National Malaria Programme Research Articles

Malaria outbreaks in China (1990-2013): a systematic review.

BackgroundChina has already achieved remarkable accomplishments in shrinking the malaria burden since the mid-20th Century. The country now plans to eliminate malaria by the year 2020. Looking at the dynamics of malaria outbreaks during the last decades might provide important information regarding the potential challenges of such an elimination strategy and might help to avoid mistakes of the past.MethodsA systematic review of the published literature (English and Chinese) was conducted to identify malaria outbreaks during the period 1990 until 2013 in China. The main causes of outbreaks as described in these papers were categorized according to whether they were related to population migration, environmental factors, vector and host related factors, and operational problems of the health services.ResultsThe review identified 36 malaria outbreaks over the 23-year study period, on which sufficient information was available. They mainly occurred in southern and central China involving 12 provinces/autonomous regions. More than half of all outbreaks (21/36, 58%) were attributed at least in part to population migration, with malaria importation to non- or low-endemic areas from high-endemic Chinese areas (13/15) or endemic countries (2/15) having been the most frequent reason (15/21, 71%). Other main causes were problems of the health services (15/36, 42%), in particular poor malaria case management (10/15, 67%), environmental factors (7/36, 19%), and vector and host related factors (5/36, 14%).ConclusionsBeside a number of other challenges, addressing population movement causing malaria appears to be of particular importance to the national malaria programme. Strengthening of surveillance for malaria and early radical treatment of cases should thus be considered among the most important tools for preventing malaria outbreaks and for the final goal of malaria elimination in China.

Long-Lasting Insecticidal Nets Are Synergistic with Mass Drug Administration for Interruption of Lymphatic Filariasis Transmission in Nigeria

In central Nigeria Anopheles mosquitoes transmit malaria and lymphatic filariasis (LF). The strategy used for interrupting LF transmission in this area is annual mass drug administration (MDA) with albendazole and ivermectin, but after 8 years of MDA, entomological evaluations in sentinel villages showed continued low-grade mosquito infection rates of 0.32%. After long-lasting insecticidal net (LLIN) distribution by the national malaria program in late 2010, however, we were no longer able to detect infected vectors over a 24-month period. This is evidence that LLINs are synergistic with MDA in interrupting LF transmission.

Community perceptions on malaria and care-seeking practices in endemic Indian settings: policy implications for the malaria control programme

BackgroundThe focus of India’s National Malaria Programme witnessed a paradigm shift recently from health facility to community-based approaches. The current thrust is on diagnosing and treating malaria by community health workers and prevention through free provision of long-lasting insecticidal nets. However, appropriate community awareness and practice are inevitable for the effectiveness of such efforts. In this context, the study assessed community perceptions and practice on malaria and similar febrile illnesses. This evidence base is intended to direct the roll-out of the new strategies and improve community acceptance and utilization of services.MethodsA qualitative study involving 26 focus group discussions and 40 key informant interviews was conducted in two districts of Odisha State in India. The key points of discussion were centred on community perceptions and practice regarding malaria prevention and treatment. Thematic analysis of data was performed.ResultsThe 272 respondents consisted of 50% females, three-quarter scheduled tribe community and 30% students. A half of them were literates. Malaria was reported to be the most common disease in their settings with multiple modes of transmission by the FGD participants. Adoption of prevention methods was seasonal with perceived mosquito density. The reported use of bed nets was low and the utilization was determined by seasonality, affordability, intoxication and alternate uses of nets. Although respondents were aware of malaria-related symptoms, care-seeking from traditional healers and unqualified providers was prevalent. The respondents expressed lack of trust in the community health workers due to frequent drug stock-outs. The major determinants of health care seeking were socio-cultural beliefs, age, gender, faith in the service provider, proximity, poverty, and perceived effectiveness of available services.ConclusionApart from the socio-cultural and behavioural factors, the availability of acceptable care can modulate the community perceptions and practices on malaria management. The current community awareness on symptoms of malaria and prevention is fair, yet the prevention and treatment practices are not optimal. Promoting active community involvement and ownership in malaria control and management through strengthening community based organizations would be relevant. Further, timely availability of drugs and commodities at the community level can improve their confidence in the public health system.

