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Osoro CB, Ochodo E, Kwambai TK, Otieno JA, Were L, Sagam CK, Owino EJ, Kariuki S, Ter Kuile FO, Hill J. Policy uptake and implementation of the RTS,S/AS01 malaria vaccine in sub-Saharan African countries: status 2 years following the WHO recommendation. BMJ Glob Health 2024; 9:e014719. [PMID: 38688566 PMCID: PMC11085798 DOI: 10.1136/bmjgh-2023-014719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 03/31/2024] [Indexed: 05/02/2024] Open
Abstract
In October 2021, the WHO recommended the world's first malaria vaccine-RTS,S/AS01-to prevent malaria in children living in areas with moderate-to-high transmission in sub-Saharan Africa (SSA). A second malaria vaccine, R21/Matrix-M, was recommended for use in October 2023 and added to the WHO list of prequalified vaccines in December 2023. This study analysis assessed the country status of implementation and delivery strategies for RTS,S/AS01 by searching websites for national malaria policies, guidelines and related documents. Direct contact with individuals working in malaria programmes was made to obtain documents not publicly available. 10 countries had documents with information relating to malaria vaccine implementation, 7 referencing RTS,S/AS01 and 3 (Burkina Faso, Kenya and Nigeria) referencing RTS,S/AS01 and R21/Matrix-M. Five other countries reported plans for malaria vaccine roll-out without specifying which vaccine. Ghana, Kenya and Malawi, which piloted RTS,S/AS01, have now integrated the vaccine into routine immunisation services. Cameroon and Burkina Faso are the first countries outside the pilot countries to incorporate the vaccine into national immunisation services. Uganda plans a phased RTS,S/AS01 introduction, while Guinea plans to first pilot RTS,S/AS01 in five districts. The RTS,S/AS01 schedule varied by country, with the first dose administered at 5 or 6 months in all countries but the fourth dose at either 18, 22 or 24 months. SSA countries have shown widespread interest in rolling out the malaria vaccine, the Global Alliance for Vaccines and Immunization having approved financial support for 20 of 30 countries which applied as of March 2024. Limited availability of RTS,S/AS01 means that some approved countries will not receive the required doses. Vaccine availability and equity must be addressed even as R21/Matrix-M becomes available.
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Affiliation(s)
- Caroline Bonareri Osoro
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
- Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
| | - Eleanor Ochodo
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
- Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
| | | | - Jenifer Akoth Otieno
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Lisa Were
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Caleb Kimutai Sagam
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Eddy Johnson Owino
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Simon Kariuki
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Feiko O Ter Kuile
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Jenny Hill
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
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Asante KP, Mathanga DP, Milligan P, Akech S, Oduro A, Mwapasa V, Moore KA, Kwambai TK, Hamel MJ, Gyan T, Westercamp N, Kapito-Tembo A, Njuguna P, Ansong D, Kariuki S, Mvalo T, Snell P, Schellenberg D, Welega P, Otieno L, Chimala A, Afari EA, Bejon P, Maleta K, Agbenyega T, Snow RW, Zulu M, Chinkhumba J, Samuels AM. Feasibility, safety, and impact of the RTS,S/AS01 E malaria vaccine when implemented through national immunisation programmes: evaluation of cluster-randomised introduction of the vaccine in Ghana, Kenya, and Malawi. Lancet 2024; 403:1660-1670. [PMID: 38583454 DOI: 10.1016/s0140-6736(24)00004-7] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 12/22/2023] [Accepted: 01/02/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND The RTS,S/AS01E malaria vaccine (RTS,S) was introduced by national immunisation programmes in Ghana, Kenya, and Malawi in 2019 in large-scale pilot schemes. We aimed to address questions about feasibility and impact, and to assess safety signals that had been observed in the phase 3 trial that included an excess of meningitis and cerebral malaria cases in RTS,S recipients, and the possibility of an excess of deaths among girls who received RTS,S than in controls, to inform decisions about wider use. METHODS In this prospective evaluation, 158 geographical clusters (66 districts in Ghana; 46 sub-counties in Kenya; and 46 groups of immunisation clinic catchment areas in Malawi) were randomly assigned to early or delayed introduction of RTS,S, with three doses to be administered between the ages of 5 months and 9 months and a fourth dose at the age of approximately 2 years. Primary outcomes of the evaluation, planned over 4 years, were mortality from all causes except injury (impact), hospital admission with severe malaria (impact), hospital admission with meningitis or cerebral malaria (safety), deaths in girls compared with boys (safety), and vaccination coverage (feasibility). Mortality was monitored in children aged 1-59 months throughout the pilot areas. Surveillance for meningitis and severe malaria was established in eight sentinel hospitals in Ghana, six in Kenya, and four in Malawi. Vaccine uptake was measured in surveys of children aged 12-23 months about 18 months after vaccine introduction. We estimated that sufficient data would have accrued after 24 months to evaluate each of the safety signals and the impact on severe malaria in a pooled analysis of the data from the three countries. We estimated incidence rate ratios (IRRs) by comparing the ratio of the number of events in children age-eligible to have received at least one dose of the vaccine (for safety outcomes), or age-eligible to have received three doses (for impact outcomes), to that in non-eligible age groups in implementation areas with the equivalent ratio in comparison areas. To establish whether there was evidence of a difference between girls and boys in the vaccine's impact on mortality, the female-to-male mortality ratio in age groups eligible to receive the vaccine (relative to the ratio in non-eligible children) was compared between implementation and comparison areas. Preliminary findings contributed to WHO's recommendation in 2021 for widespread use of RTS,S in areas of moderate-to-high malaria transmission. FINDINGS By April 30, 2021, 652 673 children had received at least one dose of RTS,S and 494 745 children had received three doses. Coverage of the first dose was 76% in Ghana, 79% in Kenya, and 73% in Malawi, and coverage of the third dose was 66% in Ghana, 62% in Kenya, and 62% in Malawi. 26 285 children aged 1-59 months were admitted to sentinel hospitals and 13 198 deaths were reported through mortality surveillance. Among children eligible to have received at least one dose of RTS,S, there was no evidence of an excess of meningitis or cerebral malaria cases in implementation areas compared with comparison areas (hospital admission with meningitis: IRR 0·63 [95% CI 0·22-1·79]; hospital admission with cerebral malaria: IRR 1·03 [95% CI 0·61-1·74]). The impact of RTS,S introduction on mortality was similar for girls and boys (relative mortality ratio 1·03 [95% CI 0·88-1·21]). Among children eligible for three vaccine doses, RTS,S introduction was associated with a 32% reduction (95% CI 5-51%) in hospital admission with severe malaria, and a 9% reduction (95% CI 0-18%) in all-cause mortality (excluding injury). INTERPRETATION In the first 2 years of implementation of RTS,S, the three primary doses were effectively deployed through national immunisation programmes. There was no evidence of the safety signals that had been observed in the phase 3 trial, and introduction of the vaccine was associated with substantial reductions in hospital admission with severe malaria. Evaluation continues to assess the impact of four doses of RTS,S. FUNDING Gavi, the Vaccine Alliance; the Global Fund to Fight AIDS, Tuberculosis and Malaria; and Unitaid.
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Affiliation(s)
- Kwaku Poku Asante
- Kintampo Health Research Centre, Research and Development Division, Ghana Health Service, Kintampo North Municipality, Ghana; London School of Hygiene & Tropical Medicine, London, UK.
| | - Don P Mathanga
- School of Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi; Malaria Alert Centre, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Paul Milligan
- London School of Hygiene & Tropical Medicine, London, UK.
| | - Samuel Akech
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Abraham Oduro
- Navrongo Health Research Centre, Research and Development Division, Ghana Health Service, Accra, Ghana
| | - Victor Mwapasa
- School of Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Kerryn A Moore
- London School of Hygiene & Tropical Medicine, London, UK; Murdoch Children's Research Institute, Infection and Immunity, New Vaccines, Parkville, VIC, Australia
| | - Titus K Kwambai
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Mary J Hamel
- Department of Immunizations, Vaccines, and Biologicals, WHO, Geneva, Switzerland
| | - Thomas Gyan
- Kintampo Health Research Centre, Research and Development Division, Ghana Health Service, Kintampo North Municipality, Ghana
| | - Nelli Westercamp
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | | | - Daniel Ansong
- Agogo Malaria Research Centre, Agogo, Ghana; Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Simon Kariuki
- Centre for Global Health Research, KEMRI, Kisumu, Kenya
| | - Tisungane Mvalo
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Paul Snell
- London School of Hygiene & Tropical Medicine, London, UK
| | | | - Paul Welega
- Navrongo Health Research Centre, Research and Development Division, Ghana Health Service, Accra, Ghana
| | - Lucas Otieno
- KEMRI-US Army Medical Research Directorate-Africa, Kisumu, Kenya
| | - Alfred Chimala
- Malaria Alert Centre, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Edwin A Afari
- School of Public Health, University of Ghana, Accra, Ghana
| | - Philip Bejon
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Nairobi, Kenya; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Kenneth Maleta
- School of Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Tsiri Agbenyega
- Agogo Malaria Research Centre, Agogo, Ghana; Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Robert W Snow
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Nairobi, Kenya; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Madaliso Zulu
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Jobiba Chinkhumba
- School of Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Aaron M Samuels
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Kisumu, Kenya; Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA.
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Phiri KS, Khairallah C, Kwambai TK, Bojang K, Dhabangi A, Opoka R, Idro R, Stepniewska K, van Hensbroek MB, John CC, Robberstad B, Greenwood B, Kuile FOT. Post-discharge malaria chemoprevention in children admitted with severe anaemia in malaria-endemic settings in Africa: a systematic review and individual patient data meta-analysis of randomised controlled trials. Lancet Glob Health 2024; 12:e33-e44. [PMID: 38097295 PMCID: PMC10733130 DOI: 10.1016/s2214-109x(23)00492-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 08/10/2023] [Revised: 09/25/2023] [Accepted: 10/11/2023] [Indexed: 12/18/2023]
Abstract
BACKGROUND Severe anaemia is associated with high in-hospital mortality among young children. In malaria-endemic areas, surviving children also have an increased risk of mortality or readmission after hospital discharge. We conducted a systematic review and individual patient data meta-analysis to determine the efficacy of monthly post-discharge malaria chemoprevention in children recovering from severe anaemia. METHODS This analysis was conducted according to PRISMA-IPD guidelines. We searched multiple databases on Aug 28, 2023, without date or language restrictions, for randomised controlled trials comparing monthly post-discharge malaria chemoprevention with placebo or standard of care among children (aged <15 years) admitted with severe anaemia in malaria-endemic Africa. Trials using daily or weekly malaria prophylaxis were not eligible. The investigators from all eligible trials shared pseudonymised datasets, which were standardised and merged for analysis. The primary outcome was all-cause mortality during the intervention period. Analyses were performed in the modified intention-to-treat population, including all randomly assigned participants who contributed to the endpoint. Fixed-effects two-stage meta-analysis of risk ratios (RRs) was used to generate pooled effect estimates for mortality. Recurrent time-to-event data (readmissions or clinic visits) were analysed using one-stage mixed-effects Prentice-Williams-Peterson total-time models to obtain hazard ratios (HRs). This study is registered with PROSPERO, CRD42022308791. FINDINGS Our search identified 91 articles, of which 78 were excluded by title and abstract, and a further ten did not meet eligibility criteria. Three double-blind, placebo-controlled trials, including 3663 children with severe anaemia, were included in the systematic review and meta-analysis; 3507 (95·7%) contributed to the modified intention-to-treat analysis. Participants received monthly sulfadoxine-pyrimethamine until the end of the malaria transmission season (mean 3·1 courses per child [range 1-6]; n=1085; The Gambia), monthly artemether-lumefantrine given at the end of weeks 4 and 8 post discharge (n=1373; Malawi), or monthly dihydroartemisinin-piperaquine given at the end of weeks 2, 6, and 10 post discharge (n=1049; Uganda and Kenya). During the intervention period, post-discharge malaria chemoprevention was associated with a 77% reduction in mortality (RR 0·23 [95% CI 0·08-0·70], p=0·0094, I2=0%) and a 55% reduction in all-cause readmissions (HR 0·45 [95% CI 0·36-0·56], p<0·0001) compared with placebo. The protective effect was restricted to the intervention period and was not sustained after the direct pharmacodynamic effect of the drugs had waned. The small number of trials limited our ability to assess heterogeneity, its sources, and publication bias. INTERPRETATION In malaria-endemic Africa, post-discharge malaria chemoprevention reduces mortality and readmissions in recently discharged children recovering from severe anaemia. Post-discharge malaria chemoprevention could be a valuable strategy for the management of this group at high risk. Future research should focus on methods of delivery, options to prolong the protection duration, other hospitalised groups at high risk, and interventions targeting non-malarial causes of post-discharge morbidity. FUNDING The Research-Council of Norway and the Bill-&-Melinda-Gates-Foundation through the Worldwide-Antimalarial-Research-Network.
