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Awasthi KR, Jancey J, Clements ACA, Rai R, Leavy JE. Community engagement approaches for malaria prevention, control and elimination: a scoping review. BMJ Open 2024; 14:e081982. [PMID: 38365295 PMCID: PMC10875526 DOI: 10.1136/bmjopen-2023-081982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 01/25/2024] [Indexed: 02/18/2024] Open
Abstract
INTRODUCTION Globally malaria programmes have adopted approaches to community engagement (ACE) to design and deliver malaria interventions. This scoping review aimed to understand, map, and synthesise intervention activities guided by ACE and implemented by countries worldwide for the prevention, control and elimination of malaria. METHODS Three databases (Web of Science, Proquest, and Medline) were searched for peer-reviewed, primary studies, published in English between 1 January 2000 and 31 December 2022. Advanced Google was used to search for grey literature. The five levels of the International Association for Public Participation were used to categorise ACE - (1) Inform, (2) Consult, (3) involve, (4) Collaborate, and (5) Co-lead. Intervention activities were categorised as health education (HE), and/or health services (HS), and/or environmental management (EM). Outcomes were collected as knowledge, attitude, behaviour, help-seeking, health and HS and environment. Enablers and barriers were identified. Malaria intervention phases were categorised as (1) prevention (P), or (2) control (C), or (3) prevention and control (PC) or prevention, control and elimination (PCE). RESULTS Seventy-five studies were included in the review. Based on ACE levels, most studies were at the inform (n=37) and involve (n=26) level. HE (n=66) and HS (n=43) were the common intervention activities. HE informed communities about malaria, its prevention and vector control. EM activities were effective when complemented by HE. Community-based HS using locally recruited health workers was well-accepted by the community. Involvement of local leaders and collaboration with local stakeholders can be enablers for malaria intervention activities. CONCLUSION Involving local leaders and community groups in all stages of malaria prevention programmes is vital for successful interventions. Key elements of successful ACE, that is, consult, collaborate, and co-lead were under-represented in the literature and require attention. National programes must consult and collaborate with community stakeholders to develop ownership of the interventions and eventually co-lead them.
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Affiliation(s)
- Kiran Raj Awasthi
- School of Population Health, Curtin University, Perth, Western Australia, Australia
| | - Jonine Jancey
- Western Australian Centre for Health Promotion Research, School of Public Health, Curtin University, Perth, Western Australia, Australia
| | | | - Rajni Rai
- School of Population Health, Curtin University, Perth, Western Australia, Australia
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Saili K, de Jager C, Sangoro OP, Nkya TE, Masaninga F, Mwenya M, Sinyolo A, Hamainza B, Chanda E, Fillinger U, Mutero CM. Anopheles rufipes implicated in malaria transmission both indoors and outdoors alongside Anopheles funestus and Anopheles arabiensis in rural south-east Zambia. Malar J 2023; 22:95. [PMID: 36927373 PMCID: PMC10018844 DOI: 10.1186/s12936-023-04489-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 02/12/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND The primary malaria vector-control interventions, indoor residual spraying and long-lasting insecticidal nets, are effective against indoor biting and resting mosquito species. Consequently, outdoor biting and resting malaria vectors might elude the primary interventions and sustain malaria transmission. Varied vector biting and resting behaviour calls for robust entomological surveillance. This study investigated the bionomics of malaria vectors in rural south-east Zambia, focusing on species composition, their resting and host-seeking behaviour and sporozoite infection rates. METHODS The study was conducted in Nyimba District, Zambia. Randomly selected households served as sentinel houses for monthly collection of mosquitoes indoors using CDC-light traps (CDC-LTs) and pyrethrum spray catches (PSC), and outdoors using only CDC-LTs for 12 months. Mosquitoes were identified using morphological taxonomic keys. Specimens belonging to the Anopheles gambiae complex and Anopheles funestus group were further identified using molecular techniques. Plasmodium falciparum sporozoite infection was determined using sandwich enzyme-linked immunosorbent assays. RESULTS From 304 indoor and 257 outdoor light trap-nights and 420 resting collection, 1409 female Anopheles species mosquitoes were collected and identified morphologically; An. funestus (n = 613; 43.5%), An. gambiae sensu lato (s.l.)(n = 293; 20.8%), Anopheles pretoriensis (n = 282; 20.0%), Anopheles maculipalpis (n = 130; 9.2%), Anopheles rufipes (n = 55; 3.9%), Anopheles coustani s.l. (n = 33; 2.3%), and Anopheles squamosus (n = 3, 0.2%). Anopheles funestus sensu stricto (s.s.) (n = 144; 91.1%) and Anopheles arabiensis (n = 77; 77.0%) were the dominant species within the An. funestus group and An. gambiae complex, respectively. Overall, outdoor CDC-LTs captured more Anopheles mosquitoes (mean = 2.25, 95% CI 1.22-3,28) than indoor CDC-LTs (mean = 2.13, 95% CI 1.54-2.73). Fewer resting mosquitoes were collected with PSC (mean = 0.44, 95% CI 0.24-0.63). Sporozoite infectivity rates for An. funestus, An. arabiensis and An. rufipes were 2.5%, 0.57% and 9.1%, respectively. Indoor entomological inoculation rates (EIRs) for An. funestus s.s, An. arabiensis and An. rufipes were estimated at 4.44, 1.15 and 1.20 infectious bites/person/year respectively. Outdoor EIRs for An. funestus s.s. and An. rufipes at 7.19 and 4.31 infectious bites/person/year, respectively. CONCLUSION The findings of this study suggest that An. rufipes may play an important role in malaria transmission alongside An. funestus s.s. and An. arabiensis in the study location.
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Affiliation(s)
- Kochelani Saili
- International Centre of Insect Physiology and Ecology (Icipe), P.O. Box 30772-00100, Nairobi, Kenya. .,University of Pretoria Institute for Sustainable Malaria Control, School of Health Systems and Public Health, University of Pretoria, Pretoria, South Africa.
| | - Christiaan de Jager
- University of Pretoria Institute for Sustainable Malaria Control, School of Health Systems and Public Health, University of Pretoria, Pretoria, South Africa
| | - Onyango P Sangoro
- International Centre of Insect Physiology and Ecology (Icipe), P.O. Box 30772-00100, Nairobi, Kenya
| | - Theresia E Nkya
- International Centre of Insect Physiology and Ecology (Icipe), P.O. Box 30772-00100, Nairobi, Kenya.,Mbeya College of Health and Allied Sciences, University of Dar es Salaam, Mbeya, Tanzania
| | | | | | - Andy Sinyolo
- National Malaria Elimination Centre, Lusaka, Zambia
| | | | - Emmanuel Chanda
- World Health Organization, Regional Office for Africa, Brazzaville, Congo
| | - Ulrike Fillinger
- International Centre of Insect Physiology and Ecology (Icipe), P.O. Box 30772-00100, Nairobi, Kenya
| | - Clifford M Mutero
- International Centre of Insect Physiology and Ecology (Icipe), P.O. Box 30772-00100, Nairobi, Kenya.,University of Pretoria Institute for Sustainable Malaria Control, School of Health Systems and Public Health, University of Pretoria, Pretoria, South Africa
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3
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Conteh L, Shuford K, Agboraw E, Kont M, Kolaczinski J, Patouillard E. Costs and Cost-Effectiveness of Malaria Control Interventions: A Systematic Literature Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:1213-1222. [PMID: 34372987 PMCID: PMC8324482 DOI: 10.1016/j.jval.2021.01.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 12/18/2020] [Accepted: 01/04/2021] [Indexed: 05/05/2023]
Abstract
OBJECTIVES To systematically review the literature on the unit cost and cost-effectiveness of malaria control. METHODS Ten databases and gray literature sources were searched to identify evidence relevant to the period 2005 to 2018. Studies with primary financial or economic cost data from malaria endemic countries that took a provider, provider and household, or societal perspective were included. RESULTS We identified 103 costing studies. The majority of studies focused on individual rather than combined interventions, notably insecticide-treated bed nets and treatment, and commonly took a provider perspective. A third of all studies took place in 3 countries. The median provider economic cost of protecting 1 person per year ranged from $1.18 to $5.70 with vector control and from $0.53 to $5.97 with chemoprevention. The median provider economic cost per case diagnosed with rapid diagnostic tests was $6.06 and per case treated $9.31 or $89.93 depending on clinical severity. Other interventions did not share enough similarities to be summarized. Cost drivers were rarely reported. Cost-effectiveness of malaria control was reiterated, but care in methodological and reporting standards is required to enhance data transferability. CONCLUSIONS Important information that can support resource allocation was reviewed. Given the variability in methods and reporting, global efforts to follow existing standards are required for the evidence to be most useful outside their study context, supplemented by guidance on options for transferring existing data across settings.
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Affiliation(s)
- Lesong Conteh
- Department of Health Policy, London School of Economics and Political Science, London, England, UK; School of Public Health, Imperial College London, St Mary's Campus, Paddington, England, UK
| | - Kathryn Shuford
- Department of Health Policy, London School of Economics and Political Science, London, England, UK
| | - Efundem Agboraw
- Vector Biology, Liverpool School of Tropical Medicine, Liverpool, England, UK
| | - Mara Kont
- Department of Infectious Disease Epidemiology, MRC Centre for Global Infectious Disease Analysis, Imperial College London, England, UK
| | - Jan Kolaczinski
- Department of the Global Malaria Programme, World Health Organization, Geneva, Switzerland
| | - Edith Patouillard
- Department of Health Systems Governance and Financing, World Health Organization, Geneva, Switzerland.
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Dzingirai B, Katsidzira L, Matyanga CMJ, Postma MJ, van Hulst M, Mafirakureva N. Progress on the elimination of viral hepatitis in Zimbabwe: A review of the policies, strategies and challenges. J Viral Hepat 2021; 28:994-1002. [PMID: 33797190 PMCID: PMC8252795 DOI: 10.1111/jvh.13510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 03/16/2021] [Accepted: 03/18/2021] [Indexed: 12/22/2022]
Abstract
Very few low-income countries have developed national plans to achieve the viral hepatitis elimination targets set in the World Health Organization (WHO) strategy. We reviewed the policy environment, strategies and challenges on the fight against viral hepatitis in Zimbabwe. The review focussed on the Ministry of Health and Child Care (MoHCC) policy documents, strategic plans and reports. We performed key informant interviews to enhance evidence generated from the document review. Twelve documents were reviewed and interviews with 10 key informants were completed. The MoHCC established a technical working group to work towards elimination of viral hepatitis. The technical working group drafted a strategic plan for elimination of viral hepatitis; however, it is still awaiting implementation. Key strategies that are working well include screening of donated blood for transfusion, safe injection practices and hepatitis B virus (HBV) three-dose vaccination. Current challenges in the drive towards elimination of viral hepatitis include poor to non-existent surveillance systems, lack of epidemiological data, absence of the HBV vaccine birth dose and lack of systematic screening and treatment services for viral hepatitis. In conclusion, despite political will demonstrated towards achieving viral hepatitis elimination, substantial investment and work are required to implement the strategic plan and realize significant success.
