Presumptive Treatment Of Malaria Research Articles

Receiving antenatal care components and associated factors in Northwestern Tanzania.

Tanzania had an estimated 5.400 maternal deaths in 2020. Suboptimal quality of antenatal care (ANC) presents a major challenge. It is not known what precisely the uptake of the various ANC components is, such as counseling on birth preparedness and complication readiness, preventive measures and screening tests. We assessed the level of receiving the various ANC components and associated factors in order to identify opportunities to improve ANC. A cross-sectional household survey using a structured questionnaire through face-to-face interviews, was conducted in April 2016 in Mara and Kagera regions, Tanzania, applying a two-stage, stratified-cluster sampling design. The analysis included 1,162 women aged 15-49 years who attended ANC during their last pregnancy and had given birth not longer than two years prior to the survey. To account for inter- and intra-cluster variations, we used mixed-effect logistic regression to examine factors associated with receiving essential ANC components: counseling around birth preparedness and complication readiness (with presumed effects on knowledge about danger signs) and preventive measures. About In 878 (76.1%) women preparedness for birth and its complications was observed to exist. Overall counseling was low where 902 (77.6%) women received adequate counseling. Overall knowledge of danger signs was low in 467 women (40.2%). Uptake of preventive measures was low, with presumptive malaria treatment in 828 (71.3%) and treatment of intestinal worms in 519 (44.7%) women. Screening test levels varied for HIV in 1,057 (91.2%), any blood pressure measurement in 803 (70.4%), syphilis in 367 (32.2%) and tuberculosis in 186 (16.3%) women. After adjusting for age, wealth and parity, the likelihood of receiving adequate counseling on essential topics was less in women without education versus primary education (aOR 0.64; 95% CI 0.42-0.96) and in women who had <4 ANC visits versus ≥4 visits (aOR 0.57; 95% CI 0.40-0.81). Receiving care in privacy or not (aOR 2.01; 95% CI 1.30-3.12) and having secondary education as compared to primary education (aOR 1.92; 95% CI 1.10-3.70) were associated with receiving adequate counseling. Odds of receiving adequate care in at least one ANC visit were lower in women with joint decision making on major purchases versus decision making by male partner or other family members alone (aOR 0.44; 95% CI 0.24-0.78), similar to being less knowledgeable on danger signs (aOR 0.70; 95% CI 0.51-0.96). Overall uptake of various essential ANC components was low. Frequent ANC visits and ensuring privacy are all essential to improve the uptake of ANC.

Overtreatment of malaria in the Nigerian healthcare setting: prescription practice, rationale and consequences.

Nigeria is one of the countries in the world with the highest burden of malaria, accounting for a quarter of all cases in Africa. According to the Centers for Disease Control and Prevention, microscopic examination remains the gold standard for laboratory confirmation of malaria. However, the policy and practice of presumptive treatment of malaria for all febrile illnesses has been widely advocated in sub-Saharan Africa. Presumptive management of fevers and/or other symptoms of malaria results in over-diagnosis, and consequently overtreatment. This article discusses the overtreatment of malaria as practiced in Nigeria and other African regions against standard treatment guidelines, highlights a wide range of its associated effects on patients and proffers possible solutions to curb the unethical practice of malaria overtreatment.

Comparative evaluation of BinaxNOW™ Malaria rapid diagnostic test, microscopy and polymerase chain reaction for Plasmodium falciparum detection among individuals suspected with malaria in Lagos, southwest Nigeria