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Affiliation(s)
- Kamija S Phiri
- School of Global and Public Health, Kamuzu University of Health Sciences (KUHeS), Blantyre, Malawi; Training and Research Unit of Excellence, Blantyre, Malawi
| | - Carole Khairallah
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Titus K Kwambai
- Division of Parasitic Diseases and Malaria, Global Health Center, Centers for Disease Control and Prevention, Kisumu, Kenya; Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Kalifa Bojang
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Aggrey Dhabangi
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Robert Opoka
- Makerere University College of Health Sciences, Kampala, Uganda; Aga Khan University, Medical College, Nairobi, Kenya
| | - Richard Idro
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Kasia Stepniewska
- Worldwide Antimalarial Resistance Network (WWARN), Oxford, UK; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; Infectious Diseases Data Observatory (IDDO), Oxford, UK
| | - Michael Boele van Hensbroek
- Amsterdam Centre for Global Child Health, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Chandy C John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Bjarne Robberstad
- Section for Ethics and Health Economics, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Brian Greenwood
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Feiko O Ter Kuile
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK; Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya.
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Winskill P, Dhabangi A, Kwambai TK, Mori AT, Mousa A, Okell LC. Estimating the burden of severe malarial anaemia and access to hospital care in East Africa. Nat Commun 2023; 14:5691. [PMID: 37709763 PMCID: PMC10502125 DOI: 10.1038/s41467-023-41275-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 08/29/2023] [Indexed: 09/16/2023] Open
Abstract
Severe malarial anaemia can be fatal if not promptly treated. Hospital studies may under-represent the true burden because cases often occur in settings with poor access to healthcare. We estimate the relationship of community prevalence of malaria infection and severe malarial anaemia with the incidence of severe malarial anaemia cases in hospital, using survey data from 21 countries and hospital data from Kenya, Tanzania and Uganda. The estimated percentage of severe malarial anaemia cases that were hospitalised is low and consistent for Kenya (21% (95% CrI: 7%, 47%)), Tanzania (18% (95% CrI: 5%, 52%)) and Uganda (23% (95% CrI: 9%, 48%)). The majority of severe malarial anaemia cases remain in the community, with the consequent public health burden being contingent upon the severity of these cases. Alongside health system strengthening, research to better understand the spectrum of disease associated with severe malarial anaemia cases in the community is a priority.
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Affiliation(s)
- Peter Winskill
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College, London, W2 1PG, UK.
| | - Aggrey Dhabangi
- Child Health and Development Centre, Makerere University College of Health Sciences, Kampala, Uganda
| | - Titus K Kwambai
- Division of Parasitic Diseases and Malaria, Global Health Center, Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Amani Thomas Mori
- Health Economics Leadership and Translational Ethics Research Group (HELTER), Department of Global Public Health and Primary Care, University of Bergen, Arstadveien 17, 5009, Bergen, Norway
- Muhimbili University of Health and Allied Sciences, P.O. Box, 65001, Dar es-Salaam, Tanzania
| | - Andria Mousa
- Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, UK
| | - Lucy C Okell
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College, London, W2 1PG, UK
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Kwambai TK, Kariuki S, Smit MR, Nevitt S, Onyango E, Oneko M, Khagayi S, Samuels AM, Hamel MJ, Laserson K, Desai M, ter Kuile FO. Post-Discharge Risk of Mortality in Children under 5 Years of Age in Western Kenya: A Retrospective Cohort Study. Am J Trop Med Hyg 2023; 109:704-712. [PMID: 37549893 PMCID: PMC10484264 DOI: 10.4269/ajtmh.23-0186] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 03/27/2023] [Accepted: 05/26/2023] [Indexed: 08/09/2023] Open
Abstract
Limited evidence suggests that children in sub-Saharan Africa hospitalized with all-cause severe anemia or severe acute malnutrition (SAM) are at high risk of dying in the first few months after discharge. We aimed to compare the risks of post-discharge mortality by health condition among hospitalized children in an area with high malaria transmission in western Kenya. We conducted a retrospective cohort study among recently discharged children aged < 5 years using mortality data from a health and demographic surveillance system that included household and pediatric in-hospital surveillance. Cox regression was used to compare post-discharge mortality. Between 2008 and 2013, overall in-hospital mortality was 2.8% (101/3,639). The mortality by 6 months after discharge (primary outcome) was 6.2% (159/2,556) and was highest in children with SAM (21.6%), followed by severe anemia (15.5%), severe pneumonia (5.6%), "other conditions" (5.6%), and severe malaria (0.7%). Overall, the 6-month post-discharge mortality in children hospitalized with SAM (hazard ratio [HR] = 3.95, 2.60-6.00, P < 0.001) or severe anemia (HR = 2.55, 1.74-3.71, P < 0.001) was significantly higher than that in children without these conditions. Severe malaria was associated with lower 6-month post-discharge mortality than children without severe malaria (HR = 0.33, 0.21-0.53, P < 0.001). The odds of dying by 6 months after discharge tended to be higher than during the in-hospital period for all children, except for those admitted with severe malaria. The first 6 months after discharge is a high-risk period for mortality among children admitted with severe anemia and SAM in western Kenya. Strategies to address this risk period are urgently needed.
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Affiliation(s)
- Titus K. Kwambai
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Simon Kariuki
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Menno R. Smit
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Amsterdam Centre for Global Child Health, Emma Children’s Hospital, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Sarah Nevitt
- Department of Health Data Science, University of Liverpool, Liverpool, United Kingdom
| | - Eric Onyango
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Martina Oneko
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Sammy Khagayi
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Aaron M. Samuels
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Kisumu, Kenya
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Mary J. Hamel
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kayla Laserson
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Meghna Desai
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Feiko O. ter Kuile
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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Okell LC, Kwambai TK, Dhabangi A, Khairallah C, Nkosi-Gondwe T, Winskill P, Opoka R, Mousa A, Kühl MJ, Lucas TCD, Challenger JD, Idro R, Weiss DJ, Cairns M, Ter Kuile FO, Phiri K, Robberstad B, Mori AT. Projected health impact of post-discharge malaria chemoprevention among children with severe malarial anaemia in Africa. Nat Commun 2023; 14:402. [PMID: 36697413 PMCID: PMC9876927 DOI: 10.1038/s41467-023-35939-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 01/09/2023] [Indexed: 01/26/2023] Open
Abstract
Children recovering from severe malarial anaemia (SMA) remain at high risk of readmission and death after discharge from hospital. However, a recent trial found that post-discharge malaria chemoprevention (PDMC) with dihydroartemisinin-piperaquine reduces this risk. We developed a mathematical model describing the daily incidence of uncomplicated and severe malaria requiring readmission among 0-5-year old children after hospitalised SMA. We fitted the model to a multicentre clinical PDMC trial using Bayesian methods and modelled the potential impact of PDMC across malaria-endemic African countries. In the 20 highest-burden countries, we estimate that only 2-5 children need to be given PDMC to prevent one hospitalised malaria episode, and less than 100 to prevent one death. If all hospitalised SMA cases access PDMC in moderate-to-high transmission areas, 38,600 (range 16,900-88,400) malaria-associated readmissions could be prevented annually, depending on access to hospital care. We estimate that recurrent SMA post-discharge constitutes 19% of all SMA episodes in moderate-to-high transmission settings.
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Affiliation(s)
- Lucy C Okell
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College, London, W2 1PG, UK.
| | - Titus K Kwambai
- Centre for Global Health Research (CGHR), Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
- Department of Clinical Sciences, Liverpool School of Tropical Medicine (LSTM), Liverpool, UK
| | - Aggrey Dhabangi
- College of Health Sciences, Makerere University, Kampala, Uganda
| | - Carole Khairallah
- Department of Clinical Sciences, Liverpool School of Tropical Medicine (LSTM), Liverpool, UK
| | - Thandile Nkosi-Gondwe
- Kamuzu University of Health Sciences, Blantyre, Malawi
- Training and Research Unit of Excellence, Blantyre, Malawi
| | - Peter Winskill
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College, London, W2 1PG, UK
| | - Robert Opoka
- College of Health Sciences, Makerere University, Kampala, Uganda
| | - Andria Mousa
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College, London, W2 1PG, UK
| | - Melf-Jakob Kühl
- Section for Ethics and Health Economics, Department of Global Public Health and Primary Care, University of Bergen, P.O. Box 7804, 5020, Bergen, Norway
| | - Tim C D Lucas
- Big Data Institute, University of Oxford, Oxford, UK
| | - Joseph D Challenger
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College, London, W2 1PG, UK
| | - Richard Idro
- College of Health Sciences, Makerere University, Kampala, Uganda
| | - Daniel J Weiss
- Malaria Atlas Project, Telethon Kids Institute, Perth Children's Hospital, 15 Hospital Avenue, Nedlands, Australia
- Curtin University, Bentley, Australia
| | - Matthew Cairns
- International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Feiko O Ter Kuile
- Centre for Global Health Research (CGHR), Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
- Department of Clinical Sciences, Liverpool School of Tropical Medicine (LSTM), Liverpool, UK
| | - Kamija Phiri
- Kamuzu University of Health Sciences, Blantyre, Malawi
- Training and Research Unit of Excellence, Blantyre, Malawi
| | - Bjarne Robberstad
- Section for Ethics and Health Economics, Department of Global Public Health and Primary Care, University of Bergen, P.O. Box 7804, 5020, Bergen, Norway
| | - Amani Thomas Mori
- Section for Ethics and Health Economics, Department of Global Public Health and Primary Care, University of Bergen, P.O. Box 7804, 5020, Bergen, Norway.