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Affiliation(s)
- Blessing Dzingirai
- School of PharmacyUniversity of ZimbabweHarareZimbabwe,Department of Health SciencesUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Leolin Katsidzira
- Department of MedicineCollege of Health Sciences University of ZimbabweHarareZimbabwe
| | | | - Maarten Jacobus Postma
- Department of Health SciencesUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands,Department of Economics, Econometrics & FinanceFaculty of Economics and BusinessUniversity of GroningenGroningenThe Netherlands
| | - Marinus van Hulst
- Department of Health SciencesUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands,Department of Clinical Pharmacy and ToxicologyMartini HospitalGroningenThe Netherlands
| | - Nyashadzaishe Mafirakureva
- Health Economics and Decision ScienceSchool of Health and Related ResearchUniversity of SheffieldUnited Kingdom
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5
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McLean ARD, Indrasuta C, Khant ZS, Phyo AK, Maung SM, Heaton J, Aung H, Aung Y, Soe K, Swe MMM, von Seidlein L, Tun NN, Tun KM, Day NPJ, Ashley EA, Hlaing T, Kyaw TT, Dondorp AM, Imwong M, White NJ, Smithuis FM. Mass drug administration for the acceleration of malaria elimination in a region of Myanmar with artemisinin-resistant falciparum malaria: a cluster-randomised trial. THE LANCET. INFECTIOUS DISEASES 2021; 21:1579-1589. [PMID: 34147154 PMCID: PMC7614510 DOI: 10.1016/s1473-3099(20)30997-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 11/18/2020] [Accepted: 12/17/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND To contain multidrug-resistant Plasmodium falciparum, malaria elimination in the Greater Mekong subregion needs to be accelerated while current antimalarials remain effective. We evaluated the safety, effectiveness, and potential resistance selection of dihydroartemisinin-piperaquine mass drug administration (MDA) in a region with artemisinin resistance in Myanmar. METHODS We did a cluster-randomised controlled trial in rural community clusters in Kayin (Karen) state in southeast Myanmar. Malaria prevalence was assessed using ultrasensitive quantitative PCR (uPCR) in villages that were operationally suitable for MDA (villages with community willingness, no other malaria control campaigns, and a population of 50-1200). Villages were eligible to participate if the prevalence of malaria (all species) in adults was greater than 30% or P falciparum prevalence was greater than 10% (or both). Contiguous villages were combined into clusters. Eligible clusters were paired based on P falciparum prevalence (estimates within 10%) and proximity. Community health workers provided routine malaria case management and distributed long-lasting insecticidal bed-nets (LLINs) in all clusters. Randomisation of clusters (1:1) to the MDA intervention group or control group was by public coin-flip. Group allocations were not concealed. Three MDA rounds (3 days of supervised dihydroartemisinin-piperaquine [target total dose 7 mg/kg dihydroartemisinin and 55 mg/kg piperaquine] and single low-dose primaquine [target dose 0·25 mg base per kg]) were delivered to intervention clusters. Parasitaemia prevalence was assessed at 3, 5, 10, 15, 21, 27, and 33 months. The primary outcomes were P falciparum prevalence at months 3 and 10. All clusters were included in the primary analysis. Adverse events were monitored from the first MDA dose until 1 month after the final dose, or until resolution of any adverse event occurring during follow-up. This trial is registered with ClinicalTrials.gov, NCT01872702. FINDINGS Baseline uPCR malaria surveys were done in January, 2015, in 43 villages that were operationally suitable for MDA (2671 individuals). 18 villages met the eligibility criteria. Three villages in close proximity were combined into one cluster because a border between them could not be defined. This gave a total of 16 clusters in eight pairs. In the intervention clusters, MDA was delivered from March 4 to March 17, from March 30 to April 10, and from April 27 to May 10, 2015. The weighted mean absolute difference in P falciparum prevalence in the MDA group relative to the control group was -10·6% (95% CI -15·1 to -6·1; p=0·0008) at month 3 and -4·5% (-10·9 to 1·9; p=0·14) at month 10. At month 3, the weighted P falciparum prevalence was 1·4% (0·6 to 3·6; 12 of 747) in the MDA group and 10·6% (7·0 to 15·6; 56 of 485) in the control group. Corresponding prevalences at month 10 were 3·2% (1·5 to 6·8; 34 of 1013) and 5·8% (2·5 to 12·9; 33 of 515). Adverse events were reported for 151 (3·6%) of 4173 treated individuals. The most common adverse events were dizziness (n=109) and rash or itching (n=20). No treatment-related deaths occurred. INTERPRETATION In this low-transmission setting, the substantial reduction in P falciparum prevalence resulting from support of community case management was accelerated by MDA. In addition to supporting community health worker case management and LLIN distribution, malaria elimination programmes should consider using MDA to reduce P falciparum prevalence rapidly in foci of higher transmission. FUNDING The Global Fund to Fight AIDS, Tuberculosis and Malaria.
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Affiliation(s)
- Alistair R D McLean
- Medical Action Myanmar, Yangon, Myanmar; Myanmar Oxford Clinical Research Unit, Yangon, Myanmar; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | | | | | | | | | | | - Hein Aung
- Medical Action Myanmar, Yangon, Myanmar
| | - Ye Aung
- Medical Action Myanmar, Yangon, Myanmar
| | - Kyaw Soe
- Myanmar Oxford Clinical Research Unit, Yangon, Myanmar
| | | | - Lorenz von Seidlein
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Ni Ni Tun
- Medical Action Myanmar, Yangon, Myanmar; Myanmar Oxford Clinical Research Unit, Yangon, Myanmar
| | - Kyaw Myo Tun
- Department of Preventive and Social Medicine, Defence Services Medical Academy, Yangon, Myanmar
| | - Nicholas P J Day
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Elizabeth A Ashley
- Myanmar Oxford Clinical Research Unit, Yangon, Myanmar; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Thaung Hlaing
- Department of Public Health, Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | - Thar Tun Kyaw
- Department of Public Health, Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | - Arjen M Dondorp
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Mallika Imwong
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Department of Molecular Tropical Medicine and Genetics, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Nicholas J White
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Frank M Smithuis
- Medical Action Myanmar, Yangon, Myanmar; Myanmar Oxford Clinical Research Unit, Yangon, Myanmar; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
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Killeen GF, Kearney PM, Perry IJ, Conroy N. Long, thin transmission chains of Severe Acute Respiratory Syndrome Coronavirus 2 may go undetected for several weeks at low to moderate reproduction numbers: Implications for containment and elimination strategy. Infect Dis Model 2021; 6:474-489. [PMID: 33644500 PMCID: PMC7901309 DOI: 10.1016/j.idm.2021.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 01/21/2021] [Accepted: 02/16/2021] [Indexed: 12/23/2022] Open
Abstract
Severe Acute Respiratory Syndrome Coronavirus 1 (SARS-CoV-1) infections almost always caused overt symptoms, so effective case and contact management enabled its effective eradication within months. However, Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) usually causes only mild symptoms, so transmission chains may grow to include several individuals before at least one index case becomes ill enough to self-report for diagnosis and care. Here, simple mathematical models were developed to evaluate the implications of delayed index case detection for retrospective contact tracing and management responses. Specifically, these simulations illustrate how: (1) Contact tracing and management may effectively contain most but not all large SARS-CoV-2 clusters arising at foci with high reproduction numbers because rapidly expanding transmission chains ensure at least one overtly symptomatic index case occurs within two viral generations a week or less apart. (2) However, lower reproduction numbers give rise to thinner transmission chains extending through longer sequences of non-reporting asymptomatic and paucisymptomatic individuals, often spanning three or more viral generations (≥2 weeks of transmission) before an overtly symptomatic index case occurs. (3) Consequently, it is not always possible to fully trace and contain such long, thin transmission chains, so the community transmission they give rise to is underrepresented in surveillance data. (4) Wherever surveillance systems are weak and/or transmission proceeds within population groups with lower rates of overt clinical symptoms and/or self-reporting, case and contact management effectiveness may be more severely limited, even at the higher reproduction numbers associated with larger outbreaks. (5) Because passive surveillance platforms may be especially slow to detect the thinner transmission chains that occur at low reproduction numbers, establishing satisfactory confidence of elimination may require that no confirmed cases are detected for two full months, throughout which presumptive preventative measures must be maintained to ensure complete collapse of undetected residual transmission. (6) Greater scope exists for overcoming these limitations by enhancing field surveillance for new suspected cases than by improving diagnostic test sensitivity. (7) While population-wide active surveillance may enable complete traceability and containment, this goal may also be achievable through enhanced passive surveillance for paucisymptomatic infections, combining readily accessible decentralized testing with population hypersensitization to self-reporting with mild symptoms. Containment and elimination of SARS-CoV-2 will rely far more upon presumptive, population-wide prevention measures than was necessary for SARS-CoV-1, necessitating greater ambition, political will, investment, public support, persistence and patience. Nevertheless, case and contact management may be invaluable for at least partially containing SARS-CoV-2 transmission, especially larger outbreaks, but only if enabled by sufficiently sensitive surveillance. Furthermore, consistently complete transmission chain containment may be enabled by focally enhanced surveillance around manageably small numbers of outbreaks in the end stages of successful elimination campaigns, so that their endpoints may be accelerated and sustained.
