental Safety Supervisor‟s approval should be obtained where felt appropriate by project Supervisor.) Indicate any procedures, activities or aspects of the proposed project which may entail hazards (including work with hazardous substances as per Section 4.4, or anything else relevant). Please set distinct hazards out separately, in a numbered list.
Indicate the precautions you will take to prevent or mitigate such potential hazards. Please number these to refer to the specific hazards identified in the preceding question.
4.6 SPECIAL REQUIREMENTS (to be completed if the project involves any special requirements, e.g. disability-related issues, or other concerns that need to be taken into account for either you as a student, study participants or colleagues) What special requirements or concerns need to be taken into account?
Do these need to be considered in planning arrangements? Yes No If „Yes‟, please give details.
Do these impact on supervision arrangements? Yes No If „Yes‟, please give details.
Does the project location need to be considered in relation to these? Yes No If „Yes‟, please give details.
Do arrangements for access to specialist medical treatment need to be Yes No considered? If „Yes‟, please give details.
SECTION 5 – APPLICATION FOR ETHICS APPROVAL *All students should answer all questions in sub-sections 5.1 and 5.2. Answers to 5.1 will make clear whether approval by the LSHTM Ethics Committee is necessary, and which later sub-sections you may need to complete. Section 5.2 covers any external approvals required.
5.1 SCOPE OF STUDY (to be completed by all students) 69
*Before completing this part of the form, please read the Ethics Approval Policy & Procedure plus guidance notes at http://intra.lshtm.ac.uk/reference/ethicsstuds.html . This describes what to do next if formal LSHTM ethics approval is required. NB that supervisor approval must be obtained before an application is submitted to the Ethics Committee. Which of the following applies to your project? (please tick one option only) *Note – the term ‘human data’ includes any documentary data, datasets or biological samples.
Project does not involve any human subjects or any human data. [If so, formal LSHTM ethics approval is not required and you do not need to complete Sections 5.3 or 5.4] Project involves human data, but all this human data is fully in the public domain. [If so, formal LSHTM ethics approval is not required and you do not need to complete Sections 5.3 or 5.4] *Public domain human data must be: available to any member of the public without special permission; to which access is not restricted in any way; and which does not enable the identification of living people, either directly or by linking to other data. Project involves some non-public-domain human data, all of which was previously collected in another study or studies. [If so, formal LSHTM ethics approval is required and Section 5.3 must be completed] Project involves some additional collection of data, further to an ongoing or previously completed study or studies. [If so, formal LSHTM ethics approval is required and Section 5.4 must be completed] Project is a completely new study which will involve human subjects or human data. [If so, formal LSHTM ethics approval is required and Section 5.4 must be completed]
5.2 LOCAL ETHICAL APPROVAL OR RESEARCH GOVERNANCE APPROVAL (to be completed by all students) * As well as approval from the LSHTM Ethics Committee, projects may require specific approval from other involved or responsible bodies. For example, in the UK you may need specific authorisation to work in an NHS facility, or to work with vulnerable groups such as patients or children. Outside the UK a wide range of requirements may apply e.g. from local or national Ethics Committees, government departments etc. Students must investigate all potential local approval required for your project work. Failure to check or gain any necessary external approval may invalidate LSHTM approval. Is local approval required for the work being done (whether this approval is Yes No still to be obtained, or has already been granted)? *This should include any forms of ethical approval, research governance approval or other specific permissions that may apply. If ‘Yes’, give details of local approval to be obtained (this must be in place before commencing fieldwork) or which has already been granted. *Please name all bodies whose approval is required, or indicate where work is expected to take place using permissions already granted for a ‘parent’ project. Where approval has already been granted, quote approval reference numbers and if possible give web links to documents. If ‘No’, explain why formal local approval is not required, and describe any less formal permissions, invitations or support you are being given for this work. *If you will be working away from LSHTM with human subjects or human data, but cannot identify a local Ethics Committee or believe that no formal approval is required, then please give details and explain what you have done to check this. In such cases, if you do not have formal approval you should always demonstrate appropriate local support, such as correspondence with local government officials or an involved Non-Governmental Organisation.
For data to be used or collected in the project, will any specific data rights No permissions be required or usage limitations apply?
5.3 PROJECTS USING ONLY PREVIOUSLY-COLLECTED HUMAN DATA (to be completed if project involves non-public-domain human data, datasets or biological samples previously collected in another study or studies; if collecting any new data, complete Section 5.4 instead) 70
*Further guidance is given at http://intra.lshtm.ac.uk/reference/ethicsstuds.html Summary of purpose and methods of the original study or studies: (max 100 words)
Give details of all approvals under which the original study or studies took place: *Please quote names of Ethics Committees and approval reference numbers (required if previous approval was from LSHTM); if possible give web link to original study application.