Progress towards malaria control targets in relation to national malaria programme funding

BackgroundMalaria control has been dramatically scaled up the past decade, mainly thanks to increasing international donor financing since 2003. This study assessed progress up to 2010 towards global malaria impact targets, in relation to Global Fund, other donor and domestic malaria programme financing over 2003 to 2009.MethodsAssessments used domestic malaria financing reported by national programmes, and Global Fund/OECD data on donor financing for 90 endemic low- and middle-income countries, WHO estimates of households owning one or more insecticide-treated mosquito net (ITN) for countries in sub-Saharan Africa, and WHO-estimated malaria case incidence and deaths in countries outside sub-Saharan Africa.ResultsGlobal Fund and other donor funding is concentrated in a subset of the highest endemic African countries. Outside Africa, donor funding is concentrated in those countries with highest malaria mortality and case incidence rates over the years 2000 to 2003. ITN coverage in 2010 in Africa, and declines in case and death rates per person at risk over 2004 to 2010 outside Africa, were greatest in countries with highest donor funding per person at risk, and smallest in countries with lowest donor malaria funding per person at risk. Outside Africa, all-source malaria programme funding over 2003 to 2009 per case averted ($56-5,749) or per death averted ($58,000-3,900,000) over 2004 to 2010 tended to be lower (more favourable) in countries with higher donor malaria funding per person at risk.ConclusionsIncreases in malaria programme funding are associated with accelerated progress towards malaria control targets. Associations between programme funding per person at risk and ITN coverage increases and declines in case and death rates suggest opportunities to maximize the impact of donor funding, by strategic re-allocation to countries with highest continued need.

Predictors of malaria-association with rubber plantations in Thailand

BackgroundThe national Global Fund-supported malaria (GFM) program in Thailand, which focuses on the household-level implementation of vector control via insecticide-treated nets (ITNs)/long-lasting insecticidal nets (LLINs) combined with indoor residual spraying (IRS), has been combating malaria risk situations in different provinces with complex epidemiological settings. By using the perception of malaria villagers (MVs), defined as villagers who recognized malaria burden and had local understanding of mosquitoes, malaria, and ITNs/LLINs and practiced preventive measures, this study investigated the predictors for malaria that are associated with rubber plantations in an area of high household-level implementation coverage of IRS (2007–2010) and ITNs/LLINs (2008–2010) in Prachuap Khiri Khan Province.MethodsA structured questionnaire addressing socio-demographics, household characteristics and health behavioral factors (knowledge, perceptions and practices) regarding the performed interventions was administered to the 313 households (70 malaria-affected and 243 malaria-unaffected) that had respondents aged ≥18 years of both genders. In the univariate and multivariate analyses, only 246 (78.6%) MV respondents (62 malaria-affected and 184 malaria-unaffected) were analyzed to determine the predictors for risk (morbidity).ResultsThe majority (70%) of households were covered by IRS. For a combination of ITNs/LLINs, there were 74% of malaria-affected households covered and 46% of malaria-unaffected households. In a logistic regression analysis using odds ratios (aORs) adjusted on the variables and a 95% confidence interval (CI), malaria affecting MVs was associated with daily worker (i.e., earning daily income by normally practicing laborious activities mostly in agriculture such as rubber tapping and rubber sheet processing at the smallholdings of rubber plantations) (aOR = 2.9, 95% CI: 1.1-7.4), low-moderate level of malaria knowledge (aOR = 2.4, 95% CI: 1.1-5.0) and sleeping under mosquito-nets (nets/ITNs/LLINs intermittently and ITNs/LLINs only) (aOR = 2.0, 95% CI: 1.0-3.7).ConclusionsThe MV predictors for malaria-association with rubber plantations included occupation (daily worker), misconceptions about malaria (mosquito and prevention) and the use of mosquito-nets. Human practices such as revisiting rubber plantations while exposed to multiple bites at multiple locations are more likely to apply to daily workers than to rubber farmers/tappers and others. The promotion and use of ITNs/LLINs depends substantially on cultural factors and defensive behaviors relevant to their occupational risk despite the perceived threats of malaria and the perceived benefits of ITNs/LLINs. This information supports the conclusion that GFM program implementation in Thailand or elsewhere for malaria-associated with rubber plantations would benefit from the potential use of ITNs/LLINs and changes in personal protection behaviors.

