PECADOM Plus

So, per allusion at the end of my last blog post, I’ve decided that it would be worthwhile to explain a little bit about the formal, actual “work” work I do here.  To date I have been reticent to do so because I know that while it is very interesting and exciting work to me, I am a pretty huge nerd and people less nerdy than I may not be predisposed to find it so fascinating. I am, after all, the one that once made Christmas sugar cookies in the shape of various parasites and diseases (HIV virus, Giardia lambila amoeba, Taenia solium tapeworm, etc.)…

Proof

And so, to make this post more digestible for those people who are not of my extreme-nerd persuasion, I have done two things.

One - throughout the blog I have sporadically placed joke answers and responses. They are not clearly identifiable simply from scrolling through the blog so you will HAVE to read through it to find them. I apologize in advance for the crude nature of many of these jokes. They are simply the ones that have stuck with me over time.

And two – I have devised rules to make the reading of this post into a drinking game. People who know me well shouldn’t be surprised by this given that I am inclined to make most anything into a game to make it more palatable or interesting.  The rules of the game are as such:

1.       Every time I say “Pecadom” take a sip of your beverage.

2.       Every time I say “Plus”, send me an email with an original compliment, something you have never said to anyone ever before (to smollenk @ gmail).

Are you ready?

What do you call a Roman soldier who is smiling with pubic hair in his teeth?

The region of Kedougou (the region in which I live), located in the southeast corner of Senegal and bordering both Guinea and Mali, has the highest rates of malaria in the country.  In my district specifically, the district of Saraya, malaria accounts for 25% of outpatient visits annually, up to 40% of outpatient visits during the malaria season (June to November), 85% of hospitalizations, two thirds of all hospital deaths, and 50% of deaths in children under the age of five.  It is the single greatest burden on the healthcare system. It also has an immense impact on the population physically, emotionally, financially and culturally.  A glad-i-ate-r.  Here, many people accept regular, debilitating, seasonal illness and the death of young children as a fact of life.  People do not know that in other parts of the world it is not normal for people to regularly fall ill with fever or that the death of young children can be only a rare exception to the rule and not the substance of it.

In efforts to control the disease and reduce its catastrophic burden, we as public health professionals emphasize two things: prevention and treatment. Why did the golfer wear two pairs of pants?

Prevention comes in several forms: the use of Insecticide-Treated Bednets (ITNs) to prevent the Anopheles night-biting mosquitoes (the vector for malaria) from biting while you are asleep; the spraying of insecticides on the inside walls of homes to eliminate resting spots for mosquitoes after they have taken a blood meal (aka Indoor Residual Spraying or IRS); mass drug administration programs to treat all children during peak transmission seasons (aka Seasonal Malaria Chemoprophylaxis or SMC); special preventative drug therapy programs for pregnant women who are particularly vulnerable to the disease for various reasons (aka Intermittent Preventative Therapy or IPTp); environmental clean-up campaigns to eliminate mosquito breeding grounds (standing water, etc.); the wearing of long sleeves and long pants or insecticides at dusk and dawn; and education about the disease and all of these techniques I have listed.

In regards to treatment we emphasize that all malaria cases should be treated and that they should be treated as soon as possible. In case they get a hole in one.  This is important to reduce the likelihood of the disease developing into the more severe, cerebral form, to reduce likelihood of death, and to minimize the opportunity for further transmission.

And here is where PECADOM Plus comes in.

Many barriers exist that prohibit rural populations from accessing care. These may be geographic (the doctor is far away, the road to get there is blocked by a seasonal river, etc.), educational (people do not know the importance of seeking medical attention early/at all when they have a fever or they think that seeking medical attention could be detrimental because if they have Yellow Fever and they are stuck by a needle they will explode – a belief unfortunately held by some here), financial (they cannot afford the consultation fee, the testing fee, the medication fee or to pay for transport to get to a health facility) or otherwise.

To address some of these barriers, the Ministry of Health in Senegal implemented a home-based care model called PECADOM. What’s the difference between like, love, and showing off?  For this program, volunteer community-based care providers known as DSDOMs (Dispensateur de Soin au Domicile) in rural villages were trained specifically to perform rapid diagnostic tests for malaria and administer malaria treatment for uncomplicated cases, referring all negative and severe cases to the local health post.  Instead of having to worry about how to get to see a doctor when their child was feverish, community members in these villages could go to the homes of these volunteers and obtain immediate, free malaria diagnosis and treatment.

While this program was very impactful, some limitations were still evident in the existing model. As case detection was passive (meaning that the DSDOMs just sat around at home passively and waited for sick people to come to them), malaria detection and treatment relied on the patient making the decision to seek care. Spit, swallow and blowing bubbles. This meant that the aforementioned educational barriers were still in play; people needed to make the decision to seek out treatment which remained an issue among community members who were not educated to do so.

In 2010, a Peace Corps volunteer named Ian Hennessee (or locally known as Fode Mari Tandian) piloted a project in his village, Missera Dantila, and two other very small villages in which they built on this program to turn it into an active model.  The DSDOMs that previously sat around at home and waited for their neighbors to show up whenever they were sick would instead be paid a small wage to conduct sweeps of every household in their village once a week during the rainy season to actively seek out cases. They would go house by house to ask if there were any people present who were sick with fever. What is similar about a Pope’s balls and the balls on a Christmas tree? Rapid diagnostic tests would be administered to anyone with symptoms and treatment would be provided on the spot, right in people’s homes. They called this new and improved version of the PECADOM Program, PECADOM Plus.

