Efficacy and safety of artemether-lumefantrine for the treatment of uncomplicated falciparum malaria in mainland Tanzania, 2018.

BACKGROUND: The use of artemisinin-based combination therapy (ACT) is recommended by the World Health Organization for the treatment of uncomplicated falciparum malaria. Artemether-lumefantrine (AL) is the most widely adopted first-line ACT for uncomplicated malaria in sub-Saharan Africa (SSA), including mainland Tanzania, where it was introduced in December 2006. The WHO recommends regular assessment to monitor the efficacy of the first-line treatment specifically considering that artemisinin partial resistance was reported in Greater Mekong sub-region and has been confirmed in East Africa (Rwanda and Uganda). The main aim of this study was to assess the efficacy and safety of AL for the treatment of uncomplicated falciparum malaria in mainland Tanzania. METHODS: A single-arm prospective anti-malarial drug efficacy trial was conducted in Kibaha, Mlimba, Mkuzi, and Ujiji (in Pwani, Morogoro, Tanga, and Kigoma regions, respectively) in 2018. The sample size of 88 patients per site was determined based on WHO 2009 standard protocol. Participants were febrile patients (documented axillary temperature ≥ 37.5 °C and/or history of fever during the past 24 h) aged 6 months to 10 years. Patients received a 6-dose AL regimen by weight twice a day for 3 days. Clinical and parasitological parameters were monitored during 28 days of follow-up to evaluate the drug efficacy and safety. RESULTS: A total of 653 children were screened for uncomplicated malaria and 349 (53.7%) were enrolled between April and August 2018. Of the enrolled children, 345 (98.9%) completed the 28 days of follow-up or attained the treatment outcomes. There were no early treatment failures, but recurrent infections were higher in Mkuzi (35.2%) and Ujiji (23%). By Kaplan-Meier analysis of polymerase chain reaction (PCR) uncorrected adequate clinical and parasitological response (ACPR) ranged from 63.4% in Mkuzi to 85.9% in Mlimba, while PCR-corrected ACPR on day 28 varied from 97.6% in Ujiji to 100% in Mlimba. The drug was well tolerated; the commonly reported adverse events were cough, runny nose, and abdominal pain. No serious adverse event was reported. CONCLUSION: This study showed that AL had adequate efficacy and safety for the treatment of uncomplicated falciparum malaria. The high number of recurrent infections were mainly due to new infections, indicating the necessity of utilizing alternative artemisinin-based combinations, such as artesunate amodiaquine, which provide a significantly longer post-treatment prophylactic effect.

Sustaining LLIN coverage with continuous distribution: the school net programme in Tanzania.

Most malaria-endemic countries have struggled in the past decade to establish effective national-scale continuous distribution mechanisms for long-lasting insecticidal nets (LLINs). Since the implementation of the Tanzania National Voucher Scheme in 2004 and mass-distribution campaigns in 2009-2011 and 2015-2016, Tanzania has been committed to finding new and innovative ways of achieving and maintaining universal bed net coverage. Planning for the School Net Programme (SNP) began in 2011 and in 2013, the country piloted a SNP in three regions. Nets were distributed annually to children attending schools in selected primary and secondary grades. Intra-family re-distribution was assumed, and hence the family as a whole, rather than just the children themselves, were the targeted beneficiaries. The programme has since expanded to 14 regions and has seen six rounds of annual distribution. In its fifth year, 3 million nets were distributed at a cost of USD 3.64 per net and USD 0.60 per person-year of protection (including the net). ITN access and use were maintained at a high level (~ 50-75%) over the first 4 years of distribution within selected evaluation areas, even in the absence of a mass distribution event. Net distribution through primary schools has proven to be a feasible and effective strategy for maintaining consistently high coverage in Tanzania.

'To be honest, women do everything': understanding roles of men and women in net care and repair in Southern Tanzania.

