Effect of Different Wall Surface Coverage With Deltamethrin-Treated Netting on the Reduction of Indoor-Biting Anopheles Mosquitoes (Diptera: Culicidae)

Indoor residual spray with deltamethrin remains the most common tool for reducing malaria transmission in Thailand. Deltamethrin is commonly used to spray the entire inner surfaces of the walls to prevent mosquitoes from resting. This study compared the mosquito landing responses on humans inside three experimental huts treated with deltamethrin at three different extents of wall coverage (25%, 50%, and full coverage), with one clean/untreated hut serving as a control. There were no significant differences between the numbers of Anopheles mosquitoes landing in the 50% and full coverage huts, whereas, in comparison to both of these, there was a significantly greater number landing in the 25% coverage hut. This study demonstrates that varying the percent coverage of indoor surfaces with deltamethrin-treated netting influences the blood-feeding success of wild Anopheles, and our findings suggest that it may be possible to reduce the extent of insecticide surface treatment while maintaining equivalent mosquito avoidance action to that seen in fully treated structures.

Insecticide-treated house screening protects against Zika-infected Aedes aegypti in Merida, Mexico

Background

The integration of house-screening and long-lasting insecticidal nets, known as insecticide-treated screening (ITS), can provide simple, safe, and low-tech Aedes aegypti control. Cluster randomised controlled trials in two endemic localities for Ae. aegypti of south Mexico, showed that ITS conferred both, immediate and sustained (~2 yr) impact on indoor-female Ae. aegypti infestations. Such encouraging results require further validation with studies quantifying more epidemiologically-related endpoints, including arbovirus infection in Ae. aegypti. We evaluated the efficacy of protecting houses with ITS on Ae. aegypti infestation and arbovirus infection during a Zika outbreak in Merida, Yucatan, Mexico.

Methodology/Principal findings

A two-arm cluster-randomised controlled trial evaluated the entomological efficacy of ITS compared to the absence of ITS (with both arms able to receive routine arbovirus vector control) in the neighbourhood Juan Pablo II of Merida. Cross-sectional entomological surveys quantified indoor adult mosquito infestation and arbovirus infection at baseline (pre-ITS installation) and throughout two post-intervention (PI) surveys spaced at 6-month intervals corresponding to dry/rainy seasons over one year (2016–2017). Household-surveys assessed the social reception of the intervention. Houses with ITS were 79–85% less infested with Aedes females than control houses up to one-year PI. A similar significant trend was observed for blood-fed Ae. aegypti females (76–82%). Houses with ITS had significantly less infected female Ae. aegypti than controls during the peak of the epidemic (OR = 0.15, 95%CI: 0.08–0.29), an effect that was significant up to a year PI (OR = 0.24, 0.15–0.39). Communities strongly accepted the intervention, due to its perceived mode of action, the prevalent risk for Aedes-borne diseases in the area, and the positive feedback from neighbours receiving ITS.

Conclusions/Significance

We show evidence of the protective efficacy of ITS against an arboviral disease of major relevance, and discuss the relevance of our findings for intervention adoption.

We evaluated the efficacy of protecting houses with insecticide-treated nets permanently fixed with aluminium frames on external doors and windows on Ae. aegypti infestation and arbovirus infection during a Zika outbreak in Merida, Yucatan, Mexico. Houses protected with screens were ≈80% less infested with Aedes females and very importantly, had significantly less infected female Ae. aegypti during the peak of the epidemic. Communities strongly accepted the intervention, due to its perceived mode of action, the prevalent risk for Aedes-borne diseases in the area, and the positive feedback from neighbours. House screening provides a simple, affordable sustainable method to reduce human-vector contact inside houses and can protect against dengue, chikungunya and Zika.

Malaria prevention and care seeking among gold miners in Guyana

Despite being a priority population in malaria elimination, there is scant literature on malaria-related behavior among gold miners. This study explores the prevalence and factors influencing malaria prevention, care seeking and treatment behaviors in Guyana gold mining camps. A cross sectional survey was conducted among adult gold miners living in mining camps in the hinterland Regions 1 (Barima-Waini), 7 (Cuyuni-Mazaruni), and 8 (Potaro-Siparuni). Multivariable logistic regressions explored factors associated with miners’ self-report of mosquito net use, prompt care-seeking; self-medication; and testing for malaria. A third of miners used a mosquito net the night preceding the survey and net use was higher among those who believed that net use was the norm in their camp (aOR: 3.11; 95% CI:1.65, 5.88). Less than half (45%) of miners had a fever in the past 12 months, among whom 36% sought care promptly, 48% tested positive for malaria while 54% self-medicated before seeking care. Prompt care-seeking was higher among miners with high malaria knowledge (aOR: 1.44; 95% CI: 1.01, 2.05). Similarly, testing rates increased with secondary education (aOR: 1.71; 95% CI: (1.16, 2.51), high malaria knowledge (aOR: 1.45; 95% CI: 1.02, 2.05), positive beliefs regarding malaria transmission, threat, self-diagnosis, testing and treatment, and, trust in government services (aOR: 1.59; 95% CI (1.12, 2.27) and experience of a prior malaria episode (aOR: 2.62; 95% CI: 1.71, 4.00). Self-medication was lower among male miners (aOR: 0. 52; 95% CI: 0.32, 0.86). Malaria prevention and care seeking behaviors among miners are somewhat low and influenced by mosquito net usage, perceived norms, malaria knowledge and prior episode of confirmed malaria. Study findings have implications for malaria interventions in the hinterland regions of Guyana such as the mass and continuous distribution of insecticide treated nets as well as community case management initiatives using trained malaria testing and treatment volunteers to curb malaria transmission among remote gold mining populations. These include efforts to identify and address gaps in distributing mosquito nets to miners and address miners’ barriers to prompt care seeking, malaria testing and treatment adherence. Targeted social and behavior change messaging is needed on net acquisition, use and care, prompt care-seeking, malaria testing and treatment adherence. Additional efforts to ensure the overall sustainability of the community case management initiative include increased publicity of the community case management initiative among miners, use of incentives to promote retention rates among the community case management volunteer testers and public private partnerships between the Guyana Ministry of Health and relevant mining organizations.

A survey of knowledge, attitudes and practices regarding malaria and bed nets on Bubaque Island, Guinea-Bissau

BACKGROUND

Malaria remains a significant public health problem in Guinea-Bissau, West Africa. Government control measures include bed net distribution campaigns, however, local knowledge, attitudes and practices towards bed nets and malaria are uncharacterized on the remote Bijagos Archipelago.

METHODS

Knowledge, attitude and practice questionnaires were conducted with household heads, aiming to explore the understanding of malaria and factors influencing bed net uptake and usage. Nets were observed in situ to appraise net quality and behaviour. All 14 villages and one semi-urban neighbourhood on Bubaque Island were included. One in 5 households containing school-aged children were randomly selected.

RESULTS

Of 100 participants, 94 were aware of malaria and 66 of those considered it a significant or severe problem, primarily because of its impact on health and income. Transmission, symptoms and risk factors were well known, however, 28.0% of participants felt under-informed. Some 80.0% reported contact with distribution campaigns, with inter-village variability. Campaign contact was associated with feeling well informed (OR 3.44; P = 0.024) and inversely with perceiving malaria a household (OR 0.18; P = 0.002) or regional problem (OR 0.25; P = 0.018). Every household contained nets; every identifiable example was a long-lasting insecticide-treated net (LLIN), however, 23.0% of households contained at least one expired net. Replacements were in demand; 89.0% of households reported that all residents used nets, and average occupancy was 2.07 people per net; 65.2% stated that the repurposing of bed nets was common. Correctly using bed nets, defined by age, integrity and demonstration, was 35.0% and strongly associated with completing intermittent preventative treatment in pregnancy (RR 3.63; P = 0.014).

CONCLUSIONS

Knowledge of malaria is good in these communities. Bed nets are used widely and are valued for their role in preventing malaria. However, their use is frequently sub-optimal and offers a target for improving malaria control by adapting popular distribution campaigns to provide more education alongside fresh LLINs. The impact of this could be significant as LLINs represent the mainstay of malaria prevention in Guinea-Bissau; however, the persistence of malaria despite the high uptake of LLINs seen in this study suggests that novel supplementary approaches must also be considered.