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Affiliation(s)
- Gerry F Killeen
- School of Biological, Earth & Environmental Sciences, University College Cork, Cork, Ireland.,Environmental Research Institute, University College Cork, Cork, Ireland
| | | | - Ivan J Perry
- School of Public Health, University College Cork, Cork, Ireland
| | - Niall Conroy
- Wide Bay Public Health Unit, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
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7
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Bennett A, Porter TR, Mwenda MC, Yukich JO, Finn TP, Lungu C, Silumbe K, Mambwe B, Chishimba S, Mulube C, Bridges DJ, Hamainza B, Slutsker L, Steketee RW, Miller JM, Eisele TP. A Longitudinal Cohort to Monitor Malaria Infection Incidence during Mass Drug Administration in Southern Province, Zambia. Am J Trop Med Hyg 2020; 103:54-65. [PMID: 32618245 PMCID: PMC7416973 DOI: 10.4269/ajtmh.19-0657] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Rigorous evidence of effectiveness is needed to determine where and when to apply mass drug administration (MDA) or focal MDA (fMDA) as part of a malaria elimination strategy. The Zambia National Malaria Elimination Centre recently completed a community-randomized controlled trial in Southern Province to evaluate MDA and fMDA for transmission reduction. To assess the role of MDA and fMDA on infection incidence, we enrolled a longitudinal cohort for an 18-month period of data collection including monthly malaria parasite infection detection based on polymerase chain reaction and compared time to first infection and cumulative infection incidence outcomes across study arms using Cox proportional hazards and negative binomial models. A total of 2,026 individuals from 733 households were enrolled and completed sufficient follow-up for inclusion in analysis. Infection incidence declined dramatically across all study arms during the period of study, and MDA was associated with reduced risk of first infection (hazards ratio: 0.36; 95% CI: 0.16–0.80) and cumulative infection incidence during the first rainy season (first 5 months of follow-up) (incidence rate ratio: 0.34; 95% CI: 0.12–0.95). No significant effect was found for fMDA or for either arm over the full study period. Polymerase chain reaction infection status at baseline was strongly associated with follow-up infection. The short-term effects of MDA suggest it may be an impactful accelerator of transmission reduction in areas with high coverage of case management and vector control and should be considered as part of a malaria elimination strategy.
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Affiliation(s)
- Adam Bennett
- Malaria Elimination Initiative, Global Health Group, University of California San Francisco, San Francisco, California
| | - Travis R Porter
- Department of Tropical Medicine, Center for Applied Malaria Research and Evaluation, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Mulenga C Mwenda
- PATH Malaria Control and Elimination Partnership in Africa (MACEPA), Lusaka, Zambia
| | - Joshua O Yukich
- Department of Tropical Medicine, Center for Applied Malaria Research and Evaluation, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Timothy P Finn
- Department of Tropical Medicine, Center for Applied Malaria Research and Evaluation, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Chris Lungu
- PATH Malaria Control and Elimination Partnership in Africa (MACEPA), Lusaka, Zambia
| | - Kafula Silumbe
- PATH Malaria Control and Elimination Partnership in Africa (MACEPA), Lusaka, Zambia
| | - Brenda Mambwe
- PATH Malaria Control and Elimination Partnership in Africa (MACEPA), Lusaka, Zambia
| | - Sandra Chishimba
- PATH Malaria Control and Elimination Partnership in Africa (MACEPA), Lusaka, Zambia
| | - Conceptor Mulube
- PATH Malaria Control and Elimination Partnership in Africa (MACEPA), Lusaka, Zambia
| | - Daniel J Bridges
- PATH Malaria Control and Elimination Partnership in Africa (MACEPA), Lusaka, Zambia
| | - Busiku Hamainza
- National Malaria Elimination Centre, Zambia Ministry of Health, Lusaka, Zambia
| | | | | | - John M Miller
- PATH Malaria Control and Elimination Partnership in Africa (MACEPA), Lusaka, Zambia
| | - Thomas P Eisele
- Department of Tropical Medicine, Center for Applied Malaria Research and Evaluation, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
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8
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Jackson KD, Higgins CR, Laing SK, Mwila C, Kobayashi T, Ippolito MM, Sylvia S, Ozawa S. Impact of substandard and falsified antimalarials in Zambia: application of the SAFARI model. BMC Public Health 2020; 20:1083. [PMID: 32646393 PMCID: PMC7350731 DOI: 10.1186/s12889-020-08852-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 05/05/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Many countries are striving to become malaria-free, but global reduction in case estimates has stagnated in recent years. Substandard and falsified medicines may contribute to this lack of progress. Zambia aims to eliminate their annual burden of 1.2 million pediatric malaria cases and 2500 child deaths due to malaria. We examined the health and economic impact of poor-quality antimalarials in Zambia. METHODS An agent-based model, Substandard and Falsified Antimalarial Research Impact (SAFARI), was modified and applied to Zambia. The model was developed to simulate population characteristics, malaria incidence, patient care-seeking, disease progression, treatment outcomes, and associated costs of malaria for children under age five. Zambia-specific demographic, epidemiological, and cost inputs were extracted from the literature. Simulations were run to estimate the health and economic impact of poor-quality antimalarials, the effect of potential artemisinin resistance, and six additional malaria focused policy interventions. RESULTS We simulated annual malaria cases among Zambian children under five. At baseline, we found 2610 deaths resulting in $141.5 million in annual economic burden of malaria. We estimated that elimination of substandard and falsified antimalarials would result in an 8.1% (n = 213) reduction in under-five deaths, prevent 937 hospitalizations, and realize $8.5 million in economic savings, annually. Potential artemisinin resistance could further increase deaths by 6.3% (n = 166) and cost an additional $9.7 million every year. CONCLUSIONS Eliminating substandard and falsified antimalarials is an important step towards a malaria-free Zambia. Beyond the dissemination of insecticide-treated bed nets, indoor residual spraying, and other malaria control measures, attention must also be paid to assure the quality of antimalarial treatments.
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Affiliation(s)
- Kathryn D Jackson
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Colleen R Higgins
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, CB#7574, Beard Hall, 115H, Chapel Hill, NC, 27599, USA
| | - Sarah K Laing
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Chiluba Mwila
- Department of Pharmacy, School of Health Sciences, University of Zambia, Lusaka, Zambia
| | - Tamaki Kobayashi
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Malaria Research Institute, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Matthew M Ippolito
- Malaria Research Institute, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Division of Clinical Pharmacology and Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sean Sylvia
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA.,Carolina Population Center, University of North Carolina, Chapel Hill, NC, USA
| | - Sachiko Ozawa
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, CB#7574, Beard Hall, 115H, Chapel Hill, NC, 27599, USA. .,Department of Maternal and Child Health, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA.
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9
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Win Han Oo, Gold L, Moore K, Agius PA, Fowkes FJI. The impact of community-delivered models of malaria control and elimination: a systematic review. Malar J 2019; 18:269. [PMID: 31387588 PMCID: PMC6683427 DOI: 10.1186/s12936-019-2900-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 07/30/2019] [Indexed: 11/30/2022] Open
Abstract
Background Community-delivered models have been widely used to reduce the burden of malaria. This review aimed to explore different community-delivered models and their relative effectiveness in terms of coverage and malaria-metric outcomes in order to inform the design and implementation of Community Health Worker (CHW) programmes for malaria control and elimination. Methods A systematic review of studies investigating the impact of community-delivered models on coverage and malaria-metric (parasitaemia and hyperparasitaemia, malaria case and mortality, anaemia, and fever) outcomes compared to non- community-delivered models was undertaken by searching in five databases of published papers and grey literature databases. Data were extracted from studies meeting inclusion and quality criteria (assessed using relevant tools for the study design) by two independent authors. Meta-analyses were performed where there was sufficient homogeneity in effect and stratified by community-delivered models to assess the impact of each model on coverage and malaria-metric outcomes. Results 28 studies were included from 7042 records identified. The majority of studies (25/28) were performed in high transmission settings in Africa and there was heterogeneity in the type of, and interventions delivered as part of the community-delivered models. Compared to non- community-delivered models, community-delivered models increased coverage of actual bed net usage (Relative Risk (RR) = 1.64 95% CI 1.39, 1.95), intermittent preventive treatment in pregnancy (RR = 1.36 95% CI 1.29, 1.44) and appropriate and timely treatment of febrile children, and improved malaria-metric outcomes such as malaria mortality (RR = 0.58 95% CI 0.52, 0.65). However, the considerable heterogeneity was found in the impact of community-delivered models in reducing, parasitaemia and hyperparasitaemia prevalence, anaemia incidence, fever prevalence and malaria caseload. Statistical comparisons of different community-delivered models were not undertaken due to the heterogeneity of the included studies in terms of method and interventions provided. Conclusion Overall, the community-delivered model is effective in improving the coverage of malaria interventions and reducing malaria-associated mortality. The heterogeneity of the community-delivered models and their impact on malaria-metric indices suggests that evidence for context-specific solutions is required. In particular, community-delivered models for malaria elimination, integrated with services for other common primary health problems, are yet to be evaluated. Electronic supplementary material The online version of this article (10.1186/s12936-019-2900-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Win Han Oo
- School of Health and Social Development, Deakin University, 221 Burwood Hwy, Burwood, VIC, 3125, Australia. .,Burnet Institute, 85 Commercial Rd, Melbourne, VIC, 3004, Australia.
| | - Lisa Gold
- School of Health and Social Development, Deakin University, 221 Burwood Hwy, Burwood, VIC, 3125, Australia
| | - Kerryn Moore
- Burnet Institute, 85 Commercial Rd, Melbourne, VIC, 3004, Australia.,Melbourne School of Population and Global Health, The University of Melbourne, 235 Bouverie St, Carlton, Melbourne, VIC, 3053, Australia
| | - Paul A Agius
- Burnet Institute, 85 Commercial Rd, Melbourne, VIC, 3004, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Judith Lumley Centre, La Trobe University, Level 3, George Singer Building Bundoora, Melbourne, VIC, 3086, Australia
| | - Freya J I Fowkes
- Burnet Institute, 85 Commercial Rd, Melbourne, VIC, 3004, Australia.,Melbourne School of Population and Global Health, The University of Melbourne, 235 Bouverie St, Carlton, Melbourne, VIC, 3053, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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10
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Mazigo HD, Mboera LEG, Rumisha SF, Kweka EJ. Malaria mosquito control in rice paddy farms using biolarvicide mixed with fertilizer in Tanzania: semi-field experiments. Malar J 2019; 18:226. [PMID: 31286986 PMCID: PMC6615286 DOI: 10.1186/s12936-019-2861-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 07/03/2019] [Indexed: 01/21/2023] Open
Abstract
Background The wide distribution of malaria mosquito breeding sites within tropical environments limits the mosquito larval source management efforts to control malaria. Rice farming contributes substantially in supporting malaria mosquito productivity in tropical countries. To overcome this challenge, this study was carried out to determine the effect of applying a mixture of biolarvicide and fertilizer on mosquito larvae density in rice farms under semi-field conditions in Tanzania. Methods A semi-field experiment was designed to determine the timing of application of a biolarvicide, Bacillus thuringiensis israelensis (Bti) and fertilizer (di-ammonium phosphate-DAP or urea) and assess their effect on mosquito larvae density and rice grain outputs. The experiment had five blocks (4 treatment arms and one control arm) and each had four replicates. Treatment arms had different intervals of days between treatments for mixtures of fertilizer and biolarvicides. The dosages used were 10 g of Bti/16 M2 and 160 g of DAP/Urea/16 m2. Results In overall, the intervention blocks (with biolarvicide) had lowest mean mosquito larvae abundance compared to control block (F = 22.42, P < 0.001). Similarly, the control arm maintained highest density of Anopheles gambiae sensu lato larvae compared to interventions blocks (F = 21.6, P < 0.001). The best determined timing for application of Bti was in 7 and in 10 days (F = 3.753, P < 0.001). There was neither significant different in mean rice grain harvest per ten panicle (F = 1.453, P = 0.27) nor mean difference in rice grain harvest (F = 1.479, P = 0.26) per intervention arms. Conclusion The findings of this study have shown that application of a mixture of Bti and fertilizer have impact on both mosquito larvae density and maintaining yield rice harvest. Thus, application of a combination of biolarvicide and fertilizer can be an alternative approach in malaria mosquito intervention among rice farming communities of rural Tanzania.