- Chr. Michelsen Institute, P.O. Box 6033, N-5892, Bergen, Norway.
- Muhimbili University of Health and Allied Sciences, P.O.Box 65001, Dar es Salaam, Tanzania.
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Kühl MJ, Gondwe T, Dhabangi A, Kwambai TK, Mori AT, Opoka R, John CC, Idro R, ter Kuile FO, Phiri KS, Robberstad B. Economic evaluation of postdischarge malaria chemoprevention in preschool children treated for severe anaemia in Malawi, Kenya, and Uganda: A cost-effectiveness analysis. EClinicalMedicine 2022; 52:101669. [PMID: 36313146 PMCID: PMC9596312 DOI: 10.1016/j.eclinm.2022.101669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 09/04/2022] [Accepted: 09/06/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Children hospitalised with severe anaemia in malaria-endemic areas are at a high risk of dying or being readmitted within six months of discharge. A trial in Kenya and Uganda showed that three months of postdischarge malaria chemoprevention (PDMC) with monthly dihydroartemisinin-piperaquine (DP) substantially reduced this risk. The World Health Organization recently included PDMC in its malaria chemoprevention guidelines. We conducted a cost-effectiveness analysis of community-based PDMC delivery (supplying all three PDMC-DP courses to caregivers at discharge to administer at home), facility-based PDMC delivery (monthly dispensing of PDMC-DP at the hospital), and the standard of care (no PDMC). METHODS We combined data from two recently completed trials; one placebo-controlled trial in Kenya and Uganda collecting efficacy data (May 6, 2016 until November 15, 2018; n=1049), and one delivery mechanism trial from Malawi collecting adherence data (March 24, 2016 until October 3, 2018; n=375). Cost data were collected alongside both trials. Three Markov decision models, one each for Malawi, Kenya, and Uganda, were used to compute incremental cost-effectiveness ratios expressed as costs per quality-adjusted life-year (QALY) gained. Deterministic and probabilistic sensitivity analyses were performed to account for uncertainty. FINDINGS Both PDMC strategies were cost-saving in each country, meaning less costly and more effective in increasing health-adjusted life expectancy than the standard of care. The estimated incremental cost savings for community-based PDMC compared to the standard of care were US$ 22·10 (Malawi), 38·52 (Kenya), and 26·23 (Uganda) per child treated. The incremental effectiveness gain using either PDMC strategy varied between 0·3 and 0·4 QALYs. Community-based PDMC was less costly and more effective than facility-based PDMC. These results remained robust in sensitivity analyses. INTERPRETATION PDMC under implementation conditions is cost-saving. Caregivers receiving PDMC at discharge is a cost-effective delivery strategy for implementation in malaria-endemic southeastern African settings. FUNDING Research Council of Norway.
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Affiliation(s)
- Melf-Jakob Kühl
- Centre for International Health (CIH), Department of Global Public Health and Primary Care, University of Bergen, Årstadveien 17, 5009 Bergen, Norway
- Health Economics Leadership and Translational Ethics Research Group (HELTER), Department of Global Public Health and Primary Care, University of Bergen, Årstadveien 17, 5009 Bergen, Norway
| | - Thandile Gondwe
- Kamuzu University of Health Sciences, 782 Mahatma Gandhi, Blantyre, Malawi
- Training and Research Unit of Excellence, 1 Kufa Road, Blantyre, Malawi
| | - Aggrey Dhabangi
- Makerere University College of Health Sciences, Upper Mulago Hill Road, Kampala, Uganda
| | - Titus K. Kwambai
- Centre for Global Health Research (CGHR), Kenya Medical Research Institute (KEMRI), Busia Rd, Kisumu, Kenya
- Department of Clinical Sciences, Liverpool School of Tropical Medicine (LSTM), Pembroke Place, Liverpool L3 5QA, United Kingdom
| | - Amani T. Mori
- Chr. Michelsen Institute, Jekteviksbakken 31, 5006 Bergen, Norway
- Health Economics Leadership and Translational Ethics Research Group (HELTER), Department of Global Public Health and Primary Care, University of Bergen, Årstadveien 17, 5009 Bergen, Norway
| | - Robert Opoka
- Makerere University College of Health Sciences, Upper Mulago Hill Road, Kampala, Uganda
| | - C. Chandy John
- Ryan White Center for Pediatric Infectious Diseases and Global Health, School of Medicine, Indiana University, 1044 W Walnut St, R4 402D Indianapolis, United States of America
| | - Richard Idro
- Makerere University College of Health Sciences, Upper Mulago Hill Road, Kampala, Uganda
| | - Feiko O. ter Kuile
- Department of Clinical Sciences, Liverpool School of Tropical Medicine (LSTM), Pembroke Place, Liverpool L3 5QA, United Kingdom
| | - Kamija S. Phiri
- Kamuzu University of Health Sciences, 782 Mahatma Gandhi, Blantyre, Malawi
- Training and Research Unit of Excellence, 1 Kufa Road, Blantyre, Malawi
| | - Bjarne Robberstad
- Health Economics Leadership and Translational Ethics Research Group (HELTER), Department of Global Public Health and Primary Care, University of Bergen, Årstadveien 17, 5009 Bergen, Norway
- Corresponding author at: Department of Global Public Health and Primary Care, University of Bergen, Årstadveien 17, 5009 Bergen, Norway.
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8
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Stepniewska K, Allen EN, Humphreys GS, Poirot E, Craig E, Kennon K, Yilma D, Bousema T, Guerin PJ, White NJ, Price RN, Raman J, Martensson A, Mwaiswelo RO, Bancone G, Bastiaens GJH, Bjorkman A, Brown JM, D'Alessandro U, Dicko AA, El-Sayed B, Elzaki SE, Eziefula AC, Gonçalves BP, Hamid MMA, Kaneko A, Kariuki S, Khan W, Kwambai TK, Ley B, Ngasala BE, Nosten F, Okebe J, Samuels AM, Smit MR, Stone WJR, Sutanto I, Ter Kuile F, Tine RC, Tiono AB, Drakeley CJ, Gosling R, Stergachis A, Barnes KI, Chen I. Safety of single-dose primaquine as a Plasmodium falciparum gametocytocide: a systematic review and meta-analysis of individual patient data. BMC Med 2022; 20:350. [PMID: 36109733 PMCID: PMC9479278 DOI: 10.1186/s12916-022-02504-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 07/29/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND In 2012, the World Health Organization (WHO) recommended single low-dose (SLD, 0.25 mg/kg) primaquine to be added as a Plasmodium (P.) falciparum gametocytocide to artemisinin-based combination therapy (ACT) without glucose-6-phosphate dehydrogenase (G6PD) testing, to accelerate malaria elimination efforts and avoid the spread of artemisinin resistance. Uptake of this recommendation has been relatively slow primarily due to safety concerns. METHODS A systematic review and individual patient data (IPD) meta-analysis of single-dose (SD) primaquine studies for P. falciparum malaria were performed. Absolute and fractional changes in haemoglobin concentration within a week and adverse effects within 28 days of treatment initiation were characterised and compared between primaquine and no primaquine arms using random intercept models. RESULTS Data comprised 20 studies that enrolled 6406 participants, of whom 5129 (80.1%) had received a single target dose of primaquine ranging between 0.0625 and 0.75 mg/kg. There was no effect of primaquine in G6PD-normal participants on haemoglobin concentrations. However, among 194 G6PD-deficient African participants, a 0.25 mg/kg primaquine target dose resulted in an additional 0.53 g/dL (95% CI 0.17-0.89) reduction in haemoglobin concentration by day 7, with a 0.27 (95% CI 0.19-0.34) g/dL haemoglobin drop estimated for every 0.1 mg/kg increase in primaquine dose. Baseline haemoglobin, young age, and hyperparasitaemia were the main determinants of becoming anaemic (Hb < 10 g/dL), with the nadir observed on ACT day 2 or 3, regardless of G6PD status and exposure to primaquine. Time to recovery from anaemia took longer in young children and those with baseline anaemia or hyperparasitaemia. Serious adverse haematological events after primaquine were few (9/3, 113, 0.3%) and transitory. One blood transfusion was reported in the primaquine arms, and there were no primaquine-related deaths. In controlled studies, the proportions with either haematological or any serious adverse event were similar between primaquine and no primaquine arms. CONCLUSIONS Our results support the WHO recommendation to use 0.25 mg/kg of primaquine as a P. falciparum gametocytocide, including in G6PD-deficient individuals. Although primaquine is associated with a transient reduction in haemoglobin levels in G6PD-deficient individuals, haemoglobin levels at clinical presentation are the major determinants of anaemia in these patients. TRIAL REGISTRATION PROSPERO, CRD42019128185.
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Affiliation(s)
- Kasia Stepniewska
- WorldWide Antimalarial Resistance Network, Oxford, UK.