Malaria Prevention Measures among Pregnant Women: A Population-Based Survey in Nnewi, Nigeria

We examined factors related to the uptake of two malaria prevention measures, insecticide-treated bed-nets and prophylactic sulphadoxine-pyrimethamine (SP), among pregnant women in Nnewi, Nigeria. The survey had a quantitative and qualitative part. For each part, the subjects meeting our inclusion criteria were systematically identified in a population-based manner. For the qualitative part, focused group discussions, in-depth interviews with a wide variety of stakeholders (e.g., health workers, males whose wives are pregnant, and drug and net sellers), and key informants including doctors and nurses were held. All data covered various aspects related to the topics. A total of 384 subjects participated. The mean age was 28.9 years (95% CI 23.4-34.5). The primigravidae (odds 1.8-2.3) and illiterates (odds 4.1-13.5) were less likely to sleep under the net. Primigravidae were 2.0x less likely to uptake adequate SP. The uptake was also associated with having adequate knowledge on SP (2.4x), completing usual (≥4 visits) antenatal visits (3.9x), and being in the best (≥9 visits) antenatal visit scenario (10.5x). Other barriers identified were thermal discomfort, lack of availability, cost, and unsupervised uptake of SP. Based on a representative sample, systematic procedures, and within current evaluation limits, we conclude that primigravidae and those with no formal education and inadequate antenatal visits should be the foremost group for encouraging uptake of malaria prevention measures. The policymakers should resolve issues of thermal discomfort, availability, cost, unsupervised uptake, and inadequate awareness and confidence on SP prophylaxis. The solutions are available and should be actively sought.

Predictors of sleeping under cost-free mosquito bed nets among children under-five years in Mbarara, Uganda: a household survey

BACKGROUND

In 2010, Uganda Malaria Control Programme distributed cost-free mosquito bed nets to households with children under-five years and pregnant women in selected sub-counties. We assessed the factors associated with sleeping under costfree mosquito nets among children under-five years in Nyakayojo sub-county, Mbarara District, Uganda.

METHODS

381 households with at least a child under-five years and benefited from cost-free bed nets in Nyakayojo were randomly selected. Caregivers of children were interviewed using a questionnaire.

RESULTS

74% children slept under bed nets a night before the study. Children from households with ≥2 nets [aOR=1.75; 95% CI: 1.09-2.81, p=0.02], female caregiver [aOR=2.11; 95% CI: 1.16-3.79, p=0.01] and children from households that did not face problems (skin irritation, torn nets, suffocation, night sweating, nasal congestion and candle fire) when sleeping under bed nets [aOR=1.81; 95% CI: 1.10-2.98, p=0.02] were more likely to use nets. Main reason for not sleeping under a net was damage to the net (47.1%).

CONCLUSION

The proportion of children sleeping under nets was comparable to MDG target. Improvements in use of mosquito nets by children can be achieved through increasing number of nets in a household.

The use of mosquito nets in fisheries: A global perspective

Free or subsidised mosquito net (MN) distribution has been an increasingly important tool in efforts to combat malaria in recent decades throughout the developing world, making great strides towards eradicating this hugely detrimental disease. However, there has been increasing concern in the natural resource management and healthcare communities over alternative use of MNs, particularly in artisanal fisheries where it has been suggested they pose a threat to sustainability of fish stocks. So far, little evidence has been presented as to the global prevalence and characteristics of MN fishing, limiting global management initiatives and incentives for action across disciplines. We conducted a rapid global assessment of mosquito net fishing (MNF) observations from expert witnesses living and/or working in malarial zones using an internet survey. MNF was found to be a broadly pan-tropical activity, particularly prevalent in sub-Saharan Africa. MNF is conducted using a variety of deployment methods and scales including seine nets, scoop/dip nets, set nets and traps. MNF was witnessed in a broad range of marine and freshwater habitats and was seen to exploit a wide range of taxa, with capture of juvenile fish reported in more than half of responses. Perceived drivers of MNF were closely related to poverty, revealing potentially complex and arguably detrimental livelihood and food security implications which we discuss in light of current literature and management paradigms. The key policies likely to influence future impacts of MNF are in health, regarding net distribution, and natural resource management regarding restrictions on use. We outline critical directions for research and highlight the need for a collaborative, interdisciplinary approach to development of both localised and broad-scale policy.

Behaviors Related to Mosquito-Borne Diseases among Different Ethnic Minority Groups along the China-Laos Border Areas

Background: In China, mosquito-borne diseases are most common in the sub-tropical area of Yunnan province. The objective of this study was to examine behaviors related to mosquito-borne diseases in different ethnic minority groups and different socioeconomic groups of people living in this region. Methods: A stratified two-stage cluster sampling technique with probability proportional to size was used in Mengla County, Xishuangbanna Prefecture, Yunnan. Twelve villages were used to recruit adult (≥18 years old) and eight schools were used for children (<18 years old). A questionnaire on behaviors and environment variables related to mosquito-borne diseases was devised. Results: Multiple correspondence analysis (MCA) grouped 20 behaviors into three domains, namely, environmental condition, bed net use behaviors, and repellent use behaviors, respectively. The Han ethnicity had the lowest odds of rearing pigs, their odds being significantly lower than those of Yi and Yao. For bed net use, Dai and other ethnic minority groups were less likely to use bed nets compared to Yi and Yao. The odds of repellent use in the Han ethnicity was lower than in Yi, but higher than in Dai. The Dai group was the most likely ethnicity to use repellents. Farmers were at a higher risk for pig rearing and not using repellents. Education of less than primary school held the lowest odds of pig rearing. Those with low income were at a higher risk for not using bed nets and repellent except in pig rearing. Those with a small family size were at a lower risk for pig rearing. Conclusion: Different ethnic and socioeconomic groups in the study areas require different specific emphases for the prevention of mosquito-borne diseases.

"Tazomoka Is Not a Problem". Local Perspectives on Malaria, Fever Case Management and Bed Net Use in Madagascar

Background

Although its incidence has been decreasing during the last decade, malaria is still a major public health issue in Madagascar. The use of Long Lasting Insecticidal Nets (LLIN) remains a key malaria control intervention strategy in Madagascar, however, it encounters some obstacles. The present study aimed to explore the local terminology related to malaria, information channels about malaria, attitude towards bed nets, and health care seeking practices in case of fever. This article presents novel qualitative findings about malaria. Until now, no such data has been published for Madagascar.

Methods

A comparative qualitative study was carried out at four sites in Madagascar, each differing by malaria epidemiology and socio-cultural background of the populations. Seventy-one semi-structured interviews were conducted with biomedical and traditional caregivers, and members of the local population. In addition, observations of the living conditions and the uses of bed net were conducted.

Results

Due to the differences between local and biomedical perspectives on malaria, official messages did not have the expected impact on population in terms of prevention and care seeking behaviors. Rather, most information retained about malaria was spread through informal information circulation channels. Most interviewees perceived malaria as a disease that is simple to treat. Tazomoka (“mosquito fever”), the Malagasy biomedical word for malaria, was not used by populations. Tazo (“fever”) and tazomahery (“strong fever”) were the terms more commonly used by members of the local population to refer to malaria related symptoms. According to local perceptions in all areas, tazo and tazomahery were not caused by mosquitos. Each of these symptoms required specific health recourse. The usual fever management strategies consisted of self-medication or recourse to traditional and biomedical caregivers. Usage of bed nets was intermittent and was not directly linked to protection against malaria in the eyes of most Malagasy people.

Conclusions

This article highlights the conflicting understanding of malaria between local perceptions and the biomedical establishment in Madagascar. Local perceptions of malaria present a holistic vision of the disease that includes various social and cultural dimensions, rather than reflecting one universal understanding, as in the biomedical image. The consideration of this “holistic vision” and other socio-cultural aspects surrounding the understanding of malaria is essential in implementing successful control intervention strategies.

Child bed net use before, during, and after a bed net distribution campaign in Bo, Sierra Leone

BACKGROUND

This analysis examined how the proportion of children less than 5-years-old who slept under a bed net the previous night changed during and after a national long-lasting insecticidal net (LLIN) distribution campaign in Sierra Leone in November-December 2010.

METHODS

A citywide cross-sectional study in 2010-2011 interviewed the caregivers of more than 3000 under-five children from across urban Bo, Sierra Leone. Chi squared tests were used to assess change in use rates over time, and multivariate regression models were used to examine the factors associated with bed net use.

RESULTS

Reported rates of last-night bed net use changed from 38.7 % (504/1304) in the months before the LLIN campaign to 21.8 % (78/357) during the week of the campaign to 75.3 % (1045/1387) in the months after the national campaign. The bed net use rate significantly increased (p < 0.01) from before the campaign to after the universal LLIN distribution campaign in all demographic, socioeconomic, and health behaviour groups, even though reported use during the campaign dropped significantly.

CONCLUSION

Future malaria prevention efforts will need to promote consistent use of LLINs and address any remaining disparities in insecticide-treated bed net (ITN) use.

