Forest malaria and prospects for anti-malarial chemoprophylaxis among forest goers: findings from a qualitative study in Thailand.

BACKGROUND: Across the Greater Mekong Subregion, malaria remains a dangerous infectious disease, particularly for people who visit forested areas where residual transmission continues. Because vector control measures offer incomplete protection to forest goers, chemoprophylaxis has been suggested as a potential supplementary measure for malaria prevention and control. To implement prophylaxis effectively, additional information is needed to understand forest goers' activities and their willingness to use malaria prevention measures, including prophylaxis, and how it could be delivered in communities. Drawing on in-depth interviews with forest goers and stakeholders, this article examines the potential acceptability and implementation challenges of malaria prophylaxis for forest goers in northeast Thailand. METHODS: In-depth interviews were conducted with forest goers (n = 11) and stakeholders (n = 16) including healthcare workers, community leaders, and policymakers. Interviews were audio-recorded, transcribed and coded using NVivo, employing an inductive and deductive approach, for thematic analysis. RESULTS: Forest goers were well aware of their (elevated) malaria risk and reported seeking care for malaria from local health care providers. Forest goers and community members have a close relationship with the forest but are not a homogenous group: their place and time-at-risk varied according to their activities and length of stay in the forest. Among stakeholders, the choice and cost of anti-malarial prophylactic regimen-its efficacy, length and complexity, number of tablets, potential side effects, and long-term impact on users-were key considerations for its feasibility. They also expressed concern about adherence to the preventive therapy and potential difficulty treating malaria patients with the same regimen. Prophylaxis was considered a low priority in areas with perceived accessible health system and approaching malaria elimination. CONCLUSIONS: In the context of multi-drug resistance, there are several considerations for implementing malaria prophylaxis: the need to target forest goers who are at-risk with a clear period of exposure, to ensure continued use of vector control measures and adherence to prophylactic anti-malarials, and to adopt an evidence-based approach to determine an appropriate regimen. Beyond addressing current intervention challenges and managing malaria incidence in low-transmission setting, it is crucial to keep malaria services available and accessible at the village level especially in areas home to highly mobile populations.

Evaluation of a capacity building intervention on malaria treatment for under-fives in rural health facilities in Niger State, Nigeria.

BACKGROUND: Despite the uptake of parasitological testing into policy and practice, appropriate prescription of anti-malarials and artemisinin-based combination therapy (ACT) in accordance with test results is variable. This study describes a National Malaria Control Programme-led capacity building intervention which was implemented in 10 States of Nigeria. Using the experience of Niger State, this study assessed the effect on malaria diagnosis and prescription practices among febrile under-fives in rural health facilities. METHODS: The multicomponent capacity building intervention consisted of revised case management manuals; cascade training from national to state level carried out at the local government area (LGA) level; and on the job capacity development through supportive supervision. The evaluation was conducted in 28, principally government-owned, health facilities in two rural LGAs of Niger State, one in which the intervention case management of malaria was implemented and the other acted as a comparison area with no implementation of the intervention. Three outcomes were considered in the context of rapid diagnostic testing (RDT) for malaria which were: the prevalence of RDT testing in febrile children; appropriate treatment of RDT-positive children; and appropriate treatment of RDT-negative children. Outcomes were compared post-intervention between intervention and comparison areas using multivariate logistic regression. RESULTS: The intervention did not improve appropriate management of under-fives in intervention facilities above that seen for under-fives in comparison facilities. Appropriate treatment with artemisinin-based combinations of RDT-positive and RDT-negative under-fives was equally high in both areas. However, appropriate treatment of RDT-negative children, when defined as receipt of no ACT or any other anti-malarials, was better in comparison areas. In both areas, a small number of RDT-positives were not given ACT, but prescribed an alternative anti-malarial, including artesunate monotherapy. Among RDT-negatives, no under-fives were prescribed artesunate as monotherapy. CONCLUSION: In a context of significant stock-outs of both ACT medicines and RDTs, under-fives were not more appropriately managed in intervention than comparison areas. The malaria case management intervention implemented through cascade training reached only approximately half of health workers managing febrile under-fives in this setting. Implementation studies on models of cascade training are needed to define what works in what context.

Decline in malaria incidence in a typical county of China: Role of climate variance and anti-malaria intervention measures.

