Effectiveness of the innovative 1,7-malaria reactive community-based testing and response (1, 7-mRCTR) approach on malaria burden reduction in Southeastern Tanzania

Current Status of Malaria Control and Elimination in Africa: Epidemiology, Diagnosis, Treatment, Progress and Challenges

The African continent carries the greatest malaria burden in the world. Falciparum malaria especially has long been the leading cause of death in Africa. Climate, economic factors, geographical location, human intervention and unstable security are factors influencing malaria transmission. Due to repeated infections and early interventions, the proportion of clinically atypical malaria or asymptomatic plasmodium carriers has increased significantly, which easily lead to misdiagnosis and missed diagnosis. African countries have made certain progress in malaria control and elimination, including rapid diagnosis of malaria, promotion of mosquito nets and insecticides, intermittent prophylactic treatment in high-risk groups, artemisinin based combination therapies, and the development of vaccines. Between 2000 and 2022, there has been a 40% decrease in malaria incidence and a 60% reduction in mortality rate in the WHO African Region. However, many challenges are emerging in the fight against malaria in Africa, such as climate change, poverty, substandard health services and coverage, increased outdoor transmission and the emergence of new vectors, and the growing threat of resistance to antimalarial drugs and insecticides. Joint prevention and treatment, identifying molecular determinants of resistance, new drug development, expanding seasonal malaria chemo-prevention intervention population, and promoting the vaccination of RTS, S/AS01 and R21/Matrix-M may help to solve the dilemma. China's experience in eliminating malaria is conducive to Africa's malaria prevention and control, and China-Africa cooperation needs to be constantly deepened and advanced. Our review aims to help the global public develop a comprehensive understanding of malaria in Africa, thereby contributing to malaria control and elimination.

China's hidden role in malaria control and elimination in Africa

BACKGROUND

Insufficient funding is hindering the achievement of malaria elimination targets in Africa, despite the pressing need for increased investment in malaria control. While Western donors attribute their inaction to financial constraints, the global health community has limited knowledge of China's expanding role in malaria prevention. This knowledge gap arises from the fact that China does not consistently report its foreign development assistance activities to established aid transparency initiatives. Our work focuses on identifying Chinese-funded malaria control projects throughout Africa and linking them to official data on malaria prevalence. By doing so, we aim to shed light on China's contributions to malaria control efforts, analysing their investments and assessing their impact. This would provide valuable insights into the development of effective financing mechanisms for future malaria control in Africa.

METHODS

Our research used AidData' s recently released Global Chinese Development Finance Dataset V.2.0 providing comprehensive coverage of all official sector Chinese development financing across Africa, from which we identify 224 Chinese-funded malaria projects in Sub-Saharan Africa (SSA) committed between 2002 and 2017. We conducted an analysis of the spending patterns by year, country and regions within Africa and compared it with data on population-adjusted malaria prevalence, sourced from the Malaria Atlas Project.

RESULTS

Chinese-financed malaria projects Africa mainly focused on three areas: the provision of medical supplies (72.32%), the construction of basic health infrastructure (17.86%) and the deployment of anti-malaria experts (3.57%). Moreover, nearly 39% of the initiatives were concentrated in just four countries: the Democratic Republic of Congo, Central African Republic, Uganda and Liberia. Additionally, China's development financing amount showed a weak negative correlation (-0.2393) with population-weighted malaria prevalence. We concluded that the extent and direction of China's support are not adequately tailored to address malaria challenges in different countries.

CONCLUSION

With China's increasing engagement in global health, it is anticipated that malaria control will continue to be a prominent priority on its development assistance agenda. This is attributed to China's vast expertise in malaria elimination, coupled with its substantial contribution as a major producer of malaria diagnostics and treatments.

Impact of 1,7-malaria reactive community-based testing and response (1,7-mRCTR) approach on malaria prevalence in Tanzania

BACKGROUND

Progress in malaria control has stalled in recent years and innovative surveillance and response approaches are needed to accelerate malaria control and elimination efforts in endemic areas of Africa. Building on a previous China-UK-Tanzania pilot study on malaria control, this study aimed to assess the impact of the 1,7-malaria Reactive Community-Based Testing and Response (1,7-mRCTR) approach implemented over two years in three districts of Tanzania.