The High Burden of Malaria in Primary School Children in Southern Malawi

Malaria among school children has received increased attention recently, yet there remain few detailed data on the health and educational burden of malaria, especially in southern Africa. This paper reports a survey among school children in 50 schools in Zomba District, Malawi. Children were assessed for Plasmodium infection, anemia, and nutritional status and took a battery of age-appropriate tests of attention, literacy, and numeracy. Overall, 60.0% of children were infected with Plasmodium falciparum, 32.4% were anemic and 32.4% reported sleeping under a mosquito net the previous night. Patterns of P. falciparum infection and anemia varied markedly by school. In multivariable analysis, higher odds of P. falciparum infection were associated with younger age and being stunted, whereas lower odds were associated with reported net use, higher parental education, and socioeconomic status. The odds of anemia were significantly associated with P. falciparum infection, with a dose-response relationship between density of infection and odds of anemia. No clear relationship was observed between health status and cognitive and educational outcomes. The high burden of malaria highlights the need to tackle malaria among school children.

High Mobility and Low Use of Malaria Preventive Measures Among the Jarai Male Youth Along the Cambodia-Vietnam Border

Malaria control along the Vietnam-Cambodia border presents a challenge for both countries' malaria elimination targets as the region is forested, inhabited by ethnic minority populations, and potentially characterized by early and outdoor malaria transmission. A mixed methods study assessed the vulnerability to malaria among the Jarai population living on both sides of the border in the provinces of Ratanakiri (Cambodia) and Gia Lai (Vietnam). A qualitative study generated preliminary hypotheses that were quantified in two surveys, one targeting youth (N = 498) and the other household leaders (N = 449). Jarai male youth, especially in Cambodia, had lower uptake of preventive measures (57.4%) and more often stayed overnight in the deep forest (35.8%) compared with the female youth and the adult population. Among male youth, a high-risk subgroup was identified that regularly slept at friends' homes or outdoors, who had fewer bed nets (32.5%) that were torn more often (77.8%). The vulnerability of Jarai youth to malaria could be attributed to the transitional character of youth itself, implying less fixed sleeping arrangements in nonpermanent spaces or non-bed sites. Additional tools such as long-lasting hammock nets could be suitable as they are in line with current practices.

Chyluria: a scourge of our region

Chyluria is endemic in the Gangetic belt of India with an average of 90 cases treated annually at our institute. It is almost exclusively caused by Wuchereria bancrofti in tropical areas. Chylomicrons and triglycerides are lost in the urine from an abnormal lymphourinary fistula due to obstructive lymphatic stasis, most commonly at the renal pelvis. It is a distressingly recurrent condition with multiple exacerbations and remissions over years. Severe weakness, weight loss and haematuria occur in some patients. Diagnosis can be made by visual examination of milky urine along with the ether test of urine for chylomicrons. Intravenous urography is used to locate the site of the fistula, although the detection rate is poor. Treatment starts with conservative measures such as a high-protein low-fat diet and diethylcarbamazine therapy. In cases where conservative measures fail, endoscopic sclerotherapy (renal pelvic instillation of silver nitrate, povidone iodine or others) and surgical therapy are used.

Health and agricultural productivity: Evidence from Zambia

We evaluate the productivity effects of investment in preventive health technology through a randomized controlled trial in rural Zambia. In the experiment, access to subsidized bed nets was randomly assigned at the community level; 516 farmers were followed over a one-year farming period. We find large positive effects of preventative health investment on productivity: among farmers provided with access to free nets, harvest value increased by US$ 76, corresponding to about 14.7% of the average output value. While only limited information was collected on farming inputs, shifts in the extensive and the intensive margins of labor supply appear to be the most likely mechanism underlying the productivity improvements observed.

National-level differences in the adoption of environmental health technologies: a cross-border comparison from Benin and Togo

Environmental health problems such as malaria, respiratory infections, diarrhoea and malnutrition pose very high burdens on the poor rural people in much of the tropics. Recent research on key interventions-the adoption and use of relatively cheap and effective environmental health technologies-has focused primarily on the influence of demand-side household-level drivers. Relatively few studies of the promotion and use of these technologies have considered the role of contextual factors such as governance, the enabling environment and national policies because of the challenges of cross-country comparisons. We exploit a natural experimental setting by comparing household adoption across the Benin-Togo national border that splits the Tamberma Valley in West Africa. Households across the border share the same culture, ethnicity, weather, physiographic features, livelihoods and infrastructure; however, they are located in countries at virtually opposite ends of the institutional spectrum of democratic elections, voice and accountability, effective governance and corruption. Binary choice models and rigorous non-parametric matching estimators confirm that households in Benin are more likely than households in Togo to plant soybeans, build improved cookstoves and purchase mosquito nets, ceteris paribus. Although we cannot identify the exact mechanism for the large and significant national-level differences in technology adoption, our findings suggest that contextual institutional factors can be more important than household characteristics for technology adoption.

Effects of bed nets and anti-malaria drugs use on childhood mortality in Kenya's malaria endemic and epidemic areas

BACKGROUND

The Kenya Demographic and Health Surveys (KDHS) data collected since 1989 indicate that malaria prone areas have consistently recorded the highest childhood mortality rates. Malaria control programme information also indicates that malaria contributes to about 20 per cent of the deaths among under-five year old children. The 2009-2017 National Malaria Strategy is being implemented to reduce malaria morbidity and mortality. Its key interventions include: bed nets use; anti-malaria drugs use during pregnancy for prevention; and, prompt treatment using anti-malaria drugs of children with fever. This study seeks to establish differentials in childhood mortality rates by these interventions in three malaria prone areas defined as highland epidemic, coast endemic and lake endemic. It also seeks to determine the effects of these interventions on childhood mortality.

METHODS

The data used is drawn from the 2008/9 KDHS. The study sample consists of 3,728 children born less than 60 months prior to the survey. The direct demographic method for estimation of childhood mortality rates and multivariate Poisson regression models are used to analyse the data.

RESULTS

The findings show that use of bed nets and anti-malaria drugs are not high in Kenya's malaria prone areas. On the average, only about 60% of the children are found to be in higher use category for each of the three intervention measures. The childhood mortality rates show that higher use of prompt treatment with anti-malaria drugs for children with fever has lower infant and under-five mortality rates in all malaria epidemic and endemic areas compared to lower use. Higher bed nets use has lower childhood mortality rates compared to lower use in coast and lake endemic areas. Higher use of anti-malaria drugs during pregnancy for prevention has lower childhood mortality rates in highland epidemic and lake endemic areas compared to lower use. The regression models fitted show that in highland epidemic area, higher use of anti-malaria drugs during pregnancy for prevention has significant reduction effect on childhood mortality compared to lower use in the presence of breastfeeding duration, toilet facility type and age of child variables. The regression models also show that in combined malaria prone areas, higher prompt treatment of children with fever using anti-malaria drugs has significant reduction effect on both infant and child mortality compared to lower prompt treatment in the presence of breastfeeding duration and toilet facility type variables.

CONCLUSION

This study underscore the need for increasing uptake of malaria interventions and complementing them with longer breastfeeding duration and improved toilet facility in efforts towards reducing infant and child mortality rates in Kenya's malaria prone areas. There is also need to improve quality of individual household data for malaria module in future KDHS undertakings.

Malaria's contribution to World War One - the unexpected adversary

Malaria in the First World War was an unexpected adversary. In 1914, the scientific community had access to new knowledge on transmission of malaria parasites and their control, but the military were unprepared, and underestimated the nature, magnitude and dispersion of this enemy. In summarizing available information for allied and axis military forces, this review contextualizes the challenge posed by malaria, because although data exist across historical, medical and military documents, descriptions are fragmented, often addressing context specific issues. Military malaria surveillance statistics have, therefore, been summarized for all theatres of the War, where available. These indicated that at least 1.5 million solders were infected, with case fatality ranging from 0.2 -5.0%. As more countries became engaged in the War, the problem grew in size, leading to major epidemics in Macedonia, Palestine, Mesopotamia and Italy. Trans-continental passages of parasites and human reservoirs of infection created ideal circumstances for parasite evolution. Details of these epidemics are reviewed, including major epidemics in England and Italy, which developed following home troop evacuations, and disruption of malaria control activities in Italy. Elsewhere, in sub-Saharan Africa many casualties resulted from high malaria exposure combined with minimal control efforts for soldiers considered semi-immune. Prevention activities eventually started but were initially poorly organized and dependent on local enthusiasm and initiative. Nets had to be designed for field use and were fundamental for personal protection. Multiple prevention approaches adopted in different settings and their relative utility are described. Clinical treatment primarily depended on quinine, although efficacy was poor as relapsing Plasmodium vivax and recrudescent Plasmodium falciparum infections were not distinguished and managed appropriately. Reasons for this are discussed and the clinical trial data summarized, as are controversies that arose from attempts at quinine prophylaxis (quininization). In essence, the First World War was a vast experiment in political, demographic, and medical practice which exposed large gaps in knowledge of tropical medicine and unfortunately, of malaria. Research efforts eventually commenced late in the War to address important clinical questions which established a platform for more effective strategies, but in 1918 this relentless foe had outwitted and weakened both allied and axis powers.

