The promise, problems and pitfalls of mass drug administration for malaria elimination: a qualitative study with scientists and policymakers

Evaluating the quality and reliability of YouTube videos on scabies in children: A cross-sectional study

BACKGROUND

Recently, there has been an increase in scabies cases among young children in low- and middle-income countries. With the rise of online health information, platforms such as YouTube have become popular sources of disease-related content, but the accuracy of this information remains a concern.

AIM

This study evaluates the reliability and quality of YouTube videos concerning scabies in children to address the lack of research in this area.

MATERIALS AND METHODS

A cross-sectional analysis was conducted on April 1, 2024, reviewing the first 200 relevant YouTube videos with the search terms "scabies" and "scabies in children." Videos were assessed using modified DISCERN (mDISCERN), Global Quality Score (GQS), and Journal of the American Medical Association (JAMA) scoring systems. Statistical analysis included descriptive statistics, Kruskal-Wallis tests, and Spearman correlation analysis.

RESULTS

Out of 200 videos, 107 met the inclusion criteria. The average mDISCERN score was 2.17, GQS was 2.63, and JAMA was 2.05, indicating generally poor quality. Videos by patients had the highest quality scores, while those from academic institutions had the highest JAMA scores. Longer videos with higher view counts were associated with better quality.

CONCLUSION

This study reveals that the majority of YouTube videos on scabies in children are of low quality. There is a need for healthcare professionals to produce more accurate and reliable content to improve the quality of information available on YouTube. Further research should focus on enhancing the quality of health information on digital platforms.

Prevalence of asymptomatic malaria and associated factors among pregnant women in Ethiopia: systematic review and meta-analysis

The proactive identification of asymptomatic patients and the mitigation of associated problems are essential to the elimination of malaria. For asymptomatic malaria and related variables among pregnant women in Ethiopia, there are no national pooled estimates. As a result, the goal of this study is to compile thorough and compelling data from several Ethiopian investigations. Google Scholar, PubMed, Scopes, the Web of Science, the Cochrane Library, and African Journals Online were a few of the electronic resources that were accessed. The investigation included all observational studies. STATA version 15 was used to extract the data from the Microsoft Excel file and conduct the analysis. The estimated pooled prevalence of asymptomatic malaria among pregnant women was calculated using a random-effects model. An inverse variance index (I2) analysis was utilized to find heterogeneity. To assess the publication bias, funnel plots, and Egger's statistical tests were used. The study determined that the combined prevalence of asymptomatic malaria among pregnant women was 7.20 (95% confidence interval = 4.22, 10.18) and 4.69 (95% confidence interval = 2.77, 6.62) by microscopy and rapid diagnostic test, respectively. The presence of stagnant water near their home (odds ratio = 4.31; 95% confidence interval = 1.66, 11.20); not using insecticide-treated nets (odds ratio = 6.93; 95% confidence interval = 3.27, 14.71); the lack of indoor residual spray service (odds ratio = 2.68; 95% confidence interval = 1.63, 4.40); and the presence of pregnant women in their neighborhood (odds ratio = 3.14; 95% confidence interval = 1.4). This study showed that pregnant women have a high pooled prevalence of asymptomatic malaria. Women living in rural areas near stagnant water and those who never used insecticide-treated nets had a two-, four-, or six-fold higher prevalence of asymptomatic malaria, respectively. The use of advanced diagnostic techniques could produce a higher magnitude of the disease. For effective intervention toward elimination, active case detection at the community level is also advised.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023411385; identifier, CRD42023411385.

Community engagement among forest goers in a malaria prophylaxis trial: implementation challenges and implications

BACKGROUND

Malaria transmission in Southeast Asia is increasingly confined to forests, where marginalized groups are exposed primarily through their work. Anti-malarial chemoprophylaxis may help to protect these people. This article examines the effectiveness and practical challenges of engaging forest-goers to participate in a randomized controlled clinical trial of anti-malarial chemoprophylaxis with artemether-lumefantrine (AL) versus a control (multivitamin, MV) for malaria in northeast Cambodia.

METHODS

The impact of engagement in terms of uptake was assessed as the proportion of people who participated during each stage of the trial: enrolment, compliance with trial procedures, and drug intake. During the trial, staff recorded the details of engagement meetings, including the views and opinions of participants and community representatives, the decision-making processes, and the challenges addressed during implementation.

RESULTS

In total, 1613 participants were assessed for eligibility and 1480 (92%) joined the trial, 1242 (84%) completed the trial and received prophylaxis (AL: 82% vs MV: 86%, p = 0.08); 157 (11%) were lost to follow-up (AL: 11% vs MV: 11%, p = 0.79); and 73 (5%) discontinued the drug (AL-7% vs MV-3%, p = 0.005). The AL arm was associated with discontinuation of the study drug (AL: 48/738, 7% vs 25/742, 3%; p = 0.01). Females (31/345, 9%) were more likely (42/1135, 4%) to discontinue taking drugs at some point in the trial (p = 0.005). Those (45/644, 7%) who had no previous history of malaria infection were more likely to discontinue the study drug than those (28/836, 3%) who had a history of malaria (p = 0.02). Engagement with the trial population was demanding because many types of forest work are illegal; and the involvement of an engagement team consisting of representatives from the local administration, health authorities, community leaders and community health workers played a significant role in building trust. Responsiveness to the needs and concerns of the community promoted acceptability and increased confidence in taking prophylaxis among participants. Recruitment of forest-goer volunteers to peer-supervise drug administration resulted in high compliance with drug intake. The development of locally-appropriate tools and messaging for the different linguistic and low-literacy groups was useful to ensure participants understood and adhered to the trial procedures. It was important to consider forest-goers` habits and social characteristics when planning the various trial activities.

