Health systems readiness and management of febrile outpatients under low malaria transmission in Vanuatu.

BACKGROUND: Vanuatu, an archipelago country in Western Pacific harbouring low Plasmodium falciparum and Plasmodium vivax malaria transmission, has been implementing a malaria case management policy, recommending parasitological testing of patients with fever and anti-malarial treatment for test-positive only patients. A health facility survey to evaluate the health systems readiness to implement the policy and the quality of outpatient management for patients with fever was undertaken. METHODS: A cross-sectional, cluster sample survey, using a range of quality-of-care methods, included all health centres and hospitals in Vanuatu. The main outcome measures were coverage of health facilities and health workers with commodities and support interventions, adherence to test and treatment recommendations, and factors influencing malaria testing. RESULTS: The survey was undertaken in 2014 during the low malaria season and included 41 health facilities, 67 health workers and 226 outpatient consultations for patients with fever. All facilities had capacity for parasitological diagnosis, 95.1 % stocked artemether-lumefantrine and 63.6 % primaquine. The coverage of health workers with support interventions ranged from 50 to 70 %. Health workers' knowledge was high only regarding treatment policy for uncomplicated P. falciparum malaria (83.4 %). History taking and clinical examination practices were sub-optimal. Some 35.0 % (95 % CI 23.4-48.6) of patients with fever were tested for malaria, of which all results were negative and only one patient received anti-malarial treatment. Testing was significantly higher for patients age 5 years and older (OR = 2.33; 95 % CI 1.48-5.02), seen by less qualified health workers (OR = 2.73; 95 % CI 1.48-5.02), health workers who received malaria case management training (OR = 2.39; 95 % CI 1.28-4.47) and patients with increased temperature (OR = 2.56; 95 % CI 1.17-5.57), main complaint of fever (OR = 5.82; 95 % CI 1.26-26.87) and without runny nose (OR = 3.75; 95 % CI 1.36-10.34). Antibiotic use was very high (77.4 %) with sub-optimal dispensing and counselling practices. CONCLUSIONS: Health facility and health worker readiness to implement policy is higher for falciparum than vivax malaria. Clinical and malaria testing practices are sub-optimal, however adherence to test negative results is nearly universal. Use of antibiotics is irrational. Quantitative and qualitative improvements of ongoing interventions are needed to re-inforce clinical practices in this area characterized by difficult access, human resource shortages but aspiring towards malaria elimination.

Successful introgression of wMel Wolbachia into Aedes aegypti populations in Fiji, Vanuatu and Kiribati.

Pacific Island countries have experienced periodic dengue, chikungunya and Zika outbreaks for decades. The prevention and control of these mosquito-borne diseases rely heavily on control of Aedes aegypti mosquitoes, which in most settings are the primary vector. Introgression of the intracellular bacterium Wolbachia pipientis (wMel strain) into Ae. aegypti populations reduces their vector competence and consequently lowers dengue incidence in the human population. Here we describe successful area-wide deployments of wMel-infected Ae. aegypti in Suva, Lautoka, Nadi (Fiji), Port Vila (Vanuatu) and South Tarawa (Kiribati). With community support, weekly releases of wMel-infected Ae. aegypti mosquitoes for between 2 to 5 months resulted in wMel introgression in nearly all locations. Long term monitoring confirmed a high, self-sustaining prevalence of wMel infecting mosquitoes in almost all deployment areas. Measurement of public health outcomes were disrupted by the Covid19 pandemic but are expected to emerge in the coming years.

A high-resolution geospatial surveillance-response system for malaria elimination in Solomon Islands and Vanuatu.