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
| | - Elizabeth N Allen
- WorldWide Antimalarial Resistance Network, Oxford, UK
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Georgina S Humphreys
- WorldWide Antimalarial Resistance Network, Oxford, UK
- Green Templeton College, University of Oxford, Oxford, UK
| | - Eugenie Poirot
- Malaria Elimination Initiative, Global Health Group, University of California San Francisco, San Francisco, USA
| | - Elaine Craig
- WorldWide Antimalarial Resistance Network, Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Kalynn Kennon
- WorldWide Antimalarial Resistance Network, Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Daniel Yilma
- WorldWide Antimalarial Resistance Network, Oxford, UK
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Jimma University Clinical Trial Unit, Department of Internal Medicine, Jimma University, Jimma, Ethiopia
| | - Teun Bousema
- Department of Infection and Immunity, London School of Hygiene and Tropical Medicine, London, UK
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Philippe J Guerin
- WorldWide Antimalarial Resistance Network, Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Nicholas J White
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Ric N Price
- WorldWide Antimalarial Resistance Network, Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Jaishree Raman
- Parasitology Reference Laboratory, National Institute for Communicable Diseases, A Division of the National Health Laboratory Services, Johannesburg, South Africa
- Wits Research Institute for Malaria, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Andreas Martensson
- Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Uppsala University, Uppsala, Sweden
| | - Richard O Mwaiswelo
- Department of Parasitology and Medical Entomology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Department of Microbiology, Immunology and Parasitology, Hubert Kairuki Memorial University, Dar es Salaam, Tanzania
| | - Germana Bancone
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Guido J H Bastiaens
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
- Laboratory of Medical Microbiology and Immunology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Anders Bjorkman
- Department of Microbiology Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Joelle M Brown
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Umberto D'Alessandro
- Medical Research Council Unit, London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Alassane A Dicko
- Malaria Research and Training Centre, Faculty of Pharmacy and Faculty of Medicine and Dentistry, University of Science, Techniques and Technologies of Bamako, Bamako, Mali
| | - Badria El-Sayed
- Department of Epidemiology, Tropical Medicine Research Institute, National Centre for Research, Khartoum, Sudan
| | - Salah-Eldin Elzaki
- Department of Epidemiology, Tropical Medicine Research Institute, National Centre for Research, Khartoum, Sudan
| | - Alice C Eziefula
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Bronner P Gonçalves
- Department of Infection and Immunity, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Akira Kaneko
- Department of Microbiology Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Simon Kariuki
- Kenya Medical Research Institute (KEMRI), Kisian, Kenya
| | - Wasif Khan
- Infectious Disease Division, International Centre for Diarrheal Diseases Research, Dhaka, Bangladesh
| | - Titus K Kwambai
- Centers for Disease Control and Prevention, Department of Parasitic Diseases and Malaria, Kisumu, Kenya
| | - Benedikt Ley
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Billy E Ngasala
- Department of Parasitology and Medical Entomology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Uppsala University, Uppsala, Sweden
| | - Francois Nosten
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Joseph Okebe
- Disease Control & Elimination Theme, Medical Research Council Unit, Fajara, The Gambia
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Aaron M Samuels
- Centers for Disease Control and Prevention, Department of Parasitic Diseases and Malaria, Kisumu, Kenya
| | - Menno R Smit
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Will J R Stone
- Department of Infection and Immunity, London School of Hygiene and Tropical Medicine, London, UK
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Inge Sutanto
- Department of Parasitology, Faculty of Medicine, University of Indonesia, Depok City, Indonesia
| | | | - Roger C Tine
- Department of Medical Parasitology, Faculty of Medicine, University Cheikh Anta Diop, Dakar, Senegal
| | - Alfred B Tiono
- Department of Biomedical Sciences, Centre National de Recherche et de Formation sur le Paludisme, Ouagadougou, Burkina Faso
| | - Chris J Drakeley
- Department of Infection Biology, London School of Tropical Medicine and Hygiene, London, UK
| | - Roly Gosling
- Malaria Elimination Initiative, Global Health Group, University of California San Francisco, San Francisco, USA
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Andy Stergachis
- Departments of Pharmacy & Global Health, Schools of Pharmacy and Public Health, University of Washington, Seattle, USA
| | - Karen I Barnes
- WorldWide Antimalarial Resistance Network, Oxford, UK
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Ingrid Chen
- Malaria Elimination Initiative, Global Health Group, University of California San Francisco, San Francisco, USA
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Samuels AM, Towett O, Seda B, Wiegand RE, Otieno K, Chomba M, Lucchi N, Ljolje D, Schneider K, Walker PGT, Kwambai TK, Slutsker L, ter Kuile FO, Kariuki SK. Diagnostic Performance of Loop-Mediated Isothermal Amplification and Ultrasensitive Rapid Diagnostic Tests for Malaria Screening Among Pregnant Women in Kenya. J Infect Dis 2022; 226:696-707. [PMID: 35811308 PMCID: PMC9585193 DOI: 10.1093/infdis/jiac289] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 07/08/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Screen-and-treat strategies with sensitive diagnostic tests may reduce malaria-associated adverse pregnancy outcomes. We conducted a diagnostic accuracy study to evaluate new point-of-care tests to screen pregnant women for malaria at their first antenatal visit in western Kenya. METHODS Consecutively women were tested for Plasmodium infection by expert microscopy, conventional rapid diagnostic test (cRDT), ultra sensitive RDT (usRDT), and loop-mediated isothermal amplification (LAMP). Photoinduced electron-transfer polymerase chain reaction (PET-PCR) served as the reference standard. Diagnostic performance was calculated and modelled at low parasite densities. RESULTS Between May and September 2018, 172 of 482 screened participants (35.7%) were PET-PCR positive. Relative to PET-PCR, expert microscopy was least sensitive (40.1%; 95% confidence interval [CI], 32.7%-47.9%), followed by cRDT (49.4%; 95% CI, 41.7%-57.1), usRDT (54.7%; 95% CI, 46.9%-62.2%), and LAMP (68.6%; 95% CI, 61.1%-75.5%). Test sensitivities were comparable in febrile women (n = 90). Among afebrile women (n = 392), the geometric-mean parasite density was 29 parasites/µL and LAMP (sensitivity = 61.9%) and usRDT (43.2%) detected 1.74 (95% CI, 1.31-2.30) and 1.21 (95% CI, 88-2.21) more infections than cRDT (35.6%). Per our model, tests performed similarly at densities >200 parasites/µL. At 50 parasites/µL, the sensitivities were 45%, 56%, 62%, and 74% with expert microscopy, cRDT, usRDT, and LAMP, respectively. CONCLUSIONS This first-generation usRDT provided moderate improvement in detecting low-density infections in afebrile pregnant women compared to cRDTs.
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Affiliation(s)
- Aaron M. Samuels
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention (CDC), Kisumu, 40100, Kenya
- Division of Parasitic Diseases and Malaria, CDC, Atlanta, GA, 30329, United States of America
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, United Kingdom
| | - Oliver Towett
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, 40100, Kenya
| | - Brian Seda
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, 40100, Kenya
| | - Ryan E. Wiegand
- Division of Parasitic Diseases and Malaria, CDC, Atlanta, GA, 30329, United States of America
| | - Kephas Otieno
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, 40100, Kenya
| | - Miriam Chomba
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, 40100, Kenya
| | - Naomi Lucchi
- Division of Parasitic Diseases and Malaria, CDC, Atlanta, GA, 30329, United States of America
| | - Dragan Ljolje
- Division of Parasitic Diseases and Malaria, CDC, Atlanta, GA, 30329, United States of America
| | - Kammerle Schneider
- Center for Malaria Control and Elimination, PATH, Seattle, WA, 98121, United States of America
| | - Patrick GT Walker
- Department of Infectious Disease Epidemiology, Imperial College London, SW7 2AZ, United Kingdom
| | - Titus K. Kwambai
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention (CDC), Kisumu, 40100, Kenya
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, 40100, Kenya
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, United Kingdom
| | - Laurence Slutsker
- Center for Malaria Control and Elimination, PATH, Seattle, WA, 98121, United States of America
| | - Feiko O. ter Kuile
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, 40100, Kenya
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, United Kingdom
| | - Simon K. Kariuki
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, 40100, Kenya
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Kwambai TK, Mori AT, Nevitt S, van Eijk AM, Samuels AM, Robberstad B, Phiri KS, Ter Kuile FO. Post-discharge morbidity and mortality in children admitted with severe anaemia and other health conditions in malaria-endemic settings in Africa: a systematic review and meta-analysis. Lancet Child Adolesc Health 2022; 6:474-483. [PMID: 35605629 DOI: 10.1016/s2352-4642(22)00074-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 02/24/2022] [Accepted: 02/28/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Severe anaemia is associated with high in-hospital mortality among young children. In malaria-endemic areas, surviving children also remain at increased risk of mortality for several months after hospital discharge. We aimed to compare the risks of morbidity and mortality among children discharged from hospital after recovery from severe anaemia versus other health conditions in malaria-endemic settings in Africa. METHODS Following PRISMA guidelines, we searched PubMed, Scopus, Web of Science, and Cochrane Central from inception to Nov 30, 2021, without language restrictions, for prospective or retrospective cohort studies and randomised controlled trials that followed up children younger than 15 years for defined periods after hospital discharge in malaria-endemic countries in Africa. We excluded the intervention groups in trials and studies or subgroups involving children with sickle cell anaemia, malignancies, or surgery or trauma, or those reporting follow-up data that were combined with the in-hospital period. Two independent reviewers extracted the data and assessed the quality and risk of bias using the Newcastle Ottawa Scale or the Cochrane Collaboration's tool. The coprimary outcomes were all-cause death and all-cause readmissions 6 months after discharge. This study is registered with PROSPERO, CRD42017079282. FINDINGS Of 2930 articles identified in our search, 27 studies were included. For children who were recently discharged following hospital admission with severe anaemia, all-cause mortality by 6 months was higher than during the in-hospital period (n=5 studies; Mantel-Haenszel odds ratio 1·72, 95% CI 1·22-2·44; p=0·0020; I2=51·5%) and more than two times higher than children previously admitted without severe anaemia (n=4 studies; relative risk [RR] 2·69, 95% CI 1·59-4·53; p<0·0001; I2=69·2%). Readmissions within 6 months of discharge were also more common in children admitted with severe anaemia than in children admitted with other conditions (n=1 study; RR 3·05, 1·12-8·35; p<0·0001). Children admitted with severe acute malnutrition (regardless of severe anaemia) also had a higher 6-month mortality after discharge than those admitted for other reasons (n=2 studies; RR=3·12, 2·02-4·68; p<0·0001; I2=54·7%). Other predictors of mortality after discharge included discharge against medical advice, HIV, bacteraemia, and hypoxia. INTERPRETATION In malaria-endemic settings in Africa, children admitted to hospital with severe anaemia and severe acute malnutrition are at increased risk of mortality in the first 6 months after discharge compared with children admitted with other health conditions. Improved strategies are needed for the management of these high-risk groups during the period after discharge. FUNDING Research Council of Norway and US Centers for Disease Control and Prevention.
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Affiliation(s)
- Titus K Kwambai
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK; Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Kisumu, Kenya.
| | - Amani T Mori
- Section for Ethics and Health Economics and Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Sarah Nevitt
- Department of Health Data Science, University of Liverpool, Liverpool, Merseyside, UK
| | - Anna Maria van Eijk
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Aaron M Samuels
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Kisumu, Kenya; Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Bjarne Robberstad
- Section for Ethics and Health Economics and Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Kamija S Phiri
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Feiko O Ter Kuile
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
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11
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Kwambai TK, Dhabangi A, Idro R, Opoka R, Watson V, Kariuki S, Kuya NA, Onyango ED, Otieno K, Samuels AM, Desai MR, Boele van Hensbroek M, Wang D, John CC, Robberstad B, Phiri KS, Ter Kuile FO. Malaria Chemoprevention in the Postdischarge Management of Severe Anemia. N Engl J Med 2020; 383:2242-2254. [PMID: 33264546 PMCID: PMC9115866 DOI: 10.1056/nejmoa2002820] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Children who have been hospitalized with severe anemia in areas of Africa in which malaria is endemic have a high risk of readmission and death within 6 months after discharge. No prevention strategy specifically addresses this period. METHODS We conducted a multicenter, two-group, randomized, placebo-controlled trial in nine hospitals in Kenya and Uganda to determine whether 3 months of malaria chemoprevention could reduce morbidity and mortality after hospital discharge in children younger than 5 years of age who had been admitted with severe anemia. All children received standard in-hospital care for severe anemia and a 3-day course of artemether-lumefantrine at discharge. Two weeks after discharge, children were randomly assigned to receive dihydroartemisinin-piperaquine (chemoprevention group) or placebo, administered as 3-day courses at 2, 6, and 10 weeks after discharge. Children were followed for 26 weeks after discharge. The primary outcome was one or more hospital readmissions for any reason or death from the time of randomization to 6 months after discharge. Conditional risk-set modeling for recurrent events was used to calculate hazard ratios with the use of the Prentice-Williams-Peterson total-time approach. RESULTS From May 2016 through May 2018, a total of 1049 children underwent randomization; 524 were assigned to the chemoprevention group and 525 to the placebo group. From week 3 through week 26, a total of 184 events of readmission or death occurred in the chemoprevention group and 316 occurred in the placebo group (hazard ratio, 0.65; 95% confidence interval [CI], 0.54 to 0.78; P<0.001). The lower incidence of readmission or death in the chemoprevention group than in the placebo group was restricted to the intervention period (week 3 through week 14) (hazard ratio, 0.30; 95% CI, 0.22 to 0.42) and was not sustained after that time (week 15 through week 26) (hazard ratio, 1.13; 95% CI, 0.87 to 1.47). No serious adverse events were attributed to dihydroartemisinin-piperaquine. CONCLUSIONS In areas with intense malaria transmission, 3 months of postdischarge malaria chemoprevention with monthly dihydroartemisinin-piperaquine in children who had recently received treatment for severe anemia prevented more deaths or readmissions for any reason after discharge than placebo. (Funded by the Research Council of Norway and the Centers for Disease Control and Prevention; ClinicalTrials.gov number, NCT02671175.).
