Durability of long-lasting insecticidal nets (LLINs) in Ethiopia.

BACKGROUND: The functional survival time of long-lasting insecticidal nets (LLINs), which varies across different field contexts, is critical for the successful prevention of malaria transmission. However, there is limited data on LLIN durability in field settings in Ethiopia. METHODS: A three-year longitudinal study was conducted to monitor attrition, physical integrity, and bio-efficacy and residual chemical concentration of LLINs in four regions in Ethiopia. World Health Organization (WHO) guidelines were used to determine sample size, measure physical integrity, and calculate attrition rates, and functional survival time. Yearly bio-efficacy testing was done on randomly selected LLINs. An excel tool developed by vector works project was used to calculate the median functional survival time of the LLINs. Predictors of functional survival were identified by fitting binary and multivariate cox proportional hazards model. RESULTS: A total of 3,396 LLINs were included in the analysis. A total of 3,396 LLINs were included in the analysis. By the end of 36 months, the proportion of LLINs functionally surviving was 12.9% [95% confidence interval (CI) 10.5, 15.6], the rates of attrition due to physical damage and repurposing were 48.8% [95% confidence interval (CI) 45.0, 52.6] and 13.8% [95% confidence interval (CI) 11.6, 14.6], respectively. The estimated median functional survival time was 19 months (95%CI 17, 21). Factors associated with shorter functional survival time include being in a low malaria transmission setting [Adjusted Hazards Ratio (AHR) (95%CI) 1.77 (1.22, 2.55)], rural locations [AHR (95%CI) 1.83 (1.17, 2.84)], and in a room where cooking occurs [AHR (95%CI) 1.28 (1.05, 1.55)]. Bioassay tests revealed that 95.3% (95%CI 86.4, 98.5) of the LLINs met the WHO criteria of bio-efficacy after 24 months of distribution. CONCLUSION: The LLIN survival time was shorter than the expected three years due to high attrition rates and rapid loss of physical integrity. National malaria programmes may consider, procuring more durable LLINs, educating communities on how to prevent damage of LLINs, and revising the current three-year LLIN distribution schedule to ensure sufficient protection is provided by LLINs against malaria transmission. While this paper contributes to the understanding of determinants impacting functional survival, further research is needed to understand factors for the rapid attrition rates and loss of physical integrity of LLINs in field settings.

Evaluation of the effect of targeted Mass Drug Administration and Reactive Case Detection on malaria transmission and elimination in Eastern Hararghe zone, Oromia, Ethiopia: a cluster randomized control trial.

BACKGROUND: Reactive and proactive case detection measures are widely implemented by national malaria elimination programs globally. Ethiopia decided to include Reactive Case Detection (RCD) and targeted Mass Drug Administration (tMDA) approaches as part of their elimination strategy along with rigorous evaluation. The purpose of this study is to compare the impact of RCD and tMDA on malaria elimination over the 2-year study period, by looking at the annual parasite incidence before and after the intervention. METHODS: The study will be conducted in the East Hararghe zone of Ethiopia. Malaria transmission in the area is low to moderate. This study will deploy a community-based, three-arm, cluster-randomized control trial implemented over 2 years. Forty-eight clusters (16 clusters per arm) will be selected based on the annual number of confirmed malaria cases seen in the cluster. All clusters will receive the current standard of care in terms of malaria elimination interventions provided by the national malaria control program. In addition, following the identification of malaria parasite infection, individuals who reside within a 100-m radius of the index case will receive a diagnosis for malaria and treatment if positive in the RCD arm or presumptive treatment in the tMDA arm. The primary effectiveness endpoint will be measured at baseline and endline for each intervention arm and compared to the control arm using a difference in difference approach. DISCUSSION: This randomized controlled trial will provide evidence of the impact of the proposed intervention approaches for malaria elimination. TRIAL REGISTRATION: ClinicalTrials.gov NCT04241705 . Registration date: January 27, 2020.

The effect of long-lasting insecticidal nets (LLINs) physical integrity on utilization.

BACKGROUND: In Ethiopia, despite improvements in coverage and access, utilization of long-lasting insecticidal nets (LLINs) remains a challenge. Different household-level factors have been identified as associated with LLIN use. However, the contribution of LLIN physical integrity to their utilization is not well investigated and documented. This study aimed to assess the association between the physical integrity of LLINs and their use. METHODS: This study employed a nested case-control design using secondary data from the Ethiopian LLIN durability monitoring study conducted from May 2015 to June 2018. LLINs not used the night before the survey were identified as cases, while those used the previous night were categorized as controls. The physical integrity of LLINs was classified as no holes, good, acceptable, and torn using the proportionate hole index (pHI). A Generalized Estimating Equation (GEE) model was used to assess and quantify the association between LLIN physical integrity and use. The model specifications included binomial probabilistic distribution, logit link, exchangeable correlation matrix structure, and robust standard errors. The factors included in the model were selected first by fitting binary regression, and then by including all factors that showed statistical significance at P-value less than 0.25 and conceptually relevant variables into the multivariate regression model. RESULTS: A total of 5277 observations fulfilled the inclusion criteria. Out of these 1767 observations were cases while the remaining 3510 were controls. LLINs that were in torn physical condition had higher odds (AOR [95% CI] = 1.76 [1.41, 2.19]) of not being used compared to LLINs with no holes. Other factors that showed significant association included the age of the LLIN, sleeping place type, washing status of LLINs, perceptions towards net care and repair, LLIN to people ratio, economic status, and study site. CONCLUSION AND RECOMMENDATION: LLINs that have some level of physical damage have a relatively higher likelihood of not being used. Community members need to be educated about proper care and prevention of LLIN damage to delay the development of holes as long as possible and use available LLINs regularly.