Fishing with bed nets on Lake Tanganyika: a randomized survey

BACKGROUND

Malaria is among the most common causes of death along Lake Tanganyika, a problem which many aid organizations have attempted to combat through the distribution of free mosquito bed nets to high-risk communities. The Lake Tanganyika Floating Health Clinic (LTFHC), a health-based non-governmental organization (NGO), has observed residents of the Lake Tanganyika basin using bed nets to fish small fry near the shoreline, despite a series of laws that prohibit bed net use and other fine-gauge nets for fishing, implemented to protect the near-shore fish ecology. The LTFHC sought to quantify the sources of bed nets and whether they were being used for fishing.

METHODS

The LTFHC conducted a survey of seven lakeside villages in Lagosa Ward, Tanzania. The government has divided each village into two to six pre-existing geographic sub-villages depending on population size. Seven households per sub-village were chosen at random for survey administration. The survey consisted of 23 questions regarding mosquito bed net practices, including the use of bed nets for fishing, as well as questions pertaining to any perceived changes to the fish supply.

RESULTS

A total of 196 surveys were administered over a four-week period with a 100% response rate. Over 87% of households surveyed have used a mosquito bed net for fishing at some point. The majority of respondents reported receiving their bed net for free (96.4%), observing "many" residents of their village using bed nets for fishing (97.4%), and noticing a subjective decrease in the fish supply over time (64.9%).

CONCLUSIONS

The findings of this study raise concerns that the use of free malaria bed nets for fishing is widespread along Lake Tanganyika, and that this dynamic will have an adverse effect on fish ecology. Further studies are indicated to fully define the scope of bed net misuse and the effects of alternative vector control strategies in water-based communities.

Social interactions and malaria preventive behaviors in sub-saharan Africa

This paper examines the existence of social interactions in malaria preventive behaviors in Sub-Saharan Africa, that is, whether an individual's social environment has an influence on the individual's preventive behaviors. We focus on the two population groups which are the most vulnerable to malaria (children under 5 years and pregnant women) and on two preventive behaviors (sleeping under a bednet and taking intermittent preventive treatment during pregnancy). We define the social environment of the individual as people living in the same region. To detect social interactions, we calculate the size of the social multiplier by comparing the effects of an exogenous variable at individual and regional levels. Our data come from 92 surveys for 29 Sub-Saharan countries between 1999 and 2012, and they cover approximately 660,000 children and 95,000 women. Our results indicate that there are social interactions in malaria preventive behaviors in the form of social multipliers effects of women's education and household wealth. The long-run effects of these characteristics on preventive behaviors at the regional level are larger than those apparent at the individual level.

The phenomenon of diminishing -returns in the use of bed nets and indoor house spraying and the emerging place of antimalarial medicines in the control of malaria in Uganda

BACKGROUND

The mosquito net existed long before it was known that mosquitoes transmitted malaria. Therefore it was not intended for malaria control.

OBJECTIVES

To scrutinise the patterns of prevalence and identify any hitherto unknown factors that could explain the findings.

METHODS

Retrieval of records on malaria prevalence.

FINDINGS

Households sprayed in the previous 12 months or owning at least one ITN: 77.8% and IRS: 31.6% in mid-northern districts. Paradoxically, this was the highest malaria prevalence at 80.1%, hence the phenomenon of diminishing-returns. The urban children (28.6%), those of post-secondary education mothers (14.3%) and in the highest wealth quintile (33.3%) had a lower malaria prevalence than those without education (55.8%) and the less wealthy (67.6%), (p < 0.001). In all, the connection was that the urban (77.4%) and the wealthy (63.8%) sought health care first from hospitals, for proper treatment. Hence the low prevalence is most likely to be due to anti-malarial medicines and not to bed-nets and IRS, since the other findings of the survey show that there are no significant differences in bed nets ownership and usage and IRS in both groups.

RECOMMENDATION

Antimalarial medicines should therefore be used to control malaria instead of the nets and IRS.

Awareness, ownership and utilization of insecticide treated nets in Abavo community of Delta State

BACKGROUND

Despite free distribution of insecticide treated nets in Nigeria, the use it as a means of malaria prevention and control has not been fuIly embraced.

AIM

The aim of this survey was to determine the level of awareness, ownership and utilization of insecticide treated nets among residents of Abavo community, Delta State Nigeria

METHOD

It is a descriptive cross-sectional survey conducted among 250 heads of households.

RESULT

One hundred and seventy five (70%) respondents were aware of insecticide treated net as a means of prevention against malaria, 111 (44%) claimed to own insecticide treated nets. On further inspection of houses of those who claimed to own ITNs, seventy four (66%) actually had theirs hanged, the rest were either in their packs or not seen. Ninety five (38%) respondents out of the total sleep under insecticide treated net. About 92 (70%) households having under-five and 39 (81.3%) of households having pregnant women claim to use ITNs. It was observed that the level of education (chi2 = 48.35, p = 0.001), presence of under 5 children in a household ?2 = 7.229, p = 0.027) influenced ownership of Insecticide treated nets. In conclusion despite a high level of awareness about ITN found in this survey, ownership and utilization of insecticide treated nets were low.

Coverage of intermittent preventive treatment and insecticide-treated nets for the control of malaria during pregnancy in sub-Saharan Africa: a synthesis and meta-analysis of national survey data, 2009-11

BACKGROUND

Pregnant women in malaria-endemic countries in sub-Saharan Africa are especially vulnerable to malaria. Recommended prevention strategies include intermittent preventive treatment with two doses of sulfadoxine-pyrimethamine and the use of insecticide-treated nets. However, progress with implementation has been slow and the Roll Back Malaria Partnership target of 80% coverage of both interventions by 2010 has not been met. We aimed to review the coverage of intermittent preventive treatment, insecticide-treated nets, and antenatal care for pregnant women in sub-Saharan Africa and to explore associations between coverage and individual and country-level factors, including the role of funding for malaria prevention.

METHODS

We used data from nationally representative household surveys from 2009-11 to estimate coverage of intermittent preventive treatment, use of insecticide-treated nets, and attendance at antenatal clinics by pregnant women in sub-Saharan Africa. Using demographic data for births and published data for malaria exposure, we also estimated the number of malaria-exposed births (livebirths and stillbirths combined) for 2010 by country. We used meta-regression analysis to investigate the factors associated with coverage of intermittent preventive treatment and use of insecticide-treated nets.

RESULTS

Of the 21·4 million estimated malaria-exposed births across 27 countries in 2010, an estimated 4·6 million (21·5%, 95% CI 19·3-23·7) were born to mothers who received intermittent preventive treatment. Insecticide-treated nets were used during pregnancy for 10·5 million of 26·9 million births across 37 countries (38·8%, 34·6-43·0). Antenatal care was attended at least once by 16·3 of 20·8 million women in 2010 (78·3%, 75·2-81·4; n=26 countries) and at least twice by 14·7 of 19·6 million women (75·1%, 72·9-77·3; n=22 countries). For the countries with previous estimates for 2007, coverage of intermittent preventive treatment increased from 13·1% (11·9-14·3) to 21·2% (18·9-23·5; n=14 countries) and use of insecticide-treated nets increased from 17·9% (15·1-20·7) to 41·6% (37·2-46·0; n=24 countries) in 2010. A fall in coverage by more than 10% was seen in two of 24 countries for intermittent preventive treatment and in three of 30 countries for insecticide-treated nets. High disbursement of funds for malaria control and a long time interval since adoption of the relevant policy were associated with the highest coverage of intermittent preventive treatment. High disbursement of funds for malaria control and high total fertility rate were associated with the greatest use of insecticide-treated nets, whereas a high per-head gross domestic product (GDP) was associated with less use of nets than was a lower GDP. Coverage of intermittent preventive treatment showed greater inequity overall than use of insecticide-treated nets, with richer, educated, and urban women more likely to receive preventive treatment than their poorer, uneducated, rural counterparts.

INTERPRETATION

Although coverage of intermittent preventive treatment and use of insecticide-treated nets by pregnant women has increased in most countries, coverage remains far below international targets, despite fairly high rates of attendance at antenatal clinics. The effect of the implementation of WHO's 2012 policy update for intermittent preventive treatment, which aims to simplify the message and align preventive treatment with the focused antenatal care schedule, should be assessed to find out whether it leads to improvements in coverage.