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Affiliation(s)
- Titus K Kwambai
- From the Centre for Global Health Research, Kenya Medical Research Institute (T.K.K., S.K., N.A.K., E.D.O., K.O., F.O.K.), and the Kisumu County Department of Health, Kenya Ministry of Health (T.K.K.) and the Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention (CDC) (A.M.S., M.R.D.) - all in Kisumu; the Department of Clinical Sciences, Liverpool School of Tropical Medicine (T.K.K., V.W., D.W., F.O.K.), and the Department of Biostatistics, University of Liverpool (V.W.), Liverpool, United Kingdom; Makerere University College of Health Sciences, Kampala, Uganda (A.D., R.I., R.O.); the Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, CDC, Atlanta (A.M.S., M.R.D.); Emma Children's Hospital, Academic Medical Center, University of Amsterdam, Amsterdam (M.B.H.); the Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis (C.C.J.); the Section for Ethics and Health Economics and the Center for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway (B.R.); and the School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre (K.S.P.)
| | - Aggrey Dhabangi
- From the Centre for Global Health Research, Kenya Medical Research Institute (T.K.K., S.K., N.A.K., E.D.O., K.O., F.O.K.), and the Kisumu County Department of Health, Kenya Ministry of Health (T.K.K.) and the Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention (CDC) (A.M.S., M.R.D.) - all in Kisumu; the Department of Clinical Sciences, Liverpool School of Tropical Medicine (T.K.K., V.W., D.W., F.O.K.), and the Department of Biostatistics, University of Liverpool (V.W.), Liverpool, United Kingdom; Makerere University College of Health Sciences, Kampala, Uganda (A.D., R.I., R.O.); the Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, CDC, Atlanta (A.M.S., M.R.D.); Emma Children's Hospital, Academic Medical Center, University of Amsterdam, Amsterdam (M.B.H.); the Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis (C.C.J.); the Section for Ethics and Health Economics and the Center for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway (B.R.); and the School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre (K.S.P.)
| | - Richard Idro
- From the Centre for Global Health Research, Kenya Medical Research Institute (T.K.K., S.K., N.A.K., E.D.O., K.O., F.O.K.), and the Kisumu County Department of Health, Kenya Ministry of Health (T.K.K.) and the Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention (CDC) (A.M.S., M.R.D.) - all in Kisumu; the Department of Clinical Sciences, Liverpool School of Tropical Medicine (T.K.K., V.W., D.W., F.O.K.), and the Department of Biostatistics, University of Liverpool (V.W.), Liverpool, United Kingdom; Makerere University College of Health Sciences, Kampala, Uganda (A.D., R.I., R.O.); the Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, CDC, Atlanta (A.M.S., M.R.D.); Emma Children's Hospital, Academic Medical Center, University of Amsterdam, Amsterdam (M.B.H.); the Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis (C.C.J.); the Section for Ethics and Health Economics and the Center for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway (B.R.); and the School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre (K.S.P.)
| | - Robert Opoka
- From the Centre for Global Health Research, Kenya Medical Research Institute (T.K.K., S.K., N.A.K., E.D.O., K.O., F.O.K.), and the Kisumu County Department of Health, Kenya Ministry of Health (T.K.K.) and the Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention (CDC) (A.M.S., M.R.D.) - all in Kisumu; the Department of Clinical Sciences, Liverpool School of Tropical Medicine (T.K.K., V.W., D.W., F.O.K.), and the Department of Biostatistics, University of Liverpool (V.W.), Liverpool, United Kingdom; Makerere University College of Health Sciences, Kampala, Uganda (A.D., R.I., R.O.); the Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, CDC, Atlanta (A.M.S., M.R.D.); Emma Children's Hospital, Academic Medical Center, University of Amsterdam, Amsterdam (M.B.H.); the Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis (C.C.J.); the Section for Ethics and Health Economics and the Center for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway (B.R.); and the School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre (K.S.P.)
| | - Victoria Watson
- From the Centre for Global Health Research, Kenya Medical Research Institute (T.K.K., S.K., N.A.K., E.D.O., K.O., F.O.K.), and the Kisumu County Department of Health, Kenya Ministry of Health (T.K.K.) and the Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention (CDC) (A.M.S., M.R.D.) - all in Kisumu; the Department of Clinical Sciences, Liverpool School of Tropical Medicine (T.K.K., V.W., D.W., F.O.K.), and the Department of Biostatistics, University of Liverpool (V.W.), Liverpool, United Kingdom; Makerere University College of Health Sciences, Kampala, Uganda (A.D., R.I., R.O.); the Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, CDC, Atlanta (A.M.S., M.R.D.); Emma Children's Hospital, Academic Medical Center, University of Amsterdam, Amsterdam (M.B.H.); the Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis (C.C.J.); the Section for Ethics and Health Economics and the Center for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway (B.R.); and the School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre (K.S.P.)
| | - Simon Kariuki
- From the Centre for Global Health Research, Kenya Medical Research Institute (T.K.K., S.K., N.A.K., E.D.O., K.O., F.O.K.), and the Kisumu County Department of Health, Kenya Ministry of Health (T.K.K.) and the Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention (CDC) (A.M.S., M.R.D.) - all in Kisumu; the Department of Clinical Sciences, Liverpool School of Tropical Medicine (T.K.K., V.W., D.W., F.O.K.), and the Department of Biostatistics, University of Liverpool (V.W.), Liverpool, United Kingdom; Makerere University College of Health Sciences, Kampala, Uganda (A.D., R.I., R.O.); the Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, CDC, Atlanta (A.M.S., M.R.D.); Emma Children's Hospital, Academic Medical Center, University of Amsterdam, Amsterdam (M.B.H.); the Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis (C.C.J.); the Section for Ethics and Health Economics and the Center for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway (B.R.); and the School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre (K.S.P.)
| | - Nickline A Kuya
- From the Centre for Global Health Research, Kenya Medical Research Institute (T.K.K., S.K., N.A.K., E.D.O., K.O., F.O.K.), and the Kisumu County Department of Health, Kenya Ministry of Health (T.K.K.) and the Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention (CDC) (A.M.S., M.R.D.) - all in Kisumu; the Department of Clinical Sciences, Liverpool School of Tropical Medicine (T.K.K., V.W., D.W., F.O.K.), and the Department of Biostatistics, University of Liverpool (V.W.), Liverpool, United Kingdom; Makerere University College of Health Sciences, Kampala, Uganda (A.D., R.I., R.O.); the Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, CDC, Atlanta (A.M.S., M.R.D.); Emma Children's Hospital, Academic Medical Center, University of Amsterdam, Amsterdam (M.B.H.); the Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis (C.C.J.); the Section for Ethics and Health Economics and the Center for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway (B.R.); and the School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre (K.S.P.)
| | - Eric D Onyango
- From the Centre for Global Health Research, Kenya Medical Research Institute (T.K.K., S.K., N.A.K., E.D.O., K.O., F.O.K.), and the Kisumu County Department of Health, Kenya Ministry of Health (T.K.K.) and the Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention (CDC) (A.M.S., M.R.D.) - all in Kisumu; the Department of Clinical Sciences, Liverpool School of Tropical Medicine (T.K.K., V.W., D.W., F.O.K.), and the Department of Biostatistics, University of Liverpool (V.W.), Liverpool, United Kingdom; Makerere University College of Health Sciences, Kampala, Uganda (A.D., R.I., R.O.); the Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, CDC, Atlanta (A.M.S., M.R.D.); Emma Children's Hospital, Academic Medical Center, University of Amsterdam, Amsterdam (M.B.H.); the Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis (C.C.J.); the Section for Ethics and Health Economics and the Center for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway (B.R.); and the School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre (K.S.P.)
| | - Kephas Otieno
- From the Centre for Global Health Research, Kenya Medical Research Institute (T.K.K., S.K., N.A.K., E.D.O., K.O., F.O.K.), and the Kisumu County Department of Health, Kenya Ministry of Health (T.K.K.) and the Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention (CDC) (A.M.S., M.R.D.) - all in Kisumu; the Department of Clinical Sciences, Liverpool School of Tropical Medicine (T.K.K., V.W., D.W., F.O.K.), and the Department of Biostatistics, University of Liverpool (V.W.), Liverpool, United Kingdom; Makerere University College of Health Sciences, Kampala, Uganda (A.D., R.I., R.O.); the Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, CDC, Atlanta (A.M.S., M.R.D.); Emma Children's Hospital, Academic Medical Center, University of Amsterdam, Amsterdam (M.B.H.); the Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis (C.C.J.); the Section for Ethics and Health Economics and the Center for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway (B.R.); and the School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre (K.S.P.)
| | - Aaron M Samuels
- From the Centre for Global Health Research, Kenya Medical Research Institute (T.K.K., S.K., N.A.K., E.D.O., K.O., F.O.K.), and the Kisumu County Department of Health, Kenya Ministry of Health (T.K.K.) and the Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention (CDC) (A.M.S., M.R.D.) - all in Kisumu; the Department of Clinical Sciences, Liverpool School of Tropical Medicine (T.K.K., V.W., D.W., F.O.K.), and the Department of Biostatistics, University of Liverpool (V.W.), Liverpool, United Kingdom; Makerere University College of Health Sciences, Kampala, Uganda (A.D., R.I., R.O.); the Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, CDC, Atlanta (A.M.S., M.R.D.); Emma Children's Hospital, Academic Medical Center, University of Amsterdam, Amsterdam (M.B.H.); the Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis (C.C.J.); the Section for Ethics and Health Economics and the Center for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway (B.R.); and the School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre (K.S.P.)
| | - Meghna R Desai
- From the Centre for Global Health Research, Kenya Medical Research Institute (T.K.K., S.K., N.A.K., E.D.O., K.O., F.O.K.), and the Kisumu County Department of Health, Kenya Ministry of Health (T.K.K.) and the Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention (CDC) (A.M.S., M.R.D.) - all in Kisumu; the Department of Clinical Sciences, Liverpool School of Tropical Medicine (T.K.K., V.W., D.W., F.O.K.), and the Department of Biostatistics, University of Liverpool (V.W.), Liverpool, United Kingdom; Makerere University College of Health Sciences, Kampala, Uganda (A.D., R.I., R.O.); the Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, CDC, Atlanta (A.M.S., M.R.D.); Emma Children's Hospital, Academic Medical Center, University of Amsterdam, Amsterdam (M.B.H.); the Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis (C.C.J.); the Section for Ethics and Health Economics and the Center for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway (B.R.); and the School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre (K.S.P.)