Malaria elimination gaining ground in the Asia Pacific

Countries in the Asia Pacific region are making substantial progress toward eliminating malaria, but their success stories are rarely heard by a global audience. “Malaria 2012: Saving Lives in the Asia-Pacific,” a conference hosted by the Australian Government in Sydney, Australia from October 31 to November 2, 2012, will provide a unique opportunity to showcase the region’s work in driving down malaria transmission. One of the features of Malaria 2012 will be the Asia Pacific Malaria Elimination Network (APMEN), which has focused on harnessing the collective experiences of 13 countries through regional political and technical collaboration since its inception in 2009. Run by country partners, APMEN unites a range of partners – from national malaria programmes and academic institutions to global and regional policymaking bodies – to support each country’s malaria elimination goals through knowledge sharing, capacity building, operational research and advocacy.

Timing of malaria messages for target audience on radio airwaves

BackgroundDue to the limitations of face-to-face communication to teach families how to manage, control and prevent malaria, national and local malaria programmes try to reach people through the radio. However, information regarding the timing of radio messages for the target audiences is lacking.MethodsWithin a large-scale trial (Clinicaltrials.gov: NCT00565071), data regarding the time at which people listen to the radio was collected from 1,628 consenting outpatients (and caregivers for minors) attending six rural government primary level health care centres in Bushenyi and Iganga districts of Uganda from February to July 2011.ResultsThe majority of households, 1,099 (67.5%) owned a radio. The majority, 1,221 (86.3%), participants had heard about malaria from the radio. Some participants started listening to the radio at about 06.00 East African local time (EAT). The peak hours at which people listen to the radio are 12.00-14.00 and 18.00-23.00 local time. The median time of listening to the radio by men is 20.00 (inter-quartile range (IQR): 18.30-21.00) and women 19.30 (IQR: 13.00-20.30).ConclusionPlanners of malaria radio interventions need to broadcast their messages within the two peak EAT of 12.00-14.00 and 18.00-23.00.

Did the first Global Fund grant (2003–2006) contribute to malaria control and health system strengthening in Timor-Leste?

BackgroundIn 2003, Timor-Leste successfully obtained its first Global Fund grant for a three-year programme for malaria control. The grant aimed to reduce malaria-related morbidity and mortality by 30 % by the end of the implementation.MethodsA mixed-methods approach was used to assess the impact of the grant implementation. Fifty-eight in-depth interviews, eight group interviews, 16 focus group discussions, and on-site observations were used. Morbidity data reported to the Ministry of Health were also examined to assess trends.ResultsThe National Malaria Programme with funding support from the Global Fund grant and other development partners contributed considerably to strengthening malaria control and the general health system. It also brought direct and indirect benefits to pregnant women and to the community at large. However, it failed to achieve the stated objective of reducing malaria morbidity and mortality by 30 %. The implementation was hampered by inadequate human resources, the rigidity of Global Fund rules, weak project management and coordination, and inadequate support from external stakeholders.ConclusionDespite limitations, the grant was implemented until the agreed closing date. Considerable contributions to malaria control, health system, and the community have been made and the malaria programme was sustained.

Cost and cost effectiveness of long-lasting insecticide-treated bed nets - a model-based analysis

