Lymphatic filariasis in Lower Shire, southern Malawi.

Surveys for lymphatic filariasis were carried out for the first time in Lower Shire (Nsanje and Chikawawa Districts) of southern Malawi, in April-June 2000. There were 3 phases. In phase I, questionnaire surveys in 48 randomly selected villages indicated that chronic manifestations of lymphatic filariasis ('swollen scrotum' and 'swollen legs') were common and widespread in the area. In phase II, volunteers from 10 of the villages reporting frequent manifestations of filariasis in phase I were examined with the ICT whole-blood test for Wuchereria bancrofti-specific circulating filarial antigen (CFA). The observed prevalence of CFA positivity was very high (range, 38.8-79.1% for the villages). In phase III, a more detailed parasitological, CFA and clinical investigation was carried out in 2 of the high CFA prevalence villages identified in phase II (1 in each district). Overall, 18.1% and 22.2% were positive for microfilariae, and 62.3% and 64.6% were positive for CFA in the 2 villages. Among those aged > or = 15 years, 3.7% and 1.3% had leg elephantiasis, and 17.9% and 13.0% (of males only) had hydrocoele. In both phase II and III, CFA prevalences were unexpectedly high, especially in children. This was probably related to a recent increase in transmission of filariasis as a result of extensive flooding in the area prior to the study. The study indicated that lymphatic filariasis is highly endemic in the Lower Shire area of Malawi, and calls for action towards its control.

Prevalence of HIV-1 and oral lesions in pregnant women in rural Malawi.

OBJECTIVE: Whether oral lesions were associated with human immunodeficiency virus-type 1 (HIV-1) status in a cohort of pregnant Malawian women was studied. STUDY DESIGN: Six hundred thirty-eight women participated in a randomized prospective study at 3 prenatal clinics in a rural area of southern Malawi. Oral examinations, followed by collection of oral fluid specimens with an HIV-1 oral specimen collection device, were performed. The specimens were tested for antibodies against HIV-1. RESULTS: Sixty-one oral lesions were found in 60 participants. While traditional HIV-1 associated lesions were rare, benign migratory glossitis was unexpectedly common (6%). Oral hairy leukoplakia was significantly more common among women who were HIV-1 positive than among women who were HIV-1 negative. An HIV-1 prevalence rate of 21.8% was estimated among the women, with the highest rate of HIV-1 infection (34.1%) among women aged 25 to 29 years. CONCLUSION: Stratifying lesions showed a small number of oral hairy leukoplakia to be markers for HIV-1. A high seroprevalence was found in this rural cohort, but there were unexpectedly few oral lesions. The relatively few oral lesions diagnosed may indicate a recent infection with HIV.

A multi-centre evaluation of the card indirect agglutination test for trypanosomiasis (TrypTect CIATT).

A version of the card indirect agglutination test for trypanosomiasis, the TrypTect CIATT, was evaluated for the diagnosis of Trypanosoma brucei gambiense and T. b. rhodesiense sleeping sickness. The results of this antigen-detection test indicated high relative sensitivity (99.3%) and specificity (99.4%), and also much higher prevalences of infection in the general population of endemic foci (27.9% for T. b. gambiense and 21.8% for T. b. rhodesiense) than detected by parasitological diagnosis (1.6% and 1.1%, respectively). TrypTect CIATT detected (and could therefore be used for the diagnosis of) non-patent infections. Among the suspected cases (i.e. those initially found to be parasite-negative but to be antigen-positive), trypanosomes were detected in 29 (4.2%) of those checked at a 3-month follow-up, and 17 more such suspects when they were followed up at 6-18 months. Moreover, a high proportion of blood samples from a random sample of the rest of the suspects tested positive for trypanosome-specific DNA by PCR (79.9% for T. b. gambiense and 13.9% for T. b. rhodesiense). ELISA also demonstrated the presence of anti-trypanosome antibodies in many of the suspects tested (63%, 38%, 24% and 66.9% of those in Cameroon, Côte d'Ivoire, Tanzania, and Malawi, respectively). A follow-up of 164 patients treated with melarsoprol revealed that, by 9 months post-treatment, 113 (69.0%) had no detectable trypanosome antigens in their peripheral blood. The test could therefore be used for evaluating chemotherapeutic cure, as well as for diagnosis.

Validity of mother's history regarding antimalarial drug use in Malawian children under five years old.