FUNDING

Bill & Melinda Gates Foundation.

Malaria prevalence, spatial clustering and risk factors in a low endemic area of Eastern Rwanda: a cross sectional study

Background

Rwanda reported significant reductions in malaria burden following scale up of control intervention from 2005 to 2010. This study sought to; measure malaria prevalence, describe spatial malaria clustering and investigate for malaria risk factors among health-centre-presumed malaria cases and their household members in Eastern Rwanda.

Methods

A two-stage health centre and household-based survey was conducted in Ruhuha sector, Eastern Rwanda from April to October 2011. At the health centre, data, including malaria diagnosis and individual level malaria risk factors, was collected. At households of these Index cases, a follow-up survey, including malaria screening for all household members and collecting household level malaria risk factor data, was conducted.

Results

Malaria prevalence among health centre attendees was 22.8%. At the household level, 90 households (out of 520) had at least one malaria-infected member and the overall malaria prevalence for the 2634 household members screened was 5.1%. Among health centre attendees, the age group 5–15 years was significantly associated with an increased malaria risk and a reported ownership of ≥4 bednets was significantly associated with a reduced malaria risk. At the household level, age groups 5–15 and >15 years and being associated with a malaria positive index case were associated with an increased malaria risk, while an observed ownership of ≥4 bednets was associated with a malaria risk-protective effect. Significant spatial malaria clustering among household cases with clusters located close to water- based agro-ecosystems was observed.

Conclusions

Malaria prevalence was significantly higher among health centre attendees and their household members in an area with significant household spatial malaria clustering. Circle surveillance involving passive case finding at health centres and proactive case detection in households can be a powerful tool for identifying household level malaria burden, risk factors and clustering.

How changes in coverage affect equity in maternal and child health interventions in 35 Countdown to 2015 countries: an analysis of national surveys

BACKGROUND

Achievement of global health goals will require assessment of progress not only nationally but also for population subgroups. We aimed to assess how the magnitude of socioeconomic inequalities in health changes in relation to different rates of national progress in coverage of interventions for the health of mothers and children.

METHODS

We assessed coverage in low-income and middle-income countries for which two Demographic Health Surveys or Multiple Indicator Cluster Surveys were available. We calculated changes in overall coverage of skilled birth attendants, measles vaccination, and a composite coverage index, and examined coverage of a newly introduced intervention, use of insecticide-treated bednets by children. We stratified coverage data according to asset-based wealth quintiles, and calculated relative and absolute indices of inequality. We adjusted correlation analyses for time between surveys and baseline coverage levels.

FINDINGS

We included 35 countries with surveys done an average of 9·1 years apart. Pro-rich inequalities were very prevalent. We noted increased coverage of skilled birth attendants, measles vaccination, and the composite index in most countries from the first to the second survey, while inequalities were reduced. Rapid changes in overall coverage were associated with improved equity. These findings were not due to a capping effect associated with limited scope for improvement in rich households. For use of insecticide-treated bednets, coverage was high for the richest households, but countries making rapid progress did almost as well in reaching the poorest groups. National increases in coverage were primarily driven by how rapidly coverage increased in the poorest quintiles.

INTERPRETATION

Equity should be accounted for when planning the scaling up of interventions and assessing national progress.

FUNDING

Bill & Melinda Gates Foundation; World Bank; Governments of Australia, Brazil, Canada, Norway, Sweden, and UK.

Impact of health education intervention on insecticide treated nets uptake among nursing mothers in rural communities in Nigeria

BACKGROUND

ITN use is generally poor in Nigeria among all categories of people. Although use of ITNs has been shown to reduce malarial morbidity and mortality, this measure needs to be supported by an adequate healthcare system providing ITN possibly at the household level. This study was therefore designed to determine the effect of health education on the uptake of ITN among nursing mothers in rural communities in Nigeria.

METHODS

The study design was a quasi-experimental study carried out in Ijebu North Local Government Area of Ogun State. A multistage random sampling technique was used in choosing the required samples for this study and a semi- structured questionnaire was used to collect relevant information. The intervention consisted of a structured educational programme based on a course content adapted from the national malaria control programme. A total of 400 respondents were recruited into the study with 200 each in both the experimental and control groups and were followed up for a period of 3 months when the knowledge and uptake of ITN was reassessed.

RESULT

There was no significant difference (P >0.05) observed between the experimental and control groups in terms of socio-dermographic characteristics such as age, marital status, religion, and income. The ITN ever users in experimental group were 59 [29.5%] and 138 [72.6%] in pre and post intervention period, respectively (p value =0.0001). These proportions of ITN ever users were 55 [27.5%] and 57 [31.6%] in control group, during the pre and post intervention periods (p = 0.37). Post health education intervention, degree of change in knowledge of ITN re-treatment [37.0%] and mounting [33.5%], readiness to use if given free [30.5%] and belief in efficacy [36.9%] improved significantly in the experimental group while there was no significant change in the control group [p = 0.84, 0.51, 0.68 & 0.69 respectively]. Majority [89%] of the respondents were willing to buy ITN for between US$ 1.5 to US$ 3.0. There was no statistically significant change (P >0.05) despite intervention in the amount the respondents were willing to pay to own an ITN in both the experimental and control groups.

CONCLUSION

The study concludes that the use of ITN in the study population was significantly increase by health education and that the free distribution of ITN may not guarantee its use. Uptake of ITN can be significantly improved in rural areas if the nets are made available and backed up with appropriate health education intervention.

Airflow attenuation and bed net utilization: observations from Africa and Asia

BACKGROUND/METHODS

Qualitative studies suggest that bed nets affect the thermal comfort of users. To understand and reduce this discomfort the effect of bed nets on temperature, humidity, and airflow was measured in rural homes in Asia and Africa, as well as in an experimental wind tunnel. Two investigators with architectural training selected 60 houses in The Gambia, Tanzania, Philippines, and Thailand. Data-loggers were used to measure indoor temperatures in hourly intervals over a 12 months period. In a subgroup of 20 houses airflow, temperature and humidity were measured at five-minute intervals for one night from 21.00 to 6.00 hrs inside and outside of bed nets using sensors and omni-directional thermo-anemometers. An investigator set up a bed net with a mesh size of 220 holes per inch 2 in each study household and slept under the bed net to simulate a realistic environment. The attenuation of airflow caused by bed nets of different mesh sizes was also measured in an experimental wind tunnel.

RESULTS

The highest indoor temperatures (49.0 C) were measured in The Gambia. During the hottest months of the year the mean temperature at night (9 pm) was between 33.1 C (The Gambia) and 26.2 C (Thailand). The bed net attenuated the airflow from a minimum of 27% (Philippines) to a maximum of 71% (The Gambia). Overall the bed nets reduced airflow compared to un-attenuated airflow from 9 to 4 cm sec-1 or 52% (p<0.001). In all sites, no statistically significant difference in temperature or humidity was detected between the inside and outside of the bed net. Wind tunnel experiments with 11 different mesh-sized bed nets showed an overall reduction in airflow of 64% (range 55 - 71%) compared to un-attenuated airflow. As expected, airflow decreased with increasing net mesh size. Nets with a mesh of 136 holes inch-2 reduced airflow by 55% (mean; range 51 - 73%). A denser net (200 holes inch-2) attenuated airflow by 59% (mean; range 56 - 74%).

DISCUSSION

Despite concerted efforts to increase the uptake of this intervention in many areas uptake remains poor. Bed nets reduce airflow, but have no influence on temperature and humidity. The discomfort associated with bed nets is likely to be most intolerable during the hottest and most humid period of the year, which frequently coincides with the peak of malaria vector densities and the force of pathogen transmission.

CONCLUSIONS

These observations suggest thermal discomfort is a factor limiting bed net use and open a range of architectural possibilities to overcome this limitation.

Plasmodium falciparum, anaemia and cognitive and educational performance among school children in an area of moderate malaria transmission: baseline results of a cluster randomized trial on the coast of Kenya

OBJECTIVES

Studies have typically investigated health and educational consequences of malaria among school-aged children in areas of high malaria transmission, but few have investigated these issues in moderate transmission settings. This study investigates the patterns of and risks for Plasmodium falciparum and anaemia and their association with cognitive and education outcomes on the Kenyan coast, an area of moderate malaria transmission.

METHODS

As part of a cluster randomised trial, a baseline cross-sectional survey assessed the prevalence of and risk factors for P. falciparum infection and anaemia and the associations between health status and measures of cognition and educational achievement. Results are presented for 2400 randomly selected children who were enrolled in the 51 intervention schools.