BackgroundThe World Health Organization recommends that national malaria programmes universally distribute long-lasting insecticide-treated bed nets (LLINs). LLINs provide effective insecticide protection for at least three years while conventional nets must be retreated every 6-12 months. LLINs may also promise longer physical durability (lifespan), but at a higher unit price. No prospective data currently available is sufficient to calculate the comparative cost effectiveness of different net types. We thus constructed a model to explore the cost effectiveness of LLINs, asking how a longer lifespan affects the relative cost effectiveness of nets, and if, when and why LLINs might be preferred to conventional insecticide-treated nets. An innovation of our model is that we also considered the replenishment need i.e. loss of nets over time.MethodsWe modelled the choice of net over a 10-year period to facilitate the comparison of nets with different lifespan (and/or price) and replenishment need over time. Our base case represents a large-scale programme which achieves high coverage and usage throughout the population by distributing either LLINs or conventional nets through existing health services, and retreats a large proportion of conventional nets regularly at low cost. We identified the determinants of bed net programme cost effectiveness and parameter values for usage rate, delivery and retreatment cost from the literature. One-way sensitivity analysis was conducted to explicitly compare the differential effect of changing parameters such as price, lifespan, usage and replenishment need.ResultsIf conventional and long-lasting bed nets have the same physical lifespan (3 years), LLINs are more cost effective unless they are priced at more than USD 1.5 above the price of conventional nets. Because a longer lifespan brings delivery cost savings, each one year increase in lifespan can be accompanied by a USD 1 or more increase in price without the cheaper net (of the same type) becoming more cost effective. Distributing replenishment nets each year in addition to the replacement of all nets every 3-4 years increases the number of under-5 deaths averted by 5-14% at a cost of USD 17-25 per additional person protected per annum or USD 1080-1610 per additional under-5 death averted.ConclusionsOur results support the World Health Organization recommendation to distribute only LLINs, while giving guidance on the price thresholds above which this recommendation will no longer hold. Programme planners should be willing to pay a premium for nets which have a longer physical lifespan, and if planners are willing to pay USD 1600 per under-5 death averted, investing in replenishment is cost effective.

The use of paediatric artemisinin combinations in sub-Saharan Africa: a snapshot questionnaire survey of health care personnel

BackgroundPaediatric drug formulations for artemisinin combination therapy (P-ACT) have been developed over the past few years and have been shown to improve the therapeutic management of young children with uncomplicated falciparum malaria. This process was however not equally paralleled by a timely adoption of P-ACT in national and international treatment recommendations. National malaria programmes in sub-Saharan Africa have not yet widely embraced this new therapeutic tool. To which extent P-ACT is used in the field in sub-Saharan Africa is not known to date.MethodsThis snapshot questionnaire survey aimed to provide an overview on the current routine practices for the availability and use of P-ACT as anti-malarial treatment for young children in sub-Saharan Africa. Health care personnel in seven countries in West-, Central, and East-Africa were invited to answer a structured questionnaire assessing use and availability of P-ACT.ResultsA total of 71 respondents including doctors, nurses and pharmacy personnel responsible for the anti-malarial treatment of young children were interviewed. P-ACT was used by 83% (95% confidence interval: 73-90%; n = 59) as first-line treatment for young children. Use of 15 different P-ACT products was reported among which only two have received WHO prequalification status and approval by a stringent registration authority. Use of a specific P-ACT product was not linked to consumer prices or availability of supporting clinical trial data, but may depend more on the marketing capacity of the manufacturer. Major differences in frequency and dosing of anti-malarial regimens with identical anti-malarial compounds and the marketing of loose combinations were recorded.ConclusionPaediatric ACT is widely used for the treatment of uncomplicated malaria in young children. However, the majority of P-ACT formulations in use do not meet highest international quality standards evoking concerns for patients' safety and the induction of drug resistance. Improving the quality of currently marketed P-ACT should constitute a public health priority besides their adoption into official treatment recommendations.

Baseline results of the first malaria indicator survey in Iran at the health facility level

BackgroundMalaria continues to be a global public health challenge, particularly in developing countries. Delivery of prompt and effective diagnosis and treatment of malaria cases, detection of malaria epidemics within one week of onset and control them in less than a month, regular disease monitoring and operational classification of malaria are among the major responsibilities of the national malaria programme. The study was conducted to determine these indicators at the different level of primary health care facilities in malaria-affected provinces of IranMethodsIn this survey, data was collected from 223 health facilities including health centres, malaria posts, health houses and hospitals as well as the profile of all 5, 836 recorded malaria cases in these facilities during the year preceding the survey. Descriptive statistics (i.e. frequencies, percentages) were used to summarize the results and Chi square test was used to analyse data.ResultsAll but one percent of uncomplicated cases took appropriate and correctly-dosed of anti-malarial drugs in accordance to the national treatment guideline. A larger proportion of patients [85.8%; 95% CI: 84.8 - 86.8] were also given complete treatment including anti-relapse course, in line with national guidelines. About one third [35.0%; 95% CI: 33.6 - 36.4] of uncomplicated malaria cases were treated more than 48 hours after first symptoms onset. Correspondingly, half of severe malaria cases took recommended anti-malarial drugs for severe or complicated disease more than 48 hours of onset of first symptoms. The latter cases had given regular anti-malarial drugs promptly.The majority of malaria epidemics [97%; 95% CI: 90.6 - 100] in study areas were detected within one week of onset, but only half of epidemics were controlled within four weeks of detection. Just half of target districts had at least one health facility/emergency site with adequate supply and equipment stocks. Nevertheless, only one-third of them [33% (95% CI: 0.00 - 67.8)] had updated inventory of malaria foci on quarterly basis.ConclusionTo sum up, malaria case management still constitutes a public health problem in Iran. Additionally, data suggest scarcity in management and evaluation of malaria foci, detection and control of malaria epidemics as well as assignment of emergency sites across different regions of the country. Consequently, massive and substantial investments need to be made at the Ministry of Health to coordinate national malaria control programmes towards achieving determined goals and targets.

