The performance of health laboratories and the quality of malaria diagnosis in six districts of Tanzania.

Early laboratory diagnosis is critical for the optimal management of human malaria, particularly following the introduction of relatively expensive, artemisinin-combination therapies (ACT). The performance of the laboratories and the quality of malaria diagnosis have recently been assessed in 36 healthcare facilities in six districts of Tanzania. Questionnaires, checklists and observations were used to collect information on the availability and functional status of equipment as well as on laboratory personnel and their performance in malaria diagnosis. Together, the surveyed facilities had 112 laboratory staff [almost half (41.1%) of whom were laboratory assistants] and 57 microscopes. Twenty-seven (75.0%) of the healthcare facilities included in the survey had only one functional microscope each. Only seven (12.3%) of the assessed microscopes had been serviced in the previous 2 years. Of the 38 microscopists who were assessed, 24 (63.2%) were re-using microscope slides, 29 (73.5%) were producing bloodsmears of low quality, and 30 (79.0%) were using Field's stain. Although the facility microscopists gave similar results to experienced research microscopists when reading bloodsmears prepared by the survey team, using high-quality reagents (kappa=0.769), they appeared far less competent when reading smears stained using the reagents from the study laboratories (kappa=0.265-0.489). The quality of malaria diagnosis at healthcare facilities in Tanzania, which is generally poor (largely because of inadequate supplies of consumables and the limited skills of laboratory staff in the preparation of bloodsmears), urgently needs to be improved if the utilization of ACT is to be sustainable.

Novel use of stir bar sorptive extraction (SBSE) as a tool for isolation of oviposition site attractants for gravid Culex quinquefasciatus.

Mosquitoes such as Culex quinquefasciatus Say (Diptera: Culicidae) are important vectors of organisms that cause disease in humans. Research into the development of effective standardized odour baits for blood-fed females (oviposition attractants), to enable entomological monitoring of vector populations, is hampered by complex protocols for extraction of physiologically active volatile chemicals from natural breeding site water samples, which have produced inconsistent results. Air entrainment and solvent extraction are technically demanding methods and are impractical for use in resource poor environments where mosquito-borne disease is most prevalent. This study reports the first use of a simple, robust extraction technique, stir bar sorptive extraction (SBSE), to extract behaviourally active small lipophilic molecules (SLMs) present in water samples collected from Cx. quinquefasciatus breeding sites in Tanzania. Extracts from a pit latrine and from a cess pool breeding site attracted more gravid Cx. quinquefasciatus in pair choice bioassays than control extracts, and coupled gas chromatography-electroantennography (GC-EAG) allowed tentative identification of 15 electrophysiologically active chemicals, including the known oviposition attractant, skatole (3-methylindole). Here, we have demonstrated, using simple pair choice bioassays in controlled laboratory conditions, that SBSE is effective for the extraction of behaviourally and electrophysiologically active semiochemicals from mosquito breeding site waters. Further research is required to confirm that SBSE is an appropriate technique for use in field surveys in the search for oviposition cues for Cx. quinquefasciatus.

Health laboratories in the Tanga region of Tanzania: the quality of diagnostic services for malaria and other communicable diseases.

Although critical for good case management and the monitoring of health interventions, the health-laboratory services in sub-Saharan Africa are grossly compromised by poor infrastructures and a lack of trained personnel, essential reagents and other supplies. The availability and quality of diagnostic services in 37 health laboratories in three districts of the Tanga region of Tanzania have recently been assessed. The results of the survey, which involved interviews with health workers, observations and a documentary review, revealed that malaria accounted for >50% of admissions and out-patient visits. Most (92%) of the laboratories were carrying out malaria diagnosis and 89% were measuring haemoglobin concentrations but only one (3%) was conducting culture and sensitivity tests, and those only on urine and pus samples. Only 14 (17%) of the 84 people found working in the visited laboratories were laboratory technologists with a diploma certificate or higher qualification. Sixteen (43%) of the study laboratories each had five or fewer types of equipment and only seven (19%) had more than 11 types each. Although 11 (30%) of the laboratories reported that they conducted internal quality control, none had standard operating procedures (SOP) on display or evidence of such quality assurance. Although malaria was the main health problem, diagnostic services for malaria and other diseases were inadequate and of poor quality because of the limited human resources, poor equipment and shortage of supplies. If the health services in Tanga are not to be overwhelmed by the progressively increasing burden of HIV/AIDS, malaria, tuberculosis and other emerging and re-emerging diseases, more funding and appropriate policies to improve the availability and quality of the area's diagnostic services will clearly be required.

