Malaria Elimination Programme Research Articles

Molecular markers of artemisinin resistance during falciparum malaria elimination in Eastern Myanmar

BackgroundArtemisinin resistance in Plasmodium falciparum threatens global malaria elimination efforts. To contain and then eliminate artemisinin resistance in Eastern Myanmar a network of community-based malaria posts was instituted and targeted mass drug administration (MDA) with dihydroartemisinin-piperaquine (three rounds at monthly intervals) was conducted. The prevalence of artemisinin resistance during the elimination campaign (2013–2019) was characterized.MethodsThroughout the six-year campaign Plasmodium falciparum positive blood samples from symptomatic patients and from cross-sectional surveys were genotyped for mutations in kelch-13—a molecular marker of artemisinin resistance.ResultThe program resulted in near elimination of falciparum malaria. Of 5162 P. falciparum positive blood samples genotyped, 3281 (63.6%) had K13 mutations. The prevalence of K13 mutations was 73.9% in 2013 and 64.4% in 2019. Overall, there was a small but significant decline in the proportion of K13 mutants (p < 0.001). In the MDA villages there was no significant change in the K13 proportions before and after MDA. The distribution of different K13 mutations changed substantially; F446I and P441L mutations increased in both MDA and non-MDA villages, while most other K13 mutations decreased. The proportion of C580Y mutations fell from 9.2% (43/467) before MDA to 2.3% (19/813) after MDA (p < 0.001). Similar changes occurred in the 487 villages where MDA was not conducted.ConclusionThe malaria elimination program in Kayin state, eastern Myanmar, led to a substantial reduction in falciparum malaria. Despite the intense use of artemisinin-based combination therapies, both in treatment and MDA, this did not select for artemisinin resistance.

System-wide governance challenges of the Ebonyi State Malaria Elimination Programme and recommendations for malaria health system strengthening: a qualitative study among stakeholders in Ebonyi state, Nigeria

ObjectivesThe burden of malaria has persistently been high in Ebonyi state and Nigeria despite long-standing collaborations with international partners with huge and increased amounts of financial investments. We explored the...

Fidelity of implementation of national guidelines on malaria diagnosis for children under-five years in Rivers State, Nigeria

BackgroundMalaria is still a disease of global public health importance and children under-five years of age are the most vulnerable to the disease. Nigeria adopted the “test and treat” strategy in the national malaria guidelines as one of the ways to control malaria transmission. The level of adherence to the guidelines is an important indicator for the success or failure of the country’s roadmap to malaria elimination by 2030. This study aimed to assess the fidelity of implementation of the national guidelines on malaria diagnosis for children under-five years and examine its associated moderating factors in health care facilities in Rivers State, Nigeria.MethodsThis was a descriptive, cross-sectional study conducted in Port Harcourt metropolis. Data were collected from 147 public, formal private and informal private health care facilities. The study used a questionnaire developed based on Carroll’s Conceptual Framework for Implementation Fidelity. Frequency, mean and median scores for implementation fidelity and its associated factors were calculated. Associations between fidelity and the measured predictors were examined using Mann Whitney U test, Kruskal Wallis test, and multiple linear regression modelling using robust estimation of errors. Regression results are presented in adjusted coefficient (β) and 95% confidence intervals.ResultsThe median (IQR) score fidelity score for all participants was 65% (43.3, 85). Informal private facilities (proprietary patent medicine vendors) had the lowest fidelity scores (47%) compared to formal private (69%) and public health facilities (79%). Intervention complexity had a statistically significant inverse relationship to implementation fidelity (β = − 1.89 [− 3.42, − 0.34]). Increase in participant responsiveness (β = 8.57 [4.83, 12.32]) and the type of malaria test offered at the facility (e.g., RDT vs. no test, β = 16.90 [6.78, 27.03]; microscopy vs. no test, β = 21.88 [13.60, 30.16]) were positively associated with fidelity score.ConclusionsThis study showed that core elements of the “test and treat” strategy, such as testing all suspected cases with approved diagnostic methods before treatment, are still not fully implemented by health facilities. There is a need for strategies to increase fidelity, especially in the informal private health sector, for malaria elimination programme outcomes to be achieved.

