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Myers J, Hennessey M, Arnold JC, McCubbin KD, Lembo T, Mateus A, Kitutu FE, Samanta I, Hutchinson E, Davis A, Mmbaga BT, Nasuwa F, Gautham M, Clarke SE. Crossover-Use of Human Antibiotics in Livestock in Agricultural Communities: A Qualitative Cross-Country Comparison between Uganda, Tanzania and India. Antibiotics (Basel) 2022; 11:1342. [PMID: 36290000 PMCID: PMC9598773 DOI: 10.3390/antibiotics11101342] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/02/2022] [Accepted: 09/28/2022] [Indexed: 12/24/2022] Open
Abstract
Antibiotic use in animal agriculture contributes significantly to antibiotic use globally and is a key driver of the rising threat of antibiotic resistance. It is becoming increasingly important to better understand antibiotic use in livestock in low-and-middle income countries where antibiotic use is predicted to increase considerably as a consequence of the growing demand for animal-derived products. Antibiotic crossover-use refers to the practice of using antibiotic formulations licensed for humans in animals and vice versa. This practice has the potential to cause adverse drug reactions and contribute to the development and spread of antibiotic resistance between humans and animals. We performed secondary data analysis of in-depth interview and focus-group discussion transcripts from independent studies investigating antibiotic use in agricultural communities in Uganda, Tanzania and India to understand the practice of antibiotic crossover-use by medicine-providers and livestock-keepers in these settings. Thematic analysis was conducted to explore driving factors of reported antibiotic crossover-use in the three countries. Similarities were found between countries regarding both the accounts of antibiotic crossover-use and its drivers. In all three countries, chickens and goats were treated with human antibiotics, and among the total range of human antibiotics reported, amoxicillin, tetracycline and penicillin were stated as used in animals in all three countries. The key themes identified to be driving crossover-use were: (1) medicine-providers' and livestock-keepers' perceptions of the effectiveness and safety of antibiotics, (2) livestock-keepers' sources of information, (3) differences in availability of human and veterinary services and antibiotics, (4) economic incentives and pressures. Antibiotic crossover-use occurs in low-intensity production agricultural settings in geographically distinct low-and-middle income countries, influenced by a similar set of interconnected contextual drivers. Improving accessibility and affordability of veterinary medicines to both livestock-keepers and medicine-providers is required alongside interventions to address understanding of the differences between human and animal antibiotics, and potential dangers of antibiotic crossover-use in order to reduce the practice. A One Health approach to studying antibiotic use is necessary to understand the implications of antibiotic accessibility and use in one sector upon antibiotic use in other sectors.
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Affiliation(s)
- Jessica Myers
- Department of Disease Control, London School of Hygiene & Tropical Medicine, Keppel Street, Bloomsbury, London WC1E 7HT, UK
- Veterinary Epidemiology, Economics and Public Health Group, Royal Veterinary College, Hawkshead Lane, Hatfield AL9 7TA, UK
| | - Mathew Hennessey
- Veterinary Epidemiology, Economics and Public Health Group, Royal Veterinary College, Hawkshead Lane, Hatfield AL9 7TA, UK
| | - Jean-Christophe Arnold
- Veterinary Epidemiology, Economics and Public Health Group, Royal Veterinary College, Hawkshead Lane, Hatfield AL9 7TA, UK
| | - Kayley D McCubbin
- Department of Production Animal Health, Faculty of Veterinary Medicine, University of Calgary, 2500 University Drive NW, Calgary, AB T2N 1N4, Canada
| | - Tiziana Lembo
- School of Biodiversity, One Health & Veterinary Medicine, University of Glasgow, Glasgow G12 8QQ, UK
| | - Ana Mateus
- Veterinary Epidemiology, Economics and Public Health Group, Royal Veterinary College, Hawkshead Lane, Hatfield AL9 7TA, UK
| | - Freddy Eric Kitutu
- School of Public Health, Makerere University, New Mulago Hill Road, Kampala P.O. Box 7072, Uganda
| | - Indranil Samanta
- Department of Veterinary Microbiology, West Bengal University of Animal and Fishery Sciences, Kolkata 700037, India
| | - Eleanor Hutchinson
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Alicia Davis
- School of Social and Political Sciences, University of Glasgow, Glasgow G12 8RT, UK
| | - Blandina T Mmbaga
- Kilimanjaro Clinical Research Institute, Moshi P.O. Box 2236, Tanzania
- Department of Paediatric and Child Health, Faculty of Medicine, Kilimanjaro Christian Medical University College, Moshi P.O. Box 2240, Tanzania
| | - Fortunata Nasuwa
- Kilimanjaro Clinical Research Institute, Moshi P.O. Box 2236, Tanzania
| | - Meenakshi Gautham
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Siân E Clarke
- Department of Disease Control, London School of Hygiene & Tropical Medicine, Keppel Street, Bloomsbury, London WC1E 7HT, UK
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Cohee LM, Opondo C, Clarke SE, Halliday KE, Cano J, Shipper AG, Barger-Kamate B, Djimde A, Diarra S, Dokras A, Kamya MR, Lutumba P, Ly AB, Nankabirwa JI, Njagi JK, Maiga H, Maiteki-Sebuguzi C, Matangila J, Okello G, Rohner F, Roschnik N, Rouhani S, Sissoko MS, Staedke SG, Thera MA, Turner EL, Van Geertruyden JP, Zimmerman MB, Jukes MCH, Brooker SJ, Allen E, Laufer MK, Chico RM. Preventive malaria treatment among school-aged children in sub-Saharan Africa: a systematic review and meta-analyses. Lancet Glob Health 2020; 8:e1499-e1511. [PMID: 33222799 PMCID: PMC7721819 DOI: 10.1016/s2214-109x(20)30325-9] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 05/09/2020] [Accepted: 07/02/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND The burden of malaria infection in sub-Saharan Africa among school-aged children aged 5-15 years is underappreciated and represents an important source of human-to-mosquito transmission of Plasmodium falciparum. Additional interventions are needed to control and eliminate malaria. We aimed to assess whether preventive treatment of malaria might be an effective means of reducing P falciparum infection and anaemia in school-aged children and lowering parasite transmission. METHODS In this systematic review and two meta-analyses, we searched the online databases PubMed, Embase, Cochrane CENTRAL, and Clinicaltrials.gov for intervention studies published between Jan 1, 1990, and Dec 14, 2018. We included randomised studies that assessed the effect of antimalarial treatment among asymptomatic school-aged children aged 5-15 years in sub-Saharan Africa on prevalence of P falciparum infection and anaemia, clinical malaria, and cognitive function. We first extracted data for a study-level meta-analysis, then contacted research groups to request data for an individual participant data meta-analysis. Outcomes of interest included prevalence of P falciparum infection detected by microscopy, anaemia (study defined values or haemoglobin less than age-adjusted and sex-adjusted values), clinical malaria (infection and symptoms on the basis of study-specific definitions) during follow-up, and code transmission test scores. We assessed effects by treatment type and duration of time protected, and explored effect modification by transmission setting. For study-level meta-analysis, we calculated risk ratios for binary outcomes and standardised mean differences for continuous outcomes and pooled outcomes using fixed-effect and random-effects models. We used a hierarchical generalised linear model for meta-analysis of individual participant data. This study is registered with PROSPERO, CRD42016030197. FINDINGS Of 628 studies identified, 13 were eligible for the study-level meta-analysis (n=16 309). Researchers from 11 studies contributed data on at least one outcome (n=15 658) for an individual participant data meta-analysis. Interventions and study designs were highly heterogeneous; overall risk of bias was low. In the study-level meta-analysis, treatment was associated with reductions in P falciparum prevalence (risk ratio [RR] 0·27, 95% CI 0·17-0·44), anaemia (0·77, 0·65-0·91), and clinical malaria (0·40, 0·28-0·56); results for cognitive outcomes are not presented because data were only available for three trials. In our individual participant data meta-analysis, we found treatment significantly decreased P falciparum prevalence (adjusted RR [ARR] 0·46, 95% CI 0·40-0·53; p<0·0001; 15 648 individuals; 11 studies), anaemia (ARR 0·85, 0·77-0·92; p<0·0001; 15 026 individuals; 11 studies), and subsequent clinical malaria (ARR 0·50, 0·39-0·60; p<0·0001; 1815 individuals; four studies) across transmission settings. We detected a marginal effect on cognitive function in children older than 10 years (adjusted mean difference in standardised test scores 0·36, 0·01-0·71; p=0·044; 3962 individuals; five studies) although we found no significant effect when combined across all ages. INTERPRETATION Preventive treatment of malaria among school-aged children significantly decreases P falciparum prevalence, anaemia, and risk of subsequent clinical malaria across transmission settings. Policy makers and programme managers should consider preventive treatment of malaria to protect this age group and advance the goal of malaria elimination, while weighing these benefits against potential risks of chemoprevention. FUNDING US National Institutes of Health and Burroughs Wellcome Fund/ASTMH Fellowship.
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Affiliation(s)
- Lauren M Cohee
- Center for Vaccine Development and Global Health, University of Maryland, Baltimore, MA, USA
| | - Charles Opondo
- Department of Medical Statistics, Faculty of Epidemiology and Population Health, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Siân E Clarke
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Katherine E Halliday
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Jorge Cano
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Andrea G Shipper
- University of Maryland School of Medicine, and Health Sciences and Human Services Library, University of Maryland, Baltimore, MA, USA
| | | | - Abdoulaye Djimde
- Faculty of Medicine, Pharmacy, and Odnonto-Stomatology, Malaria Research and Training Center, University of Sciences, Techniques and Technologies of Bamako, Mali
| | | | - Aditi Dokras
- Department of Pediatrics, University of Maryland, Baltimore, MA, USA
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Pascal Lutumba
- Tropical Medicine Department, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | | | - Joaniter I Nankabirwa
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda; Infectious Diseases Research Collaboration, Kampala, Uganda
| | - J Kiambo Njagi
- National Malaria Control Programme, Ministry of Health, Nairobi, Kenya
| | - Hamma Maiga
- Faculty of Medicine, Pharmacy, and Odnonto-Stomatology, Malaria Research and Training Center, University of Sciences, Techniques and Technologies of Bamako, Mali
| | | | - Junior Matangila
- Tropical Medicine Department, University of Kinshasa, Kinshasa, Democratic Republic of Congo; Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - George Okello
- Health Systems and Social Science Research Group, Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | | | - Saba Rouhani
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; Save the Children, Bamako, Mali
| | - Mahamadou S Sissoko
- Faculty of Medicine, Pharmacy, and Odnonto-Stomatology, Malaria Research and Training Center, University of Sciences, Techniques and Technologies of Bamako, Mali
| | - Sarah G Staedke
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Mahamadou A Thera
- Faculty of Medicine, Pharmacy, and Odnonto-Stomatology, Malaria Research and Training Center, University of Sciences, Techniques and Technologies of Bamako, Mali
| | - Elizabeth L Turner
- Department of Biostatistics & Bioinformatics and Duke Global Health Institute, Duke University, Durham, NC, USA
| | | | - Michael B Zimmerman
- Institute of Food, Nutrition, and Health, Swiss Federal Institute of Technology, Zurich, Switzerland
| | | | | | - Elizabeth Allen
- Department of Medical Statistics, Faculty of Epidemiology and Population Health, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Miriam K Laufer
- Center for Vaccine Development and Global Health, University of Maryland, Baltimore, MA, USA
| | - R Matthew Chico
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
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Mbonye AK, Buregyeya E, Rutebemberwa E, Lal S, Clarke SE, Hansen KS, Magnussen P, LaRussa P. Treatment of Sick Children Seeking Care in the Private Health Sector in Uganda: A Cluster Randomized Trial. Am J Trop Med Hyg 2020; 102:658-666. [PMID: 31971139 PMCID: PMC7056412 DOI: 10.4269/ajtmh.19-0367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
The main objective of this study was to assess whether training of private health providers and community sensitization on the importance of effective prompt care seeking and the need for referral could improve treatment of sick children in the private health sector in Uganda. Private providers were trained to diagnose and treat sick children according to the integrated community case management (iCCM) guidelines. In the control arm, routine services were offered. The outcomes were seeking care within 24 hours of onset of symptoms and appropriate case management for malaria, pneumonia, and diarrhea among children aged < 5 years. A total of 10,809 sick children (5,955 in the intervention arm and 4,854 in the control arm) presented for diagnosis and treatment. The percentage seeking care within 24 hours of onset of symptoms was 45.4% (95% CI 36.0–48.8) in the intervention arm versus 43.9% (95% CI 38.1–49.8) in the control arm (P = 0.04). Adherence to malaria rapid diagnostic test (mRDT) results was high, with 1,459 (94.3%) in the intervention arm versus 1,402 (83.0%) in the control arm (P = 0.04). Appropriate treatment of mRDT-positive children with artemisinin-based combination therapy was seen in 93.1% (95% CI 88.5–97.7) in the intervention arm versus 85.1% (95% CI 78.6–91.7) in the control arm (P = 0.03). Adherence to iCCM guidelines was very high: 89.1% of children with diarrhea in the intervention arm and 80.4% in the control arm were given oral rehydration salts and zinc (P = 0.01). Of the children with a respiratory rate > 40 breaths/minute, 1,596 (85.1%) in the intervention arm versus 104 (54.5%) in the control arm were given amoxicillin (P = 0.01). In conclusion, the intervention improved treatment of malaria, pneumonia, and diarrhea because of provider adherence to treatment guidelines. The policy implications of these findings are to initiate a dialogue at district and national levels on how to scale up the intervention in the private sector. NCT02450630 registered with ClinicalTrials.gov: May 9, 2015.
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Affiliation(s)
- Anthony K Mbonye
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Esther Buregyeya
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University, Kampala, Uganda
| | - Elizeus Rutebemberwa
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University, Kampala, Uganda
| | - Sham Lal
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Siân E Clarke
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Kristian S Hansen
- Department of Public Health and Centre for Health Economics and Policy, University of Copenhagen, Copenhagen, Denmark
| | - Pascal Magnussen
- Institute for Immunology and Microbiology, Centre for Medical Parasitology, University of Copenhagen, Copenhagen, Denmark
| | - Philip LaRussa
- Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York, New York
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O'Boyle S, Bruxvoort KJ, Ansah EK, Burchett HED, Chandler CIR, Clarke SE, Goodman C, Mbacham W, Mbonye AK, Onwujekwe OE, Staedke SG, Wiseman VL, Whitty CJM, Hopkins H. Patients with positive malaria tests not given artemisinin-based combination therapies: a research synthesis describing under-prescription of antimalarial medicines in Africa. BMC Med 2020; 18:17. [PMID: 31996199 PMCID: PMC6990477 DOI: 10.1186/s12916-019-1483-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 12/17/2019] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND There has been a successful push towards parasitological diagnosis of malaria in Africa, mainly with rapid diagnostic tests (mRDTs), which has reduced over-prescribing of artemisinin-based combination therapies (ACT) to malaria test-negative patients. The effect on prescribing for test-positive patients has received much less attention. Malaria infection in endemic Africa is often most dangerous for young children and those in low-transmission settings. This study examined non-prescription of antimalarials for patients with malaria infection demonstrated by positive mRDT results, and in particular these groups who are most vulnerable to poor outcomes if antimalarials are not given. METHODS Analysis of data from 562,762 patients in 8 studies co-designed as part of the ACT Consortium, conducted 2007-2013 in children and adults, in Cameroon, Ghana, Nigeria, Tanzania, and Uganda, in a variety of public and private health care sector settings, and across a range of malaria endemic zones. RESULTS Of 106,039 patients with positive mRDT results (median age 6 years), 7426 (7.0%) were not prescribed an ACT antimalarial. The proportion of mRDT-positive patients not prescribed ACT ranged across sites from 1.3 to 37.1%. For patients under age 5 years, 3473/44,539 (7.8%) were not prescribed an ACT, compared with 3833/60,043 (6.4%) of those aged ≥ 5 years. The proportion of < 5-year-olds not prescribed ACT ranged up to 41.8% across sites. The odds of not being prescribed an ACT were 2-32 times higher for patients in settings with lower-transmission intensity (using test positivity as a proxy) compared to areas of higher transmission. mRDT-positive children in low-transmission settings were especially likely not to be prescribed ACT, with proportions untreated up to 70%. Of the 7426 mRDT-positive patients not prescribed an ACT, 4121 (55.5%) were prescribed other, non-recommended non-ACT antimalarial medications, and the remainder (44.5%) were prescribed no antimalarial. CONCLUSIONS In eight studies of mRDT implementation in five African countries, substantial proportions of patients testing mRDT-positive were not prescribed an ACT antimalarial, and many were not prescribed an antimalarial at all. Patients most vulnerable to serious outcomes, children < 5 years and those in low-transmission settings, were most likely to not be prescribed antimalarials, and young children in low-transmission settings were least likely to be treated for malaria. This major public health risk must be addressed in training and practice. TRIAL REGISTRATION Reported in individual primary studies.