| | - Michael Boele van Hensbroek
- From the Centre for Global Health Research, Kenya Medical Research Institute (T.K.K., S.K., N.A.K., E.D.O., K.O., F.O.K.), and the Kisumu County Department of Health, Kenya Ministry of Health (T.K.K.) and the Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention (CDC) (A.M.S., M.R.D.) - all in Kisumu; the Department of Clinical Sciences, Liverpool School of Tropical Medicine (T.K.K., V.W., D.W., F.O.K.), and the Department of Biostatistics, University of Liverpool (V.W.), Liverpool, United Kingdom; Makerere University College of Health Sciences, Kampala, Uganda (A.D., R.I., R.O.); the Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, CDC, Atlanta (A.M.S., M.R.D.); Emma Children's Hospital, Academic Medical Center, University of Amsterdam, Amsterdam (M.B.H.); the Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis (C.C.J.); the Section for Ethics and Health Economics and the Center for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway (B.R.); and the School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre (K.S.P.)
| | - Duolao Wang
- From the Centre for Global Health Research, Kenya Medical Research Institute (T.K.K., S.K., N.A.K., E.D.O., K.O., F.O.K.), and the Kisumu County Department of Health, Kenya Ministry of Health (T.K.K.) and the Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention (CDC) (A.M.S., M.R.D.) - all in Kisumu; the Department of Clinical Sciences, Liverpool School of Tropical Medicine (T.K.K., V.W., D.W., F.O.K.), and the Department of Biostatistics, University of Liverpool (V.W.), Liverpool, United Kingdom; Makerere University College of Health Sciences, Kampala, Uganda (A.D., R.I., R.O.); the Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, CDC, Atlanta (A.M.S., M.R.D.); Emma Children's Hospital, Academic Medical Center, University of Amsterdam, Amsterdam (M.B.H.); the Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis (C.C.J.); the Section for Ethics and Health Economics and the Center for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway (B.R.); and the School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre (K.S.P.)
| | - Chandy C John
- From the Centre for Global Health Research, Kenya Medical Research Institute (T.K.K., S.K., N.A.K., E.D.O., K.O., F.O.K.), and the Kisumu County Department of Health, Kenya Ministry of Health (T.K.K.) and the Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention (CDC) (A.M.S., M.R.D.) - all in Kisumu; the Department of Clinical Sciences, Liverpool School of Tropical Medicine (T.K.K., V.W., D.W., F.O.K.), and the Department of Biostatistics, University of Liverpool (V.W.), Liverpool, United Kingdom; Makerere University College of Health Sciences, Kampala, Uganda (A.D., R.I., R.O.); the Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, CDC, Atlanta (A.M.S., M.R.D.); Emma Children's Hospital, Academic Medical Center, University of Amsterdam, Amsterdam (M.B.H.); the Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis (C.C.J.); the Section for Ethics and Health Economics and the Center for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway (B.R.); and the School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre (K.S.P.)
| | - Bjarne Robberstad
- From the Centre for Global Health Research, Kenya Medical Research Institute (T.K.K., S.K., N.A.K., E.D.O., K.O., F.O.K.), and the Kisumu County Department of Health, Kenya Ministry of Health (T.K.K.) and the Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention (CDC) (A.M.S., M.R.D.) - all in Kisumu; the Department of Clinical Sciences, Liverpool School of Tropical Medicine (T.K.K., V.W., D.W., F.O.K.), and the Department of Biostatistics, University of Liverpool (V.W.), Liverpool, United Kingdom; Makerere University College of Health Sciences, Kampala, Uganda (A.D., R.I., R.O.); the Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, CDC, Atlanta (A.M.S., M.R.D.); Emma Children's Hospital, Academic Medical Center, University of Amsterdam, Amsterdam (M.B.H.); the Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis (C.C.J.); the Section for Ethics and Health Economics and the Center for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway (B.R.); and the School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre (K.S.P.)
| | - Kamija S Phiri
- From the Centre for Global Health Research, Kenya Medical Research Institute (T.K.K., S.K., N.A.K., E.D.O., K.O., F.O.K.), and the Kisumu County Department of Health, Kenya Ministry of Health (T.K.K.) and the Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention (CDC) (A.M.S., M.R.D.) - all in Kisumu; the Department of Clinical Sciences, Liverpool School of Tropical Medicine (T.K.K., V.W., D.W., F.O.K.), and the Department of Biostatistics, University of Liverpool (V.W.), Liverpool, United Kingdom; Makerere University College of Health Sciences, Kampala, Uganda (A.D., R.I., R.O.); the Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, CDC, Atlanta (A.M.S., M.R.D.); Emma Children's Hospital, Academic Medical Center, University of Amsterdam, Amsterdam (M.B.H.); the Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis (C.C.J.); the Section for Ethics and Health Economics and the Center for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway (B.R.); and the School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre (K.S.P.)
| | - Feiko O Ter Kuile
- From the Centre for Global Health Research, Kenya Medical Research Institute (T.K.K., S.K., N.A.K., E.D.O., K.O., F.O.K.), and the Kisumu County Department of Health, Kenya Ministry of Health (T.K.K.) and the Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention (CDC) (A.M.S., M.R.D.) - all in Kisumu; the Department of Clinical Sciences, Liverpool School of Tropical Medicine (T.K.K., V.W., D.W., F.O.K.), and the Department of Biostatistics, University of Liverpool (V.W.), Liverpool, United Kingdom; Makerere University College of Health Sciences, Kampala, Uganda (A.D., R.I., R.O.); the Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, CDC, Atlanta (A.M.S., M.R.D.); Emma Children's Hospital, Academic Medical Center, University of Amsterdam, Amsterdam (M.B.H.); the Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis (C.C.J.); the Section for Ethics and Health Economics and the Center for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway (B.R.); and the School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre (K.S.P.)
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Smit MR, Ochomo EO, Aljayyoussi G, Kwambai TK, Abong'o BO, Bousema T, Waterhouse D, Bayoh NM, Gimnig JE, Samuels AM, Desai MR, Phillips-Howard PA, Kariuki SK, Wang D, Ward SA, Ter Kuile FO. Human Direct Skin Feeding Versus Membrane Feeding to Assess the Mosquitocidal Efficacy of High-Dose Ivermectin (IVERMAL Trial). Clin Infect Dis 2020; 69:1112-1119. [PMID: 30590537 PMCID: PMC6743833 DOI: 10.1093/cid/ciy1063] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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: 09/03/2018] [Accepted: 12/20/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Ivermectin is being considered for mass drug administration for malaria, due to its ability to kill mosquitoes feeding on recently treated individuals. In a recent trial, 3-day courses of 300 and 600 mcg/kg/day were shown to kill Anopheles mosquitoes for at least 28 days post-treatment when fed patients' venous blood using membrane feeding assays. Direct skin feeding on humans may lead to higher mosquito mortality, as ivermectin capillary concentrations are higher. We compared mosquito mortality following direct skin and membrane feeding. METHODS We conducted a mosquito feeding study, nested within a randomized, double-blind, placebo-controlled trial of 141 adults with uncomplicated malaria in Kenya, comparing 3 days of ivermectin 300 mcg/kg/day, ivermectin 600 mcg/kg/day, or placebo, all co-administered with 3 days of dihydroartemisinin-piperaquine. On post-treatment day 7, direct skin and membrane feeding assays were conducted using laboratory-reared Anopheles gambiae sensu stricto. Mosquito survival was assessed daily for 28 days post-feeding. RESULTS Between July 20, 2015, and May 7, 2016, 69 of 141 patients participated in both direct skin and membrane feeding (placebo, n = 23; 300 mcg/kg/day, n = 24; 600 mcg/kg/day, n = 22). The 14-day post-feeding mortality for mosquitoes fed 7 days post-treatment on blood from pooled patients in both ivermectin arms was similar with direct skin feeding (mosquitoes observed, n = 2941) versus membrane feeding (mosquitoes observed, n = 7380): cumulative mortality (risk ratio 0.99, 95% confidence interval [CI] 0.95-1.03, P = .69) and survival time (hazard ratio 0.96, 95% CI 0.91-1.02, P = .19). Results were consistent by sex, by body mass index, and across the range of ivermectin capillary concentrations studied (0.72-73.9 ng/mL). CONCLUSIONS Direct skin feeding and membrane feeding on day 7 resulted in similar mosquitocidal effects of ivermectin across a wide range of drug concentrations, suggesting that the mosquitocidal effects seen with membrane feeding accurately reflect those of natural biting. Membrane feeding, which is more patient friendly and ethically acceptable, can likely reliably be used to assess ivermectin's mosquitocidal efficacy. CLINICAL TRIALS REGISTRATION NCT02511353.
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Affiliation(s)
- Menno R Smit
- Liverpool School of Tropical Medicine, United Kingdom
| | - Eric O Ochomo
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu
| | | | - Titus K Kwambai
- Liverpool School of Tropical Medicine, United Kingdom.,Kenya Medical Research Institute, Centre for Global Health Research, Kisumu.,Kenya Ministry of Health, Kisumu County, Kisumu
| | - Bernard O Abong'o
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu
| | - Teun Bousema
- Radboud University Medical Center, Nijmegen, The Netherlands.,London School of Hygiene and Tropical Medicine, United Kingdom
| | | | - Nabie M Bayoh
- US Centers for Disease Control and Prevention, Center for Global Health, Division of Parasitic Diseases and Malaria, Atlanta, Georgia
| | - John E Gimnig
- US Centers for Disease Control and Prevention, Center for Global Health, Division of Parasitic Diseases and Malaria, Atlanta, Georgia
| | - Aaron M Samuels
- US Centers for Disease Control and Prevention, Center for Global Health, Division of Parasitic Diseases and Malaria, Atlanta, Georgia
| | - Meghna R Desai
- US Centers for Disease Control and Prevention, Center for Global Health, Division of Parasitic Diseases and Malaria, Atlanta, Georgia
| | | | - Simon K Kariuki
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu
| | - Duolao Wang
- Liverpool School of Tropical Medicine, United Kingdom
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13
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Stepniewska K, Humphreys GS, Gonçalves BP, Craig E, Gosling R, Guerin PJ, Price RN, Barnes KI, Raman J, Smit MR, D’Alessandro U, Stone WJR, Bjorkman A, Samuels AM, Arroyo-Arroyo MI, Bastiaens GJH, Brown JM, Dicko A, El-Sayed BB, Elzaki SEG, Eziefula AC, Kariuki S, Kwambai TK, Maestre AE, Martensson A, Mosha D, Mwaiswelo RO, Ngasala BE, Okebe J, Roh ME, Sawa P, Tiono AB, Chen I, Drakeley CJ, Bousema T. Efficacy of Single-Dose Primaquine With Artemisinin Combination Therapy on Plasmodium falciparum Gametocytes and Transmission: An Individual Patient Meta-Analysis. J Infect Dis 2020; 225:1215-1226. [PMID: 32778875 PMCID: PMC8974839 DOI: 10.1093/infdis/jiaa498] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [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: 03/20/2020] [Accepted: 08/06/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Since the World Health Organization recommended single low-dose (0.25 mg/kg) primaquine (PQ) in combination with artemisinin-based combination therapies (ACTs) in areas of low transmission or artemisinin-resistant Plasmodium falciparum, several single-site studies have been conducted to assess efficacy. METHODS An individual patient meta-analysis to assess gametocytocidal and transmission-blocking efficacy of PQ in combination with different ACTs was conducted. Random effects logistic regression was used to quantify PQ effect on (1) gametocyte carriage in the first 2 weeks post treatment; and (2) the probability of infecting at least 1 mosquito or of a mosquito becoming infected. RESULTS In 2574 participants from 14 studies, PQ reduced PCR-determined gametocyte carriage on days 7 and 14, most apparently in patients presenting with gametocytemia on day 0 (odds ratio [OR], 0.22; 95% confidence interval [CI], .17-.28 and OR, 0.12; 95% CI, .08-.16, respectively). Rate of decline in gametocyte carriage was faster when PQ was combined with artemether-lumefantrine (AL) compared to dihydroartemisinin-piperaquine (DP) (P = .010 for day 7). Addition of 0.25 mg/kg PQ was associated with near complete prevention of transmission to mosquitoes. CONCLUSIONS Transmission blocking is achieved with 0.25 mg/kg PQ. Gametocyte persistence and infectivity are lower when PQ is combined with AL compared to DP.