BACKGROUND: A high-resolution surveillance-response system has been developed within a geographic information system (GIS) to support malaria elimination in the Pacific. This paper examines the application of a GIS-based spatial decision support system (SDSS) to automatically locate and map the distribution of confirmed malaria cases, rapidly classify active transmission foci, and guide targeted responses in elimination zones. METHODS: Customized SDSS-based surveillance-response systems were developed in the three elimination provinces of Isabel and Temotu, Solomon Islands and Tafea, Vanuatu. Confirmed malaria cases were reported to provincial malaria offices upon diagnosis and updated into the respective SDSS as part of routine operations throughout 2011. Cases were automatically mapped by household within the SDSS using existing geographical reconnaissance (GR) data. GIS queries were integrated into the SDSS-framework to automatically classify and map transmission foci based on the spatiotemporal distribution of cases, highlight current areas of interest (AOI) regions to conduct foci-specific targeted response, and extract supporting household and population data. GIS simulations were run to detect AOIs triggered throughout 2011 in each elimination province and conduct a sensitivity analysis to calculate the proportion of positive cases, households and population highlighted in AOI regions of a varying geographic radius. RESULTS: A total of 183 confirmed cases were reported and mapped using the SDSS throughout 2011 and used to describe transmission within a target population of 90,354. Automatic AOI regions were also generated within each provincial SDSS identifying geographic areas to conduct response. 82.5% of confirmed cases were automatically geo-referenced and mapped at the household level, with 100% of remaining cases geo-referenced at a village level. Data from the AOI analysis indicated different stages of progress in each province, highlighting operational implications with regards to strategies for implementing surveillance-response in consideration of the spatiotemporal nature of cases as well as logistical and financial constraints of the respective programmes. CONCLUSIONS: Geospatial systems developed to guide Pacific Island malaria elimination demonstrate the application of a high resolution SDSS-based approach to support key elements of surveillance-response including understanding epidemiological variation within target areas, implementing appropriate foci-specific targeted response, and consideration of logistical constraints and costs.

Modern geographical reconnaissance of target populations in malaria elimination zones.

BACKGROUND: Geographical Reconnaissance (GR) operations using Personal Digital Assistants (PDAs) and Global Positioning Systems (GPS) have been conducted in the elimination provinces of Temotu, Solomon Islands and Tafea, Republic of Vanuatu. These operations aimed to examine modern approaches to GR to define the spatial distribution of target populations to support contemporary malaria elimination interventions. METHODS: Three GR surveys were carried out covering the outer islands of Temotu Province (October - November, 2008); Santa Cruz Island, Temotu Province (February 2009) and Tanna Island, Tafea Province (July - September 2009). Integrated PDA/GPS handheld units were used in the field to rapidly map and enumerate households, and collect associated population and household structure data to support priority elimination interventions, including bed net distribution, indoor residual spraying (IRS) and malaria case surveillance. Data were uploaded and analysed in customized Geographic Information System (GIS) databases to produce household distribution maps and generate relevant summary information pertaining to the GR operations. Following completion of field operations, group discussions were also conducted to review GR approaches and technology implemented. RESULTS: 10,459 households were geo-referenced and mapped. A population of 43,497 and 30,663 household structures were recorded during the three GR surveys. The spatial distribution of the population was concentrated in coastal village clusters. Survey operations were completed over a combined total of 77 field days covering a total land mass area of approximately 1103.2 km2. An average of 45 households, 118 structures and a population of 184 people were recorded per handheld device per day. Geo-spatial household distribution maps were also produced immediately following the completion of GR fieldwork. An overall high acceptability of modern GR techniques and technology was observed by both field operations staff and communities. CONCLUSION: GR implemented using modern techniques has provided an effective and efficient operational tool for rapidly defining the spatial distribution of target populations in designated malaria elimination zones in Solomon Islands and Vanuatu. The data generated are being used for the strategic implementation and scaling-up of priority interventions, and will be essential for establishing future surveillance using spatial decision support systems.

Recent Advances in Computed Tomography and MR Imaging.

Numerous advanced MR imaging and computed tomographic techniques have been developed and implemented in clinical practice over the past several years resulting in increased diagnostic accuracy and improved patient care. In this article, the authors highlight recent and emerging imaging techniques in functional and structural MR imaging, perfusion and vascular imaging, standardization of imaging practices, and selected applications of artificial intelligence in clinical practice.

The Utility of Malaria Rapid Diagnostic Tests as a Tool in Enhanced Surveillance for Malaria Elimination in Vanuatu.