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Affiliation(s)
| | - Katia J Bruxvoort
- London School of Hygiene and Tropical Medicine, London, UK.,Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, USA
| | - Evelyn K Ansah
- Centre for Malaria Research, University of Health and Allied Sciences, Accra, Ghana
| | | | | | - Siân E Clarke
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Wilfred Mbacham
- Public Health Biotechnology, University of Yaoundé I, Yaoundé, Cameroon
| | | | - Obinna E Onwujekwe
- Department of Pharmacology and Therapeutics, University of Nigeria, Enugu, Nigeria
| | | | - Virginia L Wiseman
- London School of Hygiene and Tropical Medicine, London, UK.,School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
| | | | - Heidi Hopkins
- London School of Hygiene and Tropical Medicine, London, UK
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Lal S, Ndyomugenyi R, Paintain L, Alexander ND, Hansen KS, Magnussen P, Chandramohan D, Clarke SE. Caregivers' compliance with referral advice: evidence from two studies introducing mRDTs into community case management of malaria in Uganda. BMC Health Serv Res 2018; 18:317. [PMID: 29720163 PMCID: PMC5932808 DOI: 10.1186/s12913-018-3124-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 04/15/2018] [Indexed: 11/16/2022] Open
Abstract
Background Several malaria endemic countries have implemented community health worker (CHW) programmes to increase access to populations underserved by health care. There is considerable evidence on CHW adherence to case management guidelines, however, there is limited evidence on the compliance to referral advice and the outcomes of children under-5 referred by CHWs. This analysis examined whether caregivers complied with CHWs referral advice. Methods Data from two cluster (village) randomised trials, one in a moderate-to-high malaria transmission setting, another in a low-transmission setting conducted between January 2010–July 2011 were analysed. CHW were trained to recognise signs and symptoms that required referral to a health centre. CHW in the intervention arm also had training on; malaria rapid diagnostic tests (mRDT) and administering artemisinin based combination therapy (ACT); CHW in the control arm were trained to treat malaria with ACTs based on fever symptoms. Caregivers’ referral forms were linked with CHW treatment forms to determine whether caregivers complied with the referral advice. Factors associated with compliance were examined with logistic regression. Results CHW saw 18,497 child visits in the moderate-to-high transmission setting and referred 15.2% (2815/18,497) of all visits; in the low-transmission setting, 35.0% (1135/3223) of all visits were referred. Compliance to referral was low, in both settings < 10% of caregivers complied with referral advice. In the moderate-to-high transmission setting compliance was higher if children were tested with mRDT compared to children who were not tested with mRDT. In both settings, nearly all children treated with pre-referral rectal artesunate failed to comply with referral and compliance was independently associated with factors such as health centre distance and day of referral by a CHW. In the moderate-to-high transmission setting, time of presentation, severity of referral were also associated with compliance, whilst in the low-transmission setting, compliance was low if an ACT was prescribed. Conclusions This analysis suggests there are several barriers to comply with CHWs referral advice by caregivers. This is concerning for children who received rectal artesunate. As CHW programmes continue scale-up, barriers to referral compliance need to be addressed to ensure a continuum of care from the community to the health centre. Trial registration The study was registered with ClinicalTrials.gov. Identifier NCT01048801, 13th January 2010. Electronic supplementary material The online version of this article (10.1186/s12913-018-3124-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sham Lal
- Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK.
| | | | - Lucy Paintain
- Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - Neal D Alexander
- MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Kristian S Hansen
- Section of Health Services Research, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Pascal Magnussen
- Department of Immunology and Microbiology, Centre for Medical Parasitology, University of Copenhagen, Copenhagen, Denmark.,Department of Veterinary Disease Biology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Daniel Chandramohan
- Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - Siân E Clarke
- Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
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Hansen KS, Clarke SE, Lal S, Magnussen P, Mbonye AK. Cost-effectiveness analysis of introducing malaria diagnostic testing in drug shops: A cluster-randomised trial in Uganda. PLoS One 2017; 12:e0189758. [PMID: 29244829 PMCID: PMC5731679 DOI: 10.1371/journal.pone.0189758] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Accepted: 12/02/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Private sector drug shops are an important source of malaria treatment in Africa, yet diagnosis without parasitological testing is common among these providers. Accurate rapid diagnostic tests for malaria (mRDTs) require limited training and present an opportunity to increase access to correct diagnosis. The present study was a cost-effectiveness analysis of the introduction of mRDTs in Ugandan drug shops. METHODS Drug shop vendors were trained to perform and sell subsidised mRDTs and artemisinin-based combination therapies (ACTs) in the intervention arm while vendors offered ACTs following presumptive diagnosis of malaria in the control arm. The effect on the proportion of customers with fever 'appropriately treated of malaria with ACT' was captured during a randomised trial in drug shops in Mukono District, Uganda. Health sector costs included: training of drug shop vendors, community sensitisation, supervision and provision of mRDTs and ACTs to drug shops. Household costs of treatment-seeking were captured in a representative sample of drug shop customers. FINDINGS The introduction of mRDTs in drug shops was associated with a large improvement of diagnosis and treatment of malaria, resulting in low incremental costs for the health sector at US$0.55 per patient appropriately treated of malaria. High expenditure on non-ACT drugs by households contributed to higher incremental societal costs of US$3.83. Sensitivity analysis showed that mRDTs would become less cost-effective compared to presumptive diagnosis with increasing malaria prevalence and lower adherence to negative mRDT results. CONCLUSION mRDTs in drug shops improved the targeting of ACTs to malaria patients and are likely to be considered cost-effective compared to presumptive diagnosis, although the increased costs borne by households when the test result is negative are a concern.
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Affiliation(s)
- Kristian Schultz Hansen
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Public Health, Section for Health Services Research, University of Copenhagen, Copenhagen, Denmark
| | - Siân E. Clarke
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sham Lal
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Pascal Magnussen
- Centre for Medical Parasitology, University of Copenhagen, Copenhagen, Denmark
| | - Anthony K. Mbonye
- Directorate of Clinical and Community Services, Ministry of Health, Kampala, Uganda
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
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Hansen KS, Ndyomugyenyi R, Magnussen P, Lal S, Clarke SE. Cost-effectiveness analysis of malaria rapid diagnostic tests for appropriate treatment of malaria at the community level in Uganda. Health Policy Plan 2017; 32:676-689. [PMID: 28453718 PMCID: PMC5406761 DOI: 10.1093/heapol/czw171] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2016] [Indexed: 11/21/2022] Open
Abstract
In Sub-Saharan Africa, malaria remains a major cause of morbidity and mortality among children under 5, due to lack of access to prompt and appropriate diagnosis and treatment. Many countries have scaled-up community health workers (CHWs) as a strategy towards improving access. The present study was a cost-effectiveness analysis of the introduction of malaria rapid diagnostic tests (mRDTs) performed by CHWs in two areas of moderate-to-high and low malaria transmission in rural Uganda. CHWs were trained to perform mRDTs and treat children with artemisinin-based combination therapy (ACT) in the intervention arm while CHWs offered treatment based on presumptive diagnosis in the control arm. Data on the proportion of children with fever ‘appropriately treated for malaria with ACT’ were captured from a randomised trial. Health sector costs included: training of CHWs, community sensitisation, supervision, allowances for CHWs and provision of mRDTs and ACTs. The opportunity costs of time utilised by CHWs were estimated based on self-reporting. Household costs of subsequent treatment-seeking at public health centres and private health providers were captured in a sample of households. mRDTs performed by CHWs was associated with large improvements in appropriate treatment of malaria in both transmission settings. This resulted in low incremental costs for the health sector at US$3.0 per appropriately treated child in the moderate-to-high transmission area. Higher incremental costs at US$13.3 were found in the low transmission area due to lower utilisation of CHW services and higher programme costs. Incremental costs from a societal perspective were marginally higher. The use of mRDTs by CHWs improved the targeting of ACTs to children with malaria and was likely to be considered a cost-effective intervention compared to a presumptive diagnosis in the moderate-to-high transmission area. In contrast to this, in the low transmission area with low attendance, RDT use by CHWs was not a low cost intervention.
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Affiliation(s)
- Kristian S Hansen
- Department of Public Health, Section for Health Services Research, University of Copenhagen, Denmark
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, UK
- Corresponding author. Department of Public Health, Section for Health Services Research, University of Copenhagen, Øster Farimagsgade 5, 1014 København K, Denmark. E-mail:
| | | | - Pascal Magnussen
- Centre for Medical Parasitology and Microbiology & Institute of Veterinary Disease Biology, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Sham Lal
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, UK
| | - Siân E Clarke
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, UK
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8
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Bruxvoort KJ, Leurent B, Chandler CIR, Ansah EK, Baiden F, Björkman A, Burchett HED, Clarke SE, Cundill B, DiLiberto DD, Elfving K, Goodman C, Hansen KS, Kachur SP, Lal S, Lalloo DG, Leslie T, Magnussen P, Mangham-Jefferies L, Mårtensson A, Mayan I, Mbonye AK, Msellem MI, Onwujekwe OE, Owusu-Agyei S, Rowland MW, Shakely D, Staedke SG, Vestergaard LS, Webster J, Whitty CJM, Wiseman VL, Yeung S, Schellenberg D, Hopkins H. The Impact of Introducing Malaria Rapid Diagnostic Tests on Fever Case Management: A Synthesis of Ten Studies from the ACT Consortium. Am J Trop Med Hyg 2017; 97:1170-1179. [PMID: 28820705 PMCID: PMC5637593 DOI: 10.4269/ajtmh.16-0955] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Since 2010, the World Health Organization has been recommending that all suspected cases of malaria be confirmed with parasite-based diagnosis before treatment. These guidelines represent a paradigm shift away from presumptive antimalarial treatment of fever. Malaria rapid diagnostic tests (mRDTs) are central to implementing this policy, intended to target artemisinin-based combination therapies (ACT) to patients with confirmed malaria and to improve management of patients with nonmalarial fevers. The ACT Consortium conducted ten linked studies, eight in sub-Saharan Africa and two in Afghanistan, to evaluate the impact of mRDT introduction on case management across settings that vary in malaria endemicity and healthcare provider type. This synthesis includes 562,368 outpatient encounters (study size range 2,400-432,513). mRDTs were associated with significantly lower ACT prescription (range 8-69% versus 20-100%). Prescribing did not always adhere to malaria test results; in several settings, ACTs were prescribed to more than 30% of test-negative patients or to fewer than 80% of test-positive patients. Either an antimalarial or an antibiotic was prescribed for more than 75% of patients across most settings; lower antimalarial prescription for malaria test-negative patients was partly offset by higher antibiotic prescription. Symptomatic management with antipyretics alone was prescribed for fewer than 25% of patients across all scenarios. In community health worker and private retailer settings, mRDTs increased referral of patients to other providers. This synthesis provides an overview of shifts in case management that may be expected with mRDT introduction and highlights areas of focus to improve design and implementation of future case management programs.
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Affiliation(s)
- Katia J Bruxvoort
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Baptiste Leurent
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | | | | | | | | | - Siân E Clarke
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Bonnie Cundill
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | | | | | - Catherine Goodman
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Kristian S Hansen
- University of Copenhagen, Copenhagen, Denmark.,London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Sham Lal
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - David G Lalloo
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Toby Leslie
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Pascal Magnussen
- Department for Veterinary and Animal Sciences, University of Copenhagen, Copenhagen, Denmark.,Centre for Medical Parasitology, University of Copenhagen and Copenhagen University Hospital, Copenhagen, Denmark
| | | | | | - Ismail Mayan
- Health Protection Research Organisation, Kabul, Afghanistan
| | - Anthony K Mbonye
- Makerere University School of Public Health, Kampala, Uganda.,Ministry of Health, Kampala, Uganda
| | | | - Obinna E Onwujekwe
- Department of Pharmacology and Therapeutics, University of Nigeria, Enugu, Nigeria
| | | | - Mark W Rowland
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Delér Shakely
- Centre for Malaria Research, Karolinska Institutet, Stockholm, Sweden.,Karolinska Institutet, Stockholm, Sweden.,Health Metrics at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Sarah G Staedke
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Lasse S Vestergaard
- Department of Infectious Disease Epidemiology and Prevention, Statens Serum Institut, Copenhagen, Denmark.,Centre for Medical Parasitology, University of Copenhagen and Copenhagen University Hospital, Copenhagen, Denmark
| | - Jayne Webster
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Virginia L Wiseman
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia.,London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Shunmay Yeung
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Heidi Hopkins
- London School of Hygiene & Tropical Medicine, London, United Kingdom
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9
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Lee AC, Kozuki N, Cousens S, Stevens GA, Blencowe H, Silveira MF, Sania A, Rosen HE, Schmiegelow C, Adair LS, Baqui AH, Barros FC, Bhutta ZA, Caulfield LE, Christian P, Clarke SE, Fawzi W, Gonzalez R, Humphrey J, Huybregts L, Kariuki S, Kolsteren P, Lusingu J, Manandhar D, Mongkolchati A, Mullany LC, Ndyomugyenyi R, Nien JK, Roberfroid D, Saville N, Terlouw DJ, Tielsch JM, Victora CG, Velaphi SC, Watson-Jones D, Willey BA, Ezzati M, Lawn JE, Black RE, Katz J. Estimates of burden and consequences of infants born small for gestational age in low and middle income countries with INTERGROWTH-21 st standard: analysis of CHERG datasets. BMJ 2017; 358:j3677. [PMID: 28819030 PMCID: PMC5558898 DOI: 10.1136/bmj.j3677] [Citation(s) in RCA: 207] [Impact Index Per Article: 29.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Objectives To estimate small for gestational age birth prevalence and attributable neonatal mortality in low and middle income countries with the INTERGROWTH-21st birth weight standard.Design Secondary analysis of data from the Child Health Epidemiology Reference Group (CHERG), including 14 birth cohorts with gestational age, birth weight, and neonatal follow-up. Small for gestational age was defined as infants weighing less than the 10th centile birth weight for gestational age and sex with the multiethnic, INTERGROWTH-21st birth weight standard. Prevalence of small for gestational age and neonatal mortality risk ratios were calculated and pooled among these datasets at the regional level. With available national level data, prevalence of small for gestational age and population attributable fractions of neonatal mortality attributable to small for gestational age were estimated.Setting CHERG birth cohorts from 14 population based sites in low and middle income countries.Main outcome measures In low and middle income countries in the year 2012, the number and proportion of infants born small for gestational age; number and proportion of neonatal deaths attributable to small for gestational age; the number and proportion of neonatal deaths that could be prevented by reducing the prevalence of small for gestational age to 10%.Results In 2012, an estimated 23.3 million infants (uncertainty range 17.6 to 31.9; 19.3% of live births) were born small for gestational age in low and middle income countries. Among these, 11.2 million (0.8 to 15.8) were term and not low birth weight (≥2500 g), 10.7 million (7.6 to 15.0) were term and low birth weight (<2500 g) and 1.5 million (0.9 to 2.6) were preterm. In low and middle income countries, an estimated 606 500 (495 000 to 773 000) neonatal deaths were attributable to infants born small for gestational age, 21.9% of all neonatal deaths. The largest burden was in South Asia, where the prevalence was the highest (34%); about 26% of neonatal deaths were attributable to infants born small for gestational age. Reduction of the prevalence of small for gestational age from 19.3% to 10.0% in these countries could reduce neonatal deaths by 9.2% (254 600 neonatal deaths; 164 800 to 449 700).Conclusions In low and middle income countries, about one in five infants are born small for gestational age, and one in four neonatal deaths are among such infants. Increased efforts are required to improve the quality of care for and survival of these high risk infants in low and middle income countries.