METHODS

The 1,7-mRCTR approach provides community-based malaria testing via rapid diagnostic tests and treatment in villages with the highest burden of malaria incidence based on surveillance data from health facilities. We used a difference-in-differences quasi-experimental design with linear probability models and two waves of cross-sectional household surveys to assess the impact of 1,7-mRCTR on malaria prevalence. We conducted sensitivity analyses to assess the robustness of our results, examined how intervention effects varied in subgroups, and explored alternative explanations for the observed results.

RESULTS

Between October 2019 and September 2021, 244,771 community-based malaria rapid tests were completed in intervention areas, and each intervention village received an average of 3.85 rounds of 1-7mRCTR. Malaria prevalence declined from 27.4% at baseline to 11.7% at endline in the intervention areas and from 26.0% to 16.0% in the control areas. 1,7-mRCTR was associated with a 4.5-percentage-point decrease in malaria prevalence (95% confidence interval: - 0.067, - 0.023), equivalent to a 17% reduction from the baseline. In Rufiji, a district characterized by lower prevalence and where larviciding was additionally provided, 1,7-mRCTR was associated with a 63.9% decline in malaria prevalence.

CONCLUSIONS

The 1,7-mRCTR approach reduced malaria prevalence. Despite implementation interruptions due to the COVID-19 pandemic and supply chain challenges, the study provided novel evidence on the effectiveness of community-based reactive approaches in moderate- to high-endemicity areas and demonstrated the potential of South-South cooperation in tackling global health challenges.

China's application of the One Health approach in addressing public health threats at the human-animal-environment interface: Advances and challenges

Background

Due to emerging issues such as global climate change and zoonotic disease pandemics, the One Health approach has gained more attention since the turn of the 21st century. Although One Health thinking has deep roots and early applications in Chinese history, significant gaps exist in China's real-world implementation at the complex interface of the human-animal-environment.

Methods

We abstracted the data from the global One Health index study and analysed China's performance in selected fields based on Structure-Process-Outcome model. By comparing China to the Belt & Road and G20 countries, the advances and gaps in China's One Health performance were determined and analysed.

Findings

For the selected scientific fields, China generally performs better in ensuring food security and controlling antimicrobial resistance and worse in addressing climate change. Based on the SPO model, the "structure" indicators have the highest proportion (80.00%) of high ranking and the "outcome" indicators have the highest proportion (20.00%) of low ranking. When compared with Belt and Road countries, China scores above the median in almost all indicators (16 out of 18) under the selected scientific fields. When compared with G20 countries, China ranks highest in food security (scores 72.56 and ranks 6th), and lowest in climate change (48.74, 11th).

Conclusion

Our results indicate that while China has made significant efforts to enhance the application of the One Health approach in national policies, it still faces challenges in translating policies into practical measures. It is recommended that a holistic One Health action framework be established for China in accordance with diverse social and cultural contexts, with a particular emphasis on overcoming data barriers and mobilizing stakeholders both domestically and globally. Implementation mechanisms, with clarified stakeholder responsibilities and incentives, should be improved along with top-level design.

Exploring activities and behaviours potentially increases school-age children's vulnerability to malaria infections in south-eastern Tanzania

BACKGROUND

Strengthening malaria control activities in Tanzania has dramatically declined human malaria infections. However, there is an increasing epidemiological shift in the burden on school-age children. The underlying causes for such an epidemiological shift remain unknown in this context. This study explored activities and behaviours that could increase the vulnerability of school-age children to transmission risk to provide insight into protection gap with existing interventions and opportunities for supplementary interventions.

METHODS

This cross-sectional study conducted twenty-four focus group discussions (FGDs) in three districts of Rufiji, Kibiti and Kilwa in south-eastern Tanzania. Sixteen FGDs worked with school-age children (13 to 18 years) separating girls and boys and eight FGDs with their parents in mixed-gender groups. A total of 205 community members participated in FGDs across the study area. Of them, 72 participants were parents, while 133 were school-age children (65 boys and 68 girls).

RESULTS

Routine domestic activities such as fetching water, washing kitchen utensils, cooking, and recreational activities such as playing and watching television and studying were the reported activities that kept school-age children outdoors early evening to night hours (between 18:00 and 23:00). Likewise, the social and cultural events including initiation ceremonies and livelihood activities also kept this age group outdoors from late evening to early night and sometimes past midnight hours. Parents migrating to farms from December to June, leaving behind school-age children unsupervised affecting their net use behaviour plus spending more time outdoors at night, and the behaviour of children sprawling legs and hands while sleeping inside treated bed nets were identified as potential risks to infectious mosquito bites.