CONCLUSIONS

The comprehensive, participatory engagement strategy mobilized a wide range of stakeholders including study participants, helped build trust, and overcame potential ethical and practical challenges. This locally-adapted approach was highly effective as evidenced by high levels of trial enrolment, compliance with trial procedures and drug intake.

Optimal Interruption of P. vivax Malaria Transmission Using Mass Drug Administration

Plasmodium vivax is the most geographically widespread malaria-causing parasite resulting in significant associated global morbidity and mortality. One of the factors driving this widespread phenomenon is the ability of the parasites to remain dormant in the liver. Known as 'hypnozoites', they reside in the liver following an initial exposure, before activating later to cause further infections, referred to as 'relapses'. As around 79-96% of infections are attributed to relapses from activating hypnozoites, we expect it will be highly impactful to apply treatment to target the hypnozoite reservoir (i.e. the collection of dormant parasites) to eliminate P. vivax. Treatment with radical cure, for example tafenoquine or primaquine, to target the hypnozoite reservoir is a potential tool to control and/or eliminate P. vivax. We have developed a deterministic multiscale mathematical model as a system of integro-differential equations that captures the complex dynamics of P. vivax hypnozoites and the effect of hypnozoite relapse on disease transmission. Here, we use our multiscale model to study the anticipated effect of radical cure treatment administered via a mass drug administration (MDA) program. We implement multiple rounds of MDA with a fixed interval between rounds, starting from different steady-state disease prevalences. We then construct an optimisation model with three different objective functions motivated on a public health basis to obtain the optimal MDA interval. We also incorporate mosquito seasonality in our model to study its effect on the optimal treatment regime. We find that the effect of MDA interventions is temporary and depends on the pre-intervention disease prevalence (and choice of model parameters) as well as the number of MDA rounds under consideration. The optimal interval between MDA rounds also depends on the objective (combinations of expected intervention outcomes). We find radical cure alone may not be enough to lead to P. vivax elimination under our mathematical model (and choice of model parameters) since the prevalence of infection eventually returns to pre-MDA levels.

Policy stakeholder perspectives on barriers and facilitators to launching a community-wide mass drug administration program for soil-transmitted helminths

BACKGROUND

Recent evidence suggests that soil-transmitted helminth (STH) transmission interruption may be feasible through community-wide mass drug administration (cMDA) that deworms community members of all ages. A change from school-based deworming to cMDA will require reconfiguring of STH programs in endemic countries. We conducted formative qualitative research in Benin, India, and Malawi to identify barriers and facilitators to successfully launching a cMDA program from the policy-stakeholder perspective.

METHODS

We conducted 40 key informant interviews with policy stakeholders identified as critical change agents at national, state/district, and sub-district levels. Participants included World Health Organization country office staff, implementing partners, and national and sub-national government officials. We used the Consolidated Framework for Implementation Research to guide data collection, coding, and analysis. Heat maps were used to organize coded data and differentiate perceived facilitators and barriers to launching cMDA by stakeholder.

RESULTS

Key facilitators to launching a cMDA program included availability of high-quality, tailored sensitization materials, and human and material resources that could be leveraged from previous MDA campaigns. Key barriers included the potential to overburden existing health workers, uncertainty of external funding to sustain a cMDA program, and concerns about weak intragovernmental coordination to implement cMDA. Cross-cutting themes included the need for rigorous trial evidence on STH transmission interruption to gain confidence in cMDA, and implementation evidence to effectively operationalize cMDA. Importantly, if policy stakeholders anticipate a cMDA program cannot be sustained due to cost and human resource barriers in the long term they may be less likely to support the launch of a program in the short term.

CONCLUSIONS

Overall, policy stakeholders were optimistic about implementing cMDA primarily because they believe that the tools necessary to successfully implement cMDA are already available. Policy stakeholders in this study were cautiously optimistic about launching cMDA to achieve STH transmission interruption and believe that it is feasible to implement. However, launching cMDA as an alternative policy to school-based deworming will require addressing key resource and evidence barriers. Trial registration This study was registered in the U.S. National Library of Medicine Clinical Trials registry (NCT03014167).

Prevalence of asymptomatic malaria and associated factors in Ethiopia: Systematic review and meta-analysis

Active detection of asymptomatic malaria cases and resolution of associated factors are essential for malaria elimination. There are no nationwide estimates for asymptomatic malaria and associated factors in Ethiopia. Therefore, this study aims to generate comprehensive and conclusive evidence from various studies conducted in Ethiopia. Published articles from various electronic databases such as PubMed, Google Scholar, CINAHL, Scopes, Cochrane Library, the Web of Science, and African Journals Online were accessed. Also, unpublished studies from Addis Ababa digital library were identified. All observational study designs were included in the search. Data were extracted on the Microsoft Excel spreadsheet and analyzed using STATA version 14.1. A random-effects model was fitted to estimate the pooled prevalence of asymptomatic malaria. A meta-regression and subgroup analysis was computed to see heterogeneity. The publication bias was assessed by the funnel plots and Egger's statistical tests. The analysis found that the pooled burden of asymptomatic malaria was 6.7 (95% confidence interval = 4.60, 8.79). The pooled prevalence of Plasmodium falciparum was 3.75 (95% confidence interval = 2.25, 5.18), and that of Plasmodium vivax was 2.22 (95% confidence interval = 1.46, 2.99). Factors such indoor residual spray service (odds ratio = 0.46; 95% confidence interval = 0.26, 0.81), never used insecticide-treated nets (odds ratio = 6.36; 95% confidence interval = 4.01, 10.09), and presence of stagnant water in the vicinity (odds ratio = 3.24; 95% confidence interval = 1.20, 8.71) were found to have a significant association with asymptomatic malaria. This study highlighted that pooled prevalence of asymptomatic malaria is high and varied by population groups. Prevalence of asymptomatic malaria was increased among those who never used insecticide-treated nets and were living near stagnant water by six and three times, respectively. The use of more sensitive diagnostic methods could yield a higher burden of the disease. Furthermore, active case detection is recommended for effective intervention toward elimination.