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Affiliation(s)
- Anne Cc Lee
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
| | - Naoko Kozuki
- International Rescue Committee, 1730 M Street NW, Suite 505, Washington, DC 20036, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205, USA
| | - Simon Cousens
- Facuty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- Maternal, Adolescent, Reproductive, and Child Health (MARCH) Centre, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Gretchen A Stevens
- Department of Information, Evidence and Research, World Health Organization (WHO), Geneva, Switzerland, CH-1211
| | - Hannah Blencowe
- Facuty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- Maternal, Adolescent, Reproductive, and Child Health (MARCH) Centre, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Mariangela F Silveira
- Programa de Pós-graduacao em Epidemiologia, Universidade Federal de Pelotas, Rua Marechal Deodoro 1160, 30 piso, Centro, CEP 96020-220, Pelotas, RS, Brazil
| | - Ayesha Sania
- Mailman School of Public Health, Columbia University, 722 W 168th St, New York, NY 10032
| | - Heather E Rosen
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205, USA
| | - Christentze Schmiegelow
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, Oester Farimagsgade 5, 1014 Copenhagen K, Denmark
| | - Linda S Adair
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC 27599, USA
- Carolina Population Center, University of North Carolina at Chapel Hill, 137 E. Franklin, Chapel Hill, NC 27516, USA
| | - Abdullah H Baqui
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205, USA
| | - Fernando C Barros
- Programa de Pós-graduação em Saúde e Comportamento, Universidade Católica de Pelotas, Félix da Cunha, 412, CEP 96010-000, Centro, Pelotas, RS, Brazil
| | - Zulfiqar A Bhutta
- Center for Global Child Health, Hospital for Sick Children, 686 Bay Street, Toronto, ON, M5G A04, Canada
- Centre of Excellence in Women and Child Health, Aga Khan University, Stadium Road PO Box 3500, Karachi 74800, India
| | - Laura E Caulfield
- Center for Human Nutrition, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, W2041, Baltimore, MD 21205 USA
| | - Parul Christian
- Women's Nutrition, Bill and Melinda Gates Foundation, Seattle, WA 98102, USA
| | - Siân E Clarke
- Faculty of Infectious Disease and Tropical Diseases, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- Malaria Centre, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Wafaie Fawzi
- Department of Global Health and Population, Harvard School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA
- Department of Nutrition, Harvard School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA
- Department of Epidemiology, Harvard School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA
| | - Rogelio Gonzalez
- Pontificia Universidad Católica de Chile, School of Medicine, Avenida Libertador General Bernardo O'Higgins #340, Santiago, Chile
- Clínica Santa María, Avenida Santa María 0410 Providencia, Santiago, Chile
| | - Jean Humphrey
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205, USA
- Center for Human Nutrition, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, W2041, Baltimore, MD 21205 USA
- Zvitambo Institute for Maternal and Child Health Research, 16 Lauchlan Road, Meyrick Park, Harare, Zimbabwe
| | - Lieven Huybregts
- Department of Food Safety and Food Quality, Ghent University, Coupure Links 653 - 9000 Ghent, Belgium
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, 2033 K St, NW Washington, DC 20006-1002, USA
| | - Simon Kariuki
- Kenya Medical Research Institute, Centre for Global Health Research, PO Box 1578-40100, Kisumu, Kenya
- Centers for Disease Control and Prevention Kenya, Off Kisumu-Busia Highway, PO Box 1578-40100, Kisumu, Kenya
| | - Patrick Kolsteren
- Department of Food Safety and Food Quality, Ghent University, Coupure Links 653 - 9000 Ghent, Belgium
| | - John Lusingu
- National Institute for Medical Research, PO Box 5004, Tanga, Tanzania
- University of Copenhagen, Denmark
| | - Dharma Manandhar
- Mother and Infant Research Activities (MIRA), YB Bhawan, Thapathali, Kathmandu 921, Nepal
| | - Aroonsri Mongkolchati
- ASEAN Institute for Health Development, Mahidol University, 999 Phuttamonthon 4 Rd, Salaya, Nakhon Pathom 73170, Thailand
| | - Luke C Mullany
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205, USA
| | - Richard Ndyomugyenyi
- Vector Control Division, Ministry of Health, Uganda, Plot 6 Lourdel Rd, Nakasero, Kampala, Uganda
| | - Jyh Kae Nien
- Fetal Maternal Medicine Unit, Clinica Davila, Avenida Recoleta 464, Santiago, Chile
- Faculty of Medicine, Universidad de Los Andes, Avda San Carlos De Apoquindo 2200, Santiago, Chile
| | - Dominique Roberfroid
- Belgian Health Care Knowledge Centre, Boulevard du Jardin Botanique 55, Brussels, Belgium
| | - Naomi Saville
- Mother and Infant Research Activities (MIRA), YB Bhawan, Thapathali, Kathmandu 921, Nepal
- Institute for Global Health, University College London Institute of Child Health, London WC1N 1EH, UK
| | - Dianne J Terlouw
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, University of Malawi, PO Box 30096, Chichiri, Blantyre 3, Malawi
| | - James M Tielsch
- Department of Global Health, Milken Institute School of Public Health, George Washington University, 950 New Hampshire Ave, NW, Suite 400, Washington, DC 20052, USA
| | - Cesar G Victora
- Programa de Pós-graduacao em Epidemiologia, Universidade Federal de Pelotas, Rua Marechal Deodoro 1160, 30 piso, Centro, CEP 96020-220, Pelotas, RS, Brazil
| | - Sithembiso C Velaphi
- Department of Paediatrics, Chris Hani Baragwaneth Hospital, Faculty of Health Sciences, University of Witwatersrand, Soweto, Johannesburg, South Africa
| | - Deborah Watson-Jones
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
- Mwanza Intervention Trial Unit, National Institute for Medical Research, Mwanza, Tanzania
| | - Barbara A Willey
- Facuty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- Maternal, Adolescent, Reproductive, and Child Health (MARCH) Centre, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Majid Ezzati
- MRC-PHE Centre for Environment and Health, Department of Epidemiology and Biostatistics, School of Public Health, Imperial College, London, London W2 1PG, UK
| | - Joy E Lawn
- Facuty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- Maternal, Adolescent, Reproductive, and Child Health (MARCH) Centre, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Robert E Black
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205, USA
- Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Joanne Katz
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205, USA
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10
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Clarke SE, Rouhani S, Diarra S, Saye R, Bamadio M, Jones R, Traore D, Traore K, Jukes MC, Thuilliez J, Brooker S, Roschnik N, Sacko M. Impact of a malaria intervention package in schools on Plasmodium infection, anaemia and cognitive function in schoolchildren in Mali: a pragmatic cluster-randomised trial. BMJ Glob Health 2017; 2:e000182. [PMID: 29081992 PMCID: PMC5656118 DOI: 10.1136/bmjgh-2016-000182] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 03/24/2017] [Accepted: 03/31/2017] [Indexed: 11/23/2022] Open
Abstract
Background School-aged children are rarely targeted by malaria control programmes, yet the prevalence of Plasmodium infection in primary school children often exceeds that seen in younger children and could affect haemoglobin concentration and school performance. Methods A cluster-randomised trial was carried out in 80 primary schools in southern Mali to evaluate the impact of a school-based malaria intervention package. Intervention schools received two interventions sequentially: (1) teacher-led participatory malaria prevention education, combined with distribution of long-lasting insecticidal nets (LLINs), followed 7 months later at the end of the transmission season by (2) mass delivery of artesunate and sulfadoxine-pyrimethamine administered by teachers, termed intermittent parasite clearance in schools (IPCs). Control schools received LLINs as part of the national universal net distribution programme. The impact of the interventions on malaria and anaemia was evaluated over 20 months using cross-sectional surveys in a random subset of 38 schools(all classes), with a range of cognitive measures (sustained attention, visual search, numeracy, vocabulary and writing) assessed in a longitudinal cohort of children aged 9–12 years in all 80 schools. Results Delivery of a single round of IPCs was associated with dramatic reductions in malaria parasitaemia (OR 0.005, 95% CI 0.002 to 0.011, p<0.001) and gametocyte carriage (OR 0.02, 95% CI 0.00 to 0.17, p<0.001) in intervention compared with control schools. This effect was sustained for 6 months until the beginning of the next transmission season. IPCs was also associated with a significant decrease in anaemia (OR 0.56, 95% CI 0.40 to 0.78, p=0.001), and increase in sustained attention (difference +0.23, 95% CI 0.10 to 0.36, p<0.001). There was no evidence of impact on other cognitive measures. Conclusion The combination of malaria prevention education, LLINs and IPCs can reduce anaemia and improve sustained attention of school children in areas of highly seasonal transmission. These findings highlight the impact of asymptomatic malaria infection on cognitive performance in schoolchildren and the benefit of IPCs in reducing this burden. Additionally, malaria control in schools can help diminish the infectious reservoir that sustains Plasmodium transmission.
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Affiliation(s)
- Siân E Clarke
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Saba Rouhani
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK.,Save the Children, Bamako, Mali
| | | | - Renion Saye
- Ministry of Health, Institut National de Recherche en Santé Publique, Bamako, Mali
| | | | - Rebecca Jones
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Diahara Traore
- Ministry of Health, Programme National de Lutte contre le Paludisme, Bamako, Mali
| | - Klenon Traore
- Ministry of Health, Programme National de Lutte contre le Paludisme, Bamako, Mali
| | | | - Josselin Thuilliez
- CNRS (Centre National de la Recherche Scientifique) - Centre d'Économie de la Sorbonne, Paris, France
| | - Simon Brooker
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Moussa Sacko
- Ministry of Health, Institut National de Recherche en Santé Publique, Bamako, Mali
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11
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Lalani M, Kitutu FE, Clarke SE, Kaur H. Anti-malarial medicine quality field studies and surveys: a systematic review of screening technologies used and reporting of findings. Malar J 2017; 16:197. [PMID: 28506234 PMCID: PMC5433090 DOI: 10.1186/s12936-017-1852-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 05/09/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Assessing the quality of medicines in low-middle income countries (LMICs) relies primarily on human inspection and screening technologies, where available. Field studies and surveys have frequently utilized screening tests to analyse medicines sampled at the point of care, such as health care facilities and medicine outlets, to provide a snap shot of medicine quality in a specific geographical area. This review presents an overview of the screening tests typically employed in surveys to assess anti-malarial medicine quality, summarizes the analytical methods used, how findings have been reported and proposes a reporting template for future studies. METHODS A systematic search of the peer-reviewed and grey literature available in the public domain (including national and multi-national medicine quality surveys) covering the period 1990-2016 was undertaken. Studies were included if they had used screening techniques to assess the quality of anti-malarial medicines. As no standardized set of guidelines for the methodology and reporting of medicine quality surveys exist, the included studies were assessed for their standard against a newly proposed list of criteria. RESULTS The titles and abstracts of 4621 records were screened and only 39 were found to meet the eligibility criteria. These 39 studies utilized visual inspection, disintegration, colorimetry and Thin Layer Chromatography (TLC) either as components of the Global Pharma Health Fund (GPHF) MiniLab® or as individual tests. Overall, 30/39 studies reported employing confirmatory testing described in international pharmacopeia to verify the quality of anti-malarials post assessment by a screening test. The authors assigned scores for the 23 criteria for the standard of reporting of each study. CONCLUSIONS There is considerable heterogeneity in study design and inconsistency in reporting of field surveys of medicine quality. A lack of standardization in the design and reporting of studies of medicine quality increases the risk of bias and error, impacting on the generalizability and reliability of study results. The criteria proposed for reporting on the standard of studies in this review can be used in conjunction with existing medicine quality survey guidelines as a checklist for designing and reporting findings of studies. The review protocol has been registered with PROSPERO (CRD42015026782).
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Affiliation(s)
- Mirza Lalani
- London School of Hygiene and Tropical Medicine, London, UK.
| | - Freddy Eric Kitutu
- Makerere University, Kampala, Uganda.,Uppsala University, Uppsala, Sweden
| | - Siân E Clarke
- London School of Hygiene and Tropical Medicine, London, UK
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12
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Hopkins H, Bruxvoort KJ, Cairns ME, Chandler CIR, Leurent B, Ansah EK, Baiden F, Baltzell KA, Björkman A, Burchett HED, Clarke SE, DiLiberto DD, Elfving K, Goodman C, Hansen KS, Kachur SP, Lal S, Lalloo DG, Leslie T, Magnussen P, Jefferies LM, Mårtensson A, Mayan I, Mbonye AK, Msellem MI, Onwujekwe OE, Owusu-Agyei S, Reyburn H, Rowland MW, Shakely D, Vestergaard LS, Webster J, Wiseman VL, Yeung S, Schellenberg D, Staedke SG, Whitty CJM. Impact of introduction of rapid diagnostic tests for malaria on antibiotic prescribing: analysis of observational and randomised studies in public and private healthcare settings. BMJ 2017; 356:j1054. [PMID: 28356302 PMCID: PMC5370398 DOI: 10.1136/bmj.j1054] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/06/2017] [Indexed: 01/21/2023]
Abstract
Objectives To examine the impact of use of rapid diagnostic tests for malaria on prescribing of antimicrobials, specifically antibiotics, for acute febrile illness in Africa and Asia.Design Analysisof nine preselected linked and codesigned observational and randomised studies (eight cluster or individually randomised trials and one observational study).Setting Public and private healthcare settings, 2007-13, in Afghanistan, Cameroon, Ghana, Nigeria, Tanzania, and Uganda.Participants 522 480 children and adults with acute febrile illness.Interventions Rapid diagnostic tests for malaria.Main outcome measures Proportions of patients for whom an antibiotic was prescribed in trial groups who had undergone rapid diagnostic testing compared with controls and in patients with negative test results compared with patients with positive results. A secondary aim compared classes of antibiotics prescribed in different settings.Results Antibiotics were prescribed to 127 052/238 797 (53%) patients in control groups and 167 714/283 683 (59%) patients in intervention groups. Antibiotics were prescribed to 40% (35 505/89 719) of patients with a positive test result for malaria and to 69% (39 400/57 080) of those with a negative result. All but one study showed a trend toward more antibiotic prescribing in groups who underwent rapid diagnostic tests. Random effects meta-analysis of the trials showed that the overall risk of antibiotic prescription was 21% higher (95% confidence interval 7% to 36%) in intervention settings. In most intervention settings, patients with negative test results received more antibiotic prescriptions than patients with positive results for all the most commonly used classes: penicillins, trimethoprim-sulfamethoxazole (one exception), tetracyclines, and metronidazole.Conclusions Introduction of rapid diagnostic tests for malaria to reduce unnecessary use of antimalarials-a beneficial public health outcome-could drive up untargeted use of antibiotics. That 69% of patients were prescribed antibiotics when test results were negative probably represents overprescription.This included antibiotics from several classes, including those like metronidazole that are seldom appropriate for febrile illness, across varied clinical, health system, and epidemiological settings. It is often assumed that better disease specific diagnostics will reduce antimicrobial overuse, but they might simply shift it from one antimicrobial class to another. Current global implementation of malaria testing might increase untargeted antibiotic use and must be examined.