Malaria elimination in Isabel Province, Solomon Islands: establishing a surveillance-response system to prevent introduction and reintroduction of malaria

BackgroundThe Solomon Islands National Malaria Programme is currently focused on intensified control and progressive elimination. Recent control efforts in Isabel Province have reduced their malaria incidence to 2.6/1,000 population in 2009 [1] whereas most neighbouring provinces have much higher incidences. A malaria surveillance-response system that involves testing all travellers entering Isabel Province using rapid diagnostic tests (RDT) to prevent cases being imported had been proposed by local health authorities. This study provides information on the feasibility and acceptability of implementing a new approach of surveillance and response in the context of low levels of indigenous malaria transmission in Isabel Province.MethodsA total of 13 focus group discussions (FGD) and 22 key informant interviews (KII) were conducted in Isabel Province, Solomon Islands. Key topics included: the travel patterns of people to, from and within Isabel Province; the acceptability, community perceptions, attitudes and suggestions towards the proposed surveillance programme; and management of suspected malaria cases. This information was triangulated with data obtained from port authorities, airlines and passenger ships travelling to and from Isabel Province in the preceding two years.ResultsTravel within Isabel Province and to and from other provinces is common with marked seasonality. The majority of inter-provincial travel is done on scheduled public transport; namely passenger ships and aircrafts. In Isabel Province there is a healthy community spirit as well as high concern regarding malaria and its importation and there is currently effective malaria passive case detection and management. Conducting malaria screening at ports and airports would be acceptable to the community.ConclusionA robust surveillance-response system is essential when moving towards malaria elimination. Many factors contribute positively towards the feasibility of an RDT based malaria surveillance system in Isabel Province. Due to financial and logistical restraints local health authorities have concluded that a system of community-based vigilance to identify new arrivals in villages and direct them to have malaria testing is more feasible than formal screening at ports and airports. A surveillance response system to prevent introduction of malaria into Isabel Province can be integrated into the National Malaria Control Programme provided the operational steps are carefully planned with regards to human and financial resources.

Mapping hypoendemic, seasonal malaria in rural Bandarban, Bangladesh: a prospective surveillance

BackgroundUntil recently the Chittagong Hill tracts have been hyperendemic for malaria. A past cross-sectional RDT based survey in 2007 recorded rates of approximately 15%. This study was designed to understand the present epidemiology of malaria in this region, to monitor and facilitate the uptake of malaria intervention activities of the national malaria programme and to serve as an area for developing new and innovative control strategies for malaria.MethodsThis research field area was established in two rural unions of Bandarban District of Bangladesh north of Bandarban city, which are known to be endemic for malaria due to Plasmodium falciparum. The project included the following elements: a) a demographic surveillance system including an initial census with updates every four months, b) periodic surveys of knowledge attitude and practice, c) a geographic information system, d) weekly active and continuous passive surveillance for malaria infections using smears, rapid tests and PCR, f) monthly mosquito surveillance, and e) daily weather measures. The programme included both traditional and molecular methods for detecting malaria as well as lab methods for speciating mosquitoes and detecting mosquitoes infected with sporozoites.ResultsThe demographic surveillance enumerated and mapped 20,563 people, 75% of which were tribal non-Bengali. The monthly mosquito surveys identified 22 Anopheles species, eight of which were positive by circumsporozoite ELISA. The annual rate of malaria was close to 1% with 85% of cases in the rainy months of May-October. Definitive clustering identified in the low transmission season persisted during the high transmission season.ConclusionThis demographically and geographically defined area, near to the Myanmar border, which is also hypoendemic for malaria, will be useful for future studies of the epidemiology of malaria and for evaluation of strategies for malaria control including new drugs and vaccines.