Proposed study: Ensure that the project outline given in Section 3.1 states the purpose, methods and procedures of the new work to be done in your project, and describes how this builds on the previous study or studies (for which participants will already have been recruited, data or samples collected, and procedures performed). Do not reproduce here. Will your analyses be for purposes not covered by the original application Yes No detailed above? If „Yes‟, indicate how you will obtain (i) permission to use the data from the principal investigator responsible for each original study; and (ii) retrospective consent, where appropriate, from the participants in each original study.
Does the project involve analysis of documentary information and/or data Yes No already collected from or about human subjects? If „Yes‟, specify analyses briefly. Records of prevalence, incidence and geographical distribution of malaria or trypanosomiasis. Does the project involve laboratory analysis of human biological samples Yes No already collected, or new or additional analysis of stored samples? If „Yes‟, specify the laboratory analyses or tests to be performed.
Specify how confidentiality will be maintained. When small numbers are involved, indicate how possible identification of individuals will be avoided.
5.4 PROJECTS COLLECTING ANY NEW HUMAN DATA (to be completed if project involves collection of human data, datasets or human biological samples – either as a completely new study, or collecting additional data further to an ongoing or previously completed study) *Further guidance is given at http://intra.lshtm.ac.uk/reference/ethicsstuds.html Proposed study: Ensure that the project outline given in Section 3.1 contains sufficient detail (inc. purpose, methods, procedures for both new data collection and any work building on previous studies), so as to allow the Ethics Committee to make an informed decision without reference to other documents. Do not reproduce here. Is your project a randomised trial? Yes No Will any human biological samples be collected? If „Yes‟, specify details. Yes No
Will any human biological material be stored at LSHTM for more than 24 Yes No hours? If „Yes‟, specify which samples and how they will be stored. *Further guidance is given at http://intra.lshtm.ac.uk/safety/Safety%20manual-3- HTA.pdf
Specify the number - with scientific justification for sample size – age, gender, source and method of recruiting subjects for the study.
State the location and likely duration of new or additional human data collection, and the extent to which this will be carried out by you alone, or in collaboration with others, or by 71 others.
State the potential distress, discomfort or hazards, and their likelihood, to which research subjects may be exposed (these may include physical, biological and/or psychological hazards). What precautions are being taken to control and modify these hazards?
Specify how confidentiality will be maintained. When small numbers are involved, indicate how possible identification of individuals will be avoided.
State the manner in which consent will be obtained from subjects and supply copies of the information sheet and consent form. Written consent is normally required. Where not possible, explain why and confirm that a record of those giving verbal consent will be kept. Where appropriate, please state if and how the information and consent form will be translated into local language(s).
As well as collecting new data, will your project also make use of any human Yes No data or biological samples collected in a previous study or studies? If „Yes‟, summarise the purpose and methods of the original study or studies – for which participants will already have been recruited, data or samples collected, and procedures performed. (max 100 words)
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APPENDIX 6: CONTACT LETTER
Dear Prof Michael After we have read your message, we are happy to inform that we agree to give support to Domingos Vita in his work about Human African Trypanosomiasis in Angola and we will do our best to help him about contacts and guidances in other field.
Best Regards
JOSENANDO Théophile
Josenando Théophile - MD, MSc, PhD Director Geral Instituto de Combate e Controlo das Tripanossomíases - ICCT/MINSA Rua Comandante Kwenha 168, Ingombota C.P. 2657 Tel: +244 222 399610 (Office) +244 923 404577 (Mobile) +244 222 399611 (Fax) Email: [email protected] Luanda - Angola
--- On Tue, 6/1/10, Domingos Vita Vita
From: Domingos Vita Vita
Dear Dr. Professor Jose Nando. Saudo-te com a paz do senhor Chamo-me Domingos Vita, sou estudante do MSc na faculdade de LONDON SCHOOL OF HYGIENE AND TROPICAL MEDICINE (UNIVERSITY OF LONDON). Pretendo viajar em Angola com objective de colheir dados para realizacao da minha tese com o seguinte tema: STRATEGIES OF CONTROLLING MALARIA AND TRYPANOSOMIASIS IN ANGOLA. Professor, a carta que a faculdade mando esta em anexo. Por favor ajuda-me, marquei a viage para o dia 16-07-2010
Obrigado Domingos Vita BSc (Hons) Public Health, MSc student in Control of Infectoius Diseases.
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