Malaria is a major public health problem in the tropics, especially in resource-limited settings where presumptive malaria treatment is well practised. Prompt malaria diagnosis is essential in ensuring definitive antimalarial therapy. Malaria rapid diagnostic tests (mRDTs) are a suitable option in resource-limited settings. The study evaluated and compared the diagnostic performance of BinaxNOW™ mRDT, microscopy and quantitative polymerase chain reaction (qPCR) in suspected malaria cases in Lagos, south-western Nigeria. The cross-sectional study was conducted in four Primary Health Centres and Ikorodu General Hospital in Lagos. A total of 146 suspected malaria patients aged 2 to 67years were screened between August 2013 and November 2013. Venous blood samples were collected after informed consent was obtained from participants or guardians for mRDT, thick blood film for microscopy and dried blood spots on filter paper for PCR assays. Sociodemographic information of each patient was collected with a structured case report form. The sensitivity, specificity, positive and negative predictive values, diagnostic accuracy, and kappa’s level of agreement were analysed. The level of statistical significance was set at ρ ≤ 0.05. Falciparum malaria positive rate and prevalence were temperature (56.8%) and age-dependent (42.5%). The sensitivity and specificity of mRDT and microscopy were 94.7%, 91.7% and 85.4%, 96.5% respectively. While the positive predictive value (PPV) and negative predictive (NPV) were 79.9%, 94.2% and 96.4%, 95.0%. The diagnostic accuracy and kappa’s level of agreement for mRDT and microscopy were 89.0%, 94.5% and 0.78 and 0.89, respectively. The performance of BinaxNOW™ malaria RDT was comparable with microscopy and can be used to guide malaria treatment in resource-limited settings to enhance parasite-based treatment of all suspected malaria cases when microscopy is unavailable.

Impact of Intermittent Presumptive Treatment for Malaria in Pregnancy on Hospital Birth Outcomes on the Kenyan Coast.

Intermittent preventive treatment (IPTp) for pregnant women with sulfadoxine-pyrimethamine (SP) is widely implemented for the prevention of malaria in pregnancy and adverse birth outcomes. The efficacy of SP is declining, and there are concerns that IPTp may have reduced impact in areas of high resistance. We sought to determine the protection afforded by SP as part of IPTp against adverse birth outcomes in an area with high levels of SP resistance on the Kenyan coast. A secondary analysis of surveillance data on deliveries at the Kilifi County Hospital between 2015 and 2021 was undertaken in an area of low malaria transmission and high parasite mutations associated with SP resistance. A multivariable logistic regression model was developed to estimate the effect of SP doses on the risk of low birthweight (LBW) deliveries and stillbirths. Among 27 786 deliveries, 3 or more doses of IPTp-SP were associated with a 27% reduction in the risk of LBW (adjusted odds ratio [aOR], 0.73; 95% confidence interval [CI], .64-.83; P < .001) compared with no dose. A dose-response association was observed with increasing doses of SP from the second trimester linked to increasing protection against LBW deliveries. Three or more doses of IPTp-SP were also associated with a 21% reduction in stillbirth deliveries (aOR, 0.79; 95% CI, .65-.97; P = .044) compared with women who did not take any dose of IPTp-SP. The continued significant association of SP on LBW deliveries suggests that the intervention may have a non-malaria impact on pregnancy outcomes.

Comparative assessment, awareness and perception of community pharmacists on use of malaria rapid diagnostic test in Lagos state

Background: Presumptive treatment of malaria has led to over diagnosis and over use of antimalarial&nbsp;leading to development of resistance to antimalarial medications. The gold standard for the detection&nbsp;of malaria is microscopic examination. However, the development of RDTs made it possible to get&nbsp;reliable diagnostic testing at all times where previously only clinical diagnosis was available. Method: A cross sectional study which involved 223 Patients and 321 Community Pharmacists in&nbsp;Lagos state, a south western part of Nigeria. Patients, who presented to the Pharmacy with symptoms&nbsp;such as chills, loss of appetite and other symptoms suggestive of malaria were recruited, and tested&nbsp;using RDT kit, and laboratory microscopic evaluation. An open and closed ended administered&nbsp;Questionnaires was used to assess the awareness and perception of Pharmacists on the use of RDT.&nbsp; Results: RDT had a sensitivity of 14.29% and a specifificity of 100%. The negative predictive value&nbsp;gotten from the study was 11.33% and a positive predictive value of 100%. The Community&nbsp;Pharmacists indicated high awareness, and were also of the opinion that RDTs were unreliable.&nbsp; Conclusion: From this study, it was shown that RDT kit is not an effiffifficient diagnostic tool for detecting&nbsp;malaria, as the result obtained showed low sensitivity as compared to microscopy. The study also&nbsp;explains why, community Pharmacists are aware of the use of RDT, but lack the willingness to use it.&nbsp;Hence, microscopy still remains a better and more reliable tool for detecting presence of malaria parasite.

