Using routine health data to evaluate the impact of indoor residual spraying on malaria transmission in Madagascar.

INTRODUCTION: Indoor residual spraying (IRS) and insecticide-treated bed nets (ITNs) are cornerstone malaria prevention methods in Madagascar. This retrospective observational study uses routine data to evaluate the impacts of IRS overall, sustained IRS exposure over multiple years and level of spray coverage (structures sprayed/found) in nine districts where non-pyrethroid IRS was deployed to complement standard pyrethroid ITNs from 2017 to 2020. METHODS: Multilevel negative-binomial generalised linear models were fit to estimate the effects of IRS exposure overall, consecutive years of IRS exposure and spray coverage level on monthly all-ages population-adjusted malaria cases confirmed by rapid diagnostic test at the health facility level. The study period extended from July 2016 to June 2021. Facilities with missing data and non-geolocated communes were excluded. Facilities in IRS districts were matched with control facilities by propensity score analysis. Models were controlled for ITN survivorship, mass drug administration coverage, precipitation, enhanced vegetation index, seasonal effects and district. Predicted cases under a counterfactual no IRS scenario and number of cases averted by IRS were estimated using the fitted models. RESULTS: Exposure to IRS overall reduced case incidence by an estimated 30.3% from 165.8 cases per 1000 population (95% CI=139.7 to 196.7) under a counterfactual no IRS scenario, to 114.3 (95% CI=96.5 to 135.3) over 12 months post-IRS campaign in nine districts. A third year of IRS reduced malaria cases 30.9% more than a first year (incidence rate ratio (IRR)=0.578, 95% CI=0.578 to 0.825, p<0.001) and 26.7% more than a second year (IRR=0.733, 95% CI=0.611 to 0.878, p=0.001). There was no significant difference between the first and second year (p>0.05). Coverage of 86%-90% was associated with a 19.7% reduction in incidence (IRR=0.803, 95% CI=0.690 to 0.934, p=0.005) compared with coverage ≤85%, although these results were not robust to sensitivity analysis. CONCLUSION: This study demonstrates that non-pyrethroid IRS appears to substantially reduce malaria incidence in Madagascar and that sustained implementation of IRS over three years confers additional benefits.

Expanding the Role of Women in Vector Control: Case Studies From Madagascar, Rwanda, and Zambia.

BACKGROUND: Historically, vector control, including entomological monitoring, has been a field dominated by men. Each year, the U.S. President's Malaria Initiative (PMI) VectorLink project hires 50,000 to 70,000 seasonal workers across the countries in which it works to implement vector control activities, creating an economic opportunity for both men and women. Remaining barriers to women's employment in vector control include social and cultural norms regarding acceptability of formal employment for women, perceptions that women are not fit to serve as spray operators, and a historical context of male-dominated fields such as entomology. METHODS: We use PMI VectorLink project data from Madagascar, Rwanda, and Zambia for 2019-2021 and key informant interviews with project staff in these countries to examine levels of female employment, effectiveness and efficiency of female versus male malaria spray operators, and strategies to expand the role of women in vector control. RESULTS: The percentage of female seasonal employees ranges from 25% in Madagascar to 32% in Rwanda and 45% in Zambia. The percentage of women in leadership positions ranges from 32% in Madagascar and Rwanda to 38% in Zambia. Men and women are equally effective and efficient as spray operators. Best practices for recruiting and retaining women in vector control include engaging community leaders in recruitment, implementing affirmative action hiring policies, mentoring women to progress to leadership positions, and ensuring equitable, safe, and attractive workplaces. DISCUSSION: As vector control programs transition away from donor funding and are increasingly government led, sustaining gains in female empowerment is critical. Country programs should work closely with national, regional, district, and local leaders to demonstrate the importance of hiring women in vector control-including leadership positions-and the impact on female economic empowerment, community well-being, and success of vector control programs.

User fee exemptions and equity in access to caesarean sections: an analysis of patient survey data in Mali.

INTRODUCTION: Little rigorous evidence exists on how health service utilization varies across socioeconomic groups after a user fee exemption policy has been implemented, and the evidence that does exist is mixed. In this paper, we estimate the distribution of caesarean section deliveries across socioeconomic groups following Mali's implementation of a fee exemption policy for caesareans in 2005. METHODS: We conducted a patient survey in 2010 to collect socioeconomic data from 2,477 women who had caesareans in a representative sample of 25 facilities across all regions of Mali. We used these data along with data from the most recent Demographic and Health Survey to construct a wealth index and classify women into population-based wealth groupings. We compared the wealth distribution of women delivering via caesarean section to that of a nationally representative sample of women giving birth. RESULTS: We found that wealthier women make up a disproportionate share of those having free caesareans, five years after implementation of the fee exemption policy. Women in the richest two quintiles accounted for 58 percent of all caesareans, while women in the poorest two quintiles accounted for 27 percent of all caesareans. Fewer women in the poorest two-fifths of the population are receiving caesareans than what we would expect given their share in the population of women giving birth. CONCLUSIONS: While fee exemptions remove important financial barriers to accessing priority maternal health services, they are insufficient to ensure equal access among wealth groups.

Efectos de la suplementacion oral con calcio y ácido linoleico conjugado en primigrávidas de alto riesgo / Effects of calcium and linoleic acid conjugated diet in pregnancy of high risk

Objetivo: Determinar el efecto de dosis bajas de calcio elemental y ácido linoleico conjugado sobre los niveles plasmáticos de tromboxano B2, insulina, aldosterona, GMP cíclico, proteína C reactiva ultrasensible y la eficacia del tratamiento en la prevención de la hipertensión arterial inducida por el embarazo. Métodos: En un ensayo clínico doble ciego, controlado con placebo se estudiaron a 48 primigrávidas con alto riesgo para desarrollar preeclampsia con dosis diarias de calcio elemental (600 mg) y ácido linoleico conjugado (450 mg) (n=24) ó 450 mg de talco y 600 mg de lactosa como placebo (n=24) desde la semana 18-22 hasta el parto. Resultados: Dos mujeres en el grupo experimental (8.3/100) desarrollaron hipertensión arterial inducida por el embarazo comparado con 10 (41.7/100) mujeres controles (riesgo relativo 0.20, IC 95/100 0.05-0.82, p=0.01). No se observaron diferencias entre los niveles plasmáticos después de 4 semanas de tratamiento ni efectos maternos o neonatales en ambos grupos. Conclusiones: La administración de dosis bajas de calcio elemental y ácido linoleico conjugado redujo significativamente la incidencia de hipertensión arterial inducida por el embarazo en mujeres embarazadas de alto riesgo sin efectos colaterales atribuibles a la intervención y sin efecto sobre los niveles de tromboxano B2, insulina, aldosterona, GMP cíclico y la respuesta sistémica inflamatoria