Abstract
BackgroundMalaria transmission is highly heterogeneous in most settings, resulting in the formation of recognizable malaria hotspots. Targeting these hotspots might represent a highly efficacious way of controlling or eliminating malaria if the hotspots fuel malaria transmission to the wider community.Methods/designHotspots of malaria will be determined based on spatial patterns in age-adjusted prevalence and density of antibodies against malaria antigens apical membrane antigen-1 and merozoite surface protein-1. The community effect of interventions targeted at these hotspots will be determined. The intervention will comprise larviciding, focal screening and treatment of the human population, distribution of long-lasting insecticide-treated nets and indoor residual spraying. The impact of the intervention will be determined inside and up to 500 m outside the targeted hotspots by PCR-based parasite prevalence in cross-sectional surveys, malaria morbidity by passive case detection in selected facilities and entomological monitoring of larval and adult Anopheles populations.DiscussionThis study aims to provide direct evidence for a community effect of hotspot-targeted interventions. The trial is powered to detect large effects on malaria transmission in the context of ongoing malaria interventions. Follow-up studies will be needed to determine the effect of individual components of the interventions and the cost-effectiveness of a hotspot-targeted approach, where savings made by reducing the number of compounds that need to receive interventions should outweigh the costs of hotspot-detection.Trial registrationNCT01575613. The protocol was registered online on 20 March 2012; the first community was randomized on 26 March 2012.
Highlights
Malaria transmission is highly heterogeneous in most settings, resulting in the formation of recognizable malaria hotspots
Targeting interventions to hotspots of malaria transmission is frequently mentioned as a cost-effective approach for malaria control and elimination [2,4,5,47], direct evidence for a community effect of hotspot-targeted interventions is currently unavailable
Valuable information on how to quantify community effects of malaria control interventions comes from trials with insecticide-treated net (ITN) [48]
Summary
Malaria transmission is highly heterogeneous in most settings, resulting in the formation of recognizable malaria hotspots. A small number of human hosts are most frequently or most heavily infected while the majority of a local population is much less affected [1,2,3,4]. In malaria, this heterogeneity of disease transmission often results in variation. R0 may be four times higher when heterogeneous mosquito exposure, as opposed to homogeneous exposure, is considered [2,4,16]
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