Predictors of presumptive treatment of uncomplicated malaria among children in private retail outlets in Kenya: mixed effects logistic regression modelling

Background: The health seeking behavior in Kenya raises concerns in malaria case management at the private sector. Adherence to the national guidelines for the diagnosis, treatment and prevention of malaria is key in management of the disease. Presumptive treatment remains a major challenge in Kenya, especially in the private sector, with major gaps in literature identified on predictors of this treatment. Mixed-effects regression modelling considers county clustering, is more accurate in prediction and is more efficient and flexible. Methods: The study design was a cross-sectional, nationally representative, retail outlet survey secondary data analysis. The study populations included the health care providers in the retail outlets sampled randomly in both the rural and urban settings in Kenya. The primary outcome of interest was the proportion of health care providers who treated patients presumptively. Multivariable analysis was conducted for the significant variables, adjusting for clustering at the county level to determine the predictors of presumptive treatment. The best fitting model was examined using the Akaike Information Criterion (AIC). Results: Out of the 333 health care providers who treated patients, 190 (57%) treated patients presumptively. From the mixed effects logistic regression model, the predictors of presumptive treatment of uncomplicated malaria were case management training (AOR = 0.44; 95% CI = (0.18 – 1.09)), asked signs or symptoms (AOR = 0.19; 95% CI = (0.10 - 0.37)) and results presented (AOR = 0.08 95% CI = (0.03 - 0.19)). Conclusions: Presumptive treatment of uncomplicated malaria remains a challenge in the private retail sector. Malaria case management training and health care providers asking of signs and symptoms and results presented predicts presumptive treatment. To address the issue of presumptive treatment of Malaria, strengthening of malaria case management training is key for health care providers in the private sector.

PRESUMPTIVE DIAGNOSIS OF MALARIA IN FEBRILE CHILDREN; IS IT JUSTIFIED?

Background: Malaria is deadly and a major disease burden in Africa especially among the under-5s. Due to the high death rate from malaria in endemic region, World Health Organization previous recommendation was presumptive treatment of malaria. Aim: This study aimed to evaluate if presumptive diagnosis of malaria in our region is still justified, and increase the awareness for proper evaluation for other causes of fever in febrile children. Methods: Apart of a single blinded prospective interventional study carried out between March and May 2016, at the children outpatient unit of Lagos State University Teaching Hospital, Ikeja, Nigeria. Consecutive children aged 6 months to 12 years with temperature of 37.50C and above at presentation without prior antimalaria treatment were recruited. Clinical and laboratory evaluation for malaria were done in these subjects. Data were analyzed using the Statistical Package for Social Sciences (SPSS) version 20.0. Test of statistical significant was set at &lt;0.05. Results: Eighty-eight (88) children were recruited. The mean age of studied subjects was 43±46.5 months with a median of 25 months. Male to female ratio was 1.1:1. The axillary temperature range of studied subjects ranged between 37.50C to 390C. The mean temperature of subjects was 37.8±0.370C. Out of 88 children recruited for the study, 51 (58%) had microscopic malaria test being positive. Up to 37 (42%) febrile children tested negative for malaria. Conclusion: Malaria infection in children is still high in our environment, but presumption treatment of malaria is no longer justified. There is a need to scale up provision of diagnostic tools for malaria so that overtreatment can be curtailed.

Predictors of Health-Seeking Behavior for Fever Cases among Caregivers of Under-Five Children in Malaria-Endemic Area of Imo State, Nigeria.

Fever is one of the most common symptoms of pediatric illnesses; it is an important early symptom of malaria. Fever had served as the entry point for presumptive treatment of malaria among children in Nigerian. Appropriate HSB is important when seeking treatment for fever among under-five children; this will help for better prognosis because treatment will be initiated early. This study attempted to identify caregiver’s HSB for under-five children with fever. A cross-sectional study was conducted in Imo-State, Nigeria. Appropriate HSB was operationally defined as seeking treatment from health facility within 24 h of fever. Data were obtained using pretested self-administered questionnaire. Data were analyzed using SPSS version 22. Simple and multiple logistic regression were used to determine predictors of appropriate HSB. A total of 559 eligible respondents were recruited; 103 (18.6%) caregivers had appropriate HSB. The predictors of HSB are being male child (aOR = 2.760; 95% CI:1.536–4.958), the age of child younger than 27 months (aOR = 2.804; 95% CI:1.485–5.295), employed caregivers (aOR = 1.882; 95% CI:1.014–3.493), number of household members (aOR = 2.504; 95% CI:1.464–4.283), and caregivers who decided to seek treatment at early stage (aOR = 7.060; 95% CI:1.616–30.852). Only 18.6% caregivers practiced appropriate HSB for fever cases among under-five children. It is essential to educate caregivers and emphasise on early treatment of fever and appropriate use of health facilities for fever. The findings will be used to improve intervention at the community level and will be compared with follow-up data to evaluate their effectiveness.