Knowledge and Practices of Women Regarding Malaria and Its Prevention: A Community-Based Study in an Area under Malaria Elimination Programme in Iran

Background: Indoor residual spraying (IRS) and long-lasting insecticidal nets (LLINs) are two core interventions for control and prevention of malaria infection. This descriptive cross-sectional study aimed to determine the knowledge and practices of women regarding malaria and its preventive measures in a malarious area in the Jask County, southeast of Iran.&#x0D; Methods: Data was collected from 400 households through a two-stage random cluster sampling method in six villages. Pre-tested structured questionnaire was used to collect data. During the survey, visual observations were also made by the interviewers to check use of LLINs and IRS. The data were analyzed by SPSS software version 21.&#x0D; Results: The majority of households had a high level of knowledge about symptoms (98%, n=392) and transmission (74.5%, n=298) of malaria. The main preventive measures against malaria were: LLINS (39.5%, n=158), IRS (32%, n=128), and screens on doors/windows (16.7%, n=67). In addition, participants with primary or higher educational level reported that they practice more malaria preventive measures, compared to those who were illiterate (OR=3.3, 95% CI= 1.6–6.6, p=0.0001, Table 6). In spite of positive perceptions about IRS and LLINs, only 35.5% (n=142) and 17% (n=68) of households used IRS and LLINs, respectively.&#x0D; Conclusion: According to the results of this study, despite a high level of knowledge about malaria and its preventive measures, a small number of participants use LLINs and IRS for malaria prevention. Therefore, implementation of ef­fective educational interventions is recommended to improve preventive practices against malaria in the study area.&#x0D;  

Implementation and effectiveness outcomes of Community Health Advocacy Teams to improve long-lasting insecticide net distribution and use in six districts in Ghana: A one-group pre-post-test study.

Malaria remains a leading cause of illness and death especially among children and pregnant women in Ghana. Despite the efforts made by the National Malaria Elimination Programme (NMEP), including distribution of Long-Lasting Insecticide Nets (LLINs) to households through periodic Point Mass Distribution (PMD) campaigns and continuous channels (antenatal, schools and postnatal), there is a gap between access and use of LLINs in Ghana. An effective and functional community-based group that would seek to improve the effectiveness of LLIN distribution before, during, after PMD Campaigns and continuous distribution at the community level could help address this gap. This paper assesses the implementation outcomes and short-term effectiveness of the pilot implementation of co-created community health advocacy teams (CHAT) intervention in Ghanaian communities to plan and implement campaigns to increase LLIN use. The study employed a one-group pre-post study design and measured implementation outcomes (acceptability, appropriateness, and feasibility) and effectiveness outcomes (LLIN awareness, LLIN access, willingness to purchase LLIN, and LLIN use) among 800 community households. The CHAT intervention was implemented for four months across six districts in the Eastern and Volta regions of Ghana. The data were downloaded directly from REDCap and analyzed statistically (descriptive and McNemar test of association) using SPSS 22 software. After the implementation period, the majority of respondents in all six districts indicated that the CHAT intervention was acceptable (89.8%), appropriate (89.5%), and feasible (90%). Also, there was a significant association between baseline and end-line assessment on all four effectiveness outcome measures. Household members' awareness of, access to, willingness to purchase, and use of LLINs increased significantly over the four-month period that the CHAT intervention was implemented. The study concludes that CHAT is an acceptable, appropriate, and feasible intervention for supporting the National Malaria Programme in LLIN PMD and for engaging in Social and Behaviour Change Communication activities through the continuous channels of distribution. Additionally, the CHAT demonstrates short-term effectiveness outcomes in terms of creating LLIN awareness, providing access to LLIN, and encouraging Ghanaian community members to be willing to purchase and use LLINs. Although the activities of CHAT members were largely voluntary, integration into the existing primary health care system will make it sustainable.