Malaria chemoprevention and drug resistance: a review of the literature and policy implications

Chemoprevention strategies reduce malaria disease and death, but the efficacy of anti-malarial drugs used for chemoprevention is perennially threatened by drug resistance. This review examines the current impact of chemoprevention on the emergence and spread of drug resistant malaria, and the impact of drug resistance on the efficacy of each of the chemoprevention strategies currently recommended by the World Health Organization, namely, intermittent preventive treatment in pregnancy (IPTp); intermittent preventive treatment in infants (IPTi); seasonal malaria chemoprevention (SMC); and mass drug administration (MDA) for the reduction of disease burden in emergency situations. While the use of drugs to prevent malaria often results in increased prevalence of genetic mutations associated with resistance, malaria chemoprevention interventions do not inevitably lead to meaningful increases in resistance, and even high rates of resistance do not necessarily impair chemoprevention efficacy. At the same time, it can reasonably be anticipated that, over time, as drugs are widely used, resistance will generally increase and efficacy will eventually be lost. Decisions about whether, where and when chemoprevention strategies should be deployed or changed will continue to need to be made on the basis of imperfect evidence, but practical considerations such as prevalence patterns of resistance markers can help guide policy recommendations.

Community engagement for malaria elimination in the Greater Mekong Sub-region: a qualitative study among malaria researchers and policymakers

BACKGROUND

Community engagement has increasingly received attention in malaria research and programme interventions, particularly as countries aim for malaria elimination. Although community engagement strategies and activities are constantly developing, little is known about how those who implement research or programmes view community engagement. This article explores the perspectives of researchers and policy makers in the Greater Mekong Sub-region (GMS) on community engagement for malaria control and elimination.

METHODS

Semi-structured interviews were conducted among 17 policymakers and 15 senior researchers working in the field of malaria. All interviews were audio-recorded and transcribed in English. Transcribed data were analysed using deductive and inductive approaches in QSR NVivo. Themes and sub-themes were generated.

RESULTS

Researchers and policymakers emphasized the importance of community engagement in promoting participation in malaria research and interventions. Building trust with the community was seen as crucial. Respondents emphasized involving authority/leadership structures and highlighted the need for intense and participatory engagement. Geographic remoteness, social, cultural, and linguistic diversity were identified as barriers to meaningful engagement. Local staff were described as an essential 'connect' between researchers or policymakers and prospective participants. Sharing information with community members, using various strategies including creative and participatory methods were highlighted.

CONCLUSIONS

Policymakers and researchers involved in malaria prevention and control in the GMS viewed community engagement as crucial for promoting participation in research or programmatic interventions. Given the difficulties of the 'last mile' to elimination, sustained investment in community engagement is needed in isolated areas of the GMS where malaria transmission continues. Involving community-based malaria workers is ever more critical to ensure the elimination efforts engage hard-to-reach populations in remote areas of GMS.

Forest malaria and prospects for anti-malarial chemoprophylaxis among forest goers: findings from a qualitative study in Lao PDR

Background

Despite significant decline in malarial incidence and mortality in countries across the Greater Mekong Subregion, the disease remains a public health challenge in the region; transmission continues mainly among people who visit forests in remote areas, often along international borders, where access to primary healthcare is limited. In the absence of effective vector-control measures and limited exposure periods, malaria chemoprophylaxis has been proposed as a strategy to protect forest goers. As a rarely used approach for indigenous populations, questions remain about its feasibility and acceptability. Drawing on in-depth interviews with forest goers and stakeholders, this article examines opportunities and challenges for implementation of anti-malarial chemoprophylaxis for forest goers in Lao PDR.

Methods

In-depth interviews were conducted with 16 forest goers and 15 stakeholders in Savannakhet province, Lao PDR. Interview topics included experience of malaria prevention and health services, and perceptions of prophylaxis as a potential component of malaria elimination strategy. The interviews were transcribed and coded using inductive and deductive approaches for qualitative thematic analysis.

Results

In ethnically and geographically diverse villages, awareness of malaria risk prompts forest goers to protect themselves, albeit sub-optimally using available preventive measures. Stakeholders highlighted challenges for targeting at-risk populations and approaches to address forest malaria in southern Lao PDR. Among policymakers, choice and cost of anti-malarials, particularly their efficacy and source of funding, were key considerations for the feasibility of malaria prophylaxis. Acceptability of prophylaxis among forest goers was also influenced by the complexity of the regimen, including the number of tablets and timing of doses. Implementation of prophylaxis may be affected by a lack of transportation and communication barriers in remote communities.