Connected diagnostics: linking digital rapid diagnostic tests and mobile health wallets to diagnose and treat brucellosis in Samburu, Kenya

BackgroundDespite WHO guidelines for testing all suspected cases of malaria before initiating treatment, presumptive malaria treatment remains common practice among some clinicians and in certain low-resource settings the capacity for microscopic testing is limited. This can lead to misdiagnosis, resulting in increased morbidity due to lack of treatment for undetected conditions, increased healthcare costs, and potential for drug resistance. This is particularly an issue as multiple conditions share the similar etiologies to malaria, including brucellosis, a rare, under-detected zoonosis. Linking rapid diagnostic tests (RDTs) and digital test readers for the detection of febrile illnesses can mitigate this risk and improve case management of febrile illness.MethodsThis technical advance study examines Connected Diagnostics, an approach that combines the use of point-of-care RDTs for malaria and brucellosis, digitally interpreted by a rapid diagnostic test reader (Deki Reader) and connected to mobile payment mechanisms to facilitate the diagnosis and treatment of febrile illness in nomadic populations in Samburu County, Kenya. Consenting febrile patients were tested with RDTs and patient diagnosis and risk information were uploaded to a cloud database via the Deki Reader. Patients with positive diagnoses were provided digital vouchers for transportation to the clinic and treatment via their health wallet on their mobile phones.ResultsIn total, 288 patients were tested during outreach visits, with 9% testing positive for brucellosis and 0.6% testing positive for malaria. All patients, regardless of diagnosis were provided with a mobile health wallet on their cellular phones to facilitate their transport to the clinic, and for patients testing positive for brucellosis or malaria, the wallet funded their treatment. The use of the Deki Reader in addition to quality diagnostics at point of care also facilitated geographic mapping of patient diagnoses in relation to key risk areas for brucellosis transmission.ConclusionsThis study demonstrates that the Connected Dx approach can be effective even when addressing a remote, nomadic population and a rare disease, indicating that this approach to diagnosing, treatment, and payment for healthcare costs is feasible and can be scaled to address more prevalent diseases and conditions in more populous contexts.

Predictors of Optimum Uptake of Intermittent Presumptive Treatment of Malaria During Pregnancy Among Women at Navakholo Sub-County, Kakamega County - Kenya

Introduction. Malaria in pregnancy is associated with high incidences of maternal and neonatal mortality in malaria endemic regions. World Health Organization recommends Intermittent Presumptive treatment of malaria in pregnancy with Sulfadoxine-Pyrimethamine (IPTp-SP). It is recommended that every pregnant woman receives at least three doses administered one month apart up to the time of delivery. Despite increased antenatal clinic attendance and concerted efforts to address known barriers to uptake of malaria preventive measures in Navakholo Sub-County, uptake of three or more IPTp-SP doses in the Sub-County has remained low. Objective . This study aimed at determining predictors of optimum uptake of intermittent presumptive treatment of malaria in pregnancy among women in Navakholo Sub-County. Methodology. This was a cross sectional study using mixed methods of data collection. The study was carried out in Navakholo Sub-County, Kakamega County, Kenya. Multistage cluster sampling method was employed to attain sample size ( n = 608 ). Data was analyzed using descriptive statistics, bivariate and multivariate logistic regression while thematic analysis was used for qualitative data. Strength of association between independent variables and dependent variables was measured using odd ratio and p ≤ 0.05 used to reject null hypothesis of no association between independent variables and the main outcome which was the uptake of optimum doses of IPTp-SP. Results. Out of the 587 participants, 294(50.1%) took optimum doses (three or more doses) of IPTp-SP, 248(42.2%) took IPTp-SP partially (one-two doses) and 45 (7.7%) did not take any dose. The following variables were statistically significantly associated with uptake of optimum doses of IPTp-SP: having attained secondary level of education and above (OR = 0.6, 95% CI 0.4-0.98, p = 0.01); distance to health facility (OR = 0.2, 95% CI 0.06-0.8, p = 0.02); perception that SP drugs are not safe during pregnancy (OR = 7.3, 95% CI 1.5-35.7, p = &lt; 0.01); opening of health facilities daily (OR = 161.8, 95% CI 29.5-885.7 p &lt; 0.0001) and giving clients return dates (OR = 21.2, 95% CI 7.9-56.5 , p = &lt; 0 .0001). Conclusion : Key factors that determine optimum uptake of IPTp-SP in the study area are: having attained at least secondary level of education; perceived safety of SP drugs; distance to health facility; opening of health facility daily and giving of return dates to clients. Recommendation: - Community awareness through health education to increase awareness on the risks of malaria in pregnancy and safety of SPs in pregnancy. The study further recommends that the daily opening of facilities within the study area, ensure return dates are given at every visit and introduction of mobile clinics to those who are staying far away from the nearest health facility. Keywords ; IPTp-SP, Malaria in Pregnancy, Optimum uptake of IPTp-SP doses, Navakholo Sub-County. DOI : 10.7176/JHMN/60-08 Publication date :March 31 st 2019