Under utilization of long-lasting insecticidal nets (LLINs) is challenging malaria elimination program in Ethiopia: a systematic review and meta-analysis

BackgroundMalaria is one of the most common causes of morbidity and mortality in developing countries including Ethiopia. Mass distribution of insecticide-treated nets and indoor residual spray for high malaria risk groups are the major prevention measures in different countries. Achievement of the malaria elimination plan is highly determined by the level of effective utilization of intervention measures. However, there is scarce information showing the national level of insecticide-treated nets utilization.ObjectiveTo estimate the pooled prevalence of insecticide-treated nets utilization in Ethiopia, 2023.MethodA Systematic Review and Meta-analysis employed to assess the utilization of long-lasting insecticidal nets in Ethiopia. Published articles were searched from Google Scholar, PubMed, Web Sciences, CINAHIL, EMBASE, and Scopus. The collected articles were screened for data extraction and further analysis using preferred reporting items for systematic review and meta-analysis (PRISMA) flow chart. The quality of each study was assessed using the Jonna Briggs Institute (JBI) checklist. The data were extracted using Microsoft Excel and exported to STATA version 17.0 for analysis. The overall pooled prevalence of long-lasting insecticidal nets utilization was determined using a random effects model.ResultOut of 1657 articles reviewed, only 21 of them were eligible for final analysis. All of the included studies were used to estimate the pooled prevalence of long-lasting insecticidal net utilization. The point prevalence of LLIN utilization ranged from 14.23 to 91.9%. The Meta-analysis estimated that the overall pooled prevalence of insecticidal nets utilization among all study participants in Ethiopia was 56.26% (95%CI: 44.04–68.48%). Subgroup analysis revealed that insecticidal nets utilization was relatively highest in the Amhara region [63.0, 95%CI (37.0–89.0%)] and during 2020–2023 [61, 95% CI (53.0–69.0%)].ConclusionLong-lasting insecticidal nets utilization in Ethiopia is lower than the national target plan. Hence, it needs extra follow-up and intervention to enhance its utilization.

An analytically tractable, age-structured model of the impact of vector control on mosquito-transmitted infections.

Vector control is a vital tool utilised by malaria control and elimination programmes worldwide, and as such it is important that we can accurately quantify the expected public health impact of these methods. There are very few previous models that consider vector-control-induced changes in the age-structure of the vector population and the resulting impact on transmission. We analytically derive the steady-state solution of a novel age-structured deterministic compartmental model describing the mosquito feeding cycle, with mosquito age represented discretely by parity-the number of cycles (or successful bloodmeals) completed. Our key model output comprises an explicit, analytically tractable solution that can be used to directly quantify key transmission statistics, such as the effective reproductive ratio under control, Rc, and investigate the age-structured impact of vector control. Application of this model reinforces current knowledge that adult-acting interventions, such as indoor residual spraying of insecticides (IRS) or long-lasting insecticidal nets (LLINs), can be highly effective at reducing transmission, due to the dual effects of repelling and killing mosquitoes. We also demonstrate how larval measures can be implemented in addition to adult-acting measures to reduce Rc and mitigate the impact of waning insecticidal efficacy, as well as how mid-ranges of LLIN coverage are likely to experience the largest effect of reduced net integrity on transmission. We conclude that whilst well-maintained adult-acting vector control measures are substantially more effective than larval-based interventions, incorporating larval control in existing LLIN or IRS programmes could substantially reduce transmission and help mitigate any waning effects of adult-acting measures.

Malaria Parasitaemia, Risk Perception, and Preventive Practices Among Women Attending Ante-Natal Clinics in Ogun State

Malaria contributes over 10% of all deaths among pregnant women. The prevalence of malaria in pregnancy in Nigeria particularly in Ogun State is high. The coverage and uptake of Intermittent Preventive Treatment with Sulphodoxine Pyrimethamine (IPT-SP) and Long-Lasting Insecticidal Nets (LLINs) in Southwest Nigeria is still very low despite their proven cost effectiveness in improving maternal and infant health. This study therefore determined the malaria parasitaemia, risk perception, preventive practices and associated factors among women attending Ante-natal Clinics (ANCs) in Ogun state. A cross-sectional study was carried out using mixed methods. An estimated sample size of 426 was computed and selected from ANCs across the state through multistage sampling technique. Pre-tested semi-structured interviewer administered questionnaire was used to collect information. Also, focused group discussions (FGDs) were conducted among women attending ANC and blood samples were taken from asymptomatic women for laboratory analysis to determine prevalence of malaria parasitaemia. Measures of association between the dependent and independent variables were tested using Chi-square. All tests of significance were done based on a ɑ-level of 0.05. Response rate was 100% for this study. The mean age of respondents was 27.9 ±5.5 years. Risk perception of malaria was observed to be good. Malaria parasitaemia was 2.7% and was 100% due to &amp;lt;i&amp;gt;Plasmodium falciparum&amp;lt;/i&amp;gt;. Maternal age was significantly associated with malaria parasitaemia. Therefore, it is recommended that malaria elimination programmes should be sustained; access and affordability of ANC care should be ensured by the Government.