Conclusion

Adding prophylaxis to existing malaria control activities requires strengthening the capacity of local health workers in Lao PDR. Ideally, this would be part of an integrated approach that includes strategies to address the other febrile illnesses that forest goers describe as priority health concerns. The prophylactic regimen also requires careful consideration in terms of effectiveness and simplicity of dosing.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-021-04027-z.

Mass drug administration for endemic scabies: a systematic review

BACKGROUND

Scabies is an extremely fastidious infestation caused by the Sarcoptes scabiei mite. It causes a persistent itch that can disrupt a person's mental health, sleep, and overall quality of life. In endemic areas, treatment by targeting symptomatic individuals and their contacts is often unsuccessful due to an asymptomatic period and high rates of re-infection. To overcome this, Mass Drug Administration (MDA) is often used to treat the whole community, irrespective of whether individuals presently have scabies. This review summarises the evidence for the effectiveness of MDA in treating scabies.

METHODS

An exhaustive literature review was conducted on MEDLINE, EMBASE, Web of Science and Scopus. All peer-reviewed articles published in English January 1990 to March 2020 were eligible and only if the studies were primary and interventional. Furthermore, the intervention had to be a pharmacological MDA method involving human subjects.

RESULTS

TWELVE articles that qualified for inclusion were identified. MDA for scabies significantly reduced its prevalence in communities at follow up. Some of the drivers of success were communities with low levels of migration, an uptake of MDA of > 85%, the use of oral Ivermectin therapy, the treatment of children and pregnant women within the treated population, and repeated treatment for participants diagnosed with scabies at baseline.

CONCLUSIONS

The average absolute reduction in prevalence of scabies was 22.0% and the relative reduction average was 73.4%. These results suggest MDA is effective in treating scabies in the endemic community. Further evidence is needed surrounding MDA use in urban areas with increased levels of migration. Importantly, MDA should not substitute the tackling of socioeconomic factors which contribute to endemic disease such as good sanitation and hygiene.

Asymptomatic malaria infection prevailing risks for human health and malaria elimination

There has been a consistent rise in malaria cases in the last few years. The existing malaria control measures are challenged by insecticide resistance in the mosquito vector, drug résistance in parasite populations, and asymptomatic malaria (ASM) in healthy individuals. The absence of apparent malaria symptoms and the presence of low parasitemia makes ASM a hidden reservoir for malaria transmission and an impediment in malaria elimination efforts. This review focuses on ASM in malaria-endemic countries and the past and present research trends from those geographical locations. The harmful impacts of asymptomatic malaria on human health and its contribution to disease transmission are highlighted. We discuss certain crucial genetic changes in the parasite and host immune response necessary for maintaining low parasitemia leading to long-term parasite survival in the host. Since the chronic health effects and the potential roles for disease transmission of ASM remain mostly unknown to significant populations, we offer proposals for developing general awareness. We also suggest advanced technology-based diagnostic methods, and treatment strategies to eliminate ASM.

From informed consent to adherence: factors influencing involvement in mass drug administration with ivermectin for malaria elimination in The Gambia

Background

The World Health Organization (WHO) recommends consideration of mass drug administration (MDA) for malaria control in low-endemic settings approaching elimination. However, MDA remains a controversial strategy, as multiple individual, social, and operational factors have shown to affect its acceptability at local levels. This is further complicated by inconsistent definitions of key indicators derived from individual and community involvement—coverage, adherence, and compliance—that cast doubts about the actual and potential epidemiological impact of MDA on disease control and elimination. This study aimed to identify limitations and enabling factors impacting involvement at different stages of a large cluster-randomized trial assessing the effect of combining dihydroartemisinin-piperaquine (DP) and ivermectin (IVM) in malaria transmission in The Gambia.

Methods

This social science study used a mixed-methods approach. Qualitative data were collected in intervention and control villages through ethnographic methods, including in-depth interviews (IDIs), focus group discussions (FGDs), and participant observation conducted with trial participants and decliners, community leaders, and field staff. A cross-sectional survey was conducted in the intervention villages after the first year of MDA. Both strands of the study explored malaria knowledge and opinions, social dynamics influencing decision-making, as well as perceived risks, burdens, and benefits associated with this MDA.

Results

157 IDIs and 11 FGDs were conducted, and 864 respondents were included in the survey. Barriers and enabling factors to involvement were differentially influential at the various stages of the MDA. Issues of social influence, concerns regarding secondary effects of the medication, costs associated with malaria, and acceptability of the implementing organization, among other factors, differently affected the decision-making processes throughout the trial. Rather than a linear trajectory, involvement in this MDA trial was subjected to multiple revaluations from enrolment and consent to medicine intake and adherence to treatment.

Conclusions

This study went beyond the individual factors often associated with coverage and adherence, and found that nuanced social dynamics greatly influence the decision-making process at all phases of the trial. These issues need to be consider for MDA implementation strategies and inform discussions about more accurate ways of reporting on critical effectiveness indicators.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-021-03732-z.

A systematic review of factors influencing participation in two types of malaria prevention intervention in Southeast Asia

Background

Multi-pronged malaria elimination strategies are increasingly being considered for accelerating efforts against malaria transmission in Southeast Asia. Two malaria prevention interventions used in in the region are insecticide-treated bed-nets (ITNs) and mass drug administration (MDA). Universal access to ITNs is recommended and high population coverage (e.g. above 80%) is needed during MDA initiatives to maximize the impact of these interventions. However, variability in ITN use and individual MDA participation exists. This systematic review aims to provide a summary and overview of literature discussing factors influencing uptake of these two malaria control strategies in Southeast Asian countries.