Impact of national malaria control scale-up programmes in Africa: magnitude and attribution of effects.

BackgroundSince 2005, malaria control scale-up has progressed in many African countries. Controlled studies of insecticide-treated mosquito nets (ITNs), indoor residual spraying (IRS), intermittent preventive treatment during pregnancy (IPTp) and malaria case management suggested that when incorporated into national programmes a dramatic health impact, likely more than a 20% decrease in all-cause childhood mortality, was possible. To assess the extent to which national malaria programmes are achieving impact the authors reviewed African country programme data available through 2009.MethodsNational survey data, published literature, and organization or country reports produced during 2000-2009 were reviewed to assess available malaria financing, intervention delivery, household or target population coverage, and reported health benefits including infection, illness, severe anaemia, and death.ResultsBy the end of 2009, reports were available for ITN household ownership (n = 34) and IPTp use (n = 27) in malaria-endemic countries in Africa, with at least two estimates (pre-2005 and post-2005 intervals). Information linking IRS and case management coverage to impact were more limited. There was generally at least a three-fold increase in household ITN ownership across these countries between pre-2005 (median of 2.4% of households with at least one ITN) and post-2005 (median of 32.5% of households with at least one ITN). Ten countries had temporal data to assess programme impact, and all reported progress on at least one impact indicator (typically on mortality); in under-five year mortality rates most observed a decline of more than 20%. The causal relationship between malaria programme scale-up and reduced child illness and mortality rates is supported by biologic plausibility including mortality declines consistent with experience from intervention efficacy trials, consistency of findings across multiple countries and different epidemiologic settings, and temporal congruity where morbidity and mortality declines have been documented in the 18 to 36 months following intervention scale-up.ConclusionsSeveral factors potentially have contributed to recent health improvement in African countries, but there is substantial evidence that achieving high malaria control intervention coverage, especially with ITNs and targeted IRS, has been the leading contributor to reduced child mortality. The documented impact provides the evidence required to support a global commitment to the expansion and long-term investment in malaria control to sustain and increase the health impact that malaria control is producing in Africa.

Critical interactions between Global Fund-supported programmes and health systems: a case study in Thailand

As part of a series of case studies on the interactions between programmes supported by the Global Fund to Fight AIDS, Tuberculosis and Malaria and health systems, we assessed the extent of integration of national HIV, tuberculosis (TB) and malaria programmes with the general health system, the integration of the Global Fund-portfolios within the national disease programmes, and system-wide effects on the health system in Thailand. The study relied on a literature review and 34 interviews with key stakeholders using the Systemic Rapid Assessment Toolkit and thematic analysis. In Thailand, the HIV, TB and malaria programmes' structures and functions are well established in the general health care system, with the Department for Disease Control and the Ministry of Public Health's network of health providers at sub-national levels as the main responsible organizations for stewardship and governance, service delivery, monitoring and evaluation, planning, and to some extent, demand generation. Civil society groups are active in certain areas, particularly in demand generation for HIV/AIDS. Overall, the Global Fund-supported programmes were almost fully integrated and coordinated with the general health system. The extent of integration varied across disease portfolios because of different number of actors and the nature of programme activities. There were also specific requirements by Global Fund that limit integration for some health system functions namely financing and monitoring and evaluation. From the view of stakeholders in Thailand, the Global Fund has contributed significantly to the three diseases, particularly HIV/AIDS. Financial support from the early Global Fund rounds was particularly helpful to the disease programmes during the time of major structural change in the MoPH. It also promoted collaborative networks of stakeholders, especially civil societies. However, the impacts on the overall health system, which is relatively well developed, are seen as minimal. One major contribution is the establishment of a health service system for neglected population groups. No specific negative impacts on the health system were raised.

Malaria on isolated Melanesian islands prior to the initiation of malaria elimination activities.