Progress towards malaria elimination in the Greater Mekong Subregion: perspectives from the World Health Organization

Malaria remains a global health challenge, disproportionately affecting vulnerable communities. Despite substantial progress, the emergence of anti-malarial drug resistance poses a constant threat. The Greater Mekong Subregion (GMS), which includes Cambodia, China’s Yunnan province, Lao People's Democratic Republic, Myanmar, Thailand, and Viet Nam has been the epicentre for the emergence of resistance to successive generations of anti-malarial therapies. From the perspective of the World Health Organization (WHO), this article considers the collaborative efforts in the GMS, to contain Plasmodium falciparum artemisinin partial resistance and multi-drug resistance and to advance malaria elimination. The emergence of artemisinin partial resistance in the GMS necessitated urgent action and regional collaboration resulting in the Strategy for Malaria Elimination in the Greater Mekong Subregion (2015–2030), advocating for accelerated malaria elimination interventions tailored to country needs, co-ordinated and supported by the WHO Mekong malaria elimination programme. The strategy has delivered substantial reductions in malaria across all GMS countries, with a 77% reduction in malaria cases and a 97% reduction in malaria deaths across the GMS between 2012 and 2022. Notably, China was certified malaria-free by WHO in 2021. Countries' ownership and accountability have been pivotal, with each GMS country outlining its priorities in strategic and annual work plans. The development of strong networks for anti-malarial drug resistance surveillance and epidemiological surveillance was essential. Harmonization of policies and guidelines enhanced collaboration, ensuring that activities were driven by evidence. Challenges persist, particularly in Myanmar, where security concerns have limited recent progress, though an intensification and acceleration plan aims to regain momentum. Barriers to implementation can slow progress and continuing innovation is needed. Accessing mobile and migrant populations is key to addressing remaining transmission foci, requiring effective cross-border collaboration. In conclusion, the GMS has made significant progress towards malaria elimination, particularly in the east where several countries are close to P. falciparum elimination. New and persisting challenges require sustained efforts and continued close collaboration. The GMS countries have repeatedly risen to every obstacle presented, and now is the time to re-double efforts and achieve the 2030 goal of malaria elimination for the region.

Evaluation of the malaria elimination programme in Muara Enim Regency: a qualitative study from Indonesia

BackgroundMalaria remains an enduring public health concern in Indonesia, exacerbated by its equatorial climate that fosters the proliferation of Anopheles mosquitoes. This study seeks to assess the performance of the malaria elimination programme comprehensively.MethodsBetween May and August 2022, a qualitative study was conducted in Muara Enim Regency, South Sumatra Province, involving 22 healthcare professionals from diverse backgrounds. These informants were strategically chosen for their pivotal roles in providing profound insights into various facets of the malaria elimination programme. This encompasses inputs such as human resources, budgetary allocation, and infrastructural support; processes like case identification and management, capacity enhancement, epidemiological surveillance, prevention measures, outbreak control, and enhanced communication and educational initiatives; and, notably, the programme’s outcomes. Data were collected through 3-h Focus Group Discussions (FGDs) divided into two groups, each with 12 participants: healthcare professionals and programme managers. Additionally, in-depth interviews (IDIs) were conducted with ten informants. Employing the Input-Process-Output (IPO) model, this study meticulously analysed the healthcare system dynamics and the interventions’ efficacy.ResultsThe study unveiled many challenges during the input phase, including the absence of entomologists and a shortage of diagnostic tools. Despite these obstacles, it documented remarkable accomplishments in the output domain, marked by significant advancements in the distribution of mosquito nets and the successful implementation of the Early Warning System (EWS). Despite the adversities, the programme has made substantial strides towards malaria elimination.ConclusionsUrgent action is imperative to bolster the effectiveness of the malaria elimination programme. Key measures encompass augmenting the entomologist workforce, optimizing resource allocation, and ensuring stringent adherence to regional regulations. Addressing these concerns will enhance programme efficacy, yielding enduring public health benefits. This research substantially contributes to Indonesia’s ongoing malaria elimination endeavours, furnishing actionable insights for programme enhancement. Consequently, this research holds significant importance for the malaria elimination drive.