CONCLUSION

The risky activities, behaviours, and social events mostly occurring outdoors might increase school-age children's vulnerability to malaria infections. The findings provide preliminary insight on potential risk factors for persisting transmission. Further studies to quantify the risk behaviour and activities are recommended to establish the magnitude and anticipated impact on supplementary control strategies to control infection in school-age children.

Understanding the China-Tanzania Malaria Control Project: lessons learned from a multi-stakeholder qualitative study

Background

Tanzania is among the countries with the highest malaria cases and deaths worldwide, where vulnerable populations have been severely affected due to poverty and weakness in health system and infrastructure. The China-Tanzania Malaria Control Project (the Project) was a two-phase global health intervention project implemented between 2015 and 2021 that aimed to transfer project-designated intervention experience in malaria elimination to the Tanzanian health system. This study aims to identify the barriers and facilitators encountered during the Project and to improve our understanding of the emerging phenomenon of South-South global health collaboration.

Methods

We conducted thematic analysis of qualitative data collected from a purposive sample of 14 participants from multiple stakeholders including project management office, project implementation agency, funding partners and external evaluators of the Project. A conceptual framework was developed to construct the interviews guides. The interviews were transcribed verbatim, crossover checked, translated into English, and analyzed with NVivo 12.0. We conducted the open coding followed by the axial coding based on the Grounded Theory to generate themes and subthemes, and identified key influencing factors that aided or hindered the malaria control in Tanzania.

Results

The findings suggested that malaria control strategies should largely be tailored due to varied socioeconomic contexts. The perceived enablers in practice include project-designated intervention experiences and technologies, professional and self-learning capabilities of the implementation team, sustainable financial assistance, and support from the international partners. The barriers include the shortage of global health talents, existing gaps to meet international standards, defects in internal communication mechanisms, inadequacy of intergovernmental dialogue, and limitations in logistical arrangements. A checklist and policy implications for China's future engagement in malaria control in resource-limited settings have been proposed.

Conclusions

The initiative of Health Silk Road has generated strong global interest in promoting development assistance in health. In the hope of generalizing the evidence-based interventions to high malaria-endemic countries in Africa, the need for China to carefully face the challenges of funding gaps and the lack of support from recipient governments remains ongoing. It is recommended that China should form an institutionalized scheme and sustainable funding pool to ensure the steady progress of development assistance in health.

Testing and treatment for malaria elimination: a systematic review

BACKGROUND

Global interest in malaria elimination has prompted research on active test and treat (TaT) strategies.

METHODS

A systematic review and meta-analysis were conducted to assess the effectiveness of TaT strategies to reduce malaria transmission.

RESULTS

A total of 72 empirical research and 24 modelling studies were identified, mainly focused on proactive mass TaT (MTaT) and reactive case detection (RACD) in higher and lower transmission settings, respectively. Ten intervention studies compared MTaT to no MTaT and the evidence for impact on malaria incidence was weak. No intervention studies compared RACD to no RACD. Compared to passive case detection (PCD) alone, PCD + RACD using standard diagnostics increased infection detection 52.7% and 11.3% in low and very low transmission settings, respectively. Using molecular methods increased this detection of infections by 1.4- and 1.1-fold, respectively.

CONCLUSION

Results suggest MTaT is not effective for reducing transmission. By increasing case detection, surveillance data provided by RACD may indirectly reduce transmission by informing coordinated responses of intervention targeting.

1-3-7 surveillance and response approach in malaria elimination: China's practice and global adaptions

There has been a significant reduction in malaria morbidity and mortality worldwide from 2000 to 2019. However, the incidence and mortality increased again in 2020 due to the disruption to services during the COVID-19 pandemic. Surveillance to reduce the burden of malaria, eliminate the disease and prevent its retransmission is, therefore, crucial. The 1-3-7 approach proposed by China has played an important role in eliminating malaria, which has been internationally popularized and adopted in some countries to help eliminate malaria. This review summarizes the experience and lessons of 1-3-7 approach in China and its application in other malaria-endemic countries, so as to provide references for its role in eliminating malaria and preventing retransmission. This approach needs to be tailored and adapted according to the region condition, considering the completion, timeliness and limitation of case-based reactive surveillance and response. It is very important to popularize malaria knowledge, train staff, improve the capacity of health centres and monitor high-risk groups to improve the performance in eliminating settings. After all, remaining vigilance in detecting malaria cases and optimizing surveillance and response systems are critical to achieving and sustaining malaria elimination.