BackgroundThe Australian Government's Pacific Malaria Initiative (PacMI) is supporting the National Malaria Program in both Solomon Islands and Vanuatu, complementing assistance from the Global Fund for AIDS, Tuberculosis and Malaria (GFATM). Two remote island groups - Tafea Province, Vanuatu and Temotu Province, Solomon Islands have been selected by the governments of both countries as possible malaria elimination areas. To provide information on the prevalence and distribution of the disease within these island groups, malariometric surveys were conducted during the wet seasons of 2008.MethodsIn Tafea Province, a school-based survey was conducted which included the 2-12 y age group, while in Temotu a village based all-ages survey was conducted. An effort was made to sample villages or schools from a wide an area as possible on all islands. Diagnosis was initially based on Giemsa stained blood slides followed by molecular analysis using polymerase chain reaction (PCR).ResultsIn Tafea Province, 73% (5238/7150) of children (2-12 y) were surveyed and in Temotu Province, in the all-ages survey, 50.2% (8742/17410) of the provincial population participated in the survey. In both Vanuatu and Solomon Islands malariometric surveys of their southern-most islands in 2008 showed relatively low over-all malaria parasite prevalence (2 to 3%). Other features of malaria in these island groups were low parasitaemia, low gametocyte carriage rates, low spleen rates, low malaria associated morbidity, a high incidence of asymptomatic infections, and a predominance of Plasmodium vivax over Plasmodium falciparum.ConclusionFor various reasons malaria rates are declining in these provinces providing a favourable situation for local malaria elimination. This will be advanced using mass distribution of bed nets and selective indoor residual spraying, the introduction of rapid diagnostic tests and artemisinin combination therapy, and intensive case detection and surveillance. It is as yet uncertain whether malaria parasites can themselves be sustainably eliminated from entire Melanesian islands, where they have previously been endemic. Key issues on the road to malaria elimination will be continued community involvement, improved field diagnostic methods and elimination of residual P. vivax parasites from the liver of asymptomatic persons.

Artemisinin derivatives Versus quinine for severe malaria in children: A systematic review and meta-analysis

In contrast, the treatment of severe/complicated childhood malaria appears to be evolving. The 2005 IAP Guideline followed the National Malaria Programme and recommended quinine, suggesting artesunate/artemether as less preferred alternatives(3). In 2008, it was modified as quinine with tetracycline/doxycycline/clindamycin(4) in line with the WHO 2006 statement. The National Guideline 2009(2) suggests artesunate, quinine, artemether, in that order, contraindicating arteether and doxycycline in children. The WHO’s 2010 Guideline(1) strongly recommends aresunate in adults with severe malaria, positioning quinine only as an alternative; however, it cites lack of evidence to frame a similar recommendation for children.

Anopheles gambiae: historical population decline associated with regional distribution of insecticide-treated bed nets in western Nyanza Province, Kenya

BackgroundHigh coverage of insecticide-treated bed nets in Asembo and low coverage in Seme, two adjacent communities in western Nyanza Province, Kenya; followed by expanded coverage of bed nets in Seme, as the Kenya national malaria programme rolled out; provided a natural experiment for quantification of changes in relative abundance of two primary malaria vectors in this holoendemic region. Both belong to the Anopheles gambiae sensu lato (s.l.) species complex, namely A. gambiae sensu stricto (s.s.) and Anopheles arabiensis. Historically, the former species was proportionately dominant in indoor resting collections of females.MethodsData of the relative abundance of adult A. gambiae s.s. and A. arabiensis sampled from inside houses were obtained from the literature from 1970 to 2002 for sites west of Kisumu, Kenya, to the region of Asembo ca. 50 km from the city. A sampling transect was established from Asembo (where bed net use was high due to presence of a managed bed net distribution programme) eastward to Seme, where no bed net programme was in place. Adults of A. gambiae s.l. were sampled from inside houses along the transect from 2003 to 2009, as were larvae from nearby aquatic habitats, providing data over a nearly 40 year period of the relative abundance of the two species. Relative proportions of A. gambiae s.s. and A. arabiensis were determined for each stage by identifying species by the polymerase chain reaction method. Household bed net ownership was measured with surveys during mosquito collections. Data of blood host choice, parity rate, and infection rate for Plasmodium falciparum in A. gambiae s.s. and A. arabiensis were obtained for a sample from Asembo and Seme from 2005.ResultsAnopheles gambiae s.s. adult females from indoor collections predominated from 1970 to 1998 (ca. 85%). Beginning in 1999, A. gambiae s.s decreased proportionately relative to A. arabiensis, then precipitously declined to rarity coincident with increased bed net ownership as national bed net distribution programmes commenced in 2004 and 2006. By 2009, A. gambiae s.s. comprised proportionately ca. 1% of indoor collections and A. arabiensis 99%. In Seme compared to Asembo in 2003, proportionately more larvae were A. gambiae s.s., larval density was higher, and more larval habitats were occupied. As bed net use rose in Seme, the proportion of A. gambiae larvae declined as well. These trends continued to 2009. Parity and malaria infection rates were lower in both species in Asembo (high bed net use) compared to Seme (low bed net use), but host choice did not vary within species in both communities (predominantly cattle for A. arabiensis, humans for A. gambiae s.s.).ConclusionsA marked decline of the A. gambiae s.s. population occurred as household ownership of bed nets rose in a region of western Kenya over a 10 year period. The increased bed net coverage likely caused a mass effect on the composition of the A. gambiae s.l. species complex, resulting in the observed proportionate increase in A. arabiensis compared to its closely related sibling species, A. gambiae s.s. These observations are important in evaluating the process of regional malaria elimination, which requires sustained vector control as a primary intervention.

