Expanding community case management of malaria to all ages can improve universal access to malaria diagnosis and treatment: results from a cluster randomized trial in Madagascar.

BACKGROUND: Global progress on malaria control has stalled recently, partly due to challenges in universal access to malaria diagnosis and treatment. Community health workers (CHWs) can play a key role in improving access to malaria care for children under 5 years (CU5), but national policies rarely permit them to treat older individuals. We conducted a two-arm cluster randomized trial in rural Madagascar to assess the impact of expanding malaria community case management (mCCM) to all ages on health care access and use. METHODS: Thirty health centers and their associated CHWs in Farafangana District were randomized 1:1 to mCCM for all ages (intervention) or mCCM for CU5 only (control). Both arms were supported with CHW trainings on malaria case management, community sensitization on free malaria care, monthly supervision of CHWs, and reinforcement of the malaria supply chain. Cross-sectional household surveys in approximately 1600 households were conducted at baseline (Nov-Dec 2019) and endline (Nov-Dec 2021). Monthly data were collected from health center and CHW registers for 36 months (2019-2021). Intervention impact was assessed via difference-in-differences analyses for survey data and interrupted time-series analyses for health system data. RESULTS: Rates of care-seeking for fever and malaria diagnosis nearly tripled in both arms (from less than 25% to over 60%), driven mostly by increases in CHW care. Age-expanded mCCM yielded additional improvements for individuals over 5 years in the intervention arm (rate ratio for RDTs done in 6-13-year-olds, RRRDT6-13 years = 1.65; 95% CIs 1.45-1.87), but increases were significant only in health system data analyses. Age-expanded mCCM was associated with larger increases for populations living further from health centers (RRRDT6-13 years = 1.21 per km; 95% CIs 1.19-1.23). CONCLUSIONS: Expanding mCCM to all ages can improve universal access to malaria diagnosis and treatment. In addition, strengthening supply chain systems can achieve significant improvements even in the absence of age-expanded mCCM. TRIAL REGISTRATION: The trial was registered at the Pan-African Clinical Trials Registry (#PACTR202001907367187).

Durable wall lining for malaria control in Liberia: results of a cluster randomized trial.

BACKGROUND: Malaria control in Liberia depends upon universal coverage with pyrethroid-impregnated long-lasting insecticidal nets (LLINs). Despite regular mass distribution, LLIN coverage and usage is patchy. Pyrethroid resistance in malaria vectors may further reduce LLIN efficacy. Durable Wall Lining (DWL), a novel material treated with two non-pyrethroid class insecticides, was designed to be installed onto the surface of inner walls, and cover openings and ceiling surfaces of rural houses. OBJECTIVES: AIM: To determine the malaria control efficacy of DWL. PRIMARY OBJECTIVE: To determine if DWL has an additional protective effect in an area of pyrethroid resistance. SECONDARY OBJECTIVES: To compare surface bio-availability of insecticides and entomological effectiveness over the study duration. DESIGN: A cluster randomized trial. PARTICIPANTS: Children aged 2-59 months. CONTROL ARM: 50 houses per 20 clusters, all of which received LLIN within the previous 12 months. ACTIVE ARM: 50 houses per 20 experimental clusters, all of which received LLINs with the previous 12 months, and had internal walls and ceilings lined with DWL. RANDOMISATION: Cluster villages were randomly allocated to control or active arms, and paired on 4 covariates. MAIN OUTCOME MEASURES: PRIMARY MEASURE: Prevalence of infection with P. falciparum in children aged 2 to 59 months. SECONDARY MEASURE: Surface bioavailability and entomological effectiveness of DWL active ingredients. RESULTS: Plasmodium falciparum prevalence in active clusters after 12 months was 34.6% compared to 40.1% in control clusters (p = 0.052). The effect varied with elevation and was significant (RR = 1.3, p = 0.022) in 14 pairs of upland villages. It was not significant (RR = 1.3, p = 0.344) in 6 pairs of coastal villages. Pooled risk ratio (RR) was calculated in SAS (Cary, NC, USA) using the Cochran-Mantel-Haenszel (CMH) test for upland and coastal cluster pairs. DWL efficacy was sustained at almost 100% for 12 months. CONCLUSIONS: Findings indicate that DWL is a scalable and effective malaria control intervention in stable transmission areas with pyrethroid-resistant vectors, where LLIN usage is difficult to achieve, and where local housing designs include large gable and eve openings. Trial registration ClinicalTrials.gov identifier: NCT02448745 (19 May 2015): https://clinicaltrials.gov/ct2/show/NCT02448745.