Methods

A search of OVID Embase, OVID MEDLINE, Cochrane Central Register of Controlled Trials, Web of Science, OpenGrey, ProQuest, and Google Scholar was undertaken in February 2020. English-language publications with any study design using data from any of the ten member countries of the Association of Southeast Asian Nations were eligible for inclusion. In addition, reference lists of identified articles were manually searched. Websites for relevant international agencies were also searched to identify related grey literature.

Results

The review identified thirty publications that met the inclusion and exclusion criteria. Most discussed ITN use (n = 18) and were relevant to populations in Myanmar (n = 14). All MDA studies were published after 2016, whereas included ITN studies spanned from 1998 to 2020. Seven main themes emerged across the studies. Knowledge of malaria and attitudes towards ITNs were emphasized as key factors associated with ITN use. For MDA participation, key factors included the importance of positive attitudes towards the program, the influence of indirect costs and incentives, and the tendency for group decision-making.

Conclusions

As countries in Southeast Asia continue to work towards becoming malaria-free by 2030, the knowledge and attitudes of local population sub-groups should be assessed and incorporated into the planning and implementation of malaria prevention activities. The role of incentives and group decision making should also be considered particularly as they relate to MDA. There is need for ongoing involvement of health educators, the continuation of implementation research and the prioritization of community engagement efforts alongside malaria interventions in the region.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-021-03733-y.

Rolling out the radical cure for vivax malaria in Asia: a qualitative study among policy makers and stakeholders

BACKGROUND

Wide-spread implementation of treatment regimens for the radical cure of vivax malaria is hindered by a range of factors. This has resulted in an increase in the relative proportion of vivax malaria and is an important obstacle in the achievement of global malaria elimination by 2030. The main objective of this study was to explore the current policies guiding the treatment plans on vivax malaria, and the factors affecting the implementation of radical cure in South/South East Asian and Asian Pacific countries.

METHODS

This was a qualitative study among respondents who represented national malaria control programmes (NMCPs) or had a role and influence in the national malaria policies. 33 respondents from 17 countries in South/South East Asia and Asia Pacific participated in interviews between October 15 and December 15, 2020. Semi-structured interviews were conducted virtually except for two face to face interviews and audio-recorded. Transcribed audio-records underwent thematic analysis using QSR NVivo.

RESULTS

Policies against vivax malaria were underprioritized, compared with the focus on falciparum malaria and, in particular, drug resistant Plasmodium falciparum strains. Despite the familiarity with primaquine (PQ) as the essential treatment to achieve the radical cure, the respondents contested the need for G6PD testing. Optional G6PD testing was reported to have poor adherence. The fear of adverse events led health workers to hesitate prescribing PQ. In countries where G6PD was mandatory, respondents experienced frequent stockouts of G6PD rapid diagnostic kits in peripheral health facilities, which was compounded by a short shelf life of these tests. These challenges were echoed across participating countries to various degrees. Most respondents agreed that a shorter treatment regimen, such as single dose tafenoquine could resolve these problems but mandatory G6PD testing will be needed. The recommendation of shorter regimens including tafenoquine or high dose PQ requires operational evidence demonstrating the robust performance of point of care G6PD tests (biosensors).

CONCLUSION

There was sparse implementation and low adherence to the radical cure in South/South East Asian and Asian pacific countries. Shorter treatment regimens with appropriate point of care quantitative G6PD tests may resolve the current challenges. Operational evidence on point of care quantitative G6PD tests that includes the feasibility of integrating such tests into the radical cure regimen are critical to ensure its implementation.

In-vitro diagnostic point-of-care tests in paediatric ambulatory care: A systematic review and meta-analysis

INTRODUCTION

Paediatric consultations form a significant proportion of all consultations in ambulatory care. Point-of-care tests (POCTs) may offer a potential solution to improve clinical outcomes for children by reducing diagnostic uncertainty in acute illness, and streamlining management of chronic diseases. However, their clinical impact in paediatric ambulatory care is unknown. We aimed to describe the clinical impact of all in-vitro diagnostic POCTs on patient outcomes and healthcare processes in paediatric ambulatory care.

METHODS

We searched MEDLINE, EMBASE, Pubmed, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Web of Science from inception to 29 January 2020 without language restrictions. We included studies of children presenting to ambulatory care settings (general practice, hospital outpatient clinics, or emergency departments, walk-in centres, registered drug shops delivering healthcare) where in-vitro diagnostic POCTs were compared to usual care. We included all quantitative clinical outcome data across all conditions or infection syndromes reporting on the impact of POCTs on clinical care and healthcare processes. Where feasible, we calculated risk ratios (RR) with 95% confidence intervals (CI) by performing meta-analysis using random effects models.

RESULTS

We included 35 studies. Data relating to at least one outcome were available for 89,439 children of whom 45,283 had a POCT across six conditions or infection syndromes: malaria (n = 14); non-specific acute fever 'illness' (n = 7); sore throat (n = 5); acute respiratory tract infections (n = 5); HIV (n = 3); and diabetes (n = 1). Outcomes centred around decision-making such as prescription of medications or hospital referral. Pooled estimates showed that malarial-POCTs (Plasmodium falciparum) better targeted antimalarial treatment by reducing over-treatment by a third compared to usual care (RR 0.67; 95% CI [0.58 to 0.77], n = 36,949). HIV-POCTs improved initiating earlier antiretroviral therapy compared to usual care (RR, 3.11; 95% CI [1.55 to 6.25], n = 912). Across the other four conditions, there was limited evidence for the benefit of POCTs in paediatric ambulatory care except for acute respiratory tract infections (RTI) in low-and-middle-income countries (LMICs), where POCT C-Reactive Protein (CRP) may reduce immediate antibiotic prescribing by a third (risk difference, -0.29 [-0.47, -0.11], n = 2,747). This difference was shown in randomised controlled trials in LMICs which included guidance on interpretation of POCT-CRP, specific training or employed a diagnostic algorithm prior to POC testing.