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Affiliation(s)
- Heidi Hopkins
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | | | - Matthew E Cairns
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | | | - Baptiste Leurent
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | | | | | | | | | | | - Siân E Clarke
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | | | | | | | - Kristian S Hansen
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- University of Copenhagen, Copenhagen, DK1014, Denmark
| | | | - Sham Lal
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | | | - Toby Leslie
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- Health Protection Research Organisation, Kabul, Afghanistan
| | - Pascal Magnussen
- Centre for Medical Parasitology, University of Copenhagen and Copenhagen University Hospital, and Department for Veterinary Disease Biology, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Ismail Mayan
- Health Protection Research Organisation, Kabul, Afghanistan
| | - Anthony K Mbonye
- Ministry of Health, Kampala, Uganda
- Makerere University School of Public Health, Kampala, Uganda
| | | | - Obinna E Onwujekwe
- Department of Pharmacology and Therapeutics, University of Nigeria, Enugu, Nigeria
| | - Seth Owusu-Agyei
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- Kintampo Health Research Centre, Kintampo, Ghana
| | - Hugh Reyburn
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Mark W Rowland
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Delér Shakely
- Centre for Malaria Research, Karolinska Institutet, Stockholm, Sweden, and Health Metrics at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lasse S Vestergaard
- Department of Infectious Disease Epidemiology, Statens Serum Institut, Copenhagen, Denmark
| | - Jayne Webster
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Virginia L Wiseman
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
| | - Shunmay Yeung
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | | | - Sarah G Staedke
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
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Visser T, Bruxvoort K, Maloney K, Leslie T, Barat LM, Allan R, Ansah EK, Anyanti J, Boulton I, Clarke SE, Cohen JL, Cohen JM, Cutherell A, Dolkart C, Eves K, Fink G, Goodman C, Hutchinson E, Lal S, Mbonye A, Onwujekwe O, Petty N, Pontarollo J, Poyer S, Schellenberg D, Streat E, Ward A, Wiseman V, Whitty CJM, Yeung S, Cunningham J, Chandler CIR. Introducing malaria rapid diagnostic tests in private medicine retail outlets: A systematic literature review. PLoS One 2017; 12:e0173093. [PMID: 28253315 PMCID: PMC5333947 DOI: 10.1371/journal.pone.0173093] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 02/15/2017] [Indexed: 11/22/2022] Open
Abstract
Background Many patients with malaria-like symptoms seek treatment in private medicine retail outlets (PMR) that distribute malaria medicines but do not traditionally provide diagnostic services, potentially leading to overtreatment with antimalarial drugs. To achieve universal access to prompt parasite-based diagnosis, many malaria-endemic countries are considering scaling up malaria rapid diagnostic tests (RDTs) in these outlets, an intervention that may require legislative changes and major investments in supporting programs and infrastructures. This review identifies studies that introduced malaria RDTs in PMRs and examines study outcomes and success factors to inform scale up decisions. Methods Published and unpublished studies that introduced malaria RDTs in PMRs were systematically identified and reviewed. Literature published before November 2016 was searched in six electronic databases, and unpublished studies were identified through personal contacts and stakeholder meetings. Outcomes were extracted from publications or provided by principal investigators. Results Six published and six unpublished studies were found. Most studies took place in sub-Saharan Africa and were small-scale pilots of RDT introduction in drug shops or pharmacies. None of the studies assessed large-scale implementation in PMRs. RDT uptake varied widely from 8%-100%. Provision of artemisinin-based combination therapy (ACT) for patients testing positive ranged from 30%-99%, and was more than 85% in five studies. Of those testing negative, provision of antimalarials varied from 2%-83% and was less than 20% in eight studies. Longer provider training, lower RDT retail prices and frequent supervision appeared to have a positive effect on RDT uptake and provider adherence to test results. Performance of RDTs by PMR vendors was generally good, but disposal of medical waste and referral of patients to public facilities were common challenges. Conclusions Expanding services of PMRs to include malaria diagnostic services may hold great promise to improve malaria case management and curb overtreatment with antimalarials. However, doing so will require careful planning, investment and additional research to develop and sustain effective training, supervision, waste-management, referral and surveillance programs beyond the public sector.
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Affiliation(s)
- Theodoor Visser
- Clinton Health Access Initiative, Boston, Massachusetts, United States of America
- * E-mail:
| | - Katia Bruxvoort
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Kathleen Maloney
- Bill and Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Toby Leslie
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Lawrence M. Barat
- US President’s Malaria Initiative, United States Agency for International Development, Washington DC, United States of America
| | | | - Evelyn K. Ansah
- Research & Development Division, Ghana Health Service, Accra, Ghana
| | | | - Ian Boulton
- TropMed Pharma Consulting, Lower Shiplake, Oxfordshire, United Kingdom
| | - Siân E. Clarke
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Jessica L. Cohen
- Harvard T.H. Chan School of Public Health, Boston, United States of America
| | - Justin M. Cohen
- Clinton Health Access Initiative, Boston, Massachusetts, United States of America
| | | | - Caitlin Dolkart
- Clinton Health Access Initiative, Boston, Massachusetts, United States of America
| | - Katie Eves
- Mentor Initiative, West Sussex, United Kingdom
| | - Günther Fink
- Harvard T.H. Chan School of Public Health, Boston, United States of America
| | - Catherine Goodman
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Eleanor Hutchinson
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Sham Lal
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | | | - Nora Petty
- Clinton Health Access Initiative, Boston, Massachusetts, United States of America
| | | | | | - David Schellenberg
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Abigail Ward
- Clinton Health Access Initiative, Boston, Massachusetts, United States of America
| | - Virginia Wiseman
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Public Health and Community Medicine, University of New South Wales, UNSW, Sydney, Australia
| | - Christopher J. M. Whitty
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Shunmay Yeung
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Jane Cunningham
- Global Malaria Program, World Health Organization, Geneva, Switzerland
| | - Clare I. R. Chandler
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Mbonye AK, Buregyeya E, Rutebemberwa E, Clarke SE, Lal S, Hansen KS, Magnussen P, LaRussa P. Referral of children seeking care at private health facilities in Uganda. Malar J 2017; 16:76. [PMID: 28196532 PMCID: PMC5309983 DOI: 10.1186/s12936-017-1723-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 02/06/2017] [Indexed: 11/30/2022] Open
Abstract
Background In Uganda, referral of sick children seeking care at public health facilities is poor and widely reported. However, studies focusing on the private health sector are scanty. The main objective of this study was to assess referral practices for sick children seeking care at private health facilities in order to explore ways of improving treatment and referral of sick children in this sector. Methods A survey was conducted from August to October 2014 in Mukono district, central Uganda. Data was collected using a structured questionnaire supplemented by Focus Group Discussions and Key Informant interviews with private providers and community members. Results A total of 241 private health facilities were surveyed; 170 (70.5%) were registered drug shops, 59 (24.5%) private clinics and 12 (5.0%) pharmacies. Overall, 104/241 (43.2%) of the private health facilities reported that they had referred sick children to higher levels of care in the two weeks prior to the survey. The main constraints to follow referral advice as perceived by caretakers were: not appreciating the importance of referral, gender-related decision-making and negotiations at household level, poor quality of care at referral facilities, inadequate finances at household level; while the perception that referral leads to loss of prestige and profit was a major constraint to private providers. Conclusion In conclusion, the results show that referral of sick children at private health facilities faces many challenges at provider, caretaker, household and community levels. Thus, interventions to address constraints to referral of sick children are urgently needed.
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Affiliation(s)
- Anthony K Mbonye
- Ministry of Health, Box 7272, Directorate of Clinical and Community Services, Kampala & Department of Community & Behavioural Sciences, School of Public Health, Makerere University, Kampala, Uganda.
| | - Esther Buregyeya
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University, Kampala, Uganda
| | - Elizeus Rutebemberwa
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University, Kampala, Uganda
| | - Siân E Clarke
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Sham Lal
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Kristian S Hansen
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Pascal Magnussen
- Institute for International Health, Immunology and Microbiology, Centre for Medical Parasitology and Institute for Veterinary Disease Biology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Philip LaRussa
- Department of Paediatrics, College of Physicians & Surgeons, Columbia University, New York, USA
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Hutchinson E, Hutchison C, Lal S, Hansen K, Kayendeke M, Nabirye C, Magnussen P, Clarke SE, Mbonye A, Chandler CIR. Introducing rapid tests for malaria into the retail sector: what are the unintended consequences? BMJ Glob Health 2017; 2:e000067. [PMID: 28588992 PMCID: PMC5321379 DOI: 10.1136/bmjgh-2016-000067] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 11/09/2016] [Accepted: 11/11/2016] [Indexed: 11/03/2022] Open
Abstract
The observation that many people in Africa seek care for febrile illness in the retail sector has led to a number of public health initiatives to try to improve the quality of care provided in these settings. The potential to support the introduction of rapid diagnostic tests for malaria (mRDTs) into drug shops is coming under increased scrutiny. Those in favour argue that it enables the harmonisation of policy around testing and treatment for malaria and maintains a focus on market-based solutions to healthcare. Despite the enthusiasm among many global health actors for this policy option, there is a limited understanding of the consequences of the introduction of mRDTs in the retail sector. We undertook an interpretive, mixed methods study with drug shop vendors (DSVs), their clients and local health workers to explore the uses and interpretations of mRDTs as they became part of daily practice in drug shops during a trial in Mukono District, Uganda. This paper reports the unintended consequences of their introduction. It describes how the test engendered trust in the professional competence of DSVs; was misconstrued by clients and providers as enabling a more definitive diagnosis of disease in general rather than malaria alone; that blood testing made drug shops more attractive places to seek care than they had previously been; was described as shifting treatment-seeking behaviour away from formal health centres and into drug shops; and influenced an increase in sales of medications, particularly antibiotics. TRIAL REGISTRATION NUMBER NCT01194557; Results.
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Affiliation(s)
- Eleanor Hutchinson
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Coll Hutchison
- Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Sham Lal
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Kristian Hansen
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Pascal Magnussen
- Department of International Health, Immunology and Microbiology, Centre for Medical Parasitology & Institute for Veterinary Disease Biology, Section for Parasitology and Aquatic Diseases, University of Copenhagen, Kobenhavn, Denmark
| | - Siân E Clarke
- Faculty of Infectious and Tropical Diseases, Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Clare I R Chandler
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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Lal S, Ndyomugenyi R, Paintain L, Alexander ND, Hansen KS, Magnussen P, Chandramohan D, Clarke SE. Community health workers adherence to referral guidelines: evidence from studies introducing RDTs in two malaria transmission settings in Uganda. Malar J 2016; 15:568. [PMID: 27881136 PMCID: PMC5121932 DOI: 10.1186/s12936-016-1609-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 11/09/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Many malaria-endemic countries have implemented national community health worker (CHW) programmes to serve remote populations that have poor access to malaria diagnosis and treatment. Despite mounting evidence of CHWs' ability to adhere to malaria rapid diagnostic tests (RDTs) and treatment guidelines, there is limited evidence whether CHWs adhere to the referral guidelines and refer severely ill children for further management. In southwest Uganda, this study examined whether CHWs referred children according to training guidelines and described factors associated with adherence to the referral guideline. METHODS A secondary analysis was undertaken of data collected during two cluster-randomized trials conducted between January 2010 and July 2011, one in a moderate-to-high malaria transmission setting and the other in a low malaria transmission setting. All CHWs were trained to prescribe artemisinin-based combination therapy (ACT) and recognize symptoms in children that required immediate referral to the nearest health centre. Intervention arm CHWs had additional training on how to conduct an RDT; CHWs in the control arm used a presumptive diagnosis for malaria using clinical signs and symptoms. CHW treatment registers were reviewed to identify children eligible for referral according to training guidelines (temperature of ≥38.5 °C), to assess whether CHWs adhered to the guidelines and referred them. Factors associated with adherence were examined with logistic regression models. RESULTS CHWs failed to refer 58.8% of children eligible in the moderate-to-high transmission and 31.2% of children in the low transmission setting. CHWs using RDTs adhered to the referral guidelines more frequently than CHWs not using RDTs (moderate-to-high transmission: 50.1 vs 18.0%, p = 0.003; low transmission: 88.5 vs 44.1%, p < 0.001). In both settings, fewer than 20% of eligible children received pre-referral treatment with rectal artesunate. Children who were prescribed ACT were very unlikely to be referred in both settings (97.7 and 73.3% were not referred in the moderate-to-high and low transmission settings, respectively). In the moderate-to-high transmission setting, day and season of visit were also associated with the likelihood of adherence to the referral guidelines, but not in the low transmission setting. CONCLUSIONS CHW adherence to referral guidelines was poor in both transmission settings. However, training CHWs to use RDT improved correct referral of children with a high fever compared to a presumptive diagnosis using sign and symptoms. As many countries scale up CHW programmes, routine monitoring of reported data should be examined carefully to assess whether CHWs adhere to referral guidelines and take remedial actions where required.
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Affiliation(s)
- Sham Lal
- Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK.
| | | | - Lucy Paintain
- Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - Neal D Alexander
- MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Kristian S Hansen
- Institute of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Pascal Magnussen
- Faculty of Health and Medical Sciences, Institute of International Health, Immunology and Microbiology & Institute of Veterinary Disease Biology, University of Copenhagen, Copenhagen, Denmark
| | - Daniel Chandramohan
- Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - Siân E Clarke
- Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
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Lal S, Ndyomugenyi R, Magnussen P, Hansen KS, Alexander ND, Paintain L, Chandramohan D, Clarke SE. Referral Patterns of Community Health Workers Diagnosing and Treating Malaria: Cluster-Randomized Trials in Two Areas of High- and Low-Malaria Transmission in Southwestern Uganda. Am J Trop Med Hyg 2016; 95:1398-1408. [PMID: 27799650 PMCID: PMC5154457 DOI: 10.4269/ajtmh.16-0598] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 09/06/2016] [Indexed: 11/07/2022] Open
Abstract
Malaria-endemic countries have implemented community health worker (CHW) programs to provide malaria diagnosis and treatment to populations living beyond the reach of health systems. However, there is limited evidence describing the referral practices of CHWs. We examined the impact of malaria rapid diagnostic tests (mRDTs) on CHW referral in two cluster-randomized trials, one conducted in a moderate-to-high malaria transmission setting and one in a low-transmission setting in Uganda, between January 2010 and July 2012. All CHWs were trained to prescribe artemisinin-based combination therapy (ACT) for malaria and recognize signs and symptoms for referral to health centers. CHWs in the control arm used a presumptive diagnosis for malaria based on clinical symptoms, whereas intervention arm CHWs used mRDTs. CHWs recorded ACT prescriptions, mRDT results, and referral in patient registers. An intention-to-treat analysis was undertaken using multivariable logistic regression. Referral was more frequent in the intervention arm versus the control arm (moderate-to-high transmission, P < 0.001; low transmission, P < 0.001). Despite this increase, referral advice was not always given when ACTs or prereferral rectal artesunate were prescribed: 14% prescribed rectal artesunate in the moderate-to-high setting were not referred. In addition, CHWs considered factors alongside mRDTs when referring. Child visits during the weekends or the rainy season were less likely to be referred, whereas visits to CHWs more distant from health centers were more likely to be referred (low transmission only). CHWs using mRDTs and ACTs increased referral compared with CHWs using a presumptive diagnosis. To address these concerns, referral training should be emphasized in CHW programs as they are scaled-up.