A qualitative study on the acceptability and preference of three types of long-lasting insecticide-treated bed nets in Solomon Islands: implications for malaria elimination

BackgroundIn March 2008, the Solomon Islands and Vanuatu governments raised the goal of their National Malaria Programmes from control to elimination. Vector control measures, such as indoor residual spraying (IRS) and long-lasting insecticidal bed nets (LLINs) are key integral components of this programme. Compliance with these interventions is dependent on their acceptability and on the socio-cultural context of the local population. These factors need to be investigated locally prior to programme implementation.MethodTwelve focus group discussions (FGDs) were carried out in Malaita and Temotu Provinces, Solomon Islands in 2008. These discussions explored user perceptions of acceptability and preference for three brands of long-lasting insecticide-treated bed nets (LLINs) and identified a number of barriers to their proper and consistent use.ResultsMosquito nuisance and perceived threat of malaria were the main determinants of bed net use. Knowledge of malaria and the means to prevent it were not sufficient to guarantee compliance with LLIN use. Factors such as climate, work and evening social activities impact on the use of bed nets, particularly in men. LLIN acceptability plays a varying role in compliance with their use in villages involved in this study. Participants in areas of reported high and year round mosquito nuisance and perceived threat of malaria reported LLIN use regardless of any reported unfavourable characteristics. Those in areas of low or seasonal mosquito nuisance were more likely to describe the unfavourable characteristics of LLINs as reasons for their intermittent or non-compliance. The main criterion for LLIN brand acceptability was effectiveness in preventing mosquito bites and malaria. Discussions highlighted considerable confusion around LLIN care and washing which may be impacting on their effectiveness and reducing their acceptability in Solomon Islands.ConclusionProviding LLINs that are acceptable will be more important for improving compliance in areas of low or seasonal mosquito nuisance and malaria transmission. The implications of these findings on malaria elimination in Solomon Islands are discussed.

Recherche clinique et action humanitaire

In the 1990s and in the absence of data, Médecins sans frontiers (MSF) initiated a series of in vivo clinical studies to measure antimalarial efficacy and optimise treatment strategies within its missions. Between 1996 and 2004, more than 12,000 patients were enrolled in 43 studies in 18 countries of Asia and Africa. These studies were conducted in insecure and difficult-to-access sites, usually conflict-affected countries of sub-Saharan Africa. The data were used by MSF to improve treatments within its missions. In several countries they were considered by health authorities for adapting treatment guidelines at a country level. They had an effect on international policy. The high number of publications in peer-reviewed journals shows that research of high quality can be performed despite the important logistical difficulties encountered in the field. These studies are essential to adapt treatments for MSF programs. They need to be rigorous enough to be scientifically valid but also have to be adapted to specific field conditions. Although this work demonstrates the potential role of medical NGOs (non governmental organisations) such as MSF in collecting scientific data, national malaria programs, WHO and other international disease control partnerships hold the primary responsibility in initiating such studies.