CONCLUSION

Overall, there is a paucity of evidence for the use of POCTs in paediatric ambulatory care. POCTs help to target prescribing for children with malaria and HIV. There is emerging evidence that POCT-CRP may better target antibiotic prescribing for children with acute RTIs in LMIC, but not in high-income countries. Research is urgently needed to understand where POCTs are likely to improve clinical outcomes in paediatric settings worldwide.

To screen or not to screen: an interactive framework for comparing costs of mass malaria treatment interventions

BACKGROUND

Mass drug administration and mass-screen-and-treat interventions have been used to interrupt malaria transmission and reduce burden in sub-Saharan Africa. Determining which strategy will reduce costs is an important challenge for implementers; however, model-based simulations and field studies have yet to develop consensus guidelines. Moreover, there is often no way for decision-makers to directly interact with these data and/or models, incorporate local knowledge and expertise, and re-fit parameters to guide their specific goals.

METHODS

We propose a general framework for comparing costs associated with mass drug administrations and mass screen and treat based on the possible outcomes of each intervention and the costs associated with each outcome. We then used publicly available data from six countries in western Africa to develop spatial-explicit probabilistic models to estimate intervention costs based on baseline malaria prevalence, diagnostic performance, and sociodemographic factors (age and urbanicity). In addition to comparing specific scenarios, we also develop interactive web applications which allow managers to select data sources and model parameters, and directly input their own cost values.

RESULTS

The regional-level models revealed substantial spatial heterogeneity in malaria prevalence and diagnostic test sensitivity and specificity, indicating that a "one-size-fits-all" approach is unlikely to maximize resource allocation. For instance, urban communities in Burkina Faso typically had lower prevalence rates compared to rural communities (0.151 versus 0.383, respectively) as well as lower diagnostic sensitivity (0.699 versus 0.862, respectively); however, there was still substantial regional variation. Adjusting the cost associated with false negative diagnostic results to included additional costs, such as delayed treated and potential lost wages, undermined the overall costs associated with MSAT.

CONCLUSIONS

The observed spatial variability and dependence on specified cost values support not only the need for location-specific intervention approaches but also the need to move beyond standard modeling approaches and towards interactive tools which allow implementers to engage directly with data and models. We believe that the framework demonstrated in this article will help connect modeling efforts and stakeholders in order to promote data-driven decision-making for the effective management of malaria, as well as other diseases.

Community engagement and ethical global health research

Community engagement is increasingly recognized as a critical element of medical research, recommended by ethicists, required by research funders and advocated in ethics guidelines. The benefits of community engagement are often stressed in instrumental terms, particularly with regard to promoting recruitment and retention in studies. Less emphasis has been placed on the value of community engagement with regard to ethical good practice, with goals often implied rather than clearly articulated. This article outlines explicitly how community engagement can contribute to ethical global health research by complementing existing established requirements such as informed consent and independent ethics review. The overarching and interlinked areas are (1) respecting individuals, communities and stakeholders; (2) building trust and social relationships; (3) determining appropriate benefits; minimizing risks, burdens and exploitation; (4) supporting the consent process; (5) understanding vulnerabilities and researcher obligations; (6) gaining permissions, approvals and building legitimacy and (7) achieving recruitment and retention targets.

Prevalence of asymptomatic malaria parasitaemia following mass testing and treatment in Pakro sub-district of Ghana

Background

Global efforts to scale-up malaria control interventions are gaining steam. These include the use of Long-Lasting Insecticide Nets, Indoor Residual Spraying, Intermittent Preventive Treatment and Test, Treat and Track. Despite these, the drive for malaria elimination is far from being realistic in endemic communities in Africa. This is partly due to the fact that asymptomatic parasite carriage, not specifically targeted by most interventions, remains the bedrock that fuels transmission. This has led to mass testing, treatment and tracking (MTTT) as an alternative strategy to target asymptomatic individuals. We report the impact of MTTT on the prevalence of asymptomatic malaria parasitaemia over a one-year period in Ghana, hypothesizing that implementing MTTT could reduce the rate of asymptomatic parasitaemia.

Methods

A population of about 5000 individuals in seven communities in the Pakro sub-district of Ghana participated in this study. A register was developed for each community following a census. MTTT engaged trained community-based health volunteers who conducted house-to-house testing using RDTs every 4 months and treated positive cases with Artemisinin–based Combination Therapy. Between interventions, community-based management of malaria was implemented for symptomatic cases.

Results

MTTT Coverage was 98.8% in July 2017 and 79.3% in July 2018. Of those tested, asymptomatic infection with malaria parasites reduced from 36.3% (1795/4941) in July 2017 to 32.9% (1303/3966) in July 2018 (p = 0.001). Prevalence of asymptomatic parasitaemia among children under 15 years declined from 52.6% (1043/1984) in July 2017 to 47.5% (820/1728) in July 2018 (p = 0.002). Implementing MTTT significantly reduced asymptomatic parasitaemia by 24% from July 2017 to July 2018 after adjusting for age, ITN use and axillary temperature (OR = 0.76, CI = 0.67, 0.85 p ≤ 0.001).