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Affiliation(s)
- Sham Lal
- Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Pascal Magnussen
- Department of Veterinary Disease Biology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of International Health, Immunology and Microbiology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kristian S Hansen
- Medical Research Council Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Neal D Alexander
- Medical Research Council Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Lucy Paintain
- Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Daniel Chandramohan
- Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Siân E Clarke
- Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Ndyomugyenyi R, Magnussen P, Lal S, Hansen K, Clarke SE. Appropriate targeting of artemisinin-based combination therapy by community health workers using malaria rapid diagnostic tests: findings from randomized trials in two contrasting areas of high and low malaria transmission in south-western Uganda. Trop Med Int Health 2016; 21:1157-70. [PMID: 27383558 PMCID: PMC5031222 DOI: 10.1111/tmi.12748] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Objective To compare the impact of malaria rapid diagnostic tests (mRDTs), used by community health workers (CHWs), on the proportion of children <5 years of age receiving appropriately targeted treatment with artemisinin‐based combination therapy (ACT), vs. presumptive treatment. Methods Cluster‐randomized trials were conducted in two contrasting areas of moderate‐to‐high and low malaria transmission in rural Uganda. Each trial examined the effectiveness of mRDTs in the management of malaria and targeting of ACTs by CHWs comparing two diagnostic approaches: (i) presumptive clinical diagnosis of malaria [control arm] and (ii) confirmatory diagnosis with mRDTs followed by ACT treatment for positive patients [intervention arm], with village as the unit of randomisation. Treatment decisions by CHWs were validated by microscopy on a reference blood slide collected at the time of consultation, to compare the proportion of children <5 years receiving appropriately targeted ACT treatment, defined as patients with microscopically‐confirmed presence of parasites in a peripheral blood smear receiving artemether‐lumefantrine or rectal artesunate, and patients with no malaria parasites not given ACT. Results In the moderate‐to‐high transmission area, ACT treatment was appropriately targeted in 79.3% (520/656) of children seen by CHWs using mRDTs to diagnose malaria, vs. 30.8% (215/699) of children seen by CHWs using presumptive diagnosis (P < 0.001). In the low transmission area, 90.1% (363/403) children seen by CHWs using mRDTs received appropriately targeted ACT treatment vs. 7.8% (64/817) seen by CHWs using presumptive diagnosis (P < 0.001). Low mRDT sensitivity in children with low‐density parasitaemia (<200 parasites/μl) was identified as a potential concern. Conclusion When equipped with mRDTs, ACT treatments delivered by CHWs are more accurately targeted to children with malaria parasites. mRDT use could play an important role in reducing overdiagnosis of malaria and improving fever case management within iCCM, in both moderate‐to‐high and low transmission areas. Nonetheless, missed treatments due to the low sensitivity of current mRDTs in patients with low parasite density are a concern. For community‐based treatment in areas of low transmission and/or non‐immune populations, presumptive treatment of all fevers as malaria may be advisable, until more sensitive diagnostic assays, suitable for routine use by CHWs in remote settings, become available.
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Affiliation(s)
| | - Pascal Magnussen
- Centre for Medical Parasitology, Department for Immunology and Microbiology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Sham Lal
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Kristian Hansen
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Siân E Clarke
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
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Mbonye AK, Buregyeya E, Rutebemberwa E, Clarke SE, Lal S, Hansen KS, Magnussen P, LaRussa P. Treatment and prevention of malaria in pregnancy in the private health sector in Uganda: implications for patient safety. Malar J 2016; 15:212. [PMID: 27075477 PMCID: PMC4831190 DOI: 10.1186/s12936-016-1245-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 03/30/2016] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Malaria in pregnancy is a major public health problem in Uganda; and it is the leading cause of anaemia among pregnant women and low birth weight in infants. Previous studies have noted poor quality of care in the private sector. Thus there is need to explore ways of improving quality of care in the private sector that provides almost a half of health services in Uganda. METHODS A survey was conducted from August to October 2014 within 57 parishes in Mukono district, central Uganda. The selected parishes had a minimum of 200 households and at least one registered drug shop, pharmacy or private clinic. Data was collected using a structured questionnaire targeting one provider who was found on duty in each selected private health facility and consented to the study. The main variables were: provider characteristics, previous training received, type of drugs stocked, treatment and prevention practices for malaria among pregnant women. The main study outcome was the proportion of private health facilities who prescribe treatment of fever among pregnant women as recommended in the guidelines. RESULTS A total of 241 private health facilities were surveyed; 70.5 % were registered drug shops, 24.5 % private clinics and 5.0 % pharmacies. Treatment of fever among pregnant women in accordance with the national treatment guidelines was poor: 40.7 % in private clinics, decreasing to 28.2 % in drug shops and 16.7 % at pharmacies. Anti-malarial monotherapies sulphadoxine-pyrimethamine and quinine were commonly prescribed, often without consideration of gestational age. The majority of providers (>75 %) at all private facilities prescribed SP for intermittent preventive treatment but artemisinin-based combination therapy was prescribed: 8.3, 6.9 and 8.3 % respectively at drug shops, private clinics and pharmacies for prevention of malaria in pregnancy. Few facilities had malaria treatment guidelines; (44.1 % of private clinics, 17.9 % of drug shops, and 41.7 % at pharmacies. Knowledge of people at risk of malaria, P = 0.02 and availability of malaria treatment guidelines, P = 0.03 were the factors that most influenced correct treatment of fever in pregnancy. CONCLUSION Treatment of fever during pregnancy was poor in this study setting. These data highlight the need to develop interventions to improve patient safety and quality of care for pregnant women in the private health sector in Uganda.
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Affiliation(s)
- Anthony K Mbonye
- Ministry of Health, Directorate of Clinical and Community Services, Kampala and Department of Community and Behavioural Sciences, School of Public Health, Makerere University, Box 7272, Kampala, Uganda.
| | - Esther Buregyeya
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University, Kampala, Uganda
| | - Elizeus Rutebemberwa
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University, Kampala, Uganda
| | - Siân E Clarke
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Sham Lal
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Kristian S Hansen
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Pascal Magnussen
- Institute for International Health, Immunology and Microbiology, Centre for Medical Parasitology and Institute for Veterinary Disease Biology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Philip LaRussa
- College of Physicians and Surgeons, Columbia University, New York, USA
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Mbonye AK, Buregyeya E, Rutebemberwa E, Clarke SE, Lal S, Hansen KS, Magnussen P, LaRussa P. Prescription for antibiotics at drug shops and strategies to improve quality of care and patient safety: a cross-sectional survey in the private sector in Uganda. BMJ Open 2016; 6:e010632. [PMID: 26980439 PMCID: PMC4800164 DOI: 10.1136/bmjopen-2015-010632] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES The main objective of this study was to assess practices of antibiotic prescription at registered drug shops with a focus on upper respiratory tract infections among children in order to provide data for policy discussions aimed at improving quality of care and patient safety in the private health sector in Uganda. METHODS A survey was conducted within 57 parishes from August to October 2014 in Mukono District, Uganda. Data was captured on the following variables: drug shop characteristics, training of staff in management of pneumonia, availability of guidelines and basic equipment, available antibiotics, knowledge on treatment of pneumonia in children aged <5 years. The main study outcome was the proportion of private health facilities prescribing an antibiotic. RESULTS A total of 170 registered drug shops were surveyed between August and October 2014. The majority of drug shops, 93.5% were prescribing antibiotics, especially amoxicillin and trimethoprim-sulfamethoxazole (septrin). The professional qualification of a provider was significantly associated with this practice, p=0.04; where lower cadre staff (nursing assistants and enrolled nurses) overprescribed antibiotics. A third, 29.4% of drug shop providers reported that antibiotics were the first-line treatment for children with diarrhoea; yet the standard guideline is to give oral rehydration salts and zinc tablets. Only few providers, 8.2%, had training on antibiotics, with 10.6% on pneumonia case management. Further to this, 7.1% drug shops had WHO-Integrated Management of Childhood Illness guidelines, and a negligible proportion (<1%) had respiratory timers and baby weighing scales. Although the majority of providers, 82.4%, knew severe signs and symptoms of pneumonia, few, 17.6%, knew that amoxicillin was the first-line drug for treatment of pneumonia in children according to the guidelines. CONCLUSIONS There is urgent need to regulate drug shop practices of prescribing and selling antibiotics, for the safety of patients seeking care at these outlets.
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Affiliation(s)
- Anthony K Mbonye
- Ministry of Health, Directorate of Clinical and Community Services, Kampala, Uganda
- Department of Community & Behavioural Sciences, School of Public Health, Makerere University, Kampala, Uganda
| | - Esther Buregyeya
- Department of Disease Control & Environmental Health, School of Public Health, Makerere University, Kampala, Uganda
| | - Elizeus Rutebemberwa
- Department of Disease Control & Environmental Health, School of Public Health, Makerere University, Kampala, Uganda
| | - Siân E Clarke
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Sham Lal
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Kristian S Hansen
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Pascal Magnussen
- Institute for International Health, Immunology and Microbiology, Centre for Medical Parasitology and Institute for Veterinary disease Biology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Philip LaRussa
- College of Physicians & Surgeons, Columbia University, New York, USA
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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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Lal S, Ndyomugenyi R, Alexander ND, Lagarde M, Paintain L, Magnussen P, Chandramohan D, Clarke SE. Health Facility Utilisation Changes during the Introduction of Community Case Management of Malaria in South Western Uganda: An Interrupted Time Series Approach. PLoS One 2015; 10:e0137448. [PMID: 26356099 PMCID: PMC4565684 DOI: 10.1371/journal.pone.0137448] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 08/17/2015] [Indexed: 11/29/2022] Open
Abstract
Background Malaria endemic countries have scaled-up community health worker (CHW) interventions, to diagnose and treat malaria in communities with limited access to public health systems. The evaluations of these programmes have centred on CHW’s compliance to guidelines, but the broader changes at public health centres including utilisation and diagnoses made, has received limited attention. Methods This analysis was conducted during a CHW–intervention for malaria in Rukungiri District, Western Uganda. Outpatient department (OPD) visit data were collected for children under-5 attending three health centres one year before the CHW-intervention started (pre-intervention period) and for 20 months during the intervention (intervention-period). An interrupted time series analysis with segmented regression models was used to compare the trends in malaria, non-malaria and overall OPD visits during the pre-intervention and intervention-period. Results The introduction of a CHW-intervention suggested the frequency of diagnoses of diarrhoeal diseases, pneumonia and helminths increased, whilst the frequency of malaria diagnoses declined at health centres. In May 2010 when the intervention began, overall health centre utilisation decreased by 63% compared to the pre-intervention period and the health centres saw 32 fewer overall visits per month compared to the pre-intervention period (p<0.001). Malaria visits also declined shortly after the intervention began and there were 27 fewer visits per month during the intervention-period compared with the pre-intervention period (p<0.05). The declines in overall and malaria visits were sustained for the entire intervention-period. In contrast, there were no observable changes in trends of non-malarial visits between the pre-intervention and intervention-period. Conclusions This analysis suggests introducing a CHW-intervention can reduce the number of child malaria visits and change the profile of cases presenting at health centres. The reduction in workload of health workers may allow them to spend more time with patients or undertake additional curative or preventative roles.
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Affiliation(s)
- Sham Lal
- Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Neal D Alexander
- MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Mylene Lagarde
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Lucy Paintain
- Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Pascal Magnussen
- Institute of International Health, Immunology and Microbiology & Institute of Veterinary Disease Biology, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Daniel Chandramohan
- Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Siân E Clarke
- Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Mbonye AK, Magnussen P, Lal S, Hansen KS, Cundill B, Chandler C, Clarke SE. A Cluster Randomised Trial Introducing Rapid Diagnostic Tests into Registered Drug Shops in Uganda: Impact on Appropriate Treatment of Malaria. PLoS One 2015. [PMID: 26200467 PMCID: PMC4511673 DOI: 10.1371/journal.pone.0129545] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Inappropriate treatment of malaria is widely reported particularly in areas where there is poor access to health facilities and self-treatment of fevers with anti-malarial drugs bought in shops is the most common form of care-seeking. The main objective of the study was to examine the impact of introducing rapid diagnostic tests for malaria (mRDTs) in registered drug shops in Uganda, with the aim to increase appropriate treatment of malaria with artemisinin-based combination therapy (ACT) in patients seeking treatment for fever in drug shops. METHODS A cluster-randomized trial of introducing mRDTs in registered drug shops was implemented in 20 geographical clusters of drug shops in Mukono district, central Uganda. Ten clusters were randomly allocated to the intervention (diagnostic confirmation of malaria by mRDT followed by ACT) and ten clusters to the control arm (presumptive treatment of fevers with ACT). Treatment decisions by providers were validated by microscopy on a reference blood slide collected at the time of consultation. The primary outcome was the proportion of febrile patients receiving appropriate treatment with ACT defined as: malaria patients with microscopically-confirmed presence of parasites in a peripheral blood smear receiving ACT or rectal artesunate, and patients with no malaria parasites not given ACT. FINDINGS A total of 15,517 eligible patients (8672 intervention and 6845 control) received treatment for fever between January-December 2011. The proportion of febrile patients who received appropriate ACT treatment was 72·9% versus 33·7% in the control arm; a difference of 36·1% (95% CI: 21·3 - 50·9), p<0·001. The majority of patients with fever in the intervention arm accepted to purchase an mRDT (97·8%), of whom 58·5% tested mRDT-positive. Drug shop vendors adhered to the mRDT results, reducing over-treatment of malaria by 72·6% (95% CI: 46·7- 98·4), p<0·001) compared to drug shop vendors using presumptive diagnosis (control arm). CONCLUSION Diagnostic testing with mRDTs compared to presumptive treatment of fevers implemented in registered drug shops substantially improved appropriate treatment of malaria with ACT. TRIAL REGISTRATION ClinicalTrials.gov NCT01194557.