Introducing malaria rapid diagnostic tests in private medicine retail outlets: A systematic literature review.

BACKGROUND: Many patients with malaria-like symptoms seek treatment in private medicine retail outlets (PMR) that distribute malaria medicines but do not traditionally provide diagnostic services, potentially leading to overtreatment with antimalarial drugs. To achieve universal access to prompt parasite-based diagnosis, many malaria-endemic countries are considering scaling up malaria rapid diagnostic tests (RDTs) in these outlets, an intervention that may require legislative changes and major investments in supporting programs and infrastructures. This review identifies studies that introduced malaria RDTs in PMRs and examines study outcomes and success factors to inform scale up decisions. METHODS: Published and unpublished studies that introduced malaria RDTs in PMRs were systematically identified and reviewed. Literature published before November 2016 was searched in six electronic databases, and unpublished studies were identified through personal contacts and stakeholder meetings. Outcomes were extracted from publications or provided by principal investigators. RESULTS: Six published and six unpublished studies were found. Most studies took place in sub-Saharan Africa and were small-scale pilots of RDT introduction in drug shops or pharmacies. None of the studies assessed large-scale implementation in PMRs. RDT uptake varied widely from 8%-100%. Provision of artemisinin-based combination therapy (ACT) for patients testing positive ranged from 30%-99%, and was more than 85% in five studies. Of those testing negative, provision of antimalarials varied from 2%-83% and was less than 20% in eight studies. Longer provider training, lower RDT retail prices and frequent supervision appeared to have a positive effect on RDT uptake and provider adherence to test results. Performance of RDTs by PMR vendors was generally good, but disposal of medical waste and referral of patients to public facilities were common challenges. CONCLUSIONS: Expanding services of PMRs to include malaria diagnostic services may hold great promise to improve malaria case management and curb overtreatment with antimalarials. However, doing so will require careful planning, investment and additional research to develop and sustain effective training, supervision, waste-management, referral and surveillance programs beyond the public sector.

[Malaria in Gabon: results of a clinical and laboratory study at the Chinese-Gabonese Friendship Hospital of Franceville]. / Paludisme au gabon: résultats d'une étude bioclinique à l'hôpital de l'amitié sino-gabonaise de Franceville.

Despite progress in the control of malaria, it remains a serious public health problem. Substantial declines in malaria transmission, morbidity and mortality have nonetheless been reported in several countries where new malaria control strategies have been implemented. We conducted this molecular and epidemiological analysis of malaria in the pediatric department of the Chinese-Gabon Friendship Hospital (HCGC) in Franceville in 2010. Franceville is the third largest town in Gabon, and malaria transmission is high year-round. We included 945 children, 756 of them febrile. Malaria was diagnosed based on the detection of P. falciparum in thick blood films, with Lambarene's method. Malaria prevalence among the febrile children included in this study was 17.9% (n=135). The burden of malaria is thus lower than in the past; it is now the second leading cause of pediatric hospital visits, rather than the leading cause as it was in 2004. The children's mean age was 48.5 ± 3.9 months, older than in 2004 (p<0.05). We also analysed the molecular drug resistance marker, Pfmdr1. The prevalence of the wild-type genotype N86 of Pfmdr1 was 47.4% (n=64), higher than in 2004 (p<0.001). The increased prevalence of codon 1246 was not significant. Socio-economic factors and known malaria risk factors were analysed. We found that the use of Insecticide-treated mosquito nets and the provision of information (education or communication) to parents and guardians about malaria were protective factors against the disease. In conclusion, a larger study of the entire region over a longer period is necessary to characterise malaria in Franceville today. Transmission factors must also be studied.