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Affiliation(s)
- Humphrey D Mazigo
- Department of Medical Parasitology, School of Medicine, Catholic University of Health and Allied Sciences-Bugando, P.O. Box 1464, Mwanza, Tanzania
| | - Leonard E G Mboera
- SACIDS Foundation for One Health, Sokoine University of Agriculture, P.O. Box 3297, Chuo Kikuu, Morogoro, Tanzania
| | - Susan F Rumisha
- National Institute for Medical Research, Headquarters, P.O. Box 9653, Dar Es Salaam, Tanzania
| | - Eliningaya J Kweka
- Department of Medical Parasitology, School of Medicine, Catholic University of Health and Allied Sciences-Bugando, P.O. Box 1464, Mwanza, Tanzania. .,Division of Livestock and Human Diseases Vector Control, Mosquito Section, Tropical Pesticides Research Institute, P.O. Box 3024, Arusha, Tanzania.
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11
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McLean ARD, Wai HP, Thu AM, Khant ZS, Indrasuta C, Ashley EA, Kyaw TT, Day NPJ, Dondorp A, White NJ, Smithuis FM. Malaria elimination in remote communities requires integration of malaria control activities into general health care: an observational study and interrupted time series analysis in Myanmar. BMC Med 2018; 16:183. [PMID: 30343666 PMCID: PMC6196466 DOI: 10.1186/s12916-018-1172-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 09/11/2018] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Community health workers (CHWs) can provide diagnosis and treatment of malaria in remote rural areas and are therefore key to the elimination of malaria. However, as incidence declines, uptake of their services could be compromised if they only treat malaria. METHODS We conducted a retrospective analysis of 571,286 malaria rapid diagnostic tests conducted between 2011 and 2016 by 1335 CHWs supported by Medical Action Myanmar. We assessed rates of decline in Plasmodium falciparum and Plasmodium vivax incidence and rapid diagnostic test (RDT) positivity rates using negative binomial mixed effects models. We investigated whether broadening the CHW remit to provide a basic health care (BHC) package was associated with a change in malaria blood examination rates. RESULTS Communities with CHWs providing malaria diagnosis and treatment experienced declines in P. falciparum and P. vivax malaria incidence of 70% (95% CI 66-73%) and 64% (59-68%) respectively each year of operation. RDT positivity rates declined similarly with declines of 70% (95% CI 66-73%) for P. falciparum and 65% (95% CI 61-69%) for P. vivax with each year of CHW operation. In four cohorts studied, adding a BHC package was associated with an immediate and sustained increase in blood examination rates (step-change rate ratios 2.3 (95% CI 2.0-2.6), 5.4 (95% CI 4.0-7.3), 1.7 (95% CI 1.4-2.1), and 1.1 (95% CI 1.0.1.3)). CONCLUSIONS CHWs have overseen dramatic declines in P. falciparum and P. vivax malaria in rural Myanmar. Expanding their remit to general health care has sustained community uptake of malaria services. In similar settings, expanding health services offered by CHWs beyond malaria testing and treatment can improve rural health care while ensuring continued progress towards the elimination of malaria.
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Affiliation(s)
- Alistair R D McLean
- Medical Action Myanmar, Yangon, Myanmar.,Myanmar Oxford Clinical Research Unit (MOCRU), Yangon, Myanmar
| | | | | | | | | | | | - Thar Tun Kyaw
- Department of Public Health, Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | - Nicholas P J Day
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Arjen Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Nicholas J White
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Frank M Smithuis
- Medical Action Myanmar, Yangon, Myanmar. .,Myanmar Oxford Clinical Research Unit (MOCRU), Yangon, Myanmar. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
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12
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Temporal variation in confirmed diagnosis of fever-related malarial cases among children under-5 years by community health workers and in health facilities between years 2013 and 2015 in Siaya County, Kenya. Malar J 2017; 16:454. [PMID: 29121954 PMCID: PMC5679183 DOI: 10.1186/s12936-017-2100-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 10/31/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Malaria case management continues to experience dynamic changes. Building community capacity is instrumental in both prevention and treatment of malaria. The World Health Organization (WHO) recommends utilization of well-trained and supervised community health workers (CHWs) to reduce the burden of malaria deaths among children under-5 years of age in Africa. Longitudinally-tracked information on utilization of CHWs by communities in terms of trends in diagnosis of malaria in children under-5 years of age is essential in influencing national and local malaria control policies and strategies. METHODS A desktop review was carried out of a database consisting of confirmed uncomplicated malaria cases in 10 villages using CHWs and out-patient departments of 10 health facilities in children under-five for the period of 3 years between January 2013 and December 2015. Analyses of association between the diagnosed cases and satellite-based rainfall, village and time (months and years) were carried out using a Poisson regression model. RESULTS Analysis of malaria diagnoses made by CHWs showed the following trends: (i) the incidence of reported documented malaria-positive fever cases increased with time (2013-2015) and the difference over the years was statistically significant (P < 0.001), (ii) specific village was significantly associated (P < 0.001) with reporting malaria-positive fever cases, (iii) the long-term monthly sequence starting from highest to lowest incidence of reported malaria-positive fever cases was July, May and June, March, August, April, September, November, and February, October and, finally, January, and the difference in reported malaria-positives between the months was statistically significant (P = 0.001) and (iv) none of the tested rainfall regimes (current, lagged or cumulative) was associated with reported malaria-positive fever cases during the 3-year period (P > 0.1). Looking at the number of diagnoses made at the health facilities, (i) The number of reported malaria-positive fever cases decreased with time (2013-2015) and the difference among the years was not statistically significant (P = 0.399), (ii) The long-term monthly sequence starting from highest to lowest number of reported malaria-positive fever cases was July, June, May, April, January, August, March, February, September, November, October and December, and the difference between the months was statistically significant (P < 0.001). CONCLUSIONS CHWs have the potential to play a major role in diagnosing and treating malaria, thereby decreasing under-five children mortality. Temporally, the risk of diagnosing malaria seems predictable and this may present opportunities for policy-targeted malaria preparedness and control. The findings are expected to support policy actions that may scale-up community health services in remote rural settings.
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13
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Gibson LE, Markwalter CF, Kimmel DW, Mudenda L, Mbambara S, Thuma PE, Wright DW. Plasmodium falciparum HRP2 ELISA for analysis of dried blood spot samples in rural Zambia. Malar J 2017; 16:350. [PMID: 28835253 PMCID: PMC5569460 DOI: 10.1186/s12936-017-1996-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 08/09/2017] [Indexed: 11/10/2022] Open
Abstract
Background Dried blood spots are commonly used for sample collection in clinical and non-clinical settings. This method is simple, and biomolecules in the samples remain stable for months at room temperature. In the field, blood samples for the study and diagnosis of malaria are often collected on dried blood spot cards, so development of a biomarker extraction and analysis method is needed. Methods A simple extraction procedure for the malarial biomarker Plasmodium falciparum histidine-rich protein 2 (HRP2) from dried blood spots was optimized to achieve maximum extraction efficiency. This method was used to assess the stability of HRP2 in dried blood spots. Furthermore, 328 patient samples made available from rural Zambia were analysed for HRP2 using the developed method. These samples were collected at the initial administration of artemisinin-based combination therapy and at several points following treatment. Results An average extraction efficiency of 70% HRP2 with a low picomolar detection limit was achieved. In specific storage conditions HRP2 was found to be stable in dried blood spots for at least 6 months. Analysis of patient samples showed the method to have a sensitivity of 94% and a specificity of 89% when compared with microscopy, and trends in HRP2 clearance after treatment were observed. Conclusions The dried blood spot ELISA for HRP2 was found to be sensitive, specific and accurate. The method was effectively used to assess biomarker clearance characteristics in patient samples, which prove it to be ideal for gaining further insight into the disease and epidemiological applications. Electronic supplementary material The online version of this article (doi:10.1186/s12936-017-1996-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lauren E Gibson
- Department of Chemistry, Vanderbilt University, Nashville, TN, 37235, USA.,Department of Chemistry and Biochemistry, Elizabethtown College, Elizabethtown, PA, 17022, USA
| | | | - Danielle W Kimmel
- Department of Chemistry, Vanderbilt University, Nashville, TN, 37235, USA
| | - Lwiindi Mudenda
- Department of Chemistry, Vanderbilt University, Nashville, TN, 37235, USA
| | | | | | - David W Wright
- Department of Chemistry, Vanderbilt University, Nashville, TN, 37235, USA.
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14
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Boyce MR, O'Meara WP. Use of malaria RDTs in various health contexts across sub-Saharan Africa: a systematic review. BMC Public Health 2017; 17:470. [PMID: 28521798 PMCID: PMC5437623 DOI: 10.1186/s12889-017-4398-1] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 05/08/2017] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The World Health Organization recommends parasitological confirmation of malaria prior to treatment. Malaria rapid diagnostic tests (RDTs) represent one diagnostic method that is used in a variety of contexts to overcome limitations of other diagnostic techniques. Malaria RDTs increase the availability and feasibility of accurate diagnosis and may result in improved quality of care. Though RDTs are used in a variety of contexts, no studies have compared how well or effectively RDTs are used across these contexts. This review assesses the diagnostic use of RDTs in four different contexts: health facilities, the community, drug shops and schools. METHODS A comprehensive search of the Pubmed database was conducted to evaluate RDT execution, test accuracy, or adherence to test results in sub-Saharan Africa. Original RDT and Plasmodium falciparum focused studies conducted in formal health care facilities, drug shops, schools, or by CHWs between the year 2000 and December 2016 were included. Studies were excluded if they were conducted exclusively in a research laboratory setting, where staff from the study team conducted RDTs, or in settings outside of sub-Saharan Africa. RESULTS The literature search identified 757 reports. A total of 52 studies were included in the analysis. Overall, RDTs were performed safely and effectively by community health workers provided they receive proper training. Analogous information was largely absent for formal health care workers. Tests were generally accurate across contexts, except for in drug shops where lower specificities were observed. Adherence to RDT results was higher among drug shop vendors and community health workers, while adherence was more variable among formal health care workers, most notably with negative test results. CONCLUSIONS Malaria RDTs are generally used well, though compliance with test results is variable - especially in the formal health care sector. If low adherence rates are extrapolated, thousands of patients may be incorrectly diagnosed and receive inappropriate treatment resulting in a low quality of care and unnecessary drug use. Multidisciplinary research should continue to explore determinants of good RDT use, and seek to better understand how to support and sustain the correct use of this diagnostic tool.