Using a mobile nanopore sequencing lab for end-to-end genomic surveillance of Plasmodium falciparum: A feasibility study.

Genomic epidemiology holds promise for malaria control and elimination efforts, for example by informing on Plasmodium falciparum genetic diversity and prevalence of mutations conferring anti-malarial drug resistance. Limited sequencing infrastructure in many malaria-endemic areas prevents the rapid generation of genomic data. To address these issues, we developed and validated assays for P. falciparum nanopore sequencing in endemic sites using a mobile laboratory, targeting key antimalarial drug resistance markers and microhaplotypes. Using two multiplexed PCR reactions, we amplified six highly polymorphic microhaplotypes and ten drug resistance markers. We developed a bioinformatics workflow that allows genotyping of polyclonal malaria infections, including minority clones. We validated the panels on mock dried blood spot (DBS) and rapid diagnostic test (RDT) samples and archived DBS, demonstrating even, high read coverage across amplicons (range: 580x to 3,212x median coverage), high haplotype calling accuracy, and the ability to explore within-sample diversity of polyclonal infections. We field-tested the feasibility of rapid genotyping in Zanzibar in close collaboration with the local malaria elimination program using DBS and routinely collected RDTs as sample inputs. Our assay identified haplotypes known to confer resistance to known antimalarials in the dhfr, dhps and mdr1 genes, but no evidence of artemisinin partial resistance. Most infections (60%) were polyclonal, with high microhaplotype diversity (median HE = 0.94). In conclusion, our assays generated actionable data within a few days, and we identified current challenges for implementing nanopore sequencing in endemic countries to accelerate malaria control and elimination.

Evaluation of the Administrative, Coordination, and Financing Capacity of the Sub-National Malaria Elimination Programs in Nigeria: A Case Study of Cross River State.

Background: This study appraised the implementers’ perspective of the program’s existing administrative and management; coordination and collaboration; and financing and accountability capacities to deliver its malaria prevention and control mandate. Method: The instrument used was a structured interviewer-administered questionnaire adapted from an already existing National Malaria Programme’s Capacity Assessment tool. Being a widely used open-source program tool, a pretest was done to ascertain its suitability and applicability to the study context and for field assistants to gain familiarity with it. The total population sampling method was used due to the small size of the target population. The target population/sample size was therefore 137, comprising the State Malaria Technical Working Group members, key officers of Cross River State Malaria Elimination Program (CRSMEP), and the Local Government Areas (LGA) Malaria implementing teams. It was a descriptive cross-sectional study. Each element per section of the questionnaire was weighted using the Likert scale and calculated using simple percentages. Results: Research results showed that the malaria program at the State and LGA level have adequate administrative and management capacity with confirmation by 64% and 82.1% of respondents respectively. 80% of respondents confirmed average coordination and collaboration capacity at the State level while 50% of respondents at the LGA level confirmed that the program has adequate coordination and collaboration capacity. For financing and accountability capacity, 36% of respondents affirmed that there is average capacity at the State level while 37.5% confirmed that there is no capacity at LGA level. Conclusion: The study revealed the program’s capacity gaps at State and LGA in the 3 aforementioned key areas. Therefore, interventions to address the capacity gaps are training/re-training of program staff and health workers on program management, administration, and finance, establishing performance management and accountability mechanisms, conducting evidence-based advocacy visits to policymakers for prioritizing allocating and releasing funds for malaria control activities, especially for intervention areas that are not supported by donor/partner organizations.

Vivax malaria: a possible stumbling block for malaria elimination in India.