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Affiliation(s)
- Anthony K. Mbonye
- Ministry of Health, Box 7272, Kampala, Uganda
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
- * E-mail:
| | - Pascal Magnussen
- Centre for Medical Parasitology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Sham Lal
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Kristian S. Hansen
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Bonnie Cundill
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Clare Chandler
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Siân E. Clarke
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Mbonye AK, Magnussen P, Chandler CIR, Hansen KS, Lal S, Cundill B, Lynch CA, Clarke SE. Introducing rapid diagnostic tests for malaria into drug shops in Uganda: design and implementation of a cluster randomized trial. Trials 2014; 15:303. [PMID: 25069975 PMCID: PMC4125706 DOI: 10.1186/1745-6215-15-303] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 07/16/2014] [Indexed: 12/03/2022] Open
Abstract
Background An intervention was designed to introduce rapid diagnostics tests for malaria (mRDTs) into registered drug shops in Uganda to encourage rational and appropriate treatment of malaria with artemisinin-based combination therapy (ACT). We conducted participatory training of drug shop vendors and implemented supporting interventions to orientate local communities (patients) and the public sector (health facility staff and district officials) to the behavioral changes in diagnosis, treatment and referral being introduced in drug shops. The intervention was designed to be evaluated through a cluster randomized trial. In this paper, we present detailed design, implementation and evaluation experiences in order to help inform future studies of a complex nature. Methods Three preparatory studies (formative, baseline and willingness-to-pay) were conducted to explore perceptions on diagnosis and treatment of malaria at drug shops, and affordable prices for mRDTs and ACTs in order to inform the design of the intervention and implementation modalities. The intervention required careful design with the intention to be acceptable, sustainable and effective. Critical components of intervention were: community sensitization and creating awareness, training of drug shop vendors to diagnose malaria with mRDTs, treat and refer customers to formal health facilities, giving pre-referral rectal artesunate and improved record-keeping. The primary outcome was the proportion of patients receiving appropriately-targeted treatment with ACT, evaluated against microscopy on a research blood slide. Results Introducing mRDTs in drug shops may seem simple, but our experience of intervention design, conduct and evaluation showed this to be a complex process requiring multiple interventions and evaluation components drawing from a combination of epidemiological, social science and health economics methodologies. The trial was conducted in phases sequenced such that each benefited from the other. Conclusions The main challenges in designing this trial were maintaining a balance between a robust intervention to support effective behaviour change and introducing practices that would be sustainable in a real-life situation in tropical Africa; as well as achieving a detailed evaluation without inadvertently influencing prescribing behaviour. Trial registration NCT01194557 registered with ClinicalTrials.gov 2 September 2010.
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Affiliation(s)
- Anthony K Mbonye
- School of Public Health, Makerere University and Ministry of Health, Box 7272, Plot 6 Lourdel Street Nakasero, Kampala, Uganda.
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Hansen KS, Ndyomugyenyi R, Magnussen P, Clarke SE. Cost-effectiveness analysis of three health interventions to prevent malaria in pregnancy in an area of low transmission in Uganda. Int Health 2013; 4:38-46. [PMID: 24030879 DOI: 10.1016/j.inhe.2011.10.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Pregnant women and their unborn children are vulnerable to malaria, increasing the risk of maternal anaemia, low birthweight (LBW) and intrauterine growth retardation. There is little evidence on the cost-effectiveness of intermittent preventive treatment in pregnancy (IPTp) and insecticide-treated bednets (ITN) in areas of low transmission. A randomised controlled trial with three arms was conducted in antenatal clinics in Kabale District (Uganda), an epidemic-prone highland area of low malaria transmission. The interventions were: (i) IPTp with sulfadoxine/pyrimethamine (SP) given twice during pregnancy (IPTp-SP); (ii) ITNs alone; and (iii) a combined intervention with both ITNs and IPTp-SP. Primary health outcomes were LBW and maternal anaemia. The costs of providing IPTp-SP and ITNs as well as treatment of malaria episodes were captured from all health centres in the study area. There were no significant differences in health outcomes among the three interventions. The cost-effectiveness analysis and sensitivity analyses performed did not provide convincing support for replacing IPTp-SP (current policy) by ITNs alone or by a combined intervention in this low-transmission setting on economic grounds. The cost per pregnant woman of providing the services was lowest for the IPTp-SP intervention (US$0.79 per woman) followed by ITNs (US$1.71) and the combined intervention of IPTp-SP + ITNs (US$2.48). The relative cost-effectiveness of antenatal distribution of ITNs might improve if the cost savings accruing from continued use of a long-lasting insecticidal net after pregnancy as well as positive externalities were also taken into account, and this warrants further study. [ClinicalTrials.gov identifier: NCT00142207].
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Affiliation(s)
- Kristian Schultz Hansen
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
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Lee ACC, Katz J, Blencowe H, Cousens S, Kozuki N, Vogel JP, Adair L, Baqui AH, Bhutta ZA, Caulfield LE, Christian P, Clarke SE, Ezzati M, Fawzi W, Gonzalez R, Huybregts L, Kariuki S, Kolsteren P, Lusingu J, Marchant T, Merialdi M, Mongkolchati A, Mullany LC, Ndirangu J, Newell ML, Nien JK, Osrin D, Roberfroid D, Rosen HE, Sania A, Silveira MF, Tielsch J, Vaidya A, Willey BA, Lawn JE, Black RE. National and regional estimates of term and preterm babies born small for gestational age in 138 low-income and middle-income countries in 2010. Lancet Glob Health 2013; 1:e26-36. [PMID: 25103583 PMCID: PMC4221634 DOI: 10.1016/s2214-109x(13)70006-8] [Citation(s) in RCA: 508] [Impact Index Per Article: 46.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background National estimates for the numbers of babies born small for gestational age and the comorbidity with preterm birth are unavailable. We aimed to estimate the prevalence of term and preterm babies born small for gestational age (term-SGA and preterm-SGA), and the relation to low birthweight (<2500 g), in 138 countries of low and middle income in 2010. Methods Small for gestational age was defined as lower than the 10th centile for fetal growth from the 1991 US national reference population. Data from 22 birth cohort studies (14 low-income and middle-income countries) and from the WHO Global Survey on Maternal and Perinatal Health (23 countries) were used to model the prevalence of term-SGA births. Prevalence of preterm-SGA infants was calculated from meta-analyses. Findings In 2010, an estimated 32·4 million infants were born small for gestational age in low-income and middle-income countries (27% of livebirths), of whom 10·6 million infants were born at term and low birthweight. The prevalence of term-SGA babies ranged from 5·3% of livebirths in east Asia to 41·5% in south Asia, and the prevalence of preterm-SGA infants ranged from 1·2% in north Africa to 3·0% in southeast Asia. Of 18 million low-birthweight babies, 59% were term-SGA and 41% were preterm. Two-thirds of small-for-gestational-age infants were born in Asia (17·4 million in south Asia). Preterm-SGA babies totalled 2·8 million births in low-income and middle-income countries. Most small-for-gestational-age infants were born in India, Pakistan, Nigeria, and Bangladesh. Interpretation The burden of small-for-gestational-age births is very high in countries of low and middle income and is concentrated in south Asia. Implementation of effective interventions for babies born too small or too soon is an urgent priority to increase survival and reduce disability, stunting, and non-communicable diseases. Funding Bill & Melinda Gates Foundation by a grant to the US Fund for UNICEF to support the activities of the Child Health Epidemiology Reference Group (CHERG).
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Affiliation(s)
- Anne C C Lee
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Newborn Medicine, Brigham and Women's Hospital, Boston, MA, USA.
| | - Joanne Katz
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Hannah Blencowe
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Simon Cousens
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Naoko Kozuki
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Joshua P Vogel
- School of Population Health, Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, Crawley, WA, Australia; UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Linda Adair
- University of North Carolina School of Public Health, Chapel Hill, NC, USA
| | - Abdullah H Baqui
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Zulfiqar A Bhutta
- Division of Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Laura E Caulfield
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Parul Christian
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Siân E Clarke
- Faculty of Infectious Disease and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK; Malaria Centre, London School of Hygiene and Tropical Medicine, London, UK
| | - Majid Ezzati
- MRC-HPA Centre for Environment and Health, Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK
| | - Wafaie Fawzi
- Department of Nutrition, Harvard School of Public Health, Boston, MA, USA; Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA; Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA
| | - Rogelio Gonzalez
- Pontificia Universidad Católica de Chile, School of Medicine, and Clínica Santa María, Santiago, Chile
| | - Lieven Huybregts
- Department of Food Safety and Food Quality, Ghent University, Ghent, Belgium; Woman and Child Health Research Center, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Simon Kariuki
- Kenya Medical Research Institute, Center for Global Health Research, and Centers for Disease Control and Prevention Kenya, Kisumu, Kenya
| | - Patrick Kolsteren
- Department of Food Safety and Food Quality, Ghent University, Ghent, Belgium; Woman and Child Health Research Center, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - John Lusingu
- National Institute Medical Research, Tanga, Tanzania
| | - Tanya Marchant
- Faculty of Infectious Disease and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK; Malaria Centre, London School of Hygiene and Tropical Medicine, London, UK; Maternal Reproductive and Child Health Centre, London School of Hygiene and Tropical Medicine, London, UK
| | - Mario Merialdi
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | | | - Luke C Mullany
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - James Ndirangu
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Kwa-Zulu Natal, South Africa
| | - Marie-Louise Newell
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Kwa-Zulu Natal, South Africa; Centre for Paediatric Epidemiology and Biostatistics, University College London Institute of Child Health, London, UK
| | - Jyh Kae Nien
- Fetal Maternal Medicine Unit, Clinica Davila, and Faculty of Medicine, Universidad de Los Andes, Santiago, Chile
| | - David Osrin
- Institute for Global Health, University College London Institute of Child Health, London, UK
| | - Dominique Roberfroid
- Woman and Child Health Research Center, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Heather E Rosen
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ayesha Sania
- Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA
| | - Mariangela F Silveira
- Programa de Pósgraduacao em Epidemiologia, Universidade Federal de Pelotas, Pelotas, RS, Brazil
| | - James Tielsch
- Department of Global Health, George Washington University School of Public Health and Health Services, Washington, DC, USA
| | - Anjana Vaidya
- Institute for Global Health, University College London Institute of Child Health, London, UK
| | - Barbara A Willey
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK; Malaria Centre, London School of Hygiene and Tropical Medicine, London, UK; Maternal Reproductive and Child Health Centre, London School of Hygiene and Tropical Medicine, London, UK
| | - Joy E Lawn
- Maternal Reproductive and Child Health Centre, London School of Hygiene and Tropical Medicine, London, UK; Saving Newborn Lives/Save the Children USA, Washington, DC, USA
| | - Robert E Black
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Ndyomugyenyi R, Clarke SE, Hutchison CL, Hansen KS, Magnussen P. Efficacy of malaria prevention during pregnancy in an area of low and unstable transmission: an individually-randomised placebo-controlled trial using intermittent preventive treatment and insecticide-treated nets in the Kabale Highlands, southwestern Uganda. Trans R Soc Trop Med Hyg 2011; 105:607-16. [PMID: 21962292 DOI: 10.1016/j.trstmh.2011.07.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Revised: 07/15/2011] [Accepted: 07/15/2011] [Indexed: 11/24/2022] Open
Abstract
Intermittent preventive treatment of malaria during pregnancy (IPTp) and insecticide-treated nets (ITN) are recommended malaria interventions during pregnancy; however, there is limited information on their efficacy in areas of low malaria transmission in sub-Saharan Africa. An individually-randomised placebo-controlled trial involving 5775 women of all parities examined the effect of IPTp, ITNs alone, or ITNs used in combination with IPTp on maternal anaemia and low birth weight (LBW) in a highland area of southwestern Uganda. The overall prevalence of malaria infection, maternal anaemia and LBW was 15.0%, 14.7% and 6.5%, respectively. Maternal and fetal outcomes were generally remarkably similar across all intervention groups (P>0.05 for all outcomes examined). A marginal difference in maternal haemoglobin was observed in the dual intervention group (12.57g/dl) compared with the IPTp and ITN alone groups (12.40g/dl and 12.44g/dl, respectively; P=0.04), but this was too slight to be of clinical importance. In conclusion, none of the preventive strategies was found to be superior to the others, and no substantial additional benefit to providing both IPTp and ITNs during routine antenatal services was observed. With ITNs offering a number of advantages over IPTp, yet showing comparable efficacy, we discuss why ITNs could be an appropriate preventive strategy for malaria control during pregnancy in areas of low and unstable transmission.
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Luster M, Clarke SE, Dietlein M, Lassmann M, Lind P, Oyen WJG, Tennvall J, Bombardieri E. Guidelines for radioiodine therapy of differentiated thyroid cancer. Eur J Nucl Med Mol Imaging 2009; 35:1941-59. [PMID: 18670773 DOI: 10.1007/s00259-008-0883-1] [Citation(s) in RCA: 412] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION The purpose of the present guidelines on the radioiodine therapy (RAIT) of differentiated thyroid cancer (DTC) formulated by the European Association of Nuclear Medicine (EANM) Therapy Committee is to provide advice to nuclear medicine clinicians and other members of the DTC-treating community on how to ablate thyroid remnant or treat inoperable advanced DTC or both employing large 131-iodine ((131)I) activities. DISCUSSION For this purpose, recommendations have been formulated based on recent literature and expert opinion regarding the rationale, indications and contraindications for these procedures, as well as the radioiodine activities and the administration and patient preparation techniques to be used. Recommendations also are provided on pre-RAIT history and examinations, patient counselling and precautions that should be associated with (131)I iodine ablation and treatment. Furthermore, potential side effects of radioiodine therapy and alternate or additional treatments to this modality are reviewed. Appendices furnish information on dosimetry and post-therapy scintigraphy.
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Affiliation(s)
- M Luster
- Department of Nuclear Medicine, University of Würzburg, Josef-Schneider-Strasse 2, 97080 Würzburg, Germany.
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Clarke SE, Jukes MC, Njagi JK, Khasakhala L, Cundill B, Otido J, Crudder C, Estambale BB, Brooker S. Effect of intermittent preventive treatment of malaria on health and education in schoolchildren: a cluster-randomised, double-blind, placebo-controlled trial. Lancet 2008; 372:127-138. [PMID: 18620950 PMCID: PMC2495044 DOI: 10.1016/s0140-6736(08)61034-x] [Citation(s) in RCA: 137] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Malaria is a major cause of morbidity and mortality in early childhood, yet its consequences for health and education during the school-age years remain poorly understood. We examined the effect of intermittent preventive treatment (IPT) in reducing anaemia and improving classroom attention and educational achievement in semi-immune schoolchildren in an area of high perennial transmission. METHODS A stratified, cluster-randomised, double-blind, placebo-controlled trial of IPT was done in 30 primary schools in western Kenya. Schools were randomly assigned to treatment (sulfadoxine-pyrimethamine in combination with amodiaquine or dual placebo) by use of a computer-generated list. Children aged 5-18 years received three treatments at 4-month intervals (IPT n=3535, placebo n=3223). The primary endpoint was the prevalence of anaemia, defined as a haemoglobin concentration below 110 g/L. This outcome was assessed through cross-sectional surveys 12 months post-intervention. Analysis was by both intention to treat, excluding children with missing data, and per protocol. This study is registered with ClinicalTrials.gov, number NCT00142246. FINDINGS 2604 children in the IPT group and 2302 in the placebo group were included in the intention-to-treat analysis of the primary outcome; the main reason for exclusion was loss to follow-up. Prevalence of anaemia at 12 months averaged 6.3% in the IPT group and 12.6% in the placebo group (adjusted risk ratio 0.52, 95% CI 0.29-0.93; p=0.028). Significant improvements were also seen in two of the class-based tests of sustained attention, with a mean increase in code transmission test score of 6.05 (95% CI 2.83-9.27; p=0.0007) and counting sounds test score of 1.80 (0.19-3.41; p=0.03), compared with controls. No effect was shown for inattentive or hyperactive-compulsive behaviours or on educational achievement. The per-protocol analysis yielded similar results. 23 serious adverse events were reported within 28 days of any treatment (19 in the IPT group and four in the placebo group); the main side-effects were problems of balance, dizziness, feeling faint, nausea, and/or vomiting shortly after treatment. INTERPRETATION IPT of malaria improves the health and cognitive ability of semi-immune schoolchildren. Effective malaria interventions could be a valuable addition to school health programmes.