Presumptive Treatment of Malaria in Ghana: Was It Ever Useful? Evidence from the Kassena-Nankana District of Northern Ghana.

Background The WHO currently advocates parasitological confirmation of malaria before treatment is commenced. However, many arguments have emerged both for and against this new position. To contribute to the debate, this secondary data analysis was conducted to determine the likelihood of malaria parasitaemia in a child presenting with fever, vomiting, or cough in the Kassena-Nankana District. Methods The dataset for this analysis was generated during a study to assess the incidence and risk factors for paediatric rotavirus diarrhoea in the Kassena-Nankana District. Over a two-year period, trained field staff recruited 2086 subjects with episodes of diarrhoea aged 24 months or below into the study. A standard case report form was used to collect data on histories of illness, symptoms, vaccination, and anthropometry. Blood smears were tested for malaria parasites. The data set generated was obtained, cleaned, and analysed using Epi Info version 7.1.1.14 statistical software. Results Of the 2086 subjects recruited, 2078 had blood smears done and 54.0% had malaria parasites. Fever and vomiting appeared to be associated with parasitaemia with odds ratios of 1.9 (95% CI: 1.5586–2.2370) and 1.2 (95% CI: 1.0352–1.4697), respectively. Cough however appeared protective with an odds ratio of 0.8 (95% CI: 0.6910–0.9765). The odds of parasitaemia appeared to increase where a child presented with more than one symptom. Conclusion Nearly half (46%) of the subjects in this study presented with symptoms but had no malaria. Presumptive treatment of malaria may therefore be useful in situations where diagnostic tests are not readily available, its routine practice should however not be encouraged.

Evaluation of GENEDIA® malaria pf/pan antigen test relative to blood smear microscopy in a malaria diagnosis in Ethiopia.

Background: Early and accurate diagnosis of malaria followed by prompt treatment is crucial to reduce morbidity and mortality in endemic regions. Presumptive treatment of malaria is widely practiced where microscopy or rapid diagnostic tests are not readily available. Introduction of rapid diagnostic tests (RDTs) for the treatment of malaria needs prior evaluation of their performance relative to reference methods. Hence, this study evaluated the diagnostic capacity of GENEDIA® Malaria Pf/pan Ag Rapid Test relative to blood smear for P. falciparum and P. vivax malaria in Ethiopia. Methods: This was a cross-sectional study conducted from November to December 2014 on malaria blood samples collected from symptomatic patients who visited malaria control center in Adama, Oromia Region, Ethiopia. Thick and thin malaria blood films stained by 10% Giemsa working solution were examined microscopically under 100x magnifications for Plasmodium detection, species identification and determination of parasitaemia. The RDT was performed as per the manufacturer’s instruction. Results: A total of 417 febrile malaria suspected outpatients were diagnosed in the study center. Of which, 149(35.7%) by light microscopy (Pf =47; Pv =93; mixed Pf/Pv =9), and 151 (36.2%) by Genedia® RDT (Pf=20; Pv=87; Pf/pan=44) were positive for malaria. RDT detected 0.6% (n=27) mixed Pf/pv cases on samples that were P. falciparum conformed by microscopy. The general sensitivity, specificity, positive and negative predictive value of GENEDIA® test relative to microscopy were respectively 95.3%, 96.6%, 94.0% and 97.4%. Conclusion: The GENEDIA® Malaria Pf/pan Ag test showed good sensitivity and specificity to diagnose malaria in Ethiopia, with respect to the blood film microscopy.