RESULTS

The overall prevalence of P. falciparum infection and anaemia was 13.0% and 45.5%, respectively. There was marked heterogeneity in the prevalence of P. falciparum infection by school. In multivariable analysis, being male, younger age, not sleeping under a mosquito net and household crowding were adjusted risk factors for P. falciparum infection, whilst P. falciparum infection, being male and indicators of poor nutritional intake were risk factors for anaemia. No association was observed between either P. falciparum or anaemia and performance on tests of sustained attention, cognition, literacy or numeracy.

CONCLUSION

The results indicate that in this moderate malaria transmission setting, P. falciparum is strongly associated with anaemia, but there is no clear association between health status and education. Intervention studies are underway to investigate whether removing the burden of chronic asymptomatic P. falciparum and related anaemia can improve education outcomes.

Social determinants of long lasting insecticidal hammock use among the Ra-glai ethnic minority in Vietnam: implications for forest malaria control

BACKGROUND

Long-lasting insecticidal hammocks (LLIHs) are being evaluated as an additional malaria prevention tool in settings where standard control strategies have a limited impact. This is the case among the Ra-glai ethnic minority communities of Ninh Thuan, one of the forested and mountainous provinces of Central Vietnam where malaria morbidity persist due to the sylvatic nature of the main malaria vector An. dirus and the dependence of the population on the forest for subsistence--as is the case for many impoverished ethnic minorities in Southeast Asia.

METHODS

A social science study was carried out ancillary to a community-based cluster randomized trial on the effectiveness of LLIHs to control forest malaria. The social science research strategy consisted of a mixed methods study triangulating qualitative data from focused ethnography and quantitative data collected during a malariometric cross-sectional survey on a random sample of 2,045 study participants.

RESULTS

To meet work requirements during the labor intensive malaria transmission and rainy season, Ra-glai slash and burn farmers combine living in government supported villages along the road with a second home at their fields located in the forest. LLIH use was evaluated in both locations. During daytime, LLIH use at village level was reported by 69.3% of all respondents, and in forest fields this was 73.2%. In the evening, 54.1% used the LLIHs in the villages, while at the fields this was 20.7%. At night, LLIH use was minimal, regardless of the location (village 4.4%; forest 6.4%).

DISCUSSION

Despite the free distribution of insecticide-treated nets (ITNs) and LLIHs, around half the local population remains largely unprotected when sleeping in their forest plot huts. In order to tackle forest malaria more effectively, control policies should explicitly target forest fields where ethnic minority farmers are more vulnerable to malaria.

[Ronald Ross, "doctor in spite of himself" and... Nobel Laureate in medicine]

After becoming a military doctor at the behest of his father, Ronald Ross was destined to make a discovery of paramout importance, i.e., malaria transmission through mosquito bites. This landmark discovery that was the fruit of a combination of curiosity, tenacity and luck, earned him the Nobel Prize in Medicine.

Adequate wound care and use of bed nets as protective factors against Buruli Ulcer: results from a case control study in Cameroon

Background

Buruli ulcer is an infectious disease involving the skin, caused by Mycobacterium ulcerans. Its exact transmission mechanism remains unknown. Several arguments indicate a possible role for insects in its transmission. A previous case-control study in the Nyong valley region in central Cameroon showed an unexpected association between bed net use and protection against Buruli ulcer. We investigated whether this association persisted in a newly discovered endemic Buruli ulcer focus in Bankim, northwestern Cameroon.

Methodology/Principal Findings

We conducted a case-control study on 77 Buruli ulcer cases and 153 age-, gender- and village-matched controls. Participants were interviewed about their activities and habits. Multivariate conditional logistic regression analysis identified systematic use of a bed net (Odds-Ratio (OR) = 0.4, 95% Confidence Interval [95%CI] = [0.2–0.9], p-value (p) = 0.04), cleansing wounds with soap (OR [95%CI] = 0.1 [0.03–0.3], p<0.0001) and growing cassava (OR [95%CI] = 0.3 [0.2–0.7], p = 0.005) as independent protective factors. Independent risk factors were bathing in the Mbam River (OR [95%CI] = 6.9 [1.4–35], p = 0.02) and reporting scratch lesions after insect bites (OR [95%CI] = 2.7 [1.4–5.4], p = 0.004). The proportion of cases that could be prevented by systematic bed net use was 32%, and by adequate wound care was 34%.

Conclusions/Significance

Our study confirms that two previously identified factors, adequate wound care and bed net use, significantly decreased the risk of Buruli ulcer. These associations withstand generalization to different geographic, climatic and epidemiologic settings. Involvement of insects in the household environment, and the relationship between wound hygiene and M. ulcerans infection should now be investigated.

Mycobacterium ulcerans is the causative agent of Buruli ulcer disease, which causes skin wounds and often results in disabilities. The transmission of M. ulcerans remains unknown. Environmental and biological studies have gathered evidence that insects could play a role in M. ulcerans circulation. A case-control study performed in central Cameroon in 2007 unexpectedly illuminated an association between bed net use and a decreased risk of Buruli ulcer. As this result suggested a potential domestic transmission involving insects, we set up a new study to investigate whether this association existed in Bankim, a newly discovered Buruli ulcer endemic site in northwestern Cameroon. Our results confirm the protective effect of bed nets in this region, despite very different population, environment, and climate factors. They also confirm the role of good hygienic practices, a protective factor repeatedly identified in previous studies. These repeated associations now warrant further research on a possible domestic or peri-domestic transmission of the disease, involving local water collections and possibly insects.

Factors influencing people's willingness-to-buy insecticide-treated bednets in Arbaminch Zuria District, southern Ethiopia

Promoting self-financing healthcare helps restore efficiency and equity to national health systems. This study was conducted in malaria-endemic areas of southern Ethiopia to assess the bednet possession of the community, determine the people's willingness-to-pay for insecticide-treated bednets (ITNs), and identify what factors influence it. The study provided relevant information for programme planners and policymakers for evidence-based decision-making. This quantitative cross-sectional community-based study was conducted in four selected malarious Kebeles of Arbaminch Zuria district using a pretested interview-administered structured questionnaire. In total, 982 household heads were interviewed. The community's willingness-to-pay was assessed by contingent valuation, technique using binary with follow-up method. The advantage, the distribution, and the payment mechanism were explained, and three different qualities of ITN were shown by constructing a hypothetical market scenario. Of the 982 respondents, 466 (47.5%) households had at least one functional bednet. Of 849 children aged less than five years in the 982 households, 185 (21.8%) slept under a net the night preceding the survey. The results of the study revealed that around 86% of the respondents were willing to buy ITNs. The average maximum willingness-to-pay for three different types of bednets was statistically different. The maximum amount the people were willing to pay was US$ 3.3 for a blue conical ITN, US$ 3.2 for a white conical one, and US$ 1.7 for a blue rectangular ITN. The community's willingness-to-pay was significantly affected by gender, educational status, perceived benefit of ITN, previous source of bednet, and characteristics of bednet. The results showed that a significant proportion of the community people were willing to pay for ITNs. Therefore, introducing a subsidized ITN market rather than free distribution for all should be considered to ensure sustainability and self-reliance in the prevention and control of malaria.

Knowledge, attitudes and practices regarding malaria control in an endemic area of southern Iran

Iran is in the malaria pre-elimination stage. In this situation community based strategies are important for malaria control. In order to intensify elimination activities we need to have a better understanding of the knowledge, attitudes and practices (KAP) of malaria prevention in the community. We carried out a KAP study in one malaria endemic district in southern Iran in 2009 using a structured questionnaire. Five villages with indigenous malaria cases during the previous year and a high potential for anopheline mosquito breeding were selected. All the households in each village were visited and the head of the household or other responsible adult was interviewed. Data were analyzed using SPSS 11.5. A total of 494 respondents from the five villages participated. More than 33% of people in the study area were living in sheds with poor facilities. The illiteracy level of the studied population was high (44.2%) and significantly affected the knowledge and practices of the respondents about malaria control (p<0.05). Descriptive analysis showed significant differences between sex, job and history of malaria infection of the respondents and their knowledge and practices about malaria control (p<0.05). Knowledge of the respondents about the route of transmission in malaria was good; 72.1% knew mosquitoes were the vector. Most people knew at least one symptom of the disease. The practices of respondents were 59.5% for bednet use and 9.3% for screening windows. The knowledge, attitudes and practices of respondents in this survey about malaria control were good in some cases, but in general needed to be improved with educational programs.