Spatiotemporal dynamics of malaria in Zanzibar, 2015-2020

BACKGROUND

Despite high coverage of malaria interventions, malaria elimination in Zanzibar remains elusive, with the annual number of cases increasing gradually over the last 3 years.

OBJECTIVE

The aims of the study were to (1) assess the spatiotemporal dynamics of malaria in Zanzibar between 2015 and 2020 and (2) identify malaria hotspots that would allow Zanzibar to develop an epidemiological stratification for more effective and granular intervention targeting.

METHODS

In this study, we analysed data routinely collected by Zanzibar's Malaria Case Notification (MCN) system. The system collects sociodemographic and epidemiological data from all malaria cases. Cases are passively detected at health facilities (ie, primary index cases) and through case follow-up and reactive case detection (ie, secondary cases). Analyses were performed to identify the spatial heterogeneity of case reporting at shehia (ward) level during transmission seasons.

RESULTS

From 1 January 2015 to 30 April 2020, the MCN system reported 22 686 index cases. Number of cases reported showed a declining trends from 2015 to 2016, followed by an increase from 2017 to 2020. More than 40% of cases had a travel history outside Zanzibar in the month prior to testing positive for malaria. The proportion of followed up index cases was approximately 70% for all years. Out of 387 shehias, 79 (20.4%) were identified as malaria hotspots in any given year; these hotspots reported 52% of all index cases during the study period. Of the 79 hotspot shehias, 12 were hotspots in more than 4 years, that is, considered temporally stable, reporting 14.5% of all index cases.

CONCLUSIONS

Our findings confirm that the scale-up of malaria interventions has greatly reduced malaria transmission in Zanzibar since 2006. Analyses identified hotspots, some of which were stable across multiple years. Malaria efforts should progress from a universal intervention coverage approach to an approach that is more tailored to a select number of hotspot shehias.

Achievements of the national malaria control and elimination program in the People's Republic of China: the Atlas of Malaria Transmission in China

In 2017, China achieved the target of zero indigenous malaria case for the first time, and has been certified as malaria free by World Health Organization in 2021. To further summarize the historical achievements and technical experiences of the elimination program, a project on the Roadmap Analysis and Verification for Malaria Elimination in China was carried out. Results of the project were compiled and published as the Atlas of Malaria Transmission in China (The Atlas). The Atlas using modern digital information technologies, has been supported by various data from 24 malaria endemic provinces of China since 1950, to assess the changes in malaria epidemic patterns from 1950 to 2019 at national and provincial levels. The Atlas is designed as two volumes, including a total of 1850 thematic maps and more than 130 charts, consisting of introductory maps, thematic maps of malaria epidemic and control at national and provincial levels. It objectively and directly shows the epidemic history, evolution process, and great achievements of the national malaria control and elimination program in China. The Atlas has important reference value for summing up historical experience in the national malaria elimination program of China, and malaria control and elimination in other endemic countries in the world.

The economic burden of malaria inpatients and its determinants during China's elimination stage

Background

Malaria burden is still worrisome, while empirical evidence from malaria-eliminated countries including China may provide inspiration for the world.

Objective

This study aimed to investigate China's malaria hospitalization costs and explore its determinants.

Methods

Stratified multistage sampling across provincial, municipal, and county hospitals was conducted in 2017. All the malaria medical records were retrieved from 2014 to 2016 in 70 hospitals. Parametric and non-parametric methods were employed to estimate hospitalization costs, and the non-parametric bootstrap was used to compare hospitalization costs among sample areas and assessed the uncertainty of its differences. Quantile regressions were conducted to identify the determinants of hospitalization costs.

Results

The median hospitalization costs of 1633 malaria inpatients were 628 USD. Medication and laboratory tests accounted for over 70% of total expenditure. The median reimbursement rate was 41.87%, and this number was even lower in higher-level hospitals (<35%) and among the New Rural Cooperative Medical Scheme (<40%). Finally, health insurance type, hospital tier, clinical units, unknown fever, and comorbidity were the main determinants of hospitalization costs.

Conclusion

The disparity of health protection for malaria hospitalization between rural and urban areas was noteworthy. Equivocal diagnosis and comorbidity are contributors of high cost as well. A reasonable payment system and enhanced capacities to treat malaria in a cost-effective way are suggested to reassure malaria economic burden.