While initial results were promising, the sample size (3 villages) for this program was very small. Therefore, in 2012 and 2013, Peace Corps volunteer Anne Linn (aka Sadio Tigana, my ancien), partnered with the Saraya Health District to scale up this program to 14 villages in the Saraya District and conduct a thorough program evaluation to test its impact.  Her results (awaiting publication) were quite convincing.

At the start of the program a similar prevalence of symptomatic malaria, just over 1% of the total population, was found in both sets of villages. By the time rainy season was half way over, the prevalence was found to be 2.5 times higher in the comparison villages (in the normal PECADOM Program) than in the intervention villages (using active case detection in the PECADOM Plus program). When the program ended the prevalence in comparison villages was nearly 16 times higher than in the intervention villages, where only six cases of symptomatic malaria were found.

They are only for decoration.  This was enough to convince the National Malaria Control Program (Program National de Lutte Contre Le Paludisme aka PNLP) to adopt the PECADOM Plus program model and scale it up to the entire region of Kedougou this year.  And if it goes well this year, they will scale it up to the entire regions of Kolda, Tambacounda and Sedhiou (also high malaria prevalence areas) next year as well.

And this is now where I come in.

I forewarn you at this juncture that I have run out of jokes and so I have supplemented further text with numerous pictures. Hopefully that suffices to keep your interest.

While PECADOM Plus is officially a PNLP program this year, Peace Corps volunteers are still playing a big role. After all, it is a sort of Peace Corps baby that we all want to take care of and see succeed.  Plus, there is generally a shortage of skilled health personnel to supervise programs like this one and it is one of our official Peace Corps roles to help fill this gap. And so we have taken on many tasks.

We are trainers. I gave my first ever presentation in French to a group of 50-some-odd DSDOMs and Community Supervisors during Ramadan about how to form care groups with women in their villages (DSDOMs are asked to gather a group of women in their village, at least one from every household, and educate them about malaria).  I also spent several weeks racing all over the district - 70km in one direction, 80km in another - to work one-on-one with DSDOMs during practical trainings to practice treatment algorithms and learn how to use reporting tools.  Often I would lead role-play activities (in Malinke) in which I would pretend that the DSDOM had just entered my home and a member of my family was sick and in need of their care. Nicole, a fellow PCV, friend and accomplice in many of these trainings, would often play the part of sick and terrified child who threw a fit when the DSDOMs tried to measure her temperature (to their utter amusement) and pretended to cry when they fake-poked her finger to draw blood for the rapid diagnostic test. We would start with simple, straightforward malaria cases and then move on to trying to trick them by unveiling secrets along the way such as the fact that I was pretend-pregnant which meant they had to refer me to the nearest health post instead of treat me.

 

Upper Left: Me and Renee training DSDOMs about using reporting forms

Upper Right: DSDOMs receiving training on using reporting forms by Renee and I

Lower Left: Nicole training DSDOMs on malaria treatment algorithms under the mango tree

Lower Right: Travelling far and wide on bush roads to go help with training

We are supervisors. Every week (before all of these Ebola shenanigans in Senegal) we would accompany DSDOMs on their house-to-house sweeps to see them in action and make sure they were doing everything correctly in the field.

Picture on Left: Nicole and Ntafe Cissokho, one of our community supervisors

Picture on Right: A DSDOM and one of the women in his women's care group

We are watch-dogs.  Every week there are Peace Corps volunteers responsible for calling all the program Community Supervisors (the people who the DSDOMs report to) to inquire about whether or not sweeps happened that week, why they didn’t if they didn’t, what medications or tests they might be running out of and any other issues they may have.  We use this information to help identify issues early and find resolutions as well as to track important program indicators.

In this capacity we are also advocates.  When there are issues and concerns, we can communicate them to actors at all levels of the health system up to partners at the PNLP and PMI/CDC/USAID with whom we have constant communication.

Me and some congressional staffers from the office of Barbara Boxer to whom I presented about PECADOM Plus

We are data collectors. For the last 5 days I have had my head buried in reporting forms, entering data into Excel spreadsheets, cleaning data, analyzing data and working on reports for health posts, the Saraya Health District and the Regional Health administrators about the status of the program half way through its duration.

We are innovators. As the program has been scaled up to new level this year, there are plenty of new challenges that come along related to scale.  We have the opportunity to identify these processes that are not functioning efficiently and devise solutions for this year’s program and for adjusting the protocol for next year’s even more expansive program scale-up.

We are also educators. To the greatest extent possible, Peace Corps volunteers were present for the formation and training of women’s care groups in all the DSDOMs’ villages, meaning that we drove or biked out to all of these far-out villages to meet with the DSDOMs, meet the women in their villages and talk about malaria in their communities.

A women's care group gathering

So that is more or less PECADOM Plus. Or as we say in Malinke, “wo le mu le PECADOM Plus ti”…

And that is what the bulk of my work has been like here so far.

Tipsy yet??

I look forward to some compliments…