History obtained from parents and carers is an important, and often the only, source of information for health workers treating children for malaria, but its validity has not been well evaluated. At 2 hospitals in Malawi, we obtained malaria treatment histories from mothers of 973 ill children reported to have had fever as part of the illness. Urine samples were collected from 755 of the 973 children (78%). Of the 755, 457 (61%) were reported to have received some kind of treatment. Among those who reportedly received treatment, 79 (17%) were said to have received chloroquine and 23 (5%) a sulphonamide-containing medicine; however, when urine specimens were tested for antimalarial drugs, chloroquine was found in 182 specimens (40%) and a sulphonamide in 148 (32%). Among urine specimens collected from 291 children who were reported to have received no treatment (no report was recorded for 7 children), chloroquine was detected in 56 (19%) and a sulphonamide in 44 (15%). Although not statistically significant, mothers often reported a child as not having received an antimalarial drug if the child was younger than 12 months or had been sick for more than 3 d. The mothers' information regarding home treatment of fever in children was highly inaccurate. Malaria treatment histories, whether collected at health facilities or in surveys of knowledge, attitudes, and practices, must be interpreted with caution.

A nation-wide malaria knowledge, attitudes and practices survey in Malawi: objectives and methodology.

A malaria knowledge, attitudes and practices survey was conducted in Malawi during April and May, 1992, to provide policy makers and program managers with information needed to design or improve malaria control programs, to establish epidemiologic and behavioral baselines, and to identify indicators for monitoring program effectiveness. Using cluster-sample survey methodology, 1531 households, in 30 clusters of 51-52 households each, were identified and members interviewed. Interviews were conducted by trained survey teams composed of young Malawian women with secondary level education. Heads of households were asked about malaria prevention methods used and about household economics; caretakers of children were asked about treatment and health seeking behavior in a recent malaria episode in a child; and women who had been pregnant in the past 5 years were asked about their antenatal clinic utilization and malaria during pregnancy. Survey results will be used to make programmatic decisions, including developing health education messages and establishing monitoring and evaluation of malaria control activities and outcomes in Malawi.

PIP: A malaria knowledge, attitudes and practices survey was conducted in Malawi in the late rainy season, April 1-May 16, 1992, corresponding to the season of peak malaria transmission to provide policy makers and program managers with information needed to design or improve malaria control programs, to establish epidemiologic and behavioral baselines, and to identify indicators for monitoring program effectiveness. A cluster-sample survey methodology, modified from the Expanded Program for Immunization cluster-sampling methodology was used to identify and interview members of a total sample of 1531 households, in 30 clusters of 51 to 52 households each. Heads of households were asked about malaria prevention methods used and about household economic; caretakers of children were asked about treatment and health seeking behavior in a recent malaria episode in a child; and women who had been pregnant in the past 5 years were asked about their antenatal clinic utilization and malaria during pregnancy. A total of 7025 persons in 1531 households were included in the survey: 1178 adults with recent fever illness and caretakers of 724 children with recent fever illness were interviewed; 1395 households included at least one woman who had ever been pregnant, with 809 women having completed a pregnancy within the last 5 years. Preventive measures used in the households and household income were ascertained for 1531 households. In several articles, detailed results will be described for each part of the survey. These results will be used to be guide policy makers and program managers in making decisions based on current data in designing and improving malaria control programs and health education messages. Baseline epidemiologic and behavioral indicators will be identified for monitoring program impact to help focus intervention efforts on high risk groups, through channels that will most effectively reach the greatest number of people.

Malaria knowledge, attitudes and practices in Malawi: survey population characteristics.

A national knowledge, attitudes and practices (KAP) survey was conducted in March-April 1992 to examine malaria illness and the people's response to illness and malaria prevention. Fifty-one households in each of 30 randomly selected communities were sampled and information was recorded from 1,531 households and 7,025 individuals. The population is characterized by low income (average household and per capita income were US $490 and $122, respectively) and low education levels (among adult women, 45% had no formal education and only 3.9% completed more than 8 years of schooling). Characteristics of the population were similar to those found in the 1987 national census, suggesting that the survey population was representative of the larger population of Malawi. Children under 5 years of age made up 15.8% of the population and had the highest rates of fever illness; these children experienced an estimated 9.7 cases/year of fever illness consistent with malaria. Although adults reported fever less frequently, women of reproductive age experienced an estimated 6.9 episodes of fever annually. The burden of malaria morbidity in this population is extremely high and occurs in all age groups.

PIP: A national knowledge, attitudes and practices (KAP) survey was conducted in March-April 1992 to examine malaria illness and the people's response to illness and malaria prevention. 51 households in each of 30 randomly selected communities were sampled and information was recorded from 1531 households and 7025 individuals. The average annual income per household was US $490 and the average per capita income was $122. Female-headed households are most commonly in the "very low" income grouping. Among adult women, 45% had no formal education and only 3.9% had completed more than 8 years of schooling. 23% of male households and 58% of female households reported no normal education. Children under 5 years of age made up 15.8% of the population and had the highest rates of fever illness. Seasonally adjusted estimates of fever episodes by age group and gender for adults showed that these children experienced the highest reported rates: an estimated 9.7 cases/year of fever illness consistent with malaria. Infants and children under 5 years of age had the highest reported rates of fever (45.6% and 49.0%, respectively). Although adults reported fever less frequently, women of reproductive age experienced an estimated 6.9 episodes of fever annually. Reported malaria-like fever in the previous 14 days was recorded for each household member; overall, 33% of the population reported fever in this interval. Data from the National Health Information System indicate that in 1989 approximately 10% of the more than 3.7 million total outpatient cases of malaria for the year were reported in the mid-April to mid-May time interval. The burden of malaria morbidity in this population is extremely high and occurs in all age groups.