BACKGROUND: In Tanzania, the roles of men and women are classified based on the local cultural context. While men are usually the breadwinners, women are traditionally responsible for most domestic chores. Particularly for malaria prevention, studies in Africa have revealed women as being responsible for daily up-keep of the net. Using social role theory, this study explored the role of men and women in net care and repair and gender-related motivation and barriers to net care and repair in Tanzania. METHODS: The study was conducted in the two villages of Ruangwa district in Lindi Region. The study applied qualitative approaches and carried out in-depth interviews and focus group discussions with men, women, women with children under the age of five, and village key informants. RESULTS: Mosquito nets were valued by all participants as a protection measure against mosquitoes. Study findings indicate that net care and repair falls under a woman's daily household responsibilities. While men were said to assist in stitching damaged nets, washing dirty bed nets was regarded inappropriate for men and not traditionally accepted. Motivation for net care and repair was reported to come from both men and women; for a woman keeping the net clean defined a caring and responsible woman, while men indirectly promoted net washing when complaining about nets being dirty. Women reported that men could do everything that women do regarding net care and repair, but that it does not fit into societal norms. CONCLUSION: With increased globalization in Tanzania, more women are becoming part of the workforce, which may limit their full commitment to net care and repair activities, leading to increased net damage, malaria incidences and higher costs for malaria treatment. The National Malaria Control Programme should consider incorporating research-informed gender-transformative messages into their behaviour change communication on mosquito nets and work closely with trusted Community Health Workers to inform communities about the importance of sharing responsibilities in net care and repair. It is acknowledged that changing people's behaviour and practices is a long process, which will require a deep cultural and political shift.

'For the poor, sleep is leisure': understanding perceptions, barriers and motivators to mosquito net care and repair in southern Tanzania.

BACKGROUND: The rate of physical deterioration of long-lasting insecticidal nets (LLINs) varies by household practices, net brand and environment. One way to sustain the protection provided by LLINs against malaria is through day-to-day care, and repairing holes as and when they occur. To ensure LLIN coverage is high between mass campaigns and, as international donor funds decrease, personal responsibility to maintain nets in good condition is becoming more important. This study aimed to understand local barriers and motivators to net care and repair in southern Tanzania in a community that receives free LLINs through a school-based distribution mechanism. METHODS: Qualitative research methods were applied in a rural and peri-urban village in Ruangwa district. Focus group discussions (FGDs) were conducted for five groups of 8-12 participants; (1) key informants, (2) young men (18-24 years old), (3) women (> 18 years) with children under the age of five, (4) older men (> 25 years), and (5) older women with or without children (> 25 years). In each village, five men, five women with or without children, and five women with children under the age of five were recruited for in-depth interviews (IDIs). After each IDI and FGD with women with young children, participants were guided through a participatory activity. The study also counted the number and size of holes in nets currently used by IDI participants to determine their physical degradation status. RESULTS: A general willingness to care and repair mosquito nets was observed in Ruangwa district for the love of a good night's sleep free of mosquito bites or noises. Net care was preferred over repair, especially among women who were the primary caretakers. The main motivation to look after nets was protection against mosquito bites and malaria. Washing nets occurred as frequently as every other week in some households to ensure cleanliness, which prevented other dirt-related problems such as sneezing and headaches. Barriers to net care included care not being a priority in the day-to-day activities and lack of net retreatment kits. Net repair was reported to be a temporary measure and necessary as soon as a hole was identified. However, during the net assessment and participatory activity, it became clear that people did not actually repair smaller holes. Protection against mosquitoes, malaria and cost saving from replacing nets were identified as motivators for net repair. Barriers to net repair included it not being a priority to repair holes that could be tucked under the mattress and lack of knowledge on when to repair nets. CONCLUSION: In Ruangwa, net care was defined as overall net maintenance, such as cleanliness, and not directly associated with the prevention of damage as reported in other studies. Net repair was reported as a temporary measure before the acquisition of a new net, hence not a priority in a busy household. Inconsistencies were observed between reported intentions to repair mosquito nets and current net condition. Targeted education through health facilities and community change agents are potential means to overcome barriers to net care and repair.

Medicine sellers and malaria treatment in sub-Saharan Africa: what do they do and how can their practice be improved?

Medicine sellers are widely used for fever and malaria treatment in sub-Saharan Africa, but concerns surround the appropriateness of drugs and information provided. Because there is increasing interest in improving their services, we reviewed the literature on their characteristics and interventions to improve their malaria-related practices. Sixteen interventions were identified, involving a mixture of training/capacity building, demand generation, quality assurance, and creating an enabling environment. Although evidence is insufficient to prove which approaches are superior, tentative conclusions were possible. Interventions increased rates of appropriate treatment, and medicine sellers were willing to participate. Features of successful interventions included a comprehensive situation analysis of the legal and market environment; buy-in from medicine sellers, community members and government; use of a combination of approaches; and maintenance of training and supervision. Interventions must be adapted to include artemisinin-based combination therapies, and their sustainability and potential to operate at a national level should be further explored.