Conclusion

This study has demonstrated that implementing MTTT is feasible and could reduce the prevalence of asymptomatic malaria parasitaemia in children under 15 years of age. Furthermore, the use of community-based health volunteers could ensure high coverage at lower cost of implementation.

Trial registration

NCT04167566, Date 14/11/2019. Retrospective registration.

Mass drug administration can be a valuable addition to the malaria elimination toolbox

The Global Technical Strategy 2016-2030 of the World Health Organization (WHO) has the ambitious goal of malaria being eliminated from at least 35 countries by 2030. However, in areas with once-stable malaria transmission, the reservoir of human infection may be intermittently symptomatic or fully silent yet still lead to transmission, posing a serious challenge to elimination. Mass drug administration (MDA), defined as the provision of a therapeutic dose of an effective anti-malarial drug to the entire target population, irrespective of infection status or symptoms, is one strategy to combat the silent human reservoir of infection. MDA is currently recommended by the WHO as a potential strategy for the elimination of Plasmodium falciparum malaria in areas approaching interruption of transmission, given the prerequisites of good access to case management, effective vector control and surveillance, and limited potential for reintroduction. Recent community randomized controlled trials of MDA with dihydroartemisinin-piperaquine, implemented as part of a comprehensive package of interventions, have shown this strategy to be safe and effective in significantly lowering the malaria burden in pre-elimination settings. Here it is argued that effectively implemented MDA should be kept in the elimination toolbox as a potential strategy for P. falciparum elimination in a variety of settings, including islands, appropriate low transmission settings, and in epidemics and complex emergencies. Effectively implemented MDA using an ACT has been shown to be safe, unrelated to the emergence of drug resistance, and may play an important role in sufficiently lowering the malaria burden to allow malaria transmission foci to be more easily identified, and to allow elimination programmes to more feasibly implement case-based surveillance and follow-up activities. To be most impactful and guard against drug resistance, MDA should use an ACT, achieve high programmatic coverage and adherence, be implemented when transmission is lowest in areas of limited risk of immediate parasite reintroduction, and must always be implemented only once good access to case management, high coverage of effective vector control, and strong surveillance have been achieved. If these considerations are taken into account, MDA should prove to be a valuable tool for the malaria elimination toolbox.

Prospects and strategies for malaria elimination in the Greater Mekong Sub-region: a qualitative study

BACKGROUND

As malaria elimination becomes a goal in malaria-endemic nations, questions of feasibility become critical. This article explores the potential challenges associated with this goal and future strategies for malaria elimination in the Greater Mekong Sub-region.

METHODS

Thirty-two semi-structured interviews were conducted with policy makers (n = 17) and principal investigators (n = 15) selected based on their involvement in malaria prevention, control and elimination in the GMS. Interviews were audio-recorded and transcribed for qualitative content (thematic) analysis using QSR NVivo.

RESULTS

All respondents described current malaria control and elimination strategies, such as case detection and management, prevention and strengthening of surveillance systems as critical and of equal priority. Aware of the emergence of multi-drug resistance in the GMS, researchers and policy makers outlined the need for additional elimination tools. As opposed to a centralized strategy, more targeted and tailored approaches to elimination were recommended. These included targeting endemic areas, consideration for local epidemiology and malaria species, and strengthening the peripheral health system. A decline in malaria transmission could lead to complacency amongst funders and policy makers resulting in a reduction or discontinuation of support for malaria elimination. Strong commitment of policymakers combined with strict monitoring and supervision by funders were considered pivotal to successful elimination programmes.

CONCLUSION

Against a backdrop of increasing anti-malarial resistance and decreasing choices of anti-malarial regimens, policy makers and researchers stressed the urgency of finding new malaria elimination strategies. There was consensus that multi-pronged strategies and approaches are needed, that no single potential tool/strategy can be appropriate to all settings. Hence there is a need to customize malaria control and elimination strategies based on the better surveillance data.

Challenges and perceptions of implementing mass testing, treatment and tracking in malaria control: a qualitative study in Pakro sub-district of Ghana

Background

Malaria remains endemic in Ghana despite several interventions. Studies have demonstrated very high levels of asymptomatic malaria parasitaemia in both under-five and school-age children. Mass testing, treatment and tracking (MTTT) of malaria in communities is being proposed for implementation with the argument that it can reduce parasite load, amplify gains from the other control interventions and consequently lead to elimination. However, challenges associated with implementing MTTT such as feasibility, levels of coverage to be achieved for effectiveness, community perceptions and cost implications need to be clearly understood. This qualitative study was therefore conducted in an area with on-going MTTT to assess community and health workers’ perceptions about feasibility of scale-up and effectiveness to guide scale-up decisions.

Methods

This qualitative study employed purposive sampling to select the study participants. Ten focus group discussions (FGDs) were conducted in seven communities; eight with community members (n = 80) and two with health workers (n = 14). In addition, two in-depth interviews (IDI) were conducted, one with a Physician Assistant and another with a Laboratory Technician at the health facility. All interviews were recorded, transcribed, translated and analyzed using QSR NVivo 12.