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Affiliation(s)
| | - Wendy P O'Meara
- Duke Global Health Institute, Durham, NC, USA.,School of Public Health, Moi University College of Health Sciences, Eldoret, Kenya
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15
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Seidman G, Atun R. Does task shifting yield cost savings and improve efficiency for health systems? A systematic review of evidence from low-income and middle-income countries. HUMAN RESOURCES FOR HEALTH 2017; 15:29. [PMID: 28407810 PMCID: PMC5390445 DOI: 10.1186/s12960-017-0200-9] [Citation(s) in RCA: 131] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 03/29/2017] [Indexed: 05/27/2023]
Abstract
BACKGROUND Task shifting has become an increasingly popular way to increase access to health services, especially in low-resource settings. Research has demonstrated that task shifting, including the use of community health workers (CHWs) to deliver care, can improve population health. This systematic review investigates whether task shifting in low-income and middle-income countries (LMICs) results in efficiency improvements by achieving cost savings. METHODS Using the PRISMA guidelines for systematic reviews, we searched PubMed, Embase, CINAHL, and the Health Economic Evaluation Database on March 22, 2016. We included any original peer-review articles that demonstrated cost impact of a task shifting program in an LMIC. RESULTS We identified 794 articles, of which 34 were included in our study. We found that substantial evidence exists for achieving cost savings and efficiency improvements from task shifting activities related to tuberculosis and HIV/AIDS, and additional evidence exists for the potential to achieve cost savings from activities related to malaria, NCDs, NTDs, childhood illness, and other disease areas, especially at the primary health care and community levels. CONCLUSIONS Task shifting presents a viable option for health system cost savings in LMICs. Going forward, program planners should carefully consider whether task shifting can improve population health and health systems efficiency in their countries, and researchers should investigate whether task shifting can also achieve cost savings for activities related to emerging global health priorities and health systems strengthening activities such as supply chain management or monitoring and evaluation.
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Affiliation(s)
- Gabriel Seidman
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115 United States of America
| | - Rifat Atun
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115 United States of America
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16
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Sunguya BF, Mlunde LB, Ayer R, Jimba M. Towards eliminating malaria in high endemic countries: the roles of community health workers and related cadres and their challenges in integrated community case management for malaria: a systematic review. Malar J 2017; 16:10. [PMID: 28049486 PMCID: PMC5209914 DOI: 10.1186/s12936-016-1667-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Accepted: 12/22/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Human resource for health crisis has impaired global efforts against malaria in highly endemic countries. To address this, the World Health Organization (WHO) recommended scaling-up of community health workers (CHWs) and related cadres owing to their documented success in malaria and other disease prevention and management. Evidence is inconsistent on the roles and challenges they encounter in malaria interventions. This systematic review aims to summarize evidence on roles and challenges of CHWs and related cadres in integrated community case management for malaria (iCCM). METHODS This systematic review retrieved evidence from PubMed, CINAHL, ISI Web of Knowledge, and WHO regional databases. Terms extracted from the Boolean phrase used for PubMed were also used in other databases. The review included studies with Randomized Control Trial, Quasi-experimental, Pre-post interventional, Longitudinal and cohort, Cross-sectional, Case study, and Secondary data analysis. Because of heterogeneity, only narrative synthesis was conducted for this review. RESULTS A total of 66 articles were eligible for analysis out of 1380 studies retrieved. CHWs and related cadre roles in malaria interventions included: malaria case management, prevention including health surveillance and health promotion specific to malaria. Despite their documented success, CHWs and related cadres succumb to health system challenges. These are poor and unsustainable finance for iCCM, workforce related challenges, lack of and unsustainable supply of medicines and diagnostics, lack of information and research, service delivery and leadership challenges. CONCLUSIONS Community health workers and related cadres had important preventive, case management and promotive roles in malaria interventions. To enable their effective integration into the health systems, the identified challenges should be addressed. They include: introducing sustainable financing on iCCM programmes, tailoring their training to address the identified gaps, improving sustainable supply chain management of malaria drugs and diagnostics, and addressing regulatory challenges in the local contexts.
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Affiliation(s)
- Bruno F. Sunguya
- Department of Community Health, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Linda B. Mlunde
- Management for Development and Health, Dar es Salaam, Tanzania
| | - Rakesh Ayer
- Department of Community and Global Health, The University of Tokyo, Tokyo, Japan
| | - Masamine Jimba
- Department of Community and Global Health, The University of Tokyo, Tokyo, Japan
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17
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Donald W, Pasay C, Guintran JO, Iata H, Anderson K, Nausien J, Gresty KJ, Waters NC, Vestergaard LS, Taleo G, Cheng Q. The Utility of Malaria Rapid Diagnostic Tests as a Tool in Enhanced Surveillance for Malaria Elimination in Vanuatu. PLoS One 2016; 11:e0167136. [PMID: 27902755 PMCID: PMC5130254 DOI: 10.1371/journal.pone.0167136] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 11/09/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND As part of efforts to eliminate malaria, Vanuatu has piloted the implementation of enhanced malaria surveillance and response strategies since 2011. This involves passive case detection (PCD) in health facilities, proactive case detection (Pro-ACD) and reactive case detection (Re-ACD) in communities using malaria rapid diagnostic tests (RDTs). While RDTs improve case management, their utility for detection of malaria infections in ACDs in this setting is unclear. METHODS The utility of malaria RDTs as diagnostic tools was evaluated in PCD, in five rounds of Pro-ACDs and five rounds of Re-ACDs conducted in Tafea and Torba Provinces between 2011 and 2014. The number of malaria infections detected by RDTs was compared to that detected by PCR from collected used-RDTs. RESULTS PCD in Tafea Province (2013) showed a RDT-positive rate of 0.21% (2/939) and a PCR-positive rate of 0.44% (2/453), indicating less than 1% of suspected malaria cases in Tafea Province were due to malaria. In Pro-ACDs conducted in Tafea and Torba Provinces, RDT-positive rates in 2013 and 2014 were 0.14% (3/2145) and 0% (0/2823), respectively, while the corresponding PCR-positive rates were 0.72% (9/1242) and 0.79% (9/1141). PCR identified villages in both provinces appearing to be transmission foci with a small number of low-density infections, mainly P. falciparum infections. In five rounds of Re-ACD, RDTs did not identify any additional infections while PCR detected only one among 173 subjects screened. CONCLUSIONS PCD and Pro-ACDs demonstrate that both Tafea and Torba Provinces in Vanuatu has achieved very low malaria prevalence. In these low-transmission areas, conducting Pro-ACD and Re-ACDs using RDTs appears not cost-effective and may have limited impact on interrupting malaria transmission due to the small number of infections identified by RDTs and considerable operational resources invested. More sensitive, field deployable and affordable diagnostic tools will improve malaria surveillance in malaria elimination settings.
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Affiliation(s)
- Wesley Donald
- Malaria & Vector Borne Diseases Control (MVBDC), Ministry of Health, Port Vila Vanuatu
| | - Cielo Pasay
- Drug Resistance and Diagnostics, Australian Army Malaria Institute, Brisbane, Australia
- Clinical Tropical Medicine, QIMR-Berghofer Medical Research Institute, Brisbane, Australia
| | | | - Harry Iata
- Malaria & Vector Borne Diseases Control (MVBDC), Ministry of Health, Port Vila Vanuatu
| | - Karen Anderson
- Drug Resistance and Diagnostics, Australian Army Malaria Institute, Brisbane, Australia
- Clinical Tropical Medicine, QIMR-Berghofer Medical Research Institute, Brisbane, Australia
| | - Johnny Nausien
- Malaria & Vector Borne Diseases Control (MVBDC), Ministry of Health, Port Vila Vanuatu
| | - Karryn J Gresty
- Drug Resistance and Diagnostics, Australian Army Malaria Institute, Brisbane, Australia
- Clinical Tropical Medicine, QIMR-Berghofer Medical Research Institute, Brisbane, Australia
| | - Norman C. Waters
- Walter Reed Army Institute of Research, Malaria Vaccine Branch, Military Malaria Research Program, Silver Spring, Maryland, United States of America
| | | | - George Taleo
- Malaria & Vector Borne Diseases Control (MVBDC), Ministry of Health, Port Vila Vanuatu
- * E-mail: (QC); (GT)
| | - Qin Cheng
- Drug Resistance and Diagnostics, Australian Army Malaria Institute, Brisbane, Australia
- Clinical Tropical Medicine, QIMR-Berghofer Medical Research Institute, Brisbane, Australia
- * E-mail: (QC); (GT)
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Bennett A, Yukich J, Miller JM, Keating J, Moonga H, Hamainza B, Kamuliwo M, Andrade-Pacheco R, Vounatsou P, Steketee RW, Eisele TP. The relative contribution of climate variability and vector control coverage to changes in malaria parasite prevalence in Zambia 2006-2012. Parasit Vectors 2016; 9:431. [PMID: 27496161 PMCID: PMC4974721 DOI: 10.1186/s13071-016-1693-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 07/11/2016] [Indexed: 12/02/2022] Open
Abstract
Background Four malaria indicator surveys (MIS) were conducted in Zambia between 2006 and 2012 to evaluate malaria control scale-up. Nationally, coverage of insecticide-treated nets (ITNs) and indoor residual spraying (IRS) increased over this period, while parasite prevalence in children 1–59 months decreased dramatically between 2006 and 2008, but then increased from 2008 to 2010. We assessed the relative effects of vector control coverage and climate variability on malaria parasite prevalence over this period. Methods Nationally-representative MISs were conducted in April-June of 2006, 2008, 2010 and 2012 to collect household-level information on malaria control interventions such as IRS, ITN ownership and use, and child parasite prevalence by microscopic examination of blood smears. We fitted Bayesian geostatistical models to assess the association between IRS and ITN coverage and climate variability and malaria parasite prevalence. We created predictions of the spatial distribution of malaria prevalence at each time point and compared results of varying IRS, ITN, and climate inputs to assess their relative contributions to changes in prevalence. Results Nationally, the proportion of households owning an ITN increased from 37.8 % in 2006 to 64.3 % in 2010 and 68.1 % in 2012, with substantial heterogeneity sub-nationally. The population-adjusted predicted child malaria parasite prevalence decreased from 19.6 % in 2006 to 10.4 % in 2008, but rose to 15.3 % in 2010 and 13.5 % in 2012. We estimated that the majority of this prevalence increase at the national level between 2008 and 2010 was due to climate effects on transmission, although there was substantial heterogeneity at the provincial level in the relative contribution of changing climate and ITN availability. We predict that if climate factors preceding the 2010 survey were the same as in 2008, the population-adjusted prevalence would have fallen to 9.9 % nationally. Conclusions These results suggest that a combination of climate factors and reduced intervention coverage in parts of the country contributed to both the reduction and rebound in malaria parasite prevalence. Unusual rainfall patterns, perhaps related to moderate El Niño conditions, may have contributed to this variation. Zambia has demonstrated considerable success in scaling up vector control. This analysis highlights the importance of accounting for climate variability when using cross-sectional data for evaluation of malaria control efforts. Electronic supplementary material The online version of this article (doi:10.1186/s13071-016-1693-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Adam Bennett
- Malaria Elimination Initiative, Global Health Group, University of California, 500 16th St, San Francisco, CA, 94158, USA. .,Center for Applied Malaria Research and Evaluation, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA.