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Affiliation(s)
- Kasia Stepniewska
- WorldWide Antimalarial Resistance Network, Oxford, United Kingdom,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom,Infectious Diseases Data Observatory, Oxford, United Kingdom,Kasia Stepniewska, PhD, WorldWide Antimalarial Resistance Network (WWARN), Centre for Tropical Medicine and Global Health, Churchill Hospital, CCVTM, University of Oxford, Old Road, Oxford OX3 7LE, UK
| | - Georgina S Humphreys
- WorldWide Antimalarial Resistance Network, Oxford, United Kingdom,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom,Infectious Diseases Data Observatory, Oxford, United Kingdom,Green Templeton College, University of Oxford, Oxford, United Kingdom
| | - Bronner P Gonçalves
- Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Elaine Craig
- WorldWide Antimalarial Resistance Network, Oxford, United Kingdom,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom,Infectious Diseases Data Observatory, Oxford, United Kingdom
| | - Roly Gosling
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA,Global Health Group, Malaria Elimination Initiative, University of California, San Francisco, California, USA
| | - Philippe J Guerin
- WorldWide Antimalarial Resistance Network, Oxford, United Kingdom,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom,Infectious Diseases Data Observatory, Oxford, United Kingdom
| | - Ric N Price
- WorldWide Antimalarial Resistance Network, Oxford, United Kingdom,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom,Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Norther Territory, Australia,Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Karen I Barnes
- WorldWide Antimalarial Resistance Network, Oxford, United Kingdom,University of Cape Town/Medical Research Council Collaborating Centre for Optimising Antimalarial Therapy, University of Cape Town, Cape Town, South Africa,Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Jaishree Raman
- University of Cape Town/Medical Research Council Collaborating Centre for Optimising Antimalarial Therapy, University of Cape Town, Cape Town, South Africa,Centre for Emerging Zoonotic and Parasitic Diseases, National Institute for Communicable Diseases, National Health Laboratory Services, Johannesburg, South Africa,Wits Research Institute for Malaria, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Menno R Smit
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Umberto D’Alessandro
- Medical Research Council Unit The Gambia, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Will J R Stone
- Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, London, United Kingdom,Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Anders Bjorkman
- Department of Microbiology Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Aaron M Samuels
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA,Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Maria I Arroyo-Arroyo
- Grupo Salud y Comunidad, Facultad de Medicina, Universidad de Antioquia, Medellin, Colombia
| | - Guido J H Bastiaens
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, the Netherlands,Department of Microbiology and Immunology, Rijnstate Hospital, Arnhem, the Netherlands
| | - Joelle M Brown
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Alassane Dicko
- Malaria Research and Training Centre, Faculty of Pharmacy and Faculty of Medicine and Dentistry, University of Science, Techniques, and Technologies of Bamako, Bamako, Mali
| | - Badria B El-Sayed
- Tropical Medicine Research Institute, National Centre for Research, Khartoum, Sudan
| | - Salah-Eldin G Elzaki
- Tropical Medicine Research Institute, National Centre for Research, Khartoum, Sudan
| | - Alice C Eziefula
- Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, London, United Kingdom,Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, United Kingdom
| | | | - Titus K Kwambai
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom,Kenya Medical Research Institute, Kisian, Kenya
| | - Amanda E Maestre
- Grupo Salud y Comunidad, Facultad de Medicina, Universidad de Antioquia, Medellin, Colombia
| | - Andreas Martensson
- Department of Women’s and Children’s Health, International Maternal and Child Health, Uppsala University, Uppsala, Sweden
| | - Dominic Mosha
- Bagamoyo Research and Training Centre, Ifakara Health Institute, Bagamoyo, Tanzania,Africa Academy for Public Health, Dar es Salaam, Tanzania
| | - Richard O Mwaiswelo
- Department of Parasitology and Medical Entomology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Billy E Ngasala
- Department of Parasitology and Medical Entomology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Joseph Okebe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Michelle E Roh
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA,Global Health Group, Malaria Elimination Initiative, University of California, San Francisco, California, USA
| | - Patrick Sawa
- Human Health Division, International Centre for Insect Physiology and Ecology, Mbita Point, Kenya
| | - Alfred B Tiono
- Department of Biomedical Sciences, Centre National de Recherche et de Formation sur le Paludisme, Ouagadougou, Burkina Faso
| | - Ingrid Chen
- Global Health Group, Malaria Elimination Initiative, University of California, San Francisco, California, USA
| | - Chris J Drakeley
- Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Teun Bousema
- Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, London, United Kingdom,Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, the Netherlands,Correspondence: Teun Bousema, PhD, Department of Medical Microbiology, Radboud Institute for Health Science, Radboudumc, PO Box 9101, 6500 HB Nijmegen, The Netherlands ()
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14
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Kwambai TK, Dhabangi A, Idro R, Opoka R, Kariuki S, Samuels AM, Desai M, van Hensbroek MB, John CC, Robberstad B, Wang D, Phiri K, Ter Kuile FO. Malaria chemoprevention with monthly dihydroartemisinin-piperaquine for the post-discharge management of severe anaemia in children aged less than 5 years in Uganda and Kenya: study protocol for a multi-centre, two-arm, randomised, placebo-controlled, superiority trial. Trials 2018; 19:610. [PMID: 30400934 PMCID: PMC6220494 DOI: 10.1186/s13063-018-2972-1] [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: 04/19/2018] [Accepted: 10/08/2018] [Indexed: 01/02/2023] Open
Abstract
Background Children hospitalised with severe anaemia in malaria endemic areas in Africa are at high risk of readmission or death within 6 months post-discharge. Currently, no strategy specifically addresses this period. In Malawi, 3 months of post-discharge malaria chemoprevention (PMC) with monthly treatment courses of artemether-lumefantrine given at discharge and at 1 and 2 months prevented 30% of all-cause readmissions by 6 months post-discharge. Another efficacy trial is needed before a policy of malaria chemoprevention can be considered for the post-discharge management of severe anaemia in children under 5 years of age living in malaria endemic areas. Objective We aim to determine if 3 months of PMC with monthly 3-day treatment courses of dihydroartemisinin-piperaquine is safe and superior to a single 3-day treatment course with artemether-lumefantrine provided as part of standard in-hospital care in reducing all-cause readmissions and deaths (composite primary endpoint) by 6 months in the post-discharge management of children less than 5 years of age admitted with severe anaemia of any or undetermined cause. Methods/design This is a multi-centre, two-arm, placebo-controlled, individually randomised trial in children under 5 years of age recently discharged following management for severe anaemia. Children in both arms will receive standard in-hospital care for severe anaemia and a 3-day course of artemether-lumefantrine at discharge. At 2 weeks after discharge, surviving children will be randomised to receive either 3-day courses of dihydroartemisinin-piperaquine at 2, 6 and 10 weeks or an identical placebo and followed for 26 weeks through passive case detection. The trial will be conducted in hospitals in malaria endemic areas in Kenya and Uganda. The study is designed to detect a 25% reduction in the incidence of all-cause readmissions or death (composite primary outcome) from 1152 to 864 per 1000 child years (power 80%, α = 0.05) and requires 520 children per arm (1040 total children). Results Participant recruitment started in May 2016 and is ongoing. Trial registration ClinicalTrials.gov, NCT02671175. Registered on 28 January 2016. Electronic supplementary material The online version of this article (10.1186/s13063-018-2972-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Titus K Kwambai
- Kenya Medical Research Institute (KEMRI), Centre for Global Health Research (CGHR), PO Box 1578, Kisumu, 40100, Kenya. .,Kisumu County Department of Health, Kenya Ministry of Health, Kisumu, Kenya. .,Department of Clinical Sciences, Liverpool School of Tropical Medicine (LSTM), Liverpool, UK.
| | - Aggrey Dhabangi
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Richard Idro
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Robert Opoka
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Simon Kariuki
- Kenya Medical Research Institute (KEMRI), Centre for Global Health Research (CGHR), PO Box 1578, Kisumu, 40100, Kenya
| | - Aaron M Samuels
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Meghna Desai
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Michael Boele van Hensbroek
- Department of Global Child Health, Emma Children's Hospital Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Chandy C John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Bjarne Robberstad
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine (LSTM), Liverpool, UK
| | - Kamija Phiri
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Feiko O Ter Kuile
- Kenya Medical Research Institute (KEMRI), Centre for Global Health Research (CGHR), PO Box 1578, Kisumu, 40100, Kenya.,Department of Clinical Sciences, Liverpool School of Tropical Medicine (LSTM), Liverpool, UK
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15
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Smit MR, Ochomo EO, Waterhouse D, Kwambai TK, Abong'o BO, Bousema T, Bayoh NM, Gimnig JE, Samuels AM, Desai MR, Phillips-Howard PA, Kariuki SK, Wang D, Ter Kuile FO, Ward SA, Aljayyoussi G. Pharmacokinetics-Pharmacodynamics of High-Dose Ivermectin with Dihydroartemisinin-Piperaquine on Mosquitocidal Activity and QT-Prolongation (IVERMAL). Clin Pharmacol Ther 2018; 105:388-401. [PMID: 30125353 PMCID: PMC6585895 DOI: 10.1002/cpt.1219] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [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: 03/21/2018] [Accepted: 08/05/2018] [Indexed: 12/26/2022]
Abstract
High‐dose ivermectin, co‐administered for 3 days with dihydroartemisinin‐piperaquine (DP), killed mosquitoes feeding on individuals for at least 28 days posttreatment in a recent trial (IVERMAL), whereas 7 days was predicted pretrial. The current study assessed the relationship between ivermectin blood concentrations and the observed mosquitocidal effects against Anopheles gambiae s.s. Three days of ivermectin 0, 300, or 600 mcg/kg/day plus DP was randomly assigned to 141 adults with uncomplicated malaria in Kenya. During 28 days of follow‐up, 1,393 venous and 335 paired capillary plasma samples, 850 mosquito‐cluster mortality rates, and 524 QTcF‐intervals were collected. Using pharmacokinetic/pharmacodynamic (PK/PD) modeling, we show a consistent correlation between predicted ivermectin concentrations and observed mosquitocidal‐effects throughout the 28‐day study duration, without invoking an unidentified mosquitocidal metabolite or drug‐drug interaction. Ivermectin had no effect on piperaquine's PKs or QTcF‐prolongation. The PK/PD model can be used to design new treatment regimens with predicted mosquitocidal effect. This methodology could be used to evaluate effectiveness of other endectocides.