Results

Both health workers and community members expressed positive perceptions about the feasibility of implementation and effectiveness of MTTT as an intervention that could reduce the burden of malaria in the community. MTTT implementation was perceived to have increased sensitisation about malaria, reduced the incidence of malaria, reduced household expenditure on malaria and alleviated the need to travel long distances for healthcare. Key challenges to implementation were doubts about the expertise of trained Community-Based Health Volunteers (CBHVs) to diagnose and treat malaria appropriately, side effects of Artemisinin-based Combination Therapies (ACTs) and misconceptions that CBHVs could infect children with epilepsy.

Conclusion

The study demonstrated that MTTT was perceived to be effective in reducing malaria incidence and related hospital visits in participating communities. MTTT was deemed useful in breaking financial and geographical barriers to accessing healthcare. The interventions were feasible and acceptable to community members, despite observed challenges to implementation such as concerns about CBHVs’ knowledge and skills and reduced revenue from internally generated funds (IGF) of the health facility.

Treatment-seeking behaviour for febrile illnesses and its implications for malaria control and elimination in Savannakhet Province, Lao PDR (Laos): a mixed method study

Background

How people respond to febrile illness is critical to malaria prevention, control, and ultimately elimination. This article explores factors affecting treatment-seeking behaviour for febrile illnesses in a remote area of Lao PDR.

Methods

Household heads or their representatives (n = 281) were interviewed using a structured questionnaire. A total of twelve focus group discussions (FGDs) each with eight to ten participants were conducted in four villages. In addition, observations were recorded as field notes (n = 130) and were used to collect information on the local context, including the treatment seeking behaviour and the health services.

Results

Almost three-quarters (201/281) of respondents reported fever in past two months. Most (92%, 185/201) sought treatment of which 80% (149/185) sought treatment at a health centre. Geographic proximity to a health centre (AOR = 6.5; CI = 1.74–24.25; for those < 3.5 km versus those > 3.6 km) and previous experience of attending a health centre (AOR = 4.7; CI = 1.2–19.1) were strong predictors of visiting a health centre for febrile symptoms. During FGDs, respondents described seeking treatment from traditional healers and at health centre for mild to moderate illnesses. Respondents also explained how if symptoms, including fever, were severe or persisted after receiving treatment elsewhere, they sought assistance at health centres. Access to local health centres/hospitals was often constrained by a lack of transportation and an ability to meet the direct and indirect costs of a visit.

Conclusion

In Nong District, a rural area bordering Vietnam, people seek care from health centres offering allopathic medicine and from spiritual healers. Decisions about where and when to attend health care depended on their economic status, mobility (distance to the health centre, road conditions, availability of transport), symptoms severity and illness recognition. Current and future malaria control/elimination programmes could benefit from greater collaboration with the locally accessible sources of treatments, such as health volunteers and traditional healers.

Community engagement, social context and coverage of mass anti-malarial administration: Comparative findings from multi-site research in the Greater Mekong sub-Region

BACKGROUND

Between 2013 and 2017, targeted malaria elimination (TME), a package of interventions that includes mass drug administration (MDA)-was piloted in communities with reservoirs of asymptomatic P. falciparum across the Greater Mekong sub-Region (GMS). Coverage in target communities is a key determinant of the effectiveness of MDA. Drawing on mixed methods research conducted alongside TME pilot studies, this article examines the impact of the community engagement, local social context and study design on MDA coverage.

METHODS AND FINDINGS

Qualitative and quantitative data were collected using questionnaire-based surveys, semi-structured and in-depth interviews, focus group discussions, informal conversations, and observations of study activities. Over 1500 respondents were interviewed in Myanmar, Vietnam, Cambodia and Laos. Interview topics included attitudes to malaria and experiences of MDA. Overall coverage of mass anti-malarial administration was high, particularly participation in at least a single round (85%). Familiarity with and concern about malaria prompted participation in MDA; as did awareness of MDA and familiarity with the aim of eliminating malaria. Fear of adverse events and blood draws discouraged people. Hence, community engagement activities sought to address these concerns but their impact was mediated by the trust relationships that study staff could engender in communities. In contexts of weak healthcare infrastructure and (cash) poverty, communities valued the study's ancillary care and the financial compensation. However, coverage did not necessarily decrease in the absence of cash compensation. Community dynamics, affected by politics, village conformity, and household decision-making also affected coverage.

CONCLUSIONS

The experimental nature of TME presented particular challenges to achieving high coverage. Nonetheless, the findings reflect those from studies of MDA under implementation conditions and offer useful guidance for potential regional roll-out of MDA: it is key to understand target communities and provide appropriate information in tailored ways, using community engagement that engenders trust.

Drug discovery and drug marketing with the critical roles of modern administration

Drug research and development is a long-term and complicated process with the involvement of multidisciplinary, multi-sector cooperation and regulations of the Food and Drug Administration (FDA). It is of high risk, high cost, high benefit and time-consuming. Therefore, the drug administration and management is extremely necessary and useful. We discussed the whole process including laboratory study, target determination, drug discovery and screening, leading compound and optimization, preclinical and clinical trials, FDA approval and marketing. Actively exploring and applying modern administration and innovative management technology, we can scientifically and effectively enhance the discovery of new drug research and development, and strengthen the supervision of drug market. In recent years, innovation such as artificial intelligence has been applied to drug discovery and drug administration. We further analyzed the possibility of applying management technology to reduce risks, generate profits and benefit patients in the whole process of new drug research and development. In conclusion, drug administration and management plays critical roles in modern drug research and development, and the new technology can be helpful for drug launching.