Malaria is an important vector-borne disease which is widespread in tropical and subtropical areas worldwide as well as in south China. Previous research has separately focused on the association between malaria incidence and meteorological variables or between malaria incidence and anti-malaria intervention measures in China, especially in Yunnan Province. Therefore, a typical county, Tengchong County, in Yunnan Province with high malaria incidence was selected as the study area to investigate the integrated influence of climate variance and anti-malaria intervention measures. Malaria incidence and meteorological variables were analyzed with a 2-month lag. The variables include average monthly temperature, minimum temperature, maximum temperature, cumulative precipitation, wind speed, maximum wind speed, relative humidity and minimum relative humidity. First, the principal component analysis was introduced to investigate the relationship between malaria incidence and meteorological variables; classification and regression trees were used to clarify contributions of key meteorological variables to malaria incidence afterwards. Second, based on existing anti-malaria intervention measures and above results, the integrated impact of climate variance and anti-malaria interventions on interannual trends of malaria incidence was analyzed. High malaria incidence occurred under one of the two meteorological conditions: 1) high minimum temperature combined with high minimum relative humidity or both precipitation and minimum relative humidity above middle level; 2) middle minimum temperature combined with both precipitation and minimum relative humidity below middle levels. Moreover, the steep interannual decline of malaria incidence in Tengchong was determined by slight climate variance and persistent anti-malaria intervention measures during malaria epidemics, predominantly by the latter. These findings will provide evidence data for developing malaria surveillance strategies in China.

State of inequality in malaria intervention coverage in sub-Saharan African countries.

BACKGROUND: Scale-up of malaria interventions over the last decade have yielded a significant reduction in malaria transmission and disease burden in sub-Saharan Africa. We estimated economic gradients in the distribution of these efforts and of their impacts within and across endemic countries. METHODS: Using Demographic and Health Surveys we computed equity metrics to characterize the distribution of malaria interventions in 30 endemic countries proxying economic position with an asset-wealth index. Gradients were summarized in a concentration index, tabulated against level of coverage, and compared among interventions, across countries, and against respective trends over the period 2005-2015. RESULTS: There remain broad differences in coverage of malaria interventions and their distribution by wealth within and across countries. In most, economic gradients are lacking or favor the poorest for vector control; malaria services delivered through the formal healthcare sector are much less equitable. Scale-up of interventions in many countries improved access across the wealth continuum; in some, these efforts consistently prioritized the poorest. Expansions in control programs generally narrowed coverage gaps between economic strata; gradients persist in countries where growth was slower in the poorest quintile or where baseline inequality was large. Despite progress, malaria is consistently concentrated in the poorest, with the degree of inequality in burden far surpassing that expected given gradients in the distribution of interventions. CONCLUSIONS: Economic gradients in the distribution of interventions persist over time, limiting progress toward equity in malaria control. We found that, in countries with large baseline inequality in the distribution of interventions, even a small bias in expansion favoring the least poor yielded large gradients in intervention coverage while pro-poor growth failed to close the gap between the poorest and least poor. We demonstrated that dimensions of disadvantage compound for the poor; a lack of economic gradients in the distribution of malaria services does not translate to equity in coverage nor can it be interpreted to imply equity in distribution of risk or disease burden. Our analysis testifies to the progress made by countries in narrowing economic gradients in malaria interventions and highlights the scope for continued monitoring of programs with respect to equity.

Why some sites are responding better to anti-malarial interventions? A case study from western Kenya.