Plasmodium vivax is geographically the most widely dispersed human malaria parasite species. It has shown resilience and a great deal of adaptability. Genomic studies suggest that P. vivax originated from Asia or Africa and moved to the rest of the world. Although P. vivax is evolutionarily an older species than Plasmodium falciparum, its biology, transmission, pathology, and control still require better elucidation. P. vivax poses problems for malaria elimination because of the ability of a single primary infection to produce multiple relapses over months and years. P. vivax malaria elimination program needs early diagnosis, and prompt and complete radical treatment, which is challenging, to simultaneously exterminate the circulating parasites and dormant hypnozoites lodged in the hepatocytes of the host liver. As prompt surveillance and effective treatments are rolled out, preventing primaquine toxicity in the patients having glucose-6-phosphate dehydrogenase (G6PD) deficiency should be a priority for the vivax elimination program. This review sheds light on the burden of P. vivax, changing epidemiological patterns, the hurdles in elimination efforts, and the essential tools needed not just in India but globally. These tools encompass innovative treatments for eliminating dormant parasites, coping with evolving drug resistance, and the development of potential vaccines against the parasite.

Situational Analysis of Malaria Incidence Under Integrated Malaria Service in Hotspot Township - Minbya Township, Rakhine State, Myanmar, 2017-2020.

Malaria is a significant public health concern and tropical disease, particularly affecting Myanmar within the Greater Mekong Subregion. The annual parasite index (API) exceeds 1 per 10,000 population in the northern seven townships of Rakhine State, with Minbya Township designated as a high-burden area for malaria by the World Health Organization (WHO) Myanmar and the National Malaria Control Programme (NMCP). Since 2017, the Malaria reduction intensification plan has been in place in this township to combat the high disease transmission rates. This study aims to assess the malaria epidemiology in Minbya Township from 2017 to 2020 under the intensification plan for elimination, as well as to evaluate the effectiveness of the integrated strategy in reducing cases in hotspot areas. The study utilized a surveillance study design to collect secondary data from the Malaria surveillance system (MSS) and the epidemiologic monitoring dashboard of Minbya Township, Maruk-U District, located in Rakhine State. Since 2017, the Malaria prevention and control (P&C) Program in Minbya Township has successfully decreased malaria morbidity, eliminated malaria-related deaths, and bolstered malaria testing capabilities through the participation of village health volunteers (VHVs). Approximately 87% of malaria prevention and control services are executed by the township's malaria elimination and disease control programs, with additional support from stakeholders. The API dropped from 13 in 2017 to 2.5 in 2020, with Plasmodium vivax being the most prevalent malaria species, accounting for 55% of cases. The study suggests that early diagnosis and promotion of artemisinin-based combination treatment (ACT), along with strategic planning including expanding active case detection in rural health centers and implementing a community-based integrated healthcare approach, are effective and efficient strategies for malaria elimination.

Impact of urbanization on the abundance and distribution of Anophelines population in Ghaziabad district, Uttar Pradesh, India

Background &amp; objectives: In urban areas, upsurge in population has resulted in more breeding sites for malaria vectors, and hence this scenario potentially undermine malaria elimination and control programs. The change in land use due to urbanization may result in the presence and distribution of malaria vectors. Understanding potential malaria vectors is essential for current and future malaria transmission control strategies. This study investigated the effects of rapid urbanization on malaria vectors An. culicifacies s.l. and An. stephensi L. in Ghaziabad district. Methods: Ghaziabad district which presents several levels of urbanization was selected for this study. Entomological investigations were conducted seasonally from 2014-2016 in the rural, urban, and peri-urban regions. Vector incrimination study was done using ELISA (confirmation by PCR) on suspected Anopheles vectors viz. An. culicifacies, An. stephensi, An. annularis and An. subpictus. Results: An. culicifacies showed alteration in distribution influenced by rural and agricultural land whereas An. stephensi was found to be influenced by artificial habitats and population growth. Interpretation &amp; conclusion: The study also confirms the association between the abundance of malaria vectors and land use change.