Spatial Distribution of Falciparum Malaria Infections in Zanzibar: Implications for Focal Drug Administration Strategies Targeting Asymptomatic Parasite Carriers.

Optimal use of mass/targeted screen-and-treat or mass or focal drug administration as malaria elimination strategies remains unclear. We therefore studied spatial distribution of Plasmodium falciparum infections to compare simulated effects of these strategies on reducing the parasite reservoir in a pre-elimination setting. P. falciparum rapid diagnostic tests (RDTs) and molecular (polymerase chain reaction [PCR]) and serological (enzyme-linked immunosorbent assay) analyses were performed on finger-prick blood samples from a population-based survey in 3 adjacent communities. Among 5278 persons screened, 13 (0.2%) were positive by RDT and 123 (2.3%) by PCR. PCR-positive individuals were scattered over the study area, but logistic regression analysis suggested a propensity of these infections to cluster around RDT-positive individuals. The odds ratios for being PCR positive was 7.4 (95% confidence interval, 2.8-19.9) for those living in the household of an RDT-positive individual and 1.64 (1.0-2.8; P = .06) for those living within <300 m, compared with >1000 m. Treating everyone within households of RDT-positive individuals (1% population) would target 13% of those who are PCR positive. Treating all living within a radius of <300 or <1000 m (14% or 58% population) would target 30% or 66% of infections, respectively. Among 4431 serologically screened individuals, 26% were seropositive. Treating everyone within seropositive households (63% population) would target 77% of PCR-positive individuals. Presumptive malaria treatment seemed justified within RDT-positive households and potentially worth considering within, for example, a radius of <300 m. Serology was not discriminative enough in identifying ongoing infections for improving focal interventions in this setting but may rather be useful to detect larger transmission foci.

Precarity and Preparedness: Non-Adherence as Institutional Work in Diagnosing and Treating Malaria in Uganda

ABSTRACTAccess to anti-malarial drugs is increasingly governed by novel regulation technologies like rapid diagnostic tests (RDTs). However, high rates of non-adherence particularly to negative RDT results have been reported, threatening the cost-effectiveness of the two interrelated goals of improving diagnosis and reducing the over-prescription of expensive anti-malarial drugs. Below I set out to reconstruct prior treatment forms like presumptive treatment of malaria by paying particular attention to their institutional groundings. I show how novel regulation technologies affect existing institutions of care and argue that the institutional work of presumptive treatment goes beyond the diagnosis and treatment of a currently observed fever episode. Instead, in contexts of precarity, through what I will call “practices of preparedness,” presumptive treatment includes a variety of practices, performances, temporalities, and opportunities that allow individuals to prepare for future episodes of fever.

The impact of prenatal exposure to parasitic infections and to anthelminthic treatment on antibody responses to routine immunisations given in infancy: Secondary analysis of a randomised controlled trial

BackgroundChronic parasitic infections are associated with active immunomodulation which may include by-stander effects on unrelated antigens. It has been suggested that pre-natal exposure to parasitic infections in the mother impacts immunological development in the fetus and hence the offspring’s response to vaccines, and that control of parasitic infection among pregnant women will therefore be beneficial.Methodology/Principal findingsWe used new data from the Entebbe Mother and Baby Study, a trial of anthelminthic treatment during pregnancy conducted in Uganda, to further investigate this hypothesis. 2705 mothers were investigated for parasitic infections and then randomised to albendazole (400mg) versus placebo and praziquantel (40mg/kg) during pregnancy in a factorial design. All mothers received sulfadoxine/pyrimethamine for presumptive treatment of malaria. Offspring received Expanded Programme on Immunisation vaccines at birth, six, 10 and 14 weeks. New data on antibody levels to diphtheria toxin, three pertussis antigens, Haemophilus influenzae type B (HiB) and Hepatitis B, measured at one year (April 2004 –May 2007) from 1379 infants were analysed for this report. Additional observational analyses relating maternal infections to infant vaccine responses were also conducted. Helminth infections were highly prevalent amongst mothers (hookworm 43.1%, Mansonella 20.9%, Schistosoma mansoni 17.3%, Strongyloides 11.7%, Trichuris 8.1%) and 9.4% had malaria at enrolment. In the trial analysis we found no overall effect of either anthelminthic intervention on the measured infant vaccine responses. In observational analyses, no species was associated with suppressed responses. Strongyloidiasis was associated with enhanced responses to pertussis toxin, HiB and Hep B vaccine antigens.Conclusions/SignificanceOur results do not support the hypothesis that routine anthelminthic treatment during pregnancy has a benefit for the infant’s vaccine response, or that maternal helminth infection has a net suppressive effect on the offspring’s response to vaccines.Trial RegistrationISRCTN.com ISRCTN32849447