| | - Josh Yukich
- Center for Applied Malaria Research and Evaluation, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
| | - John M Miller
- PATH Malaria Control and Evaluation Partnership in Africa (MACEPA), Lusaka, Zambia
| | - Joseph Keating
- Center for Applied Malaria Research and Evaluation, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
| | - Hawela Moonga
- National Malaria Control Centre, Ministry of Health, Lusaka, Zambia
| | - Busiku Hamainza
- National Malaria Control Centre, Ministry of Health, Lusaka, Zambia
| | - Mulakwa Kamuliwo
- National Malaria Control Centre, Ministry of Health, Lusaka, Zambia
| | - Ricardo Andrade-Pacheco
- Malaria Elimination Initiative, Global Health Group, University of California, 500 16th St, San Francisco, CA, 94158, USA
| | - Penelope Vounatsou
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Richard W Steketee
- PATH Malaria Control and Evaluation Partnership in Africa (MACEPA), Lusaka, Zambia
| | - Thomas P Eisele
- Center for Applied Malaria Research and Evaluation, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
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Mobile phone imaging and cloud-based analysis for standardized malaria detection and reporting. Sci Rep 2016; 6:28645. [PMID: 27345590 PMCID: PMC4921854 DOI: 10.1038/srep28645] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 06/06/2016] [Indexed: 01/16/2023] Open
Abstract
Rapid diagnostic tests (RDTs) have been widely deployed in low-resource settings. These tests are typically read by visual inspection, and accurate record keeping and data aggregation remains a substantial challenge. A successful malaria elimination campaign will require new strategies that maximize the sensitivity of RDTs, reduce user error, and integrate results reporting tools. In this report, an unmodified mobile phone was used to photograph RDTs, which were subsequently uploaded into a globally accessible database, REDCap, and then analyzed three ways: with an automated image processing program, visual inspection, and a commercial lateral flow reader. The mobile phone image processing detected 20.6 malaria parasites/microliter of blood, compared to the commercial lateral flow reader which detected 64.4 parasites/microliter. Experienced observers visually identified positive malaria cases at 12.5 parasites/microliter, but encountered reporting errors and false negatives. Visual interpretation by inexperienced users resulted in only an 80.2% true negative rate, with substantial disagreement in the lower parasitemia range. We have demonstrated that combining a globally accessible database, such as REDCap, with mobile phone based imaging of RDTs provides objective, secure, automated, data collection and result reporting. This simple combination of existing technologies would appear to be an attractive tool for malaria elimination campaigns.
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20
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Bisoffi Z, Leoni S, Angheben A, Beltrame A, Eseme FE, Gobbi F, Lodesani C, Marocco S, Buonfrate D. Chronic malaria and hyper-reactive malarial splenomegaly: a retrospective study on the largest series observed in a non-endemic country. Malar J 2016; 15:230. [PMID: 27098596 PMCID: PMC4839070 DOI: 10.1186/s12936-016-1274-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 04/03/2016] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Chronic malaria is usually defined as a long-term malarial infection in semi-immune subjects, usually without fever or other acute symptoms. The untreated infection may evolve to hyper-reactive malarial splenomegaly (HMS), a life-threatening complication. This paper describes the largest series of HMS ever observed outside endemic countries, and the clinical outcome after a single anti-malarial treatment. Contrarily to most authors, still reporting the traditional, long-term treatment, regardless possible further exposure, the patients in this series did not receive any further prophylaxis if they were not re-exposed to malaria infection. METHODS A retrospective, longitudinal study, describing all patients with HMS diagnosed at the Centre for Tropical Diseases of Negrar, Verona, took place over a 25-year period. HMS was defined by a longitudinal spleen diameter ≥16 cm, IgM ≥ 2.5 g/L, anti-malarial antibody titre ≥160, exclusion of other causes of splenomegaly. The short-term (≤6 months) clinical outcome after a single anti-malarial treatment was analysed and so was the long-term outcome of subjects re-exposed to malaria and submitted or not to anti-malarial prophylaxis or intermittent treatment. The association of the outcome with the main independent variables was first assessed with univariate analysis. Logistic regression was also performed. RESULTS Forty-four subjects with HMS were retrieved. Of those with a short-term follow-up visit (<6 months, median 43 days) available before returning to endemic areas, 20/22 resulted improved/cured, two were unchanged. Of 22 expatriates seen at long-term follow-up after re-exposure, 18 were improved/cured, including eight out of nine who had followed an anti-malarial prophylaxis and 10/13 who had opted for the alternative of an intermittent treatment. CONCLUSION HMS is the most severe form of chronic malaria. A single anti-malarial treatment is probably adequate to treat HMS in the absence of re-exposure, while an adequate prophylaxis is necessary for patients exposed again to malaria transmission. Intermittent treatment would probably be the only viable approach in endemic countries.
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Affiliation(s)
- Zeno Bisoffi
- />Centre for Tropical Diseases, Sacro Cuore – Don Calabria Hospital, 37024 Negrar, Verona Italy
| | - Stefania Leoni
- />Centre for Tropical Diseases, Sacro Cuore – Don Calabria Hospital, 37024 Negrar, Verona Italy
| | - Andrea Angheben
- />Centre for Tropical Diseases, Sacro Cuore – Don Calabria Hospital, 37024 Negrar, Verona Italy
| | - Anna Beltrame
- />Centre for Tropical Diseases, Sacro Cuore – Don Calabria Hospital, 37024 Negrar, Verona Italy
| | - Franklyn Esoka Eseme
- />Ospedale Dell’Angelo, Via Don Federico Tosatto, 147, 30174 Venezia Mestre, Italy
| | - Federico Gobbi
- />Centre for Tropical Diseases, Sacro Cuore – Don Calabria Hospital, 37024 Negrar, Verona Italy
| | - Claudia Lodesani
- />Medici Senza Frontiere Italia, Via Magenta 5, 00186 Rome, Italy
| | - Stefania Marocco
- />Centre for Tropical Diseases, Sacro Cuore – Don Calabria Hospital, 37024 Negrar, Verona Italy
| | - Dora Buonfrate
- />Centre for Tropical Diseases, Sacro Cuore – Don Calabria Hospital, 37024 Negrar, Verona Italy
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21
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Hamainza B, Sikaala CH, Moonga HB, Chanda J, Chinula D, Mwenda M, Kamuliwo M, Bennett A, Seyoum A, Killeen GF. Incremental impact upon malaria transmission of supplementing pyrethroid-impregnated long-lasting insecticidal nets with indoor residual spraying using pyrethroids or the organophosphate, pirimiphos methyl. Malar J 2016; 15:100. [PMID: 26893012 PMCID: PMC4758014 DOI: 10.1186/s12936-016-1143-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Accepted: 02/04/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Long-lasting, insecticidal nets (LLINs) and indoor residual spraying (IRS) are the most widely accepted and applied malaria vector control methods. However, evidence that incremental impact is achieved when they are combined remains limited and inconsistent. METHODS Fourteen population clusters of approximately 1000 residents each in Zambia's Luangwa and Nyimba districts, which had high pre-existing usage rates (81.7 %) of pyrethroid-impregnated LLINs were quasi-randomly assigned to receive IRS with either of two pyrethroids, namely deltamethrin [Wetable granules (WG)] and lambdacyhalothrin [capsule suspension (CS)], with an emulsifiable concentrate (EC) or CS formulation of the organophosphate pirimiphos methyl (PM), or with no supplementary vector control measure. Diagnostic positivity of patients tested for malaria by community health workers in these clusters was surveyed longitudinally over pre- and post-treatment periods spanning 29 months, over which the treatments were allocated and re-allocated in advance of three sequential rainy seasons. RESULTS Supplementation of LLINs with PM CS offered the greatest initial level of protection against malaria in the first 3 months of application (incremental protective efficacy (IPE) [95 % confidence interval (CI)] = 0.63 [CI 0.57, 0.69], P < 0.001), followed by lambdacyhalothrin (IPE [95 % CI] = 0.31 [0.10, 0.47], P = 0.006) and PM EC (IPE, 0.23 [CI 0.15, 0.31], P < 0.001) and then by deltamethrin (IPE [95 % CI] = 0.19 [-0.01, 0.35], P = 0.064). Neither pyrethroid formulation provided protection beyond 3 months after spraying, but the protection provided by both PM formulations persisted undiminished for longer periods: 6 months for CS and 12 months for EC. The CS formulation of PM provided greater protection than the combined pyrethroid IRS formulations throughout its effective life IPE [95 % CI] = 0.79 [0.75, 0.83] over 6 months. The EC formulation of PM provided incremental protection for the first 3 months (IPE [95 % CI] = 0.23 [0.15, 0.31]) that was approximately equivalent to the two pyrethroid formulations (lambdacyhalothrin, IPE [95 % CI] = 0.31 [0.10, 0.47] and deltamethrin, IPE [95 % CI] = 0.19 [-0.01, 0.35]) but the additional protection provided by the former, apparently lasted an entire year. CONCLUSION Where universal coverage targets for LLIN utilization has been achieved, supplementing LLINs with IRS using pyrethroids may reduce malaria transmission below levels achieved by LLIN use alone, even in settings where pyrethroid resistance occurs in the vector population. However, far greater reduction of transmission can be achieved under such conditions by supplementing LLINs with IRS using non-pyrethroid insecticide classes, such as organophosphates, so this is a viable approach to mitigating and managing pyrethroid resistance.