BACKGROUND: As part of efforts to eliminate malaria, Vanuatu has piloted the implementation of enhanced malaria surveillance and response strategies since 2011. This involves passive case detection (PCD) in health facilities, proactive case detection (Pro-ACD) and reactive case detection (Re-ACD) in communities using malaria rapid diagnostic tests (RDTs). While RDTs improve case management, their utility for detection of malaria infections in ACDs in this setting is unclear. METHODS: The utility of malaria RDTs as diagnostic tools was evaluated in PCD, in five rounds of Pro-ACDs and five rounds of Re-ACDs conducted in Tafea and Torba Provinces between 2011 and 2014. The number of malaria infections detected by RDTs was compared to that detected by PCR from collected used-RDTs. RESULTS: PCD in Tafea Province (2013) showed a RDT-positive rate of 0.21% (2/939) and a PCR-positive rate of 0.44% (2/453), indicating less than 1% of suspected malaria cases in Tafea Province were due to malaria. In Pro-ACDs conducted in Tafea and Torba Provinces, RDT-positive rates in 2013 and 2014 were 0.14% (3/2145) and 0% (0/2823), respectively, while the corresponding PCR-positive rates were 0.72% (9/1242) and 0.79% (9/1141). PCR identified villages in both provinces appearing to be transmission foci with a small number of low-density infections, mainly P. falciparum infections. In five rounds of Re-ACD, RDTs did not identify any additional infections while PCR detected only one among 173 subjects screened. CONCLUSIONS: PCD and Pro-ACDs demonstrate that both Tafea and Torba Provinces in Vanuatu has achieved very low malaria prevalence. In these low-transmission areas, conducting Pro-ACD and Re-ACDs using RDTs appears not cost-effective and may have limited impact on interrupting malaria transmission due to the small number of infections identified by RDTs and considerable operational resources invested. More sensitive, field deployable and affordable diagnostic tools will improve malaria surveillance in malaria elimination settings.

Oral ingestion of transgenic RIDL Ae. aegypti larvae has no negative effect on two predator Toxorhynchites species.

Dengue is the most important mosquito-borne viral disease. No specific treatment or vaccine is currently available; traditional vector control methods can rarely achieve adequate control. Recently, the RIDL (Release of Insect carrying Dominant Lethality) approach has been developed, based on the sterile insect technique, in which genetically engineered 'sterile' homozygous RIDL male insects are released to mate wild females; the offspring inherit a copy of the RIDL construct and die. A RIDL strain of the dengue mosquito, Aedes aegypti, OX513A, expresses a fluorescent marker gene for identification (DsRed2) and a protein (tTAV) that causes the offspring to die. We examined whether these proteins could adversely affect predators that may feed on the insect. Aedes aegypti is a peri-domestic mosquito that typically breeds in small, rain-water-filled containers and has no specific predators. Toxorhynchites larvae feed on small aquatic organisms and are easily reared in the laboratory where they can be fed exclusively on mosquito larvae. To evaluate the effect of a predator feeding on a diet of RIDL insects, OX513A Ae. aegypti larvae were fed to two different species of Toxorhynchites (Tx. splendens and Tx. amboinensis) and effects on life table parameters of all life stages were compared to being fed on wild type larvae. No significant negative effect was observed on any life table parameter studied; this outcome and the benign nature of the expressed proteins (tTAV and DsRed2) indicate that Ae. aegypti OX513A RIDL strain is unlikely to have any adverse effects on predators in the environment.

A spatial decision support system for guiding focal indoor residual interventions in a malaria elimination zone.

A customized geographical information system (GIS) has been developed to support focal indoor residual spraying (IRS) operations as part of a scaled-up campaign to progressively eliminate malaria in Vanuatu. The aims of the GISbased spatial decision support system (SDSS) were to guide the planning, implementation and assessment of IRS at the household level. Additional aims of this study were to evaluate the user acceptability of a SDSS guiding IRS interventions. IRS was conducted on Tanna Island, Republic of Vanuatu between 26 October and 5 December 2009. Geo-referenced household information provided a baseline within the SDSS. An interactive mapping interface was used to delineate operation areas, extract relevant data to support IRS field teams. In addition, it was used as a monitoring tool to assess overall intervention coverage. Surveys and group discussions were conducted during the operations to ascertain user acceptability. Twenty-one operation areas, comprising a total of 187 settlements and 3,422 households were identified and mapped. A total of 3,230 households and 12,156 household structures were sprayed, covering a population of 13,512 individuals, achieving coverage of 94.4% of the households and 95.7% of the population. Village status maps were produced to visualize the distribution of IRS at the sub-village level. One hundred percent of survey respondents declared the SDSS a useful and effective tool to support IRS. The GIS-based SDSS adopted in Tanna empowered programme managers at the provincial level to implement and asses the IRS intervention with the degree of detail required for malaria elimination. Since completion, SDSS applications have expanded to additional provinces in Vanuatu and the neighbouring Solomon Islands supporting not only specific malaria elimination and control interventions, but also the broader public health sector in general.