Bottleneck analysis at district level to illustrate gaps within the district health system in Uganda

ABSTRACTBackground: Poor quality of care and access to effective and affordable interventions have been attributed to constraints and bottlenecks within and outside the health system. However, there is limited understanding of health system barriers to utilization and delivery of appropriate, high-impact, and cost-effective interventions at the point of service delivery in districts and sub-districts in low-income countries. In this study we illustrate the use of the bottleneck analysis approach, which could be used to identify bottlenecks in service delivery within the district health system.Methods: A modified Tanahashi model with six determinants for effective coverage was used to determine bottlenecks in service provision for maternal and newborn care. The following interventions provided during antenatal care were used as tracer interventions: use of iron and folic acid, intermittent presumptive treatment for malaria, HIV counseling and testing, and syphilis testing. Data from cross-sectional household and health facility surveys in Mayuge and Namayingo districts in Uganda were used in this study.Results: Effective coverage and human resource gaps were identified as the biggest bottlenecks in both districts, with coverage ranging from 0% to 66% for effective coverage and from 46% to 58% for availability of health facility staff. Our findings revealed a similar pattern in bottlenecks in both districts for particular interventions although the districts are functionally independent.Conclusion: The modified Tanahashi model is an analysis tool that can be used to identify bottlenecks to effective coverage within the district health system, for instance, the effective coverage for maternal and newborn care interventions. However, the analysis is highly dependent on the availability of data to populate all six determinants and could benefit from further validation analysis for the causes of bottlenecks identified.

How effective are trained role model caregivers in prompt presumptive treatment of malaria of under 5 children in Kaduna state, North western Nigeria?

Objective: Malaria is Africa's leading cause of under 5 mortality, constituting 10% of the overall disease burden. A major strategy for reducing the burden of malaria is prompt access to effective antimalarials. Community Case Management of malaria (CCMm) can be used to achieve the 80% treatment target of uncomplicated malaria within 24 hours of onset of symptoms. CCMm aims to train selected community members to recognize symptoms of malaria and give appropriate early and prompt treatment. We conducted this study to assess CCMm in trained Role Model caregivers (RMCs) of under fives in Kaduna state, Nigeria. Methods: We conducted a descriptive cross sectional survey in Kaduna state. A sample of 308 RMCs were selected by multistage sampling and interviewed using a standardized questionnaire. The questionnaire had questions on sociodemographic characteristics, malaria transmission and treatment. Results: Mean age (SD) of RMCs was 35.34 years (±8.67). Females were 294(95.5%) and 285(92.5%) were literate. Out of 308, 294 (95.5%) correctly identified that malaria was transmitted by mosquitoes. Two hundred and sixty three (85.4 %) RMCs had treated a child under five years for presumptive malaria in the two weeks preceding the survey. Out of 267 children, 232 (88.2%) received the correct dose of antimalarials and 220 (84.3%) were treated within 24 hours of onset of symptoms. Level of education was significantly found to affect receiving the correct dose of antimalarials.(p<0.05). Conclusion: Use of RMCs achieved the 80% treatment target of malaria within 24 hours of onset of symptoms. Continuing training and supervision are necessary for correct dosage to be given. Keywords: malaria, under fives, Community Case management of malaria, caregivers

Risks of Hemolysis in Glucose-6-Phosphate Dehydrogenase Deficient Infants Exposed to Chlorproguanil-Dapsone, Mefloquine and Sulfadoxine-Pyrimethamine as Part of Intermittent Presumptive Treatment of Malaria in Infants.

