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    Mosquitoes around the home can be reduced significantly by minimizing the amount of standing water available for mosquito breeding. Residents are urged to reduce standing water around the home in a variety of ways.


    The best way is to avoid being bitten by mosquitoes.This can be accomplished using personal protecting  while outdoors when mosquitoes are present. Treated bed nets should be used sleeping. Mosquito repellent should be used when outdoor.


    Nearly half of the world’s population is at risk of getting malaria. Pregnant women are particularly at risk of malaria. Children under 5 years are at high risk of malaria.


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  • Volume 1

Maximising Effectiveness

This five-letter name—INESS—is gaining popularity especially among health researchers and health policy makers in Tanzania. INESS stands for INDEPTH Network Effectiveness and Safety Studies.  It is a platform created in 2009 to assess the effectiveness and safety of new anti-malarial drugs and vaccines in real life health systems. The platform operates in Tanzania, Ghana, Burkina Faso and Mozambique with financial support from Bill and Melinda Gates Foundation through the INDEPTH Network. In an interview with Mbarwa Kivuyo of AMMREN Tanzania, the project manager in Tanzania, Dr Rashid Khatib, gives an account of the successes and challenges facing the project and the way forward.

AMMREN: Can you briefly explain what INESS is all about?
INESS is a project established to provide national, regional and international health decision makers with independent and objective evidence on the safety and effectiveness of new anti-malarial drugs as a basis for malaria treatment policy. The INESS objectives in Tanzania are similar to those of the network as a whole. Hence, INESS Tanzania is trying to answer the same research questions that are being asked in Ghana, Burkina Faso and Mozambique. The project is primarily intended to help strengthen Health and Demographic Surveillance System (HDSS) sites in those countries to become a platform suitable for monitoring safety and community effectiveness of new medical products including malaria control interventions such as drugs, vector control tools and vaccines.

AMMREN: You mentioned HDSS sites. What are they?
HDSS sites are stations initiated and hosted in respective countries in Africa, Asia, Latin America and Oceania for the purpose of tracking health, demographic and mortality events at village level. All but few HDSS sites are members of IN-DEPTH Network. There are three sites in Tanzania—two of them are run by Ifakara Health Institute (IHI) located at Rufiji and Ifakara Districts in Pwani and Morogoro regions respectively.

AMMREN: Why do you think INESS is important in a country like Tanzania?
There is a general concern that poor countries adopt various new medical products for routine use without adequate information on their safety and effectiveness. Decisions governing the use of these products are based on evidence generated from experimental studies whose study samples are not always typical of the routine populations. A good example is the artemisinin-based combination therapies for malaria (ACTs) such as, artemether-lumefantrine (ALu) that has been recommended for malaria treatment in Tanzania. The policy decision was made in 2006 based on initial evidence that the medicine could safely cure more than nine out of ten children under-five with malaria caused by plasmodium falciparum only. A close look at the decision revealed that the groups that were involved in the study were too narrow. Infants, pregnant women, other age groups, mixed infections and severe cases were not allowed in these experiments. As the medicines have been adopted for widespread use, it is expected that malaria patients will be given ALu.

AMMREN: What is wrong with the narrow sample used in the experiments?
Treatments conditions observed in the clinical trials are hardly repeated when drugs are delivered in the health system. The safety of the medical products and their impact on the population could be improved if policy formulations are comprehensively informed by evidence generated from platforms that INESS has spearheaded. In the clinical trials, the patients who are involved in the studies are few and managed properly. Drugs are dispensed subject to confirmation that they had parasites in their blood and they had eaten fatty foods. Dosages are dispensed accurately and drugs are taken under the supervision of trained and reasonably paid nurses. In addition, drugs are given for free and every cost is covered by a project. Patients are given incentives for participating in the study. In real life situation however, the challenge is reaching a large population of patients, diagnosing the disease accurately, dispensing the right doses of drugs, assuring patients that the drugs are safe and supervising drugs taken, are some of the components of the phenomenon called “health system.” The public health impacts of the drugs such as reduction of deaths largely depend on the strength of the health system that encompasses the things I have cited.

AMMREN: So, what does INESS do to avert such potential risks?
INESS is a platform that enables authorities to follow up on the performance of medical products after they have been deployed for normal use. The INESS platform in Tanzania allows us to monitor more than 10,000 patients who are using medical products. It is likely that adverse events arising from their use, no matter how rare, will be captured. The platform will also identify health systems barriers in the delivery of the products.

AMMREN: What interventions is INESS monitoring at the moment?
Although the platform is designed for monitoring every health intervention, in the initial phase the project has focused on drugs for malaria case management. And the first drug being investigated using the platform is the currently used artemisinin-based combination therapy for malaria (ACT). The ACT used in Tanzania is ALu. Hence the project has just finished evaluating safety and effectiveness of ALu using the platform that INESS has created.

AMMREN: What are the results of your first evaluation?
The results of our first evaluations suggest Alu is still safe. However, we have observed its community effectiveness is below 20 percent. Hence, a lot still needs to be done to strengthen the health systems for the country to reap the potential benefits of the drug. Preliminary results have been shared with stakeholders responsible for formulating policies on health, regulators and implementers of malaria control programs.

AMMREN: Who are the key actors and what are their roles?
As we are investigating health system to determine drugs’ community effectiveness, we do not intervene on our own. Several agencies are the stakeholders of INESS Tanzania. The Ministry of Health and Social Welfare through the Tanzania Food and Drugs Authority (TFDA) is one of the key actors. All the medical products must be registered with TFDA. NMCP oversees the smooth running of drugs treatment outlets at district level.

AMMREN: What are the successes of the project to date?
INESS Tanzania is proud of numerous successes since its inception. First, it has strengthened HDSS sites to be platforms not only for monitoring disease outcomes but also for monitoring safety and community effectiveness of medical products. Second, INESS has set up an electronic data linkage system where patients’ data from the health facilities and from the community can easily be linked to determine the outcome of treatment dispensed from the health facilities. This kind of infrastructures can generate health information that cannot be generated anywhere in Tanzania. Third, the project has so far recruited and followed up 16,164 patients treated with ALu from its platforms. A total of 2,945 events have been registered. An event is any happening that occurs after the use of drug other than the favorable expected ones. Fourth, the project has followed up more than 230,000 individuals to estimate fever events in order to determine their treatment seeking practices. Through these follow ups, the project has been able to suggest whether the health systems in these study areas are working perfectly to maximize the community effectiveness of ALu.

AMMREN: What are the challenges facing the project to date?
One key challenge is the intermittent stock outs in health facilities where the monitoring is being done. Stock outs hamper the smooth monitoring of ACTs. We also experienced technical problems with some of the machines used for data linkage. Erratic power supplies in the villages made it difficult to carry out some of our activities in time.

AMMREN: Lastly, given the challenges, what is the way forward?
Our plan is to share all the data widely in order to make an impact on the health systems of the country. The project will broaden sharing by initiating dissemination forums where policy makers are involved. IHI will strengthen the link between INESS and councils’ health management teams.

Iness Edition