BACKGROUND: In sub-Saharan Africa, malaria interventions over the last decades have been successful in reducing both mortality and morbidity. In western Kenya however some areas experience contrasting outcomes of the ongoing interventions while the causes for this observation remains not yet clearly known. METHODS: The WHO insecticide (deltamethrin) susceptibility test of the common malaria vectors was studied. Multiple surveys on household use and hospital prescriptions of antimalarial drugs from 2003 to 2015 were done. Along with this, cross sectional surveys on their availability in the local drug dispensing outlets were also done in 2015. Monthly precipitations and air temperature data was collected along with systematic review on abundance and composition of common malaria vectors in the study area before and during interventions. The above factors were used to explain the possible causes of contrasting outcome of malaria interventions between the three study sites. RESULTS: Areas with malaria resurgence or sustained high transmission (Kombewa and Marani) showed higher composition of Anopheles funestus sensu lato (s.l.) than the previously abundant Anopheles gambiae sensu stricto (s.s.) and the later had higher composition to an area with a sustained infection decline (Iguhu). Anopheles gambiae s.l. from Kombewa showed highest resistance (50% mortality) upon exposure to WHO deltamethrin discriminating dosage of 0.75% while those from Marani and Iguhu had reduced resistance status (both had a mean mortality of 91%). Sampled An. funestus s.l. from Marani were also highly resistant to deltamethrin as 57% of the exposed vectors survived. An increasing of mean air temperature by 2 °C was noted for Marani and Iguhu from 2013 to 2015 and was accompanied by an increased rainfall at Marani. Community drug use and availability in selling outlets along with prescription in hospitals were not linked to the struggling control of the disease. CONCLUSIONS: The malaria vector species composition shift, insecticide resistance and climatic warming were the likely cause of the contrasting outcome of malaria intervention in western Kenya. Surveillance of malaria parasite and vector dynamics along with insecticide resistance and vector biting behaviour monitoring are highly recommended in these areas.

Assessing the effects of malaria interventions on the geographical distribution of parasitaemia risk in Burkina Faso.

BACKGROUND: Burkina Faso conducted its first nationally representative household malaria survey in 2010/2011. The survey collected among others, information on malaria interventions, treatment choices and malaria parasite prevalence in children aged 6-59 months. METHODS: In this study, Bayesian geostatistical models were employed to assess the effects of health interventions related to insecticide-treated bed nets (ITN), indoor residual spray (IRS), artemisinin-based combination therapy (ACT) coverage associated with childhood malaria parasite risk at national and sub-national level, after taking into account geographical disparities of climatic/environmental and socio-economic factors. Several ITN coverage measures were calculated and Bayesian variable selection was used to identify the most important ones. Parasitaemia risk depicting spatial patterns of infections were estimated. RESULTS: The results show that the predicted population-adjusted parasitaemia risk ranges from 4.04 % in Kadiogo province to 82 % in Kompienga province. The effect of ITN coverage was not important at national level; however ITNs have an important protective effect in Ouagadougou as well as in three districts in the western part of the country with high parasitaemia prevalence and low to moderate coverage. There is a large variation in ACT coverage between the districts. Although at national level the ACT effects on parasitaemia risk was not important, at sub-national level 18 districts around Ouagadougou deliver effective treatment. CONCLUSION: The produced maps show great variations in parasitaemia risk across the country and identify the districts where interventions are being effective. These outputs are valuable tools that can help improve malaria control in Burkina Faso.

Socio-economic predictors of uptake of malaria interventions among pregnant women and mothers of under 5 children in Oyo State, Nigeria: a cross-sectional study.

Introduction: socio-economic status (SES), especially for women, influence access to care. This study aimed to determine the relationship between SES and uptake of malaria intervention by pregnant women and non-pregnant mothers of children under 5 years old in Ibadan, Oyo state, Nigeria. Methods: this cross-sectional study was conducted at Adeoyo teaching hospital located in Ibadan, Nigeria. The hospital-based study population included consenting mothers. Data were collected using an interviewer-administered modified validated demographic health survey questionnaire. The statistical analysis involved both descriptive (mean, count, frequency) and inferential statistics (Chi-square, logistic regression). Level of statistical significance was set at 0.05. Results: mean age of the study´s total of 1373 respondents was 29 years (SD: 5.2). Of these, 60% (818) were pregnant. The non-pregnant mothers of children under five years old showed a significantly increased odds (OR: 7.55, 95% CI: 3.81, 14.93) for the uptake of malaria intervention. Within the low SES category, women aged 35 years and above were significantly less likely to utilize malaria intervention (OR=0.08; 95% CI: 0.01-0.46; p=0.005) compared to those younger. In the middle SES, women who have one or two children were 3.51 times more likely than women with three or more children to utilize malaria intervention (OR=3.51; 95% CI: 1.67-7.37; p=0.001). Conclusion: the findings provide evidence that age, maternal grouping, and parity within the SES category can significantly impact on uptake of malaria interventions. There is a need for strategies to boost the SES of women because they play significant roles in the wellbeing of members of the home.