The epidemiology of malaria in the Papua New Guinea highlands: 7. Southern Highlands Province

As the last part of a program to survey the extent of malaria transmission in the Papua New Guinea highlands, a series of rapid malaria surveys were conducted in 2003-2004 and 2005 in different parts of Southern Highlands Province. Malaria was found to be highly endemic in Lake Kutubu (prevalence rate (PR): 17-33%), moderate to highly endemic in Erave (PR: 10-31%) and moderately endemic in low-lying parts (< 1500 m) of Poroma and Kagua (PR: 12-17%), but was rare or absent elsewhere. A reported malaria epidemic prior to the 2004 surveys could be confirmed for the Poroma (PR: 26%) but not for the lower Kagua area. In Kutubu/Erave Plasmodium falciparum was the most common cause of infection (42%), followed by P. vivax (39%) and P. malariae (16%). In other areas most infections were due to P. vivax (63%). Most infections were of low density (72% < 500/ microl) and not associated with febrile illness. Overall, malaria was only a significant source of febrile illness when prevalence rates rose above 10%, or in epidemics. However, concurrent parasitaemia led to a significant reduction in haemoglobin (Hb) level (1.2 g/dl, CI95: [1.1-1.4.], p < 0.001) and population mean Hb levels were strongly correlated with overall prevalence of malarial infections (r = -0.79, p < 0.001). Based on the survey results, areas of different malaria epidemiology are delineated and options for control in each area are discussed.

Oro-facial manifestations of Burkitt's lymphoma: an analysis of 680 cases from Malawi

Burkitt's lymphoma (BL) is a highly aggressive, fast growing, mature B-cell non-Hodgkin's Lymphoma (NHL) and has one of the highest proliferation rates of any human tumour. There are three forms of BL: endemic or the African form (eBL), sporadic or non-endemic form (sBL) and the immunodeficiency-associated form in HIV-AIDS. The survival rate of a child with BL is dependent upon rapid diagnosis and treatment. The aim of the present study was to determine the oro-facial manifestations in children with BL in Malawi. It was carried out in two parts: the first, a retrospective record-based study (2005-2007) consisting of 661 cases of BL and the second, a prospective study (June 2008 -October 2009) documenting 19 cases of suspected and confirmed cases of BL. In the retrospective study, two thirds presented with BL at various sites of which the abdomen was the most common site. The 5-9 year age group predominated with an average peak incidence of 7 years and accounted for 60.0% of all the cases. There was a male preponderance with a ratio of male to female of 1.6:1. The maxilla was the most common site for oro-facial BL (13.7%) followed by the mandible (7.2%), cheeks (5.7%), maxilla and mandible (4.5%) and cervical lymph nodes (4.1%). Of the 397 with BL, 41.4% were tested for HIV and 37.97% were HIV-negative while 5% were HIV-positive. In the prospective study, females predominated with a male to female ratio of 1.1:1 and the mandible was the most common site accounting for 19.04%. The age group 5-9 years predominated with 68.4% relative frequency. Generally the trend of BL had decreased from 2005 to 2007 possibly due to better access to health services, increased use of bed-treated mosquito nets for malaria prevention and knowledgeable healthcare workers. All oral healthcare and other healthcare workers need to be educated on the oro-facial manifestations of BL for prompt referral and management. This would result in a better prognosis since BL is curable as it responds favourably to chemotherapy. Furthermore, communities need to be educated on the early signs and symptoms of BL and the importance of visiting a hospital as soon as possible.

Community awareness, perceptions, acceptability and preferences for using LLIN against malaria in villages of Uttar Pradesh, India

BACKGROUND & OBJECTIVES

Long-lasting insecticidal nets (LLINs) have been introduced in India recently into the vector control programme. A study was undertaken to assess the community perception regarding use of LLIN, their acceptability, collateral benefits, etc. in certain villages of District Gautam Budh Nagar, Uttar Pradesh, India where LLINs are in use by the community.

METHOD

A randomized community-based survey was undertaken during April- May 2009 covering 596 respondents in LLIN villages where LLINs have been distributed along with 307 respondents in untreated net villages where untreated nets were distributed using structured questionnaire. Qualitative data were collected and the difference in proportion was calculated by z-test.

RESULTS

A substantial number of respondents had good knowledge of the symptoms of malaria. According to respondents, LLINs were very much effective in bringing down the malaria incidence in their families. About 98.3% of the respondents asserted the use of LLINs as their use not only reduced the number of mosquitoes as well as other non-target insects, but also reduced the malaria incidence. About 93.2% of the respondents were ready to purchase LLINs if available at nominal prices. All the respondents were satisfied about the performance of the LLINs in reducing the mosquito nuisance, safety of use and collateral benefits in LLIN villages.

CONCLUSION

LLINs are safe, socially acceptable and should be promoted for vector control to reduce the disease burden in the communities.

Possession and usage of insecticidal bed nets among the people of Uganda: is BRAC Uganda Health Programme pursuing a pro-poor path?

Background

The use of insecticidal bed nets is found to be an effective public health tool for control of malaria, especially for under-five children and pregnant women. BRAC, an indigenous Bangladeshi non-governmental development organization, started working in the East African state of Uganda in June 2006. As part of its efforts to improve the health and well-being of its participants, BRAC Uganda has been distributing long lasting insecticide-treated bed nets (LLIN) at a subsidized price through health volunteers since February 2008. This study was conducted in March-April 2009 to examine how equitable the programme had been in consistence with BRAC Uganda's pro-poor policy.

Methodology/Principal Findings

Information on possession of LLINs and relevant knowledge on its proper use and maintenance was collected from households either with an under-five child and/or a pregnant woman. The sample included three villages from each of the 10 branch offices where BRAC Uganda's community-based health programme was operating. Data were collected by trained enumerators through face-to-face interviews using a hand-held personal digital assistant (PDA). Findings reveal that the study population had superficial knowledge on malaria and its transmission, including the use and maintenance of LLINs. The households' rate of possession of bed nets (41–59%), and the proportion of under-five children (17–19%) and pregnant women (25–27%) who reported sleeping under an LLIN were not encouraging. Inequity was observed in the number of LLINs possessed by the households, in the knowledge on its use and maintenance, and between the two programme areas.

Conclusions/Significance

The BRAC Uganda's LLINs distribution at a subsidized price appeared to be inadequate and inequitable, and BRAC's knowledge dissemination is insufficient for initiating preventive actions such as proper use of LLINs to interrupt malaria transmission. Findings contribute to the on-going debate on LLINs distribution in Africa and make a strong case for its free distribution.

Decreasing burden of malaria in pregnancy in Malawian women and its relationship to use of intermittent preventive therapy or bed nets

Background

The World Health Organization recommends insecticidal bednets and intermittent preventive treatment to reduce malaria in pregnancy. Longitudinal data of malaria prevalence and pregnancy outcomes are valuable in gauging the impact of these antimalarial interventions.

Methodology/Principal Findings

We recruited 8,131 women delivering in a single Malawian hospital over 9 years. We recorded demographic data, antenatal prescription of intermittent preventive therapy during pregnancy with sulfadoxine-pyrimethamine and bed net use, and examined finger-prick blood for malaria parasites and hemoglobin concentration. In 4,712 women, we examined placental blood for malaria parasites and recorded the infant's birth weight. Peripheral and placental parasitemia prevalence declined from 23.5% to 5.0% and from 25.2% to 6.8% respectively. Smaller declines in prevalence of low birth weight and anemia were observed. Coverage of intermittent preventive treatment and bednets increased. Number of sulfadoxine-pyrimethamine doses received correlated inversely with placental parasitemia (Odds Ratio (95% CI): 0.79 (0.68, 0.91)), maternal anemia (0.81, (0.73, 0.90)) and low birth weight from 1997–2001 (0.63 (0.53, 0.75)), but not from 2002–2006. Bednet use protected from peripheral parasitemia (0.47, (0.37, 0.60)) and placental parasitemia (0.41, (0.31, 0.54)) and low birth weight (0.75 (0.59, 0.95)) but not anemia throughout the study. Compared to women without nets who did not receive 2-dose sulfadoxine-pyrimethamine, women using nets and receiving 2-dose sulfadoxine-pyrimethamine were less likely to have parasitemia or low birth weight babies. Women receiving 2-dose sulfadoxine-pyrimethamine alone had little evidence of protection whereas bednets alone gave intermediate protection.

Conclusions/Significance

Increased bednet coverage explains changes in parasitemia and birth weight among pregnant women better than sulfadoxine-pyrimethamine use. High bed net coverage, and sulfadoxine-pyrimethamine resistance, may be contributing to its apparent loss of effectiveness.