Malaria Elimination in West Java, Indonesia: A Descriptive-and-Qualitative Study

ABSTRACT Background &amp; objectives: Following the World Health Organization (WHO) plans for 35 malaria-endemic countries, Indonesia will eliminate malaria by 2030. As one of the Indonesian provinces, West Java targeted sub-national malaria elimination in 2022. This article aims to describe malaria surveillance data and elimination programs, including weaknesses in sustaining the program. Methods: This study used secondary data from malaria surveillance information system regencies/cities’ case reports for 2019–2022 and achievement data of sub-national malaria elimination certification from each regency/city in 2014–2022. The data was confirmed from the evaluation study document, analysis of reported cases, and interviews. Results: Most cases were confirmed by microscopic examination (84.1% in 2021 and 94.4% in 2022) and rapid diagnostic tests (57% in 2019 and 58.1% in 2020). Malaria is more prevalent among men (93% in 2019, 95% in 2020, 96% in 2021, and 95.9% in 2022) and productive ages 15–64 (98.8% in 2019, 100% in 2020, 99.2% in 2021, and 98.8% in 2022), frequently occurs in the military (56.3% in 2019, 75.7% in 2020, 45.2% in 2021) and police (40.5% in 2022), often use passive case detection for identifying cases (97.9% in 2019 and 2020, 95.2% in 2021, and 97.6% in 2022), and the majority undergo inpatient treatment (86.4% in 2019, 81.7% in 2021, and 82.6% in 2022). Most positive cases originated from imported cases, and the last indigenous cases were still found in 2019. Plasmodium vivax dominated malaria cases, and relapses were high (55.0% in 2020, and 47.3% in 2022). Interpretation &amp; conclusion: All regencies/cities have obtained sub-national malaria elimination certification in 2022. West Java has the potential to be verified for Java-Bali sub-national malaria elimination targeted in 2023, albeit cases of imported malaria still occur. It is imperative to address the issue of imported cases transitioning into locally transmitted cases (introduced) by effective coordination across all regencies/cities and inter-provincial efforts.

Evaluation of the administrative, coordination and financing capacity of the sub-national malaria elimination programs in Nigeria: a case study of cross river state.

This study appraised the implementers' perspective of the program's existing administrative and management; coordination and collaboration; and financing and accountability capacities to deliver its malaria prevention and control mandate. The instrument used was a structured interviewer-administered questionnaire adapted from an already existing National Malaria Programme's Capacity Assessment tool. Being a widely used open-source program tool, a pretest was done to ascertain its suitability and applicability to the study context and for field assistants to gain familiarity with it. The total population sampling method was used due to the small size of the target population. The target population/sample size was therefore 137, comprising the State Malaria Technical Working Group members, key officers of Cross River State Malaria Elimination Program (CRSMEP), and the Local Government Areas (LGA) Malaria implementing teams. It was a descriptive cross-sectional study. Each element per section of the questionnaire was weighted using the Likert scale and calculated using simple percentages. Research results showed that the malaria program at the State and LGA level have adequate administrative and management capacity with confirmation by 64 and 82.1% of respondents respectively. 80% of respondents confirmed average coordination and collaboration capacity at the State level while 50% of respondents at the LGA level confirmed that the program has adequate coordination and collaboration capacity. For financing and accountability capacity, 36% of respondents affirmed that there is average capacity at the State level while 37.5% confirmed that there is no capacity at LGA level. The study revealed the program's capacity gaps at State and LGA in the 3 aforementioned key areas. Therefore, interventions to address the capacity gaps are training/re-training of program staff and health workers on program management, administration, and finance, establishing performance management and accountability mechanisms, conducting evidence-based advocacy visits to policymakers for prioritizing allocating and releasing funds for malaria control activities, especially for intervention areas that are not supported by donor/partner organizations.

Introducing a Regulatory Sandbox Into the Indonesian Health System Using e-Malaria as a Use Case: Participatory Action Study.

Regulatory sandboxes offer an alternative solution to address regulatory challenges in adopting disruptive technologies. Although regulatory sandboxes have been widely implemented in the financial sector across more than 50 countries, their application to the health sector remains limited. This study aims to explore stakeholders' perspectives on introducing a regulatory sandbox into the Indonesian health system using e-malaria as a use case. Using a participatory action research approach, this study conducted qualitative research, including desk reviews, focus group discussions, and in-depth interviews with stakeholders. This study sought to understand stakeholders' concerns and interests regarding the regulatory sandbox and to collaboratively develop a regulatory sandbox model to support the malaria program. The study revealed that most stakeholders had limited awareness of the regulatory sandbox concept. Concerns have been raised regarding the time required to establish regulations, knowledge gaps among stakeholders, data protection issues, and limited digital infrastructure in malaria endemic areas. Existing regulations have been found to be inadequate to accommodate disruptive healthtech for malaria. Nevertheless, through a collaborative process, stakeholders successfully developed a regulatory sandbox model specifically for e-malaria, with the crucial support of the Ministry of Health. The regulatory sandbox holds the potential for adoption in the Indonesian health system to address the limited legal framework and to facilitate the rapid and safe adoption of disruptive healthtech in support of the malaria elimination program. Through stakeholder involvement, guidelines for implementing the regulatory sandbox were developed and innovators were successfully invited to participate in the first-ever trial of a health regulatory sandbox for e-malaria in Indonesia. Future studies should provide further insights into the challenges encountered during the e-malaria regulatory sandbox pilot study, offering a detailed account of the implementation process.