Research on the Driving Factors of Constructing Innovative Thinking Environment from the Perspective of Online Community

With the development of Internet information technology, the Internet space and the real space are increasingly integrated, and the influence of the Internet community has surpassed the cyberspace. The online community is not only a product of virtual space, but also integrates with the real society in terms of community interaction mode, network communityization of geographic communities, and dematerialization of social organizations. This offline integration trend objectively requires changes in online community governance at the level of thinking and system. Internet governance and social governance should be integrated to build a diversified, collaborative, and intelligent innovative online social governance system. This paper discusses the factors of creative thinking from the perspective of online community. Therefore, from the perspective of online community, more attention should be paid to the innovative thinking of online community, and the online community itself should play a more important role in the online social governance system.

Role of international network on surveillance and response system leading to malaria elimination: China's engagement in global health

China has accumulated multiple practices and experiences in building and enhancing malaria surveillance and response system. As China’s engagement into global health has gathered stronger momentum than ever, China together with the Swiss Tropical and Public Health Institute and WHO has organised five sessions of the International Forum on Surveillance-Response System Leading to Tropical Diseases Elimination during 2012–2020, in which malaria elimination has always been one of the hottest topics. In this study, the roles of international network on the surveillance and response system were explored to achieve a global malaria-free goal. China’s approach to malaria elimination has demonstrated significance of global collaboration on taking joint prevention and control, and building a worldwide institutional-based network.

Could China's journey of malaria elimination extend to Africa?

World Health Organization (WHO) certified China malaria-free on June 30, 2021, which brightens the goal of global malaria elimination efforts. China contributed its unique innovations to the global community: Artemisinin, discovered by Tu Youyou, has saved millions of lives globally; the "1-3-7" norm developed in 2012, has been adapted in the local contexts of countries in the Southeast Asia and Africa. How to the targets of Global Technical Strategy for Malaria (GTS) 2016-2030. By looking into the malaria control phase, towards elimination phase from 1960 to 2011 in sub-Saharan Africa and China, we found that the gap in malaria burden will widen unless the interventions in Africa are enhanced. It is imperative to identify the key China-Africa cooperation areas on malaria control and elimination, so that synergized efforts could be pooled together to help African countries achieve the elimination goal. The practices from China malaria control and elimination efforts could be leveraged to fast-track malaria elimination efforts in Africa, which makes it possible that the China's journey of malaria elimination extends to Africa.

Key takeaways from China's success in eliminating malaria: leveraging existing evidence for a malaria-free world

Although the total number of malaria cases and fatalities have declined globally since 2010, there were still 241 million malaria cases identified across 85 countries and territories in 2020. As the global malaria eradication process accelerates, more countries have launched their own initiatives of elimination. Notably, China achieved this goal by 2021, ending thousands of years of endemic. Undoubtedly, tremendous experience and vital lessons have been accrued en route to the malaria-free goal in malaria-eliminated countries including China. To enhance prospects of a malaria-free world by bridging the key evidence from a malaria-eliminated country to the contexts of affected, this personal view highlights concerted commitments and universal investment in healthcare, improved surveillance and response system, constant capacity building, demand-oriented scientific research, and multiway cooperation, which have helped China to eliminate this ancient scourge. We discuss how these key takeaways could be leveraged to different contexts. We also argue the long-term challenges and barriers on the pathway to malaria elimination and underline the needs for consistent efforts to maintain zero indigenous cases and prevent re-introduction of malaria. Through concerted efforts from global collaboration, a malaria-free world can become a reality.

Impact of the malaria comprehensive case management programme in Odisha, India

Background

The Comprehensive Case Management Project (CCMP), was a collaborative implementation research initiative to strengthen malaria early detection and complete treatment in Odisha State, India.

Methods

A two-arm quasi-experimental design was deployed across four districts in Odisha, representing a range of malaria endemicity: Bolangir (low), Dhenkanal (moderate), Angul (high), and Kandhamal (hyper). In each district, a control block received routine malaria control measures, whereas a CCMP block received a range of interventions to intensify surveillance, diagnosis, and case management. Impact was evaluated by difference-in-difference (DID) analysis and interrupted time-series (ITS) analysis of monthly blood examination rate (MBER) and monthly parasite index (MPI) over three phases: phase 1 pre-CCMP (2009–2012) phase 2 CCMP intervention (2013–2015), and phase 3 post-CCMP (2016–2017).