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Affiliation(s)
- Siân E Clarke
- London School of Hygiene and Tropical Medicine, London, UK.
| | | | - J Kiambo Njagi
- Division of Malaria Control, Ministry of Health, Nairobi, Kenya
| | | | - Bonnie Cundill
- London School of Hygiene and Tropical Medicine, London, UK
| | - Julius Otido
- Institute of Tropical and Infectious Diseases, University of Nairobi, Kenya
| | | | | | - Simon Brooker
- London School of Hygiene and Tropical Medicine, London, UK; Malaria Public Health and Epidemiology Group, Centre for Geographic Medicine Research-Coast, KEMRI-Wellcome Trust Collaborative Programme, Nairobi, Kenya
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Koukounari A, Estambale BBA, Njagi JK, Cundill B, Ajanga A, Crudder C, Otido J, Jukes MCH, Clarke SE, Brooker S. Relationships between anaemia and parasitic infections in Kenyan schoolchildren: a Bayesian hierarchical modelling approach. Int J Parasitol 2008; 38:1663-71. [PMID: 18621051 PMCID: PMC2649416 DOI: 10.1016/j.ijpara.2008.05.013] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2008] [Revised: 04/11/2008] [Accepted: 05/20/2008] [Indexed: 11/28/2022]
Abstract
Anaemia is multi-factorial in origin and disentangling its aetiology remains problematic, with surprisingly few studies investigating the relative contribution of different parasitic infections to anaemia amongst schoolchildren. We report cross-sectional data on haemoglobin, malaria parasitaemia, helminth infection and undernutrition among 1523 schoolchildren enrolled in classes 5 and 6 (aged 10–21 years) in 30 primary schools in western Kenya. Bayesian hierarchical modelling was used to investigate putative relationships. Children infected with Plasmodium falciparum or with a heavy Schistosoma mansoni infection, stunted children and girls were found to have lower haemoglobin concentrations. Children heavily infected with S. mansoni were also more likely to be anaemic compared with uninfected children. This study further highlights the importance of malaria and intestinal schistosomiasis as contributors to reduced haemoglobin levels among schoolchildren and helps guide the implementation of integrated school health programmes in areas of differing parasite transmission.
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Affiliation(s)
- Artemis Koukounari
- Schistosomiasis Control Initiative, Department of Infectious Disease Epidemiology, Faculty of Medicine, Imperial College, Norfolk Place, London W2 1PG, UK.
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Brooker S, Estambale B, Pullan R, Akhwale W, Hotez PJ, Snow RW, Clarke SE. Epidemiology of Plasmodium-Helminth Co-Infection in Africa: Populations at Risk, Potential Impact on Anemia, and Prospects for Combining Control. Am J Trop Med Hyg 2007. [DOI: 10.4269/ajtmh.2007.77.88] [Citation(s) in RCA: 233] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Clarke SE, Evans S, Macdonald A, Davies P, Booth IW. Randomized comparison of a nutrient-dense formula with an energy-supplemented formula for infants with faltering growth. J Hum Nutr Diet 2007; 20:329-39. [PMID: 17635310 DOI: 10.1111/j.1365-277x.2007.00805.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The practice of supplementing standard infant formula with energy for infants with faltering growth has been widespread. This increases energy density but disturbs the protein : energy ratio, and increases risks of microbial contamination and errors in feed preparation. This study aimed to compare the effectiveness of a nutrient-dense formula (NDF) with an energy-supplemented formula (ESF) in infants with faltering growth. METHODS In an open, parallel, randomized study, 49 infants with faltering growth were randomized to receive a NDF (4.2 kJ mL(-1)) or an ESF (4.2 kJ mL(-1)), for 6 weeks. Anthropometry, biochemistry, feed intake, stool and vomit frequency were collected. RESULTS No significant differences in tolerance, feed volumes or energy intakes were recorded but the NDF group received 42% more protein and 15-40% more vitamins and minerals. Blood urea concentration in the ESF group fell by 50% over the trial period, suggesting a suboptimal protein : energy ratio in the ESF feed. The NDF group retained a normal mean blood urea concentration, a higher urinary potassium concentration and did not have the significant fall in length z-score seen in the ESF group. CONCLUSION Increasing the energy content of normal infant formula without also increasing protein and micronutrients should not be practiced in infants with faltering growth.
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Affiliation(s)
- S E Clarke
- Dietetic Department, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, UK
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Bøgh C, Lindsay SW, Clarke SE, Dean A, Jawara M, Pinder M, Thomas CJ. High spatial resolution mapping of malaria transmission risk in the Gambia, west Africa, using LANDSAT TM satellite imagery. Am J Trop Med Hyg 2007; 76:875-81. [PMID: 17488908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023] Open
Abstract
Understanding local variability in malaria transmission risk is critically important when designing intervention or vaccine trials. Using a combination of field data, satellite image analysis, and GIS modeling, we developed a high-resolution map of malaria entomological inoculation rates (EIR) in The Gambia, West Africa. The analyses are based on the variation in exposure to malaria parasites experienced in 48 villages in 1996 and 21 villages in 1997. The entomological inoculation rate (EIR) varied from 0 to 166 infective bites per person per rainy season. Detailed field surveys identified the major Anopheles gambiae s.l. breeding habitats. These habitats were mapped by classification of a LANDSAT TM satellite image with an overall accuracy of 85%. Village EIRs decreased as a power function based on the breeding areas size and proximity. We use this relationship and the breeding habitats to map the variation in EIR over the entire 2500-km(2) study area.
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Affiliation(s)
- Claus Bøgh
- DBL-Institute for Health Research and Development, Charlottenlund, Denmark.
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Ghanbari F, Rowland-Yeo K, Bloomer JC, Clarke SE, Lennard MS, Tucker GT, Rostami-Hodjegan A. A Critical Evaluation of the Experimental Design of Studies of Mechanism Based Enzyme Inhibition, with Implications for In Vitro-In Vivo Extrapolation. Curr Drug Metab 2006; 7:315-34. [PMID: 16611025 DOI: 10.2174/138920006776359293] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The published literature on mechanism based inhibition (MBI) of CYPs was evaluated with respect to experimental design, methodology and data analysis. Significant variation was apparent in the dilution factor, ratio of preincubation to incubation times and probe substrate concentrations used, and there were some anomalies in the estimation of associated kinetic parameters (k(inact), K(I), r). The impact of the application of inaccurate values of k(inact) and K(I) when extrapolating to the extent of inhibition in vivo is likely to be greatest for those compounds of intermediate inhibitory potency, but this also depends on the fraction of the net clearance of substrate subject to MBI and the pre-systemic and systemic exposure to the inhibitor. For potent inhibitors, the experimental procedure is unlikely to have a material influence on the maximum inhibition. Nevertheless, the bias in the values of the kinetic parameters may influence the time for recovery of enzyme activity following re-synthesis of the enzyme. Careful attention to the design of in vitro experiments to obtain accurate kinetic parameters is necessary for a reliable prediction of different aspects of the in vivo consequences of MBI. The review calls for experimental studies to quantify the impact of study design in studies of MBI, with a view to better harmonisation of protocols.
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Affiliation(s)
- F Ghanbari
- Academic Unit of Clinical Pharmacology, Division of Clinical Sciences South, University of Sheffield, Sheffield S10 2JF, UK
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Shapiro AE, Tukahebwa EM, Kasten J, Clarke SE, Magnussen P, Olsen A, Kabatereine NB, Ndyomugyenyi R, Brooker S. Epidemiology of helminth infections and their relationship to clinical malaria in southwest Uganda. Trans R Soc Trop Med Hyg 2005; 99:18-24. [PMID: 15550257 DOI: 10.1016/j.trstmh.2004.02.006] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2003] [Revised: 01/26/2004] [Accepted: 02/04/2004] [Indexed: 11/18/2022] Open
Abstract
It has recently been suggested that helminth infections may adversely influence susceptibility to other infections, including malaria. To investigate this hypothesis in a sub-Saharan African setting, surveys of helminth infections were conducted in 2003 among individuals who had been under weekly active case detection for clinical malaria during the preceding 18 months in four villages in Kabale District, southwest Uganda. Overall, 47.3% of individuals had at least one intestinal nematode species infection: hookworm, Ascaris lumbricoides and Trichuris trichiura were detected in 32.1, 17.4 and 8.1% of individuals, respectively. We found evidence of significant household clustering of A. lumbricoides, T. trichiura and hookworm, and clustering of heavy infection of each species. The association between helminth infection and clinical malaria was investigated in two villages and no evidence for an association was observed between the presence of infection or heavy infection and risk of malaria.
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Affiliation(s)
- Adrienne E Shapiro
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
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Clarke SE, Brooker S, Njagi JK, Njau E, Estambale B, Muchiri E, Magnussen P. Malaria morbidity among school children living in two areas of contrasting transmission in western Kenya. Am J Trop Med Hyg 2004; 71:732-8. [PMID: 15642962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023] Open
Abstract
Research in malaria-endemic areas is usually focused on malaria during early childhood. Less is known about malaria among older school age children. The incidence of clinical attacks of malaria was monitored, using active case detection in primary schools, in two areas of western Kenya that differ in the intensity of transmission. Clinical malaria was more common in schools in the Nandi highlands, with a six-fold higher incidence of malaria attacks during the malaria epidemic in 2002, compared with school children living in a holoendemic area with intense perennial transmission during the same period. The high incidence coupled with the high parasite densities among cases is compatible with a low level of protective immunity in the highlands. The malaria incidence among school children exposed to intense year-round transmission (26 per 100 school children per year) was consistent with reports from other holoendemic areas. Taken together with other published studies, the data suggest that malaria morbidity among school age children increases as transmission intensity decreases. The implications for malaria control are discussed.
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Affiliation(s)
- Siân E Clarke
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.
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Abstract
Home treatment with antimalarials is a common practice in many countries, and may save lives by ensuring that more malaria cases receive prompt treatment. Through retrospective surveys we found that home treatment of young children with antimalarials was uncommon in rural Gambia. Few families kept medicines in the home in case of illness, 28% kept paracetamol and only 8% kept chloroquine. Less than 10% of cases of childhood 'malaria' had been treated with chloroquine at home, and 69% of those giving home medication did not know the correct dosage for a child. The most common course of treatment was the use of paracetamol and/or tepid sponging to reduce fever, before the child was taken to a government health facility. Treating a child with antimalarials at home was more costly than other forms of treatment. The low cost associated with the use of health services for children and the limited availability of antimalarials outside major towns contribute to the high use of government health services. This shows that that home treatment cannot be assumed to be the predominant mode of malaria treatment throughout Africa, and highlights the need for country-specific policies based on accurate local knowledge of treatment practices in both rural and urban areas.
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Affiliation(s)
- Siân E Clarke
- Danish Bilharziasis Laboratory, Charlottenlund, Denmark.
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Abstract
The aim of this study was to find out from patients who had undergone a myringoplasty via either an endaural or postaural approach whether or not they had experienced problems or symptoms relating to their scar, and if these differed depending on which incision had been used. A questionnaire was sent to 91 patients who had undergone myringoplasty between 18 and 62 months earlier. Thirty-four patients who had undergone previous or subsequent ear surgery were excluded. The only statistically significant difference found between groups having either a postauricular or endaural incision was in how likely others were to comment on their scar. There seem to be few long-term sequealae relating to the scar from myringoplasty. From a patient perspective, between 18 and 62 months postoperatively, there was very little difference in symptoms or problems whether or not an endaural or a postaural incision had been used for the surgery.
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Affiliation(s)
- J L Inwood
- Department of ENT Surgery, Pinderfields General Hospital, Wakefield, UK.
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Bøgh C, Bøgh C, Clarke SE, Jawara M, Thomas CJ, Lindsay SW. Localized breeding of the Anopheles gambiae complex (Diptera: Culicidae) along the River Gambia, West Africa. Bull Entomol Res 2003; 93:279-287. [PMID: 12908913 DOI: 10.1079/ber2003239] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
A study was undertaken to identify the major larval habitats of the Anopheles gambiae (Giles) complex in rural Gambia. Mosquito larvae and pupae were sampled along transects and in specific habitats in the central region of the country during the rainy seasons of 1996 and 1997. The sampling showed that the major breeding sites were located on the flooded alluvial soils bordering the river. The largest numbers of larvae were found during September, one month after the peak rains. Polymerase chain reaction analysis of specimens showed that Anopheles melas (Theobald) was the dominant species in the flooded areas (81.5%), followed by A. gambiae sensu stricto (Giles) (18.0%) and A. arabiensis (Patton) (0.5%). By sampling in specific habitats it was evident that A. arabiensis was mainly breeding in rain-fed rice fields along the edge of the alluvial soils. Anopheles melas and A. gambiae s.s. often coexisted but whereas A. melas were found in water with a salinity of up to 72% sea water (25.2 g NaCl l(-1)), A. gambiae s.s. only occurred in water with up to 30% sea water (10.5 g NaCl l(-1)). Anopheles melas larvae were found in association with plant communities dominated by sedges and grasses (Eleocharis sp., Paspalum sp., Sporobolus sp.) and sea-purslane Sesuvium portulacastrum (L.) and the presence of cattle hoof prints, whereas A. gambiae s.s. larvae mainly occurred in association with Paspalum sp. and Eleocharis sp. The study showed that even during the peak rainy season, breeding of the A. gambiae complex is almost entirely restricted to the extensive alluvial areas along the river.
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Affiliation(s)
- C Bøgh
- Danish Bilharziasis Laboratory Jaegersborg Allé 1D Charlottenlund DK-2920 Denmark.
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Bøgh C, Clarke SE, Walraven GEL, Lindsay SW. Zooprophylaxis, artefact or reality? A paired-cohort study of the effect of passive zooprophylaxis on malaria in The Gambia. Trans R Soc Trop Med Hyg 2002; 96:593-6. [PMID: 12625129 DOI: 10.1016/s0035-9203(02)90320-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The World Health Organization has recommended the use of cattle for zooprophylaxis as a protective measure against malaria since 1982. However, concern has been raised about this practice, since some studies have shown that the presence of cattle may instead increase malaria prevalence. This study was designed to investigate the effect of passive zooprophylaxis on malaria in an area of moderate seasonal transmission in The Gambia, West Africa. The study was based on a paired-cohort of 204 children aged < 7 years, sleeping < 20 m or > 50 m from cattle, and surveys were done from 14 October to 2 December 1997. Entomological investigations showed that the presence of cattle did not alter the risk of malaria transmission in nearby houses. There was also no significant difference in the prevalence of Plasmodium falciparum between the 2 groups. Although the presence of cattle appeared to be protective against high parasitaemia, cattle were also associated with greater wealth of the children's families. Conditional logistic regression analysis showed that the decreased risk of high parasitaemia in the group with cattle present was an artefact associated with the higher general wealth of the cattle owners. We concluded that zooprophylaxis is not an effective intervention method against malaria in settings similar to The Gambia.