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Affiliation(s)
- Busiku Hamainza
- National Malaria Control Centre, Ministry of Health, Chainama Hospital, College Grounds, off Great East road, PO Box 32509, Lusaka, Zambia.
- Malaria Elimination Initiative, Global Health Group, University of California, 550 16th St., San Francisco, CA, 94158, USA.
| | - Chadwick H Sikaala
- National Malaria Control Centre, Ministry of Health, Chainama Hospital, College Grounds, off Great East road, PO Box 32509, Lusaka, Zambia.
- Malaria Elimination Initiative, Global Health Group, University of California, 550 16th St., San Francisco, CA, 94158, USA.
| | - Hawela B Moonga
- National Malaria Control Centre, Ministry of Health, Chainama Hospital, College Grounds, off Great East road, PO Box 32509, Lusaka, Zambia.
| | - Javan Chanda
- National Malaria Control Centre, Ministry of Health, Chainama Hospital, College Grounds, off Great East road, PO Box 32509, Lusaka, Zambia.
| | - Dingani Chinula
- National Malaria Control Centre, Ministry of Health, Chainama Hospital, College Grounds, off Great East road, PO Box 32509, Lusaka, Zambia.
| | - Mulenga Mwenda
- National Malaria Control Centre, Ministry of Health, Chainama Hospital, College Grounds, off Great East road, PO Box 32509, Lusaka, Zambia.
| | - Mulakwa Kamuliwo
- National Malaria Control Centre, Ministry of Health, Chainama Hospital, College Grounds, off Great East road, PO Box 32509, Lusaka, Zambia.
| | - Adam Bennett
- Malaria Elimination Initiative, Global Health Group, University of California, 550 16th St., San Francisco, CA, 94158, USA.
| | - Aklilu Seyoum
- Vector Biology Department, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
| | - Gerry F Killeen
- Vector Biology Department, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
- Environmental Health and Ecological Sciences Thematic Group, Ifakara Health Institute, PO Box 53, Ifakara, Morogoro, United Republic of Tanzania.
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Chen I, Clarke SE, Gosling R, Hamainza B, Killeen G, Magill A, O’Meara W, Price RN, Riley EM. "Asymptomatic" Malaria: A Chronic and Debilitating Infection That Should Be Treated. PLoS Med 2016; 13:e1001942. [PMID: 26783752 PMCID: PMC4718522 DOI: 10.1371/journal.pmed.1001942] [Citation(s) in RCA: 226] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Roland Gosling and colleagues argue that "asymptomatic" malaria infections have significant health and societal consequences, and propose that they should be renamed "chronic" malaria infections.
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Affiliation(s)
- Ingrid Chen
- Global Health Sciences, Malaria Elimination Initiative, University of California, San Francisco, San Francisco, California, United States of America
| | - Siân E. Clarke
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Roly Gosling
- Global Health Sciences, Malaria Elimination Initiative, University of California, San Francisco, San Francisco, California, United States of America
- * E-mail:
| | - Busiku Hamainza
- Ministry of Health, National Malaria Control Centre, Lusaka, Zambia
| | - Gerry Killeen
- Liverpool School of Tropical Medicine, Vector Biology Department, Liverpool, United Kingdom
- Ifakara Health Institute, Ifakara, Morogoro, United Republic of Tanzania
| | - Alan Magill
- Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Wendy O’Meara
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Ric N. Price
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Eleanor M. Riley
- Department of Immunology and Infection, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
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23
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Ndiath MM, Cisse B, Ndiaye JL, Gomis JF, Bathiery O, Dia AT, Gaye O, Faye B. Application of geographically-weighted regression analysis to assess risk factors for malaria hotspots in Keur Soce health and demographic surveillance site. Malar J 2015; 14:463. [PMID: 26581562 PMCID: PMC4652414 DOI: 10.1186/s12936-015-0976-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 10/28/2015] [Indexed: 12/01/2022] Open
Abstract
Background In Senegal, considerable efforts have been made to reduce malaria morbidity and mortality during the last decade. This resulted in a marked decrease of malaria cases. With the decline of malaria cases, transmission has become sparse in most Senegalese health districts. This study investigated malaria hotspots in Keur Soce sites by using geographically-weighted regression. Because of the occurrence of hotspots, spatial modelling of malaria cases could have a considerable effect in disease surveillance. Methods This study explored and analysed the spatial relationships between malaria occurrence and socio-economic and environmental factors in small communities in Keur Soce, Senegal, using 6 months passive surveillance. Geographically-weighted regression was used to explore the spatial variability of relationships between malaria incidence or persistence and the selected socio-economic, and human predictors. A model comparison of between ordinary least square and geographically-weighted regression was also explored. Vector dataset (spatial) of the study area by village levels and statistical data (non-spatial) on malaria confirmed cases, socio-economic status (bed net use), population data (size of the household) and environmental factors (temperature, rain fall) were used in this exploratory analysis. ArcMap 10.2 and Stata 11 were used to perform malaria hotspots analysis. Results From Jun to December, a total of 408 confirmed malaria cases were notified. The explanatory variables-household size, housing materials, sleeping rooms, sheep and distance to breeding site returned significant t values of −0.25, 2.3, 4.39, 1.25 and 2.36, respectively. The OLS global model revealed that it explained about 70 % (adjusted R2 = 0.70) of the variation in malaria occurrence with AIC = 756.23. The geographically-weighted regression of malaria hotspots resulted in coefficient intercept ranging from 1.89 to 6.22 with a median of 3.5. Large positive values are distributed mainly in the southeast of the district where hotspots are more accurate while low values are mainly found in the centre and in the north. Conclusion Geographically-weighted regression and OLS showed important risks factors of malaria hotspots in Keur Soce. The outputs of such models can be a useful tool to understand occurrence of malaria hotspots in Senegal. An understanding of geographical variation and determination of the core areas of the disease may provide an explanation regarding possible proximal and distal contributors to malaria elimination in Senegal.
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Affiliation(s)
- Mansour M Ndiath
- Service Parasitologie, Université Cheikh Anta Diop, Dakar, Senegal.
| | - Badara Cisse
- Service Parasitologie, Université Cheikh Anta Diop, Dakar, Senegal. .,London School of Hygiene and Tropical Medicine, London, UK.
| | | | - Jules F Gomis
- Service Parasitologie, Université Cheikh Anta Diop, Dakar, Senegal.
| | | | - Anta Tal Dia
- Institut de santé et de développement, UCAD, Dakar, Senegal.
| | - Oumar Gaye
- Service Parasitologie, Université Cheikh Anta Diop, Dakar, Senegal.
| | - Babacar Faye
- Service Parasitologie, Université Cheikh Anta Diop, Dakar, Senegal. .,Unité Mixte Internationale « Environnement, Santé, Sociétés » (UMI3189 ESS), CNRS-UCAD-CNRST-USTTB-UGB, Dakar, Senegal.
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24
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Vaughan K, Kok MC, Witter S, Dieleman M. Costs and cost-effectiveness of community health workers: evidence from a literature review. HUMAN RESOURCES FOR HEALTH 2015; 13:71. [PMID: 26329455 PMCID: PMC4557864 DOI: 10.1186/s12960-015-0070-y] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 08/18/2015] [Indexed: 05/20/2023]
Abstract
OBJECTIVE This study sought to synthesize and critically review evidence on costs and cost-effectiveness of community health worker (CHW) programmes in low- and middle-income countries (LMICs) to inform policy dialogue around their role in health systems. METHODS From a larger systematic review on effectiveness and factors influencing performance of close-to-community providers, complemented by a supplementary search in PubMed, we did an exploratory review of a subset of papers (32 published primary studies and 4 reviews from the period January 2003-July 2015) about the costs and cost-effectiveness of CHWs. Studies were assessed using a data extraction matrix including methodological approach and findings. RESULTS Existing evidence suggests that, compared with standard care, using CHWs in health programmes can be a cost-effective intervention in LMICs, particularly for tuberculosis, but also - although evidence is weaker - in other areas such as reproductive, maternal, newborn and child health (RMNCH) and malaria. CONCLUSION Notwithstanding important caveats about the heterogeneity of the studies and their methodological limitations, findings reinforce the hypothesis that CHWs may represent, in some settings, a cost-effective approach for the delivery of essential health services. The less conclusive evidence about the cost-effectiveness of CHWs in other areas may reflect that these areas have been evaluated less (and less rigorously) than others, rather than an actual difference in cost-effectiveness in the various service delivery areas or interventions. Methodologically, areas for further development include how to properly assess costs from a societal perspective rather than just through the lens of the cost to government and accounting for non-tangible costs and non-health benefits commonly associated with CHWs.
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Affiliation(s)
- Kelsey Vaughan
- Royal Tropical Institute (KIT), P.O. Box 95001, 1090 HA, Amsterdam, The Netherlands.
| | - Maryse C Kok
- Royal Tropical Institute (KIT), P.O. Box 95001, 1090 HA, Amsterdam, The Netherlands.
| | | | - Marjolein Dieleman
- Royal Tropical Institute (KIT), P.O. Box 95001, 1090 HA, Amsterdam, The Netherlands.
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25
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Linn AM, Ndiaye Y, Hennessee I, Gaye S, Linn P, Nordstrom K, McLaughlin M. Reduction in symptomatic malaria prevalence through proactive community treatment in rural Senegal. Trop Med Int Health 2015; 20:1438-1446. [PMID: 26171642 DOI: 10.1111/tmi.12564] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES We piloted a community-based proactive malaria case detection model in rural Senegal to evaluate whether this model can increase testing and treatment and reduce prevalence of symptomatic malaria in target communities. METHODS Home care providers conducted weekly sweeps of every household in their village throughout the transmission season to identify patients with symptoms of malaria, perform rapid diagnostic tests (RDT) on symptomatic patients and provide treatment for positive cases. The model was implemented in 15 villages from July to November 2013, the high transmission season. Fifteen comparison villages were chosen from those implementing Senegal's original, passive model of community case management of malaria. Three sweeps were conducted in the comparison villages to compare prevalence of symptomatic malaria using difference in differences analysis. RESULTS At baseline, prevalence of symptomatic malaria confirmed by RDT for all symptomatic individuals found during sweeps was similar in both sets of villages (P = 0.79). At end line, prevalence was 16 times higher in the comparison villages than in the intervention villages (P = 0.003). Adjusting for potential confounders, the intervention was associated with a 30-fold reduction in odds of symptomatic malaria in the intervention villages (AOR = 0.033; 95% CI: 0.017, 0.065). Treatment seeking also increased in the intervention villages, with 57% of consultations by home care providers conducted between sweeps through routine community case management. CONCLUSIONS This pilot study suggests that community-based proactive case detection reduces symptomatic malaria prevalence, likely through more timely case management and improved care seeking behaviour. A randomised controlled trial is needed to further evaluate the impact of this model.