Which family members use the best nets? An analysis of the condition of mosquito nets and their distribution within households in Tanzania

BACKGROUND

Household ownership of insecticide-treated mosquito nets (ITNs) is increasing, and coverage targets have been revised to address universal coverage with ITNs. However, many households do not have enough nets to cover everyone, and the nets available vary in physical condition and insecticide treatment status. Since 2004, the Government of Tanzania has been implementing the Tanzania National Voucher Scheme (TNVS), which distributes vouchers for ITNs through antenatal clinics to target pregnant women and their infants. This analysis aimed to determine the following: (1) coverage patterns of bed nets within households according to physical condition and treatment status; (2) who might be at risk if mosquitoes were diverted from occupants of untreated nets to those not using nets? (3) the degree to which those at highest risk of malaria use the most protective nets.

METHODS

Data from the 2006 TNVS household survey were analysed to assess within-household distribution of net use. The associations between net characteristics and net user were also evaluated. Multivariate analysis was applied to the relationship between the number of holes per net and user characteristics while adjusting for confounders.

RESULTS

In households with a net:person ratio better than 1:4 (one net for every four household members), more than 80% of the people in such households reported using a net the previous night. ITNs were most likely to be used by infants, young children (1-4 y), and women of childbearing age; they were least likely to be used by older women (>or=50 y), older children (5-14 y), and adult men. The nets used by infants and women of childbearing age were in better-than-average physical condition; the nets used by older women and older children were in worse-than-average condition; while young children and adult men used nets in intermediate (average) condition. When adjusted for confounders, the nets used by young and older children had more holes than nets used by infants.

CONCLUSIONS

Infants and other vulnerable groups were most likely to sleep under the most protective nets. Nevertheless, more communication efforts are needed to increase use of intact ITNs within households for children. Further research is necessary to fully understand motivations influencing within-household net distribution.

Knowledge, attitudes and practices regarding dengue infection in Westmoreland, Jamaica

BACKGROUND

Dengue virus infection causes significant morbidity and mortality in most tropical and sub-tropical countries of the world. Dengue fever is endemic in Jamaica and continues to be a public health concern. There is a paucity of information on knowledge, attitudes and practices (KAP) of Jamaicans regarding dengue infection.

OBJECTIVE

To describe dengue-related knowledge, attitudes and practices (KAP) of residents of Westmoreland, Jamaica.

METHODS

A cross-sectional questionnaire survey of 192 parents attending child health clinics in the Parish of Westmoreland was conducted.

RESULTS

More than half of the parents (54%) had good knowledge about signs, symptoms and mode of transmission of dengue. Approximately 47% considered dengue to be a serious but preventable disease to which they are vulnerable. Nevertheless, a majority (77%) did not use effective dengue preventive methods such as screening of homes and 51% did not use bed nets. Educational attainment (OR, 2.98; CI, 1.23, 7.23) was positively associated with knowledge of dengue. There was no correlation between knowledge about dengue and preventive practices (p = 0.34). Radio and TV were the predominant sources of information about dengue fever.

CONCLUSION

Findings suggest that the good knowledge about dengue fever among residents of Westmoreland did not translate to adoption of preventive measures. Health programme planners and practitioners need to identify and facilitate removal of barriers to behaviour change related to control of dengue fever among the population. Future campaigns should focus on educating and encouraging individuals and families to adopt simple, preventive actions, such as, use of insecticide treated bed nets and screening of homes.

An assessment of Lot Quality Assurance Sampling to evaluate malaria outcome indicators: extending malaria indicator surveys

BACKGROUND

Large investments and increased global prioritization of malaria prevention and treatment have resulted in greater emphasis on programme monitoring and evaluation (M&E) in many countries. Many countries currently use large multistage cluster sample surveys to monitor malaria outcome indicators on a regional and national level. However, these surveys often mask local-level variability important to programme management. Lot Quality Assurance Sampling (LQAS) has played a valuable role for local-level programme M&E. If incorporated into these larger surveys, it would provide a comprehensive M&E plan at little, if any, extra cost.

METHODS

The Mozambique Ministry of Health conducted a Malaria Indicator Survey (MIS) in June and July 2007. We applied LQAS classification rules to the 345 sampled enumeration areas to demonstrate identifying high- and low-performing areas with respect to two malaria program indicators-'household possession of any bednet' and 'household possession of any insecticide-treated bednet (ITN)'.

RESULTS

As shown by the MIS, no province in Mozambique achieved the 70% coverage target for household possession of bednets or ITNs. By applying LQAS classification rules to the data, we identify 266 of the 345 enumeration areas as having bednet coverage severely below the 70% target. An additional 73 were identified with low ITN coverage.

CONCLUSIONS

This article demonstrates the feasibility of integrating LQAS into multistage cluster sampling surveys and using these results to support a comprehensive national, regional and local programme M&E system. Furthermore, in the recommendations we outlined how to integrate the Large Country-LQAS design into macro-surveys while still obtaining results available through current sampling practices.

Plasmodium infection and its risk factors in eastern Uganda

BACKGROUND

Malaria is a leading cause of disease burden in Uganda, although surprisingly few contemporary, age-stratified data exist on malaria epidemiology in the country. This report presents results from a total population survey of malaria infection and intervention coverage in a rural area of eastern Uganda, with a specific focus on how risk factors differ between demographic groups in this population.

METHODS

In 2008, a cross-sectional survey was conducted in four contiguous villages in Mulanda, sub-county in Tororo district, eastern Uganda, to investigate the epidemiology and risk factors of Plasmodium species infection. All permanent residents were invited to participate, with blood smears collected from 1,844 individuals aged between six months and 88 years (representing 78% of the population). Demographic, household and socio-economic characteristics were combined with environmental data using a Geographical Information System. Hierarchical models were used to explore patterns of malaria infection and identify individual, household and environmental risk factors.

RESULTS

Overall, 709 individuals were infected with Plasmodium, with prevalence highest among 5-9 year olds (63.5%). Thin films from a random sample of 20% of parasite positive participants showed that 94.0% of infections were Plasmodium falciparum and 6.0% were P. malariae; no other species or mixed infections were seen. In total, 68% of households owned at least one mosquito although only 27% of school-aged children reported sleeping under a net the previous night. In multivariate analysis, infection risk was highest amongst children aged 5-9 years and remained high in older children. Risk of infection was lower for those that reported sleeping under a bed net the previous night and living more than 750 m from a rice-growing area. After accounting for clustering within compounds, there was no evidence for an association between infection prevalence and socio-economic status, and no evidence for spatial clustering.

CONCLUSION

These findings demonstrate that mosquito net usage remains inadequate and is strongly associated with risk of malaria among school-aged children. Infection risk amongst adults is influenced by proximity to potential mosquito breeding grounds. Taken together, these findings emphasize the importance of increasing net coverage, especially among school-aged children.

[Pharmacovigilance and impact of intermittent preventive treatment with sulfadoxine-pyrimethamine in pregnant women in Sélingué, Mali]

This study aimed to evaluate the impact of intermittent preventive treatment (IPT) and the associated adverse effects in pregnant women living in hyperendemic area of Sélingué in Mali on pregnancy outcome. Pharmacovigilance aims, monitoring the risk of adverse effects resulting from the use of drugs and products for human use licensees of marketing. IPT with sulfadoxine-pyrimethamine (SP) is based on the administration of 2 doses of SP treatment in pregnant women at defined intervals after about 18-20 weeks of pregnancy. The survey on attitudes and behavioural practices (KAP) has allowed us to interview 210 pregnant women attending antenatal clinics at the health district of Sélingué. Almost all women (99%) affirm to know malaria and 84.8% to know clinical signs of malaria. Self medication was practiced by 40% of the expectant mothers. A small proportion of women affirm to have mosquito nets (8.6%) while 14.3% affirm to use impregnated insecticide mosquito nets. The rate of severe anaemia was 30.5% (Hb < 7 g/dl) after the first dose and 13.3% after the second dose of S-P. In parallel, the rate of moderate anaemia (Hb 7-9g /dl) decreased by 54.8% after the first dose to 26.2% after the second dose. Anaemia was higher within multigestes (32.1%) compared with the primigestes (21.7%). We did not observe any case of therapeutic failure with S-P nor infection in our study. The rate of prematurity was 3% while the rate low birth weight was 17.6%. Observed adverse reactions were primarily nauseas and stomach upset (1.9% after first S-P dose and 1% after the 2nd dose of S-P). No case of severe side effects or malformations was observed within new-born babies. In conclusion, IPT with S-P was well tolerated by pregnant women living in Sélingué and presents very few minor secondary reactions. The S-P is currently the only antimalarial drug with a single-dose which has a prolonged action and which also has ideal properties (low cost, several data on its tolerance and its facility of use) for a better use during the pregnancy in Africa.