Malaria and childbearing women in Malawi: knowledge, attitudes and practices.

Information on women's use of antenatal clinic (ANC) service, including malaria prevention and treatment during pregnancy, was collected during a national malaria knowledge, attitudes, and practices survey in Malawi. Among 1531 households, 809 (53%) included a woman who had carried a pregnancy past the second trimester within the past 5 years. Of these, 756 (93%) women reported at least one ANC visit during pregnancy (median = 4); 336 (42%) attended 5 or more times. Approximately half (51%) reported delivering in a hospital; 5% delivered in a clinic; 13% delivered at home with a trained birth attendant; and 28% delivered at home with only family attending. Women at increased risk for delivery complications (e.g. primigravidas and grand multigravidas) were no more likely to attend ANC or deliver in hospital than women without increased risk. The woman's level of education was the only significant predictor of initiating ANC care, continued ANC attendance, and delivery in hospital. In a setting where 43% of women pregnant within the past 5 years had received no formal education and 70% had completed less than 5 years, this survey identified a critical need for targeting health messages towards poorly educated women to ensure proper utilization of antenatal care services, including coverage with malaria prevention throughout pregnancy.

PIP: Information on women's use of antenatal clinic (ANC) service, including malaria prevention and treatment during pregnancy, was collected during a national malaria knowledge, attitudes, and practices survey in Malawi. Among 1531 households, 809 (53%) included a woman who had carried a pregnancy past the second trimester within the past 5 years. Of these, 756 (93%) women reported at least one ANC visit during pregnancy (median = 4); 336 (42%) attended 5 or more times. Among ANC attenders, 723 (96%) reported receiving an ANC card, but only 210 (26%) could produce the card for examination by the interviewer. Delivery occurred at home with a family member attending among 225 (28%) women; 103 (13%) reported home delivery with a TBA present; 421 (51%) delivered in hospital; and 43 (5%) in a clinic. Women at an increased risk for delivery complications (e.g. primigravidas and grand multigravidas) were no more likely to attend ANC or deliver in hospital than women without increased risk. Tetanus toxoid immunization was reported by 689 (91%) ANC attenders, and 576 (76%) reported receiving iron. Women who attended ANC were significantly more likely to deliver at a hospital or clinic (452/756, 60%) than women who had never attended ANC (3/53, 6%) (p .001). For those delivering at a health care facility, 309 (68%) walked to the facility; most of the women were accompanied by a female relative (274, 60%). Most women (80%) reported waiting until the onset of labor to travel to the facility. The woman's level of education was the only significant predictor of initiating ANC care, continued ANC attendance, and delivery in hospital. In a setting where 43% of women pregnant within the past 5 years had received no formal education and 70% had completed less than 5 years, this survey identified a critical need for targeting health messages towards poorly educated women to ensure proper utilization of antenatal care services, including coverage with malaria prevention throughout pregnancy.

Malaria knowledge, attitudes and practices in Malawi: policy implications for the National Malaria Control Program.

PIP: Following data analysis and the presentation of the summary report to Ministry of Health officials, a group of Ministry of Health staff examined results for implications for national policy development, those elements which were relevant to 1) health education messages; 2) the development of programmatic indicators; 3) constraints on the use of services and access to treatment and prevention; and 4) direct and indirect costs of malaria in Malawi. Despite years of chloroquine use, less than 30% of children were reported to receive an appropriate dose, thereby limiting effective therapy. Plans to implement a new first line drug for therapy for use of sulfadoxine-pyrimethamine must be clearly spelled out. 10% of children attending government clinics and 43% of those attending private facilities receive an injection for malaria, a gross overuse of injectable drugs. With 83% of women perceiving malaria as a problem during pregnancy and 68% thinking that antimalarials can prevent it, there is a need for increased management of malaria in pregnancy. Use of malaria preventive measures is very low and income-dependent. Educational messages must include teaching that mosquitoes transmit malaria, as only 55% of household heads reported this as the cause of malaria fevers. In certain locally based public health projects, use of bed nets could be much higher. There is an imbalance between the average household expenditure on treatment (US $13.33) compared to prevention ($2.47). In addition, 40% of households have an annual income of less than US $110 and expenditure on treatment exceeds 10% of these family incomes. The use of malaria prevention measures was closely linked to household income and, estimated annual expenditure on sprays, coils and bed nets was high ($42.60, $12.56, and $12.42, respectively). This underscores that 1) households that do spend money on prevention tend to spend substantial amounts; and 2) the money spent might be more effective if it were spent on bed nets rather than sprays.^ieng