Adherence to Anti-Malarial Treatment in Malaria Endemic Areas of Bangladesh.

Ensuring adherence to antimalarial treatment is crucial for achieving a radical cure and elimination of malaria, especially in hard-to-reach areas. We conducted this study to assess the current scenario of drug adherence in four endemic sub-districts of Bangladesh. Among 110 enrolled participants, 70% were mono-infected with Plasmodium falciparum and the remaining 30% with P. vivax. The overall treatment adherence frequency was 92.7% (95% CI: 83.0-96.3%). A total of eight participants were found to be nonadherent to treatment and all of them were from Bandarban. Level of nonadherence was equally observed in two age groups: 11-17 and 18+ years. However, male participants (n = 6) were found to be more nonadherent than females (n = 2). Among 7.3% with nonadherence to treatment, a single participant with P. falciparum mono-infection refused to take medication and became nonadherent. Remaining participants stated that they were feeling well and going to work, thus leaving treatment course uncompleted. Although overall compliance with malaria medication seems good, a gradual increase in noncompliance to P. vivax malaria treatment suggests that the National Malaria Elimination Program must be enhanced and monitored to fulfil the projected malaria elimination goal before 2030 from Bangladesh.

Asymptomatic and submicroscopic malaria infections in sugar cane and rice development areas of Ethiopia

BackgroundWater resource development projects, such as dams and irrigation schemes, have a positive impact on food security and poverty reduction. However, such projects could increase prevalence of vector borne disease, such as malaria. This study investigate the impact of different agroecosystems and prevalence of malaria infection in Southwest Ethiopia.MethodsTwo cross-sectional surveys were conducted in the dry and wet seasons in irrigated and non-irrigated clusters of Arjo sugarcane and Gambella rice development areas of Ethiopia in 2019. A total of 4464 and 2176 study participants from 1449 households in Arjo and 546 households in Gambella enrolled in the study and blood samples were collected, respectively. All blood samples were microscopically examined and a subset of microscopy negative blood samples (n = 2244) were analysed by qPCR. Mixed effect logistic regression and generalized estimating equation were used to determine microscopic and submicroscopic malaria infection and the associated risk factors, respectively.ResultsPrevalence by microscopy was 2.0% (88/4464) in Arjo and 6.1% (133/2176) in Gambella. In Gambella, prevalence was significantly higher in irrigated clusters (10.4% vs 3.6%) than in non-irrigated clusters (p < 0.001), but no difference was found in Arjo (2.0% vs 2.0%; p = 0.993). On the other hand, of the 1713 and 531 samples analysed by qPCR from Arjo and Gambella the presence of submicroscopic infection was 1.2% and 12.8%, respectively. Plasmodium falciparum, Plasmodium vivax, and Plasmodium ovale were identified by qPCR in both sites. Irrigation was a risk factor for submicroscopic infection in both Arjo and Gambella. Irrigation, being a migrant worker, outdoor job, < 6 months length of stay in the area were risk factors for microscopic infection in Gambella. Moreover, school-age children and length of stay in the area for 1–3 years were significant predictors for submicroscopic malaria in Gambella. However, no ITN utilization was a predictor for both submicroscopic and microscopic infection in Arjo. Season was also a risk factor for microscopic infection in Arjo.ConclusionThe study highlighted the potential importance of different irrigation practices impacting on submicroscopic malaria transmission. Moreover, microscopic and submicroscopic infections coupled with population movement may contribute to residual malaria transmission and could hinder malaria control and elimination programmes in the country. Therefore, strengthening malaria surveillance and control by using highly sensitive diagnostic tools to detect low-density parasites, screening migrant workers upon arrival and departure, ensuring adequate coverage and proper utilization of vector control tools, and health education for at-risk groups residing or working in such development corridors is needed.