Knowledge and perception towards net care and repair practice in Ethiopia.

BACKGROUND: Long-lasting insecticidal nets (LLINs) are a key malaria control intervention. Although LLINs are presumed to be effective for 3 years under field or programmatic conditions, net care and repair approaches by users influence the physical and chemical durability. Understanding how knowledge, perception and practices influence net care and repair practices could guide the development of targeted behavioural change communication interventions related to net care and repair in Ethiopia and elsewhere. METHODS: This population-based, household survey was conducted in four regions of Ethiopia [Amhara, Oromia, Tigray, Southern Nations Nationalities Peoples Region (SNNPR)] in June 2015. A total of 1839 households were selected using multi-stage sampling procedures. The household respondents were the heads of households. A questionnaire was administered and the data were captured electronically. STATA software version 12 was used to analyse the data. Survey commands were used to account for the multi-stage sampling approach. Household descriptive statistics related to characteristics and levels of knowledge and perception on net care and repair are presented. Ordinal logistic regression was used to identify factors associated with net care and repair perceptions. RESULTS: Less than a quarter of the respondents (22.3%: 95% CI 20.4-24.3%) reported adequate knowledge of net care and repair; 24.6% (95% CI 22.7-26.5%) of the respondents reported receiving information on net care and repair in the previous 6 months. Thirty-five per cent of the respondents (35.1%: 95% CI 32.9-37.4%) reported positive perceptions towards net care and repair. Respondents with adequate knowledge on net care and repair (AOR 1.58: 95% CI 1.2-2.02), and those who discussed net care and repair with their family (AOR 1.47: 95% CI 1.14-1.89) had higher odds of having positive perceptions towards net care and repair. CONCLUSIONS: The low level of reported knowledge on net care and repair, as well as the low level of reported positive perception towards net repair need to be addressed. Targeted behavioural change communication campaigns could be used to target specific groups; increased net care and repair would lead to longer lasting nets.

Neurological evaluation of untreated human immunodeficiency virus infected adults in Ethiopia.

Human immunodeficiency virus (HIV) has been implicated in neurological complications in developed countries. Developing countries have different viral clades and potentially different genetic and social risks for these complications. Baseline neurological performance measures associated with HIV infection have rarely been available from developing countries. The authors carried our a cross-sectional neurological evaluation of a cohort of community-dwelling treatment-naïve HIV-infected patients and similar control subjects from the same communities in Ethiopia. Blinded evaluation using standardized structured questionnaires and a neurological examination was performed by neurologists and treating physicians trained by an HIV neurology specialist. Quantitative performance measures for cognitive and motor function were employed. Data were analyzed with descriptive statistical methods, standard contingency table methods, and nonparametric methods. HIV-positive and control groups were similar by age, gender, and job site. Participants included 73 HIV-positive and 87 HIV-negative controls. Fingertapping speed in the dominant hand was more poorly performed in HIV positives than negatives (P = .01) and was significantly associated with HIV viral load levels (P = .03). Other quantitative neuropsychiatric tests including timed gait, grooved pegboard, task learning, and animal naming did not show significant differences between the two groups. The overall prevalence of central nervous system (CNS) and/or peripheral nervous system (PNS) disease did not significantly differ in the two populations. HIV patients had slowed fingertapping speed correlating with viral load. Other measures of CNS and/or peripheral nervous performance did not differ from controls. The unanticipated minor evidence of HIV-associated neurocognitive and peripheral nerve deficits in this untreated HIV-positive population invite further investigation.

HIV-1 seroprevalence and subtypes in police recruits from Afar regional state, Ethiopia.

Surveillance for HIV-1 prevalence and subtypes in Afar Region, Ethiopia was performed among police recruits in the year 2000, by unlinked anonymous testing. Of 408 samples tested, 26 (6.4%) appeared positive for HIV-1 antibodies. There was a trend for higher HIV-1 seroprevalence in women (9.5%, 9/95) than men (5.4%, 17/313), which was significant in one of the 5 administrative areas: Zone 4 (p = 0.01). Around the principal transportation route connecting Addis Ababa to the harbor of Djibouti there was a significantly (p = 0.03) higher HIV-1 seroprevalence of 12.7% (14/110) than elsewhere in Afar Region. In addition, 13 (34%) of the 29 administrative sub-areas (woredas) of Afar Region delivered HIV-1 positive police recruits. Prevalence of syphilis antibodies was 7.4% (30/408), increasing by age, correlating with HIV-1 positive serology (p = 0.001) and with 23.3% (7/30) active cases. Of 22 specimens sequenced, 12 had gp120 V3 regions from Ethiopian subtype C, 9 subtype C' and 1 subtype A. In conclusion, even in very remote areas in Ethiopia, such as Afar Region, the HIV-1 epidemic is established, being primarily of subtype C. Regular HIV-1 surveillances will be necessary to guide action to prevent further spread in this vulnerable area.