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Affiliation(s)
- Annē M Linn
- Peace Corps, Department of Saraya, Senegal.,Rutgers School of Nursing, Newark, NJ, USA
| | | | - Ian Hennessee
- Peace Corps, Department of Saraya, Senegal.,Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Patrick Linn
- Peace Corps, Department of Saraya, Senegal.,Woodrow Wilson School of Public and International Affairs, Princeton University, Princeton, NJ, USA
| | - Karin Nordstrom
- Peace Corps, Department of Saraya, Senegal.,Moritz College of Law, The Ohio State University, Winchester, OH, USA
| | - Matt McLaughlin
- Stomping Out Malaria in Africa Initiative, US Peace Corps, Washington, DC, USA
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Stresman GH, Baidjoe AY, Stevenson J, Grignard L, Odongo W, Owaga C, Osoti V, Makori E, Shagari S, Marube E, Cox J, Drakeley C, Bousema T. Focal Screening to Identify the Subpatent Parasite Reservoir in an Area of Low and Heterogeneous Transmission in the Kenya Highlands. J Infect Dis 2015; 212:1768-77. [PMID: 26019285 DOI: 10.1093/infdis/jiv302] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 05/14/2015] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Mass screening and treatment currently fails to identify a considerable fraction of low parasite density infections, while mass treatment exposes many uninfected individuals to antimalarial drugs. Here we test a hybrid approach to screen a sentinel population to identify clusters of subpatent infections in the Kenya highlands with low, heterogeneous malaria transmission. METHODS Two thousand eighty-two inhabitants were screened for parasitemia by nested polymerase chain reaction (nPCR). Children aged ≤ 15 years and febrile adults were also tested for malaria by rapid diagnostic test (RDT) and served as sentinel members to identify subpatent infections within the household. All parasitemic individuals were assessed for multiplicity of infections by nPCR and gametocyte carriage by nucleic acid sequence-based amplification. RESULTS Households with RDT-positive individuals in the sentinel population were more likely to have nPCR-positive individuals (odds ratio: 1.71, 95% confidence interval, 1.60-1.84). The sentinel population identified 64.5% (locality range: 31.6%-81.2%) of nPCR-positive households and 77.3% (locality range: 24.2%-91.0%) of nPCR-positive individuals. The sensitivity of the sentinel screening approach was positively associated with transmission intensity (P = .037). CONCLUSIONS In this low endemic area, a focal screening approach with RDTs prior to the high transmission season was able to identify the majority of the subpatent parasite reservoirs.
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Affiliation(s)
- Gillian H Stresman
- Department of Immunology and Infection; Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, United Kingdom
| | | | - Jennifer Stevenson
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, United Kingdom The Johns Hopkins Malaria Research Institute, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Lynn Grignard
- Department of Immunology and Infection; Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Wycliffe Odongo
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu
| | - Chrispin Owaga
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu
| | - Victor Osoti
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu
| | - Euniah Makori
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu
| | - Shehu Shagari
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu
| | - Elisabeth Marube
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu
| | - Jonathan Cox
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Chris Drakeley
- Department of Immunology and Infection; Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Teun Bousema
- Department of Immunology and Infection; Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, United Kingdom Radboud University Nijmegen Medical Centre, The Netherlands
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Hamainza B, Killeen GF, Kamuliwo M, Bennett A, Yukich JO. Comparison of a mobile phone-based malaria reporting system with source participant register data for capturing spatial and temporal trends in epidemiological indicators of malaria transmission collected by community health workers in rural Zambia. Malar J 2014; 13:489. [PMID: 25495698 PMCID: PMC4295270 DOI: 10.1186/1475-2875-13-489] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 12/09/2014] [Indexed: 01/22/2023] Open
Abstract
Background Timeliness, completeness, and accuracy are key requirements for any surveillance system to reliably monitor disease burden and guide efficient resource prioritization. Evidence that electronic reporting of malaria cases by community health workers (CHWs) meet these requirements remains limited. Methodology Residents of two adjacent rural districts in Zambia were provided with both passive and active malaria testing and treatment services with malaria rapid diagnostic tests (RDTs) and artemisinin-based combination therapy by 42 CHWs serving 14 population clusters centred around public sector health facilities. Reference data describing total numbers of RDT-detected infections and diagnostic positivity (DP) were extracted from detailed participant register books kept by CHWs. These were compared with equivalent weekly summaries relayed directly by the CHWs themselves through a mobile phone short messaging system (SMS) reporting platform. Results Slightly more RDT-detected malaria infections were recorded in extracted participant registers than were reported in weekly mobile phone summaries but the difference was equivalent to only 19.2% (31,665 versus 25,583, respectively). The majority (81%) of weekly SMS reports were received within one week and the remainder within one month. Overall mean [95% confidence limits] difference between the numbers of register-recorded and SMS-reported RDT-detected malaria infections per CHW per week, as estimated by the Bland Altman method, was only −2.3 [−21.9, 17.2]. The mean [range] for both the number of RDT-detected malaria infections (86 [0, 463] versus 73.6 [0, 519], respectively)) and DP (22.8% [0.0 to 96.3%] versus 23.2% [0.4 to 75.8%], respectively) reported by SMS were generally very consistent with those recorded in the reference paper-based register data and exhibited similar seasonality patterns across all study clusters. Overall, mean relative differences in the SMS reports and reference register data were more consistent with each other for DP than for absolute numbers of RDT-detected infections, presumably because this indicator is robust to variations in patient reporting rates by location, weather, season and calendar event because these are included in both the nominator and denominator. Discussion/Conclusion The SMS reports captured malaria transmission trends with adequate accuracy and could be used for population-wide, continuous, longitudinal monitoring of malaria transmission.
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Affiliation(s)
- Busiku Hamainza
- Ministry of Health, National Malaria Control Centre, Chainama Hospital College Grounds, off Great East road, P,O, Box 32509, Lusaka, Zambia.
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A review of malaria transmission dynamics in forest ecosystems. Parasit Vectors 2014; 7:265. [PMID: 24912923 PMCID: PMC4057614 DOI: 10.1186/1756-3305-7-265] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Accepted: 05/23/2014] [Indexed: 12/25/2022] Open
Abstract
Malaria continues to be a major health problem in more than 100 endemic countries located primarily in tropical and sub-tropical regions around the world. Malaria transmission is a dynamic process and involves many interlinked factors, from uncontrollable natural environmental conditions to man-made disturbances to nature. Almost half of the population at risk of malaria lives in forest areas. Forests are hot beds of malaria transmission as they provide conditions such as vegetation cover, temperature, rainfall and humidity conditions that are conducive to distribution and survival of malaria vectors. Forests often lack infrastructure and harbor tribes with distinct genetic traits, socio-cultural beliefs and practices that greatly influence malaria transmission dynamics. Here we summarize the various topographical, entomological, parasitological, human ecological and socio-economic factors, which are crucial and shape malaria transmission in forested areas. An in-depth understanding and synthesis of the intricate relationship of these parameters in achieving better malaria control in various types of forest ecosystems is emphasized.
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Sikaala CH, Chinula D, Chanda J, Hamainza B, Mwenda M, Mukali I, Kamuliwo M, Lobo NF, Seyoum A, Killeen GF. A cost-effective, community-based, mosquito-trapping scheme that captures spatial and temporal heterogeneities of malaria transmission in rural Zambia. Malar J 2014; 13:225. [PMID: 24906704 PMCID: PMC4060139 DOI: 10.1186/1475-2875-13-225] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Accepted: 05/21/2014] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Monitoring mosquito population dynamics is essential to guide selection and evaluation of malaria vector control interventions but is typically implemented by mobile, centrally-managed teams who can only visit a limited number of locations frequently enough to capture longitudinal trends. Community-based (CB) mosquito trapping schemes for parallel, continuous monitoring of multiple locations are therefore required that are practical, affordable, effective, and reliable. METHODS A CB surveillance scheme, with a monthly sampling and reporting cycle for capturing malaria vectors, using Centers for Disease Control and Prevention light traps (LT) and Ifakara Tent Traps (ITT), were conducted by trained community health workers (CHW) in 14 clusters of households immediately surrounding health facilities in rural south-east Zambia. At the end of the study, a controlled quality assurance (QA) survey was conducted by a centrally supervised expert team using human landing catch (HLC), LT and ITT to evaluate accuracy of the CB trapping data. Active surveillance of malaria parasite infection rates amongst humans was conducted by CHWs in the same clusters to determine the epidemiological relevance of these CB entomological surveys. RESULTS CB-LT and CB-ITT exhibited relative sampling efficiencies of 50 and 7%, respectively, compared with QA surveys using the same traps. However, cost per sampling night was lowest for CB-LT ($13.6), followed closely by CB-ITT ($18.0), both of which were far less expensive than any QA survey (HLC: $138, LT: $289, ITT: $269). Cost per specimen of Anopheles funestus captured was lowest for CB-LT ($5.3), followed by potentially hazardous QA-HLC ($10.5) and then CB-ITT ($28.0), all of which were far more cost-effective than QA-LT ($141) and QA-ITT ($168). Time-trends of malaria diagnostic positivity (DP) followed those of An. funestus density with a one-month lag and the wide range of mean DP across clusters was closely associated with mean densities of An. funestus caught by CB-LT (P < 0.001). CONCLUSIONS CB trapping schemes appear to be far more affordable, epidemiologically relevant and cost-effective than centrally supervised trapping schemes and may well be applicable to enhance intervention trials and even enable routine programmatic monitoring of vector population dynamics on unprecedented national scales.
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Affiliation(s)
- Chadwick H Sikaala
- National Malaria Control Centre, Chainama Hospital College Grounds, Off Great East road, P,O, Box 32509 Lusaka, Zambia.
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