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Affiliation(s)
- Menno R Smit
- Liverpool School of Tropical Medicine (LSTM), Liverpool, UK
| | - Eric O Ochomo
- Kenya Medical Research Institute (KEMRI), Centre for Global Health Research, Kisumu, Kenya
| | | | - Titus K Kwambai
- Liverpool School of Tropical Medicine (LSTM), Liverpool, UK.,Kenya Medical Research Institute (KEMRI), Centre for Global Health Research, Kisumu, Kenya.,Kenya Ministry of Health (MoH), Kisumu County, Kisumu, Kenya
| | - Bernard O Abong'o
- Kenya Medical Research Institute (KEMRI), Centre for Global Health Research, Kisumu, Kenya
| | - Teun Bousema
- Radboud University Nijmegen Medical Center (Radboud), Nijmegen, The Netherlands.,London School of Hygiene and Tropical Medicine (LSHTM), London, UK
| | - Nabie M Bayoh
- US Centers for Disease Control and Prevention (CDC), Center for Global Health, Division of Parasitic Diseases and Malaria, Atlanta, Georgia, USA
| | - John E Gimnig
- US Centers for Disease Control and Prevention (CDC), Center for Global Health, Division of Parasitic Diseases and Malaria, Atlanta, Georgia, USA
| | - Aaron M Samuels
- US Centers for Disease Control and Prevention (CDC), Center for Global Health, Division of Parasitic Diseases and Malaria, Atlanta, Georgia, USA
| | - Meghna R Desai
- US Centers for Disease Control and Prevention (CDC), Center for Global Health, Division of Parasitic Diseases and Malaria, Atlanta, Georgia, USA
| | | | - Simon K Kariuki
- Kenya Medical Research Institute (KEMRI), Centre for Global Health Research, Kisumu, Kenya
| | - Duolao Wang
- Liverpool School of Tropical Medicine (LSTM), Liverpool, UK
| | | | - Stephen A Ward
- Liverpool School of Tropical Medicine (LSTM), Liverpool, UK
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16
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Smit MR, Ochomo EO, Aljayyoussi G, Kwambai TK, Abong'o BO, Chen T, Bousema T, Slater HC, Waterhouse D, Bayoh NM, Gimnig JE, Samuels AM, Desai MR, Phillips-Howard PA, Kariuki SK, Wang D, Ward SA, Ter Kuile FO. Safety and mosquitocidal efficacy of high-dose ivermectin when co-administered with dihydroartemisinin-piperaquine in Kenyan adults with uncomplicated malaria (IVERMAL): a randomised, double-blind, placebo-controlled trial. Lancet Infect Dis 2018; 18:615-626. [PMID: 29602751 DOI: 10.1016/s1473-3099(18)30163-4] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 02/09/2018] [Accepted: 02/14/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Ivermectin is being considered for mass drug administration for malaria due to its ability to kill mosquitoes feeding on recently treated individuals. However, standard, single doses of 150-200 μg/kg used for onchocerciasis and lymphatic filariasis have a short-lived mosquitocidal effect (<7 days). Because ivermectin is well tolerated up to 2000 μg/kg, we aimed to establish the safety, tolerability, and mosquitocidal efficacy of 3 day courses of high-dose ivermectin, co-administered with a standard malaria treatment. METHODS We did a randomised, double-blind, placebo-controlled, superiority trial at the Jaramogi Oginga Odinga Teaching and Referral Hospital (Kisumu, Kenya). Adults (aged 18-50 years) were eligible if they had confirmed symptomatic uncomplicated Plasmodium falciparum malaria and agreed to the follow-up schedule. Participants were randomly assigned (1:1:1) using sealed envelopes, stratified by sex and body-mass index (men: <21 vs ≥21 kg/m2; women: <23 vs ≥23 kg/m2), with permuted blocks of three, to receive 3 days of ivermectin 300 μg/kg per day, ivermectin 600 μg/kg per day, or placebo, all co-administered with 3 days of dihydroartemisinin-piperaquine. Blood of patients taken on post-treatment days 0, 2 + 4 h, 7, 10, 14, 21, and 28 was fed to laboratory-reared Anopheles gambiae sensu stricto mosquitoes, and mosquito survival was assessed daily for 28 days after feeding. The primary outcome was 14-day cumulative mortality of mosquitoes fed 7 days after ivermectin treatment (from participants who received at least one dose of study medication). The study is registered with ClinicalTrials.gov, number NCT02511353. FINDINGS Between July 20, 2015, and May 7, 2016, 741 adults with malaria were assessed for eligibility, of whom 141 were randomly assigned to receive ivermectin 600 μg/kg per day (n=47), ivermectin 300 μg/kg per day (n=48), or placebo (n=46). 128 patients (91%) attended the primary outcome visit 7 days post treatment. Compared with placebo, ivermectin was associated with higher 14 day post-feeding mosquito mortality when fed on blood taken 7 days post treatment (ivermectin 600 μg/kg per day risk ratio [RR] 2·26, 95% CI 1·93-2·65, p<0·0001; hazard ratio [HR] 6·32, 4·61-8·67, p<0·0001; ivermectin 300 μg/kg per day RR 2·18, 1·86-2·57, p<0·0001; HR 4·21, 3·06-5·79, p<0·0001). Mosquito mortality remained significantly increased 28 days post treatment (ivermectin 600 μg/kg per day RR 1·23, 1·01-1·50, p=0·0374; and ivermectin 300 μg/kg per day 1·21, 1·01-1·44, p=0·0337). Five (11%) of 45 patients receiving ivermectin 600 μg/kg per day, two (4%) of 48 patients receiving ivermectin 300 μg/kg per day, and none of 46 patients receiving placebo had one or more treatment-related adverse events. INTERPRETATION Ivermectin at both doses assessed was well tolerated and reduced mosquito survival for at least 28 days after treatment. Ivermectin 300 μg/kg per day for 3 days provided a good balance between efficacy and tolerability, and this drug shows promise as a potential new tool for malaria elimination. FUNDING Malaria Eradication Scientific Alliance (MESA) and US Centers for Disease Control and Prevention (CDC).
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Affiliation(s)
- Menno R Smit
- Liverpool School of Tropical Medicine, Liverpool, UK.
| | - Eric O Ochomo
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | | | - Titus K Kwambai
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya; Kenya Ministry of Health, Kisumu County, Kisumu, Kenya
| | - Bernard O Abong'o
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Tao Chen
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Teun Bousema
- Radboud University Medical Center, Nijmegen, Netherlands; London School of Hygiene & Tropical Medicine, London, UK
| | - Hannah C Slater
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | | | - Nabie M Bayoh
- US Centers for Disease Control and Prevention, Center for Global Health, Division of Parasitic Diseases and Malaria, Atlanta, GA, USA
| | - John E Gimnig
- US Centers for Disease Control and Prevention, Center for Global Health, Division of Parasitic Diseases and Malaria, Atlanta, GA, USA
| | - Aaron M Samuels
- US Centers for Disease Control and Prevention, Center for Global Health, Division of Parasitic Diseases and Malaria, Atlanta, GA, USA
| | - Meghna R Desai
- US Centers for Disease Control and Prevention, Center for Global Health, Division of Parasitic Diseases and Malaria, Atlanta, GA, USA
| | | | - Simon K Kariuki
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Duolao Wang
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Steve A Ward
- Liverpool School of Tropical Medicine, Liverpool, UK
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17
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Kwambai TK, Dellicour S, Desai M, Ameh CA, Person B, Achieng F, Mason L, Laserson KF, ter Kuile FO. Perspectives of men on antenatal and delivery care service utilisation in rural western Kenya: a qualitative study. BMC Pregnancy Childbirth 2013; 13:134. [PMID: 23800139 PMCID: PMC3691751 DOI: 10.1186/1471-2393-13-134] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Accepted: 06/11/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Poor utilisation of facility-based antenatal and delivery care services in Kenya hampers reduction of maternal mortality. Studies suggest that the participation of men in antenatal and delivery care is associated with better health care seeking behaviour, yet many reproductive health programs do not facilitate their involvement. This qualitative study conducted in rural Western Kenya, explored men's perceptions of antenatal and delivery care services and identified factors that facilitated or constrained their involvement. METHODS Eight focus group discussions were conducted with 68 married men between 20-65 years of age in May 2011. Participants were of the Luo ethnic group residing in Asembo, western Kenya. The area has a high HIV-prevalence and polygamy is common. A topic guide was used to guide the discussions and a thematic framework approach for data analysis. RESULTS Overall, men were positive in their views of antenatal and delivery care, as decision makers they often encouraged, some even 'forced', their wives to attend for antenatal or delivery care. Many reasons why it was beneficial to accompany their wives were provided, yet few did this in practice unless there was a clinical complication. The three main barriers relating to cultural norms identified were: 1) pregnancy support was considered a female role; and the male role that of provider; 2) negative health care worker attitudes towards men's participation, and 3) couple unfriendly antenatal and delivery unit infrastructure. CONCLUSION Although men reported to facilitate their wives' utilisation of antenatal and delivery care services, this does not translate to practice as adherence to antenatal-care schedules and facility based delivery is generally poor. Equally, reasons proffered why they should accompany their wives are not carried through into practice, with barriers outweighing facilitators. Recommendations to improve men involvement and potentially increase services utilisation include awareness campaigns targeting men, exploring promotion of joint HIV testing and counselling, staff training, and design of couple friendly antenatal and delivery units.
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Affiliation(s)
- Titus K Kwambai
- KEMRI/CDC Research and Public Health Collaboration, Kisumu, Kenya
- Ministry of Public Health and Sanitation, Nairobi, Kenya
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Stephanie Dellicour
- KEMRI/CDC Research and Public Health Collaboration, Kisumu, Kenya
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Meghna Desai
- KEMRI/CDC Research and Public Health Collaboration, Kisumu, Kenya
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centre for Diseases Control and Prevention, Atlanta, GA, USA
| | | | - Bobbie Person
- National Centre for Emerging and Zoonotic Infectious Diseases, Centres for Disease Control and Prevention, Atlanta, GA, USA
| | - Florence Achieng
- KEMRI/CDC Research and Public Health Collaboration, Kisumu, Kenya
| | - Linda Mason
- Department of Public Health and Policy, University of Liverpool, Liverpool, UK
| | - Kayla F Laserson
- KEMRI/CDC Research and Public Health Collaboration, Kisumu, Kenya
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centre for Diseases Control and Prevention, Atlanta, GA, USA
- Center for Global Health, Centres for Disease Control and Prevention, Atlanta, GA, USA
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