Results

During CCMP implementation, adjusting for control blocks, DID and ITS analysis indicated a 25% increase in MBER and a 96% increase in MPI, followed by a –47% decline in MPI post-CCMP, though MBER was maintained. Level changes in MPI between phases 1 and 2 were most marked in Dhenkanal and Angul with increases of 976% and 287%, respectively, but declines in Bolangir (−57%) and Kandhamal (−22%). Between phase 2 and phase 3, despite the MBER remaining relatively constant, substantial decreases in MPI were observed in Dhenkanal (−78%), and Angul (−59%), with a more modest decline in Bolangir (−13%), and an increase in Kandhamal (14%).

Conclusions

Overall, CCMP improved malaria early detection and treatment through the enhancement of the existing network of malaria services which positively impacted case incidence in three districts. In Kandhamal, which is hyperendemic, the impact was not evident. However, in Dhenkanal and Angul, areas of moderate-to-high malaria endemicity, CCMP interventions precipitated a dramatic increase in case detection and a subsequent decline in malaria incidence, particularly in previously difficult-to-reach communities.

China's long march to malaria elimination: a case of adaptive management

Since the 1950s, China has transitioned from a malaria pandemic country with tens of millions of annual cases, through phases of local control and elimination, to sustained national malaria elimination efforts. This marks the first time a country in the World Health Organization (WHO) Western Pacific region has been certified malaria-free in more than 3 decades. This article provides an innovative approach to understanding China’s malaria elimination journey. A number of articles and commentaries have analysed the effectiveness of specific technical approaches implemented in China. Our argument is that we need to look beyond these, and consider the ways in which policy development and implementation capacities have been fostered to support the dynamic change management. The article makes a number of arguments. First is the pragmatic adaptiveness of policies and strategies—and implementation capacities. Second, China has invested in building systems as well as capacities to support the elimination of parasitic diseases, including malaria. Third, the country has both benefited from, and contributed to, global health collaboration on malaria elimination. The ongoing work by the authors is identifying a number of key factors.

A malaria-free China: global importance and key experience

Malaria has a worldwide distribution and is the world's deadliest mosquito-borne disease. The goal of malaria elimination is also reflected in the United Nations Sustainable Development Goals and the Global Technical Strategy for Malaria 2016-2030 issued by the World Health Organization (WHO). China succeeded in its malaria elimination programme after being certified as malaria-free by the WHO on 30 June 2021. Therefore, we document some of the key lessons learnt in the course of the malaria elimination effort in China in this special volume, showing how different strategies made elimination feasible in different subregions of China with different epidemiological and socioeconomic characteristics, in order to present strong signals to other malaria-endemic countries that malaria elimination is feasible within one generation.

Spatial-temporal clustering of malaria using routinely collected health facility data on the Kenyan Coast

BACKGROUND

The over-distributed pattern of malaria transmission has led to attempts to define malaria "hotspots" that could be targeted for purposes of malaria control in Africa. However, few studies have investigated the use of routine health facility data in the more stable, endemic areas of Africa as a low-cost strategy to identify hotspots. Here the objective was to explore the spatial and temporal dynamics of fever positive rapid diagnostic test (RDT) malaria cases routinely collected along the Kenyan Coast.

METHODS

Data on fever positive RDT cases between March 2018 and February 2019 were obtained from patients presenting to six out-patients health-facilities in a rural area of Kilifi County on the Kenyan Coast. To quantify spatial clustering, homestead level geocoded addresses were used as well as aggregated homesteads level data at enumeration zone. Data were sub-divided into quarterly intervals. Kulldorff's spatial scan statistics using Bernoulli probability model was used to detect hotspots of fever positive RDTs across all ages, where cases were febrile individuals with a positive test and controls were individuals with a negative test.

RESULTS

Across 12 months of surveillance, there were nine significant clusters that were identified using the spatial scan statistics among RDT positive fevers. These clusters included 52% of all fever positive RDT cases detected in 29% of the geocoded homesteads in the study area. When the resolution of the data was aggregated at enumeration zone (village) level the hotspots identified were located in the same areas. Only two of the nine hotspots were temporally stable accounting for 2.7% of the homesteads and included 10.8% of all fever positive RDT cases detected.

CONCLUSION

Taking together the temporal instability of spatial hotspots and the relatively modest fraction of the malaria cases that they account for; it would seem inadvisable to re-design the sub-county control strategies around targeting hotspots.