BackgroundChlorproguanil-dapsone (CD) has been linked to hemolysis in symptomatic glucose-6-phosphate dehydrogenase deficient (G6PDd) children. Few studies have explored the effects of G6PD status on hemolysis in children treated with Intermittent Preventive Treatment in infants (IPTi) antimalarial regimens. We sought to examine the joint effects of G6PD status and IPTi antimalarial treatment on incidence of hemolysis in asymptomatic children treated with CD, sulfadoxine-pyrimethamine (SP), and mefloquine (MQ).MethodsA secondary analysis of data from a double-blind, placebo-controlled trial of IPTi was conducted. Hemoglobin (Hb) measurements were made at IPTi doses, regular follow-up and emergency visits. G6PD genotype was determined at 9 months looking for SNPs for the A- genotype at coding position 202. Multivariable linear and logistic regression models were used to examine hemolysis among children with valid G6PD genotyping results. Hemolysis was defined as the absolute change in Hb or as any post-dose Hb <8 g/dL. These outcomes were assessed using either a single follow-up Hb on day 7 after an IPTi dose or Hb obtained 1 to 14 or 28 days after each IPTi dose.FindingsRelative to placebo, CD reduced Hb by approximately 0.5 g/dL at day 7 and within 14 days of an IPTi dose, and by 0.2 g/dL within 28 days. Adjusted declines in the CD group were larger than in the MQ and SP groups. At day 7, homo-/hemizygous genotype was associated with higher odds of Hb <8 g/dL (adjusted odds ratio = 6.7, 95% CI 1.7 to 27.0) and greater absolute reductions in Hb (-0.6 g/dL, 95% CI -1.1 to 0.003). There was no evidence to suggest increased reductions in Hb among homo-/hemizygous children treated with CD compared to placebo, SP or MQ.ConclusionsWhile treatment with CD demonstrated greater reductions in Hb at 7 and 14 days after an IPTi dose compared to both SP and MQ, there was no evidence that G6PD deficiency exacerbated the adverse effects of CD, despite evidence for higher hemolysis risk among G6PDd infants.

Knowledge and perceptions of antenatal services need and delivery and reasons for seeking such services among women in Tanzania: Implications for utilization and coverage of intermittent presumptive treatment of malaria in pregnancy in two districts

Background: Learning from a volume of the literature that lacks information regarding people’s opportunity to access health services for disease control, a study was conducted to assess knowledge, perceptions of antenatal care (ANC) services and actually delivered services and reasons for seeking ANC including intermittent presumptive treatment during pregnancy (IPTp) against malaria in Mkuranga and Mufindi districts, Tanzania. Methodology: Quantitative and qualitative techniques were employed, involving interviews with ANC clients, informal communications with health care workers, focus group discussions with mothers of young children, and intertemporal observations. Data were collected for six months in 2006. Results: ANC seeking was mainly influenced by motivation for one’s safe pregnancy and childbirth and not necessarily and specifically seeking IPTp. The main barriers reported to hinder pregnant women effectively utilize ANC include socio-cultural values stigmatizing and discriminating women during pregnancy, service providers’ unfriendly attitudes towards clients, shortages of drugs and other essential service supplies, existence of user-fees in health facilities, and pregnant women’s unawareness of essential ANC services needed or actually delivered at ANC clinics. Conclusion: While client demand for services depends on volume, cost/price and quality of services supplied, lack of knowledge of what one deserves also influences one’s care seeking behavior. Therefore, it is imperative to do periodic evaluations of population knowledge, perceptions of the introduced policy, and service delivery programs if the health care system is to be made more effective by providing a room for corrective actions.Key words: antenatal care, malaria, pregnancy, maternal health, intermittent preventive treatment

Knowledge and perceptions of antenatal services need and delivery and reasons for seeking such services among women in Tanzania: Implications for utilization and coverage of intermittent presumptive treatment of malaria in pregnancy in two districts

Knowledge and perceptions of antenatal services need and delivery and reasons for seeking such services among women in Tanzania: Implications for utilization and coverage of intermittent presumptive treatment of malaria in pregnancy in two districts