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Affiliation(s)
- Claus Bøgh
- Danish Bilharziasis Laboratory, Jaegersborg Allé 1D, DK-2920 Charlottenlund, Denmark.
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Clarke SE, Bøgh C, Brown RC, Walraven GEL, Thomas CJ, Lindsay SW. Risk of malaria attacks in Gambian children is greater away from malaria vector breeding sites. Trans R Soc Trop Med Hyg 2002; 96:499-506. [PMID: 12474476 DOI: 10.1016/s0035-9203(02)90419-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The causes of local variation in the prevalence of malaria were investigated in rural Gambia. Cross-sectional prevalence surveys were carried out among 1184 young children (aged 6 months-5 years) in 48 villages, at the end of the transmission season in 1996. Villages were categorized according to distance from the nearest vector breeding sites, and the patterns of malaria transmission, infection and disease compared. Children living in villages within 3 km of breeding sites experienced more infective bites, and higher prevalences of parasitaemia and spleen enlargement than less-exposed children living further away. Clinical illness, in contrast, was more common among infected children who were less exposed. Infected children living 3 km or more from breeding sites were more likely to have high-density parasitaemia (odds ratio [OR] = 1.98), fever (OR = 2.60) and high-density parasitaemia together with fever (OR = 3.17). Clinical attacks did not decline in older children, as seen amongst children who were more exposed. These findings show that significant differences in the risk of infection and clinical attacks can occur over very short distances. The age at which protective immunity is acquired may be delayed in villages where transmission intensity is lower, thus increasing the risk of a clinical attack following infection. Communities with the lowest vector densities may be those at greatest risk of disease.
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Affiliation(s)
- Siân E Clarke
- Danish Bilharziasis Laboratory, Jaegersborg Allé 1D, DK-2920 Charlottenlund, Denmark.
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Ijumba JN, Shenton FC, Clarke SE, Mosha FW, Lindsay SW. Irrigated crop production is associated with less malaria than traditional agricultural practices in Tanzania. Trans R Soc Trop Med Hyg 2002; 96:476-80. [PMID: 12474470 DOI: 10.1016/s0035-9203(02)90408-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
There is concern that crop irrigation that results in increased numbers of vector mosquitoes will lead to a rise in malaria in local communities. We evaluated the level of malaria experienced in 3 communities in northern Tanzania with different agricultural practices: rice irrigation, sugar-cane irrigation and traditional maize cultivation. Five cross-sectional surveys were used to measure the prevalence of infection with falciparum malaria in 1-4 years old children in each community over a period of 12 months. Active case detection was also carried out to record clinical episodes of malaria during the study period. Information on antimalarial measures was also recorded. Results from the cross-sectional surveys showed that the overall prevalence of malaria parasites was less near the rice irrigation (12.5%) and sugar-cane (16.9%) schemes than the savannah village (29.4%). There were also significantly fewer clinical episodes of malaria in the rice village (15 cases/1000 child-weeks at risk [cwar]) than either the sugar-cane (36 cases/1000 cwar) or savannah (40 cases/1000 cwar) villages. Overall, rice irrigation was associated with less malaria than alternative agricultural practices, despite the considerable numbers of vectors produced in the paddies. This finding supports other studies that indicate that irrigation in much of sub-Saharan Africa will not lead to increased malaria. Nonetheless, African governments planning irrigation projects need effective policies to encourage local communities to use personal protection measures, such as insecticide-treated bednets, and to ensure that these communities have access to effective antimalarial drugs and efficient health services.
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Affiliation(s)
- J N Ijumba
- Tropical Pesticides Research Institute, P.O. Box 3024, Arusha, Tanzania.
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Deeni YY, Paine MJ, Ayrton AD, Clarke SE, Chenery R, Wolf CR. Expression, purification, and biochemical characterization of a human cytochrome P450 CYP2D6-NADPH cytochrome P450 reductase fusion protein. Arch Biochem Biophys 2001; 396:16-24. [PMID: 11716457 DOI: 10.1006/abbi.2001.2585] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Cytochrome P450 CYP2D6 metabolizes a wide range of pharmaceutical compounds. A CYP2D6 fusion enzyme (CYP2D6F), containing an amino-terminal human CYP2D6 sequence and a carboxyterminal human NADPH-cytochrome P450 oxidoreductase (CPR) moiety, was constructed. High levels of expression were achieved in Escherichia coli (60-100 nmol/liter) and the enzyme was catalytically active with optimal activities achieved in the presence of the antioxidant, GSH. Turnover values for bufuralol 1'-hydroxylation, metoprolol alpha-hydroxylation, O-desmethylation, and dextromethorphan O-demethylation, using membranes expressing the fusion enzyme, were 5.6, 0.4, 0.72, and 6.19 min(-1), respectively. These values were similar to E. coli membranes which coexpressed human CYP2D6 and CPR (CYP2D6/R). The K(m) and k(cat) values for bufuralol metabolism were estimated to be 10.2 microM and 4.1 min(-1), respectively. The enzyme was purified using ion-exchange chromatography, affinity chromatography (2'-5' ADP-Sepharose), and gel filtration. Estimated turnover rates for bufuralol 1'-hydroxylation, metoprolol alpha-hydroxylation, O-desmethylation, and dextromethorphan O-demethylation were 1.2, 0.52, 0.79, and 0.76 min(-1), respectively. Bufuralol 1'-hydroxylase activity by purified CYP2D6F was enhanced by phospholipids and added CPR. The CYP2D6F enzyme was able to stimulate CYP3A4 testosterone 6beta-hydroxylase activity in a reconstitution system indicating that electron transfer may be largely intermolecular. The catalytically self-sufficient CYP2D6F enzyme will facilitate investigations of P450-CPR interactions and the development of new biocatalysts.
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Affiliation(s)
- Y Y Deeni
- Biomedical Research Centre, University of Dundee, Dundee, DD1 9SY, United Kingdom
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Kenworthy KE, Clarke SE, Andrews J, Houston JB. Multisite kinetic models for CYP3A4: simultaneous activation and inhibition of diazepam and testosterone metabolism. Drug Metab Dispos 2001; 29:1644-51. [PMID: 11717184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
Some substrates of cytochrome P450 (CYP) 3A4, the most abundant CYP in the human liver responsible for the metabolism of many structurally diverse therapeutic agents, do not obey classical Michaelis-Menten kinetics and demonstrate homotropic and/or heterotropic cooperativity. The unusual kinetics and differential effects observed between substrates of this enzyme confound the prediction of drug clearance and drug-drug interactions from in vitro data. We have investigated the hypothesis that CYP3A4 may bind multiple molecules simultaneously using diazepam (DZ) and testosterone (TS). Both substrates showed sigmoidal kinetics in B-lymphoblastoid microsomes containing a recombinant human CYP3A4 and reductase. When analyzed in combination, TS activated the formation of 3-hydroxydiazepam (3HDZ) and N-desmethyldiazepam (NDZ) (maximal activation 374 and 205%, respectively). For 3HDZ, V(max) values remained constant with increasing TS, whereas the S(50) and Hill values decreased, tending to make the data less sigmoidal. Similar trends were observed for the NDZ pathway. DZ inhibited the formation 6beta-hydroxytestosterone (maximal inhibition, 45% of control), causing a decrease in V(max) but no significant change to the S(50) and Hill values, suggesting that DZ may inhibit via a separate effector site. Multisite rate equation models have been derived to explore the analysis of such complex kinetic data and to allow accurate determination of the kinetic parameters for activation and inhibition. The data and models presented are consistent with proposals that CYP3A4 can bind and metabolize multiple substrate molecules simultaneously; they also provide a generic solution for the interpretation of the complex kinetic data derived from CYP3A4 substrates.
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Affiliation(s)
- K E Kenworthy
- Department of Mechanism and Extrapolation Technologies, GlaxoSmithKline, The Frythe, Welwyn, Herts, United Kingdom
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Abstract
The effect of zooprophylaxis on malaria transmission has not been studied on the African continent despite that the World Health Organization has recommended this intervention method since 1982. The effect of passive zooprophylaxis on malaria vector abundance, mosquito feeding preferences, and infectivity was studied in an area of moderate seasonal transmission in The Gambia. A paired cohort of 204 children <7 yr of age was selected and matched in groups for presence or absence of cattle (Bos taurus) within 20 m of their bedroom. Comparisons were made between mosquitoes collected from the bedrooms of the two groups of children. Other ruminants and equines were present in both groups of compounds. Most of the anopheline mosquitoes (98.5%) collected were Anopheles gambiae sensu lato. There was no difference in the geometric mean number of An. gambiae s.l. mosquitoes caught in houses near or far from cattle. The species composition of the An. gambiae complex was similar in both groups. Blood meal analysis of specimens collected in houses without cattle showed a human blood index (HBI) of 82% for An. Arabiensis (Patton), 56% for An. gambiae sensu stricto (Giles), and 36% for Anopheles Melas (Theobald), indicating that each of these sibling species fed readily on animals. The presence of cattle reduced the HBI of An. arabiensis but did not significantly alter the HBI of An. gambiae s.s. or An. melas. There was no significant difference between the groups in the sporozoite rates of An. gambiae s.l. nor in the estimated malaria transmission risk. These findings suggest that passive zooprophylaxis using cattle does not alter the individual exposure to malaria parasites in The Gambia.
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Affiliation(s)
- C Bøgh
- Danish Bilharziasis Laboratory, Charlottenlund, Denmark.
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Abstract
Bednets are thought to offer little, if any, protection against malaria, unless treated with insecticide. There is also concern that the use of untreated nets will cause people sleeping without nets to receive more mosquito bites, and thus increase the malaria risk for other community members. Regular retreatment of nets is therefore viewed as critical for malaria control. However, despite good uptake of nets, many control programmes in Africa have reported low re-treatment rates. We investigated whether untreated bednets had any protective benefit (in October and November 1996) in The Gambia where nets, although widely used, are mostly untreated. Cross-sectional prevalence surveys were carried out in 48 villages and the risk of malaria parasitaemia was compared in young children sleeping with or without nets. Use of an untreated bednet in good condition was associated with a significantly lower prevalence of Plasmodium falciparum infection (51% protection [95% CI 34-64%], P < 0.001). This finding was only partly explained by differences in wealth between households, and children in the poorest households benefited most from sleeping under an untreated net (62% protection [14-83%], P = 0.018). There was no evidence that mosquitoes were diverted to feed on children sleeping without nets. These findings suggest that an untreated net, provided it is in relatively good condition, can protect against malaria. Control programmes should target the poorest households as they may have the most to gain from using nets.
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Affiliation(s)
- S E Clarke
- Danish Bilharziasis Laboratory, Jaegersborg Allé 1D, DK-2920 Charlottenlund, Denmark.
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47
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Abstract
1. The ability of hepatic microsomal metabolic stability assessments to predict in vivo clearance in rat has been retrospectively evaluated for 1,163 compounds from 48 programmes of chemistry. Using a simple binary classification system, the in vivo clearances of approximately 64% of the compounds were correctly classified. 2. About 24% of compounds were metalbolically stable yet had clearance greater than half of liver blood flow in vivo. This might be expected as microsomes only contain a limited number of fully functioning drug-metabolizing enzymes and cannot be expected to account for extrahepatic or non-metabolic clearance processes. 3. About 13% of compounds had in vivo clearances of less than half liver blood flow despite being classified as metabolically unstable. Despite overcoming metabolic instability, these compounds had other undesirable properties and were generally more highly bound to plasma proteins, had smaller volumes of distribution (and shorter half-lives despite their clearance) and were more inhibitory against the major human cytochrome P450s. 4. Taking plasma protein binding into consideration reduced the proportion of misclassified low-clearance compounds but did not improve the overall success appreciably. Somewhat surprisingly, human microsomes were nearly as effective as rat microsomes at classifying rat in vivo clearance.
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Affiliation(s)
- S E Clarke
- Drug Metabolism and Pharmacokinetics, GlaxoSmithKline Pharmaceuticals, Welwyn, UK.
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48
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Abstract
The purpose of the study was to assess the role of radionuclide imaging of hyperthyroid patients with no suspicion of nodules. (99)Tc(m) radionuclide scans performed on all 190 patients referred over a 2-year period with symptoms and thyroid function tests compatible with thyrotoxicosis were retrospectively reviewed. 73% of patients were referred by a hospital clinician and 27% were referred direct from the general practitioner. Referral letters and, where applicable, the clinical notes were reviewed and patients with suspected thyroid nodules were excluded. The results of (99)Tc(m) thyroid scans of the 190 patients (age range 23-93 years, mean 48 years) were reviewed. 152 (80%) patients had Graves' disease, 10 (5.3%) had Graves' disease with nodules, 6 (3.2%) had Graves' disease with non-functioning nodules, 5 (2.6%) had viral thyroiditis, 5 (2.6%) had autonomously functioning nodules and 12 (6.3%) were normal studies. Therefore, 20% of patients had a diagnosis other than solely Graves' disease. These diagnoses are important with respect to clinical management. In conclusion, routine radionuclide imaging is worthwhile, as a significant proportion of patients with clinical "Graves' disease" in this study would have received incorrect treatment without the result of this scan.
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Affiliation(s)
- N A Lacey
- Departments of Radiology and Nuclear Medicine, Guy's & St Thomas NHS Trust, St Thomas' Street, London SE1 5RT, UK
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49
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Abstract
The contribution of nuclear medicine to the diagnosis and treatment of endocrine malignancy is increasing. Advances in molecular biology offer new opportunities for tumour targeting via surface receptor recognition and tumour-specific metabolic markers. Imaging the biodistribution of these markers allows quantitative, in vivo characterization of tumour function. There is growing interest in the therapeutic potential of nuclear medicine targeting, substituting therapeutic beta-emitting radionuclides for the gamma-emitters used in diagnostic imaging. Limited clinical experience supports the rationale of this approach in patients with inoperable or disseminated disease and controlled trials are in progress. This chapter outlines the place of nuclear medicine techniques in the routine management of endocrine malignancy and explores areas for further development.
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Affiliation(s)
- V J Lewington
- Department of Nuclear Medicine, Southampton University Hospitals NHS Trust, Tremona Road, Southampton, SO16 6YD, UK
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50
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Abstract
Magnetic resonance imaging (MRI) of carotid plaque has undergone significant improvements in the last decade. Early studies utilizing ex vivo specimens and spin-echo or fast spin-echo imaging led to the conclusion that T2 weighting is the best single contrast to characterize carotid plaque morphology. On these images, the fibrous plaque appears bright and the lipid core is dark; thrombus can have variable intensity. There can be an overlap in T2-weighted signal intensities among the various plaque components, which can be partially offset by the use of multispectral analysis of multiple contrast images. With improvements in coil design, sequence design, and main field and gradient capabilities, accurate in vivo differentiation and measurement of these various carotid plaque components should be possible in 3 to 5 years. Ex vivo and in vivo studies have yielded high-resolution measurements of the complex three-dimensional lumen geometry, which are being used to predict hemodynamic forces acting on the lumenal surface. Carotid plaque burden can be accurately measured in vivo today; ongoing longitudinal studies should lead to a better understanding of the relationship between plaque burden and the risk of thromboembolic complications, as well as the effect of diet and drug therapy in hyperlipidemic patients. With these developments in place or soon to be available, MRI of the diseased carotid artery wall may prove to be even more important than magnetic resonance angiography.
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Affiliation(s)
- J K Demarco
- University Radiology Group, University of Medicine and Dentistry of New Jersey, Laurie Imaging Center, New Brunswick 08901, USA
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