Bancroftian filariasis: house-to-house variation in the vectors and transmission -- and the relationship to human infection -- in an endemic community of coastal Tanzania.

The house-to-house variation in Wuchereria bancrofti vector abundance and transmission intensity, and the relationship of these parameters to human infection, were investigated in an endemic community in coastal Tanzania. Vector mosquitoes were collected in light traps set up in 50 randomly selected households once weekly for 1 year. They were identified, dissected and checked for filarial larvae. Vector densities and transmission potentials varied markedly between households, both for all vectors combined and for the individual vector species (Anopheles gambiae s.1., An. funestus and Culex quinquefasciatus), even between households located close to each other. The variation in vector abundance was probably mainly attributable to differences in the distance to breeding sites, to specific household features likely to ease mosquito entry and hiding, and to the number of household inhabitants. Household annual biting rates (ABR) correlated positively with household annual transmission potentials (ATP), indicating that intense vector biting led to a high transmission intensity. Intriguingly, however, the human filarial-infection status (as indicated by microfilaraemia or circulating filarial antigenemia) did not differ significantly between households with relatively high and lower ABR or ATP. Possible reasons for this result include the long time required for W. bancrofti infection to establish in humans, human behaviour affecting exposure, the sharing of mosquito populations between households, and differential susceptibility of humans to infection. The marked heterogeneity in exposure between households, and the lack of immediate relationship between transmission and detectable human infection at household level, should be taken into account when considering the transmission pattern of lymphatic filariasis.

Insecticide-treated bed-nets for malaria mosquito control.

Pyrethroid-treated bed-nets act against late-night biting mosquitoes, like traps baited by the body odor of the occupant. The personal protective effect of treated nets is considerable, even if they are torn. However, some biting of the occupants does occur, as shown by matching microsatellite alleles in mosquito blood meals to those of net occupants. When whole communities were provided with treated nets, ovarian age grading showed that mosquito survival was reduced, and so was the number of sporozoite-positive mosquitoes in malarious communities. Thus, a high percentage of coverage of all members of malaria-endemic communities is considered to be the most effective way of providing protection for highly malaria-vulnerable children and pregnant women. Teams distributing nets or retreating them free of charge show high productivity, and we consider this the most cost-effective way to proceed. There is evidence for reduced anti-malaria antibody levels in children in communities where treated nets have long been used. However, overall benefits in reduced anemia and mortality are sustained. A high frequency of the kdr resistance gene has not prevented pyrethroid-treated nets from functioning, but it is important to develop alternative fabric treatments in case stronger forms of resistance emerge.

Comparison of coverage with insecticide-treated nets in a Tanzanian town and villages where nets and insecticide are either marketed or provided free of charge.

BACKGROUND: There is much emphasis on social marketing as a means of scaling up coverage with insecticide-treated nets and the question has arisen whether nets provided free-of-charge will be looked after by householders. METHODS: Over several years questionnaires and surveys of usage and condition of nets were carried out throughout a town and 15 villages in north-east Tanzania, where nets and insecticide have to be purchased and in 24 other villages where over 15000 nets had been donated and annual re-treatment is provided free-of-charge. RESULTS: There was very high population coverage in the town but, in the villages where nets have to be purchased, only 9.3% of people used nets which were intact and/or had been insecticide-treated and could, therefore, provide protection. However, where nets had been provided free, over 90% of the nets were still present and were brought for re-treatment several years later. CONCLUSION: In this part of Tanzania, social marketing has performed well in a town but very poorly in villages. However, the study showed that people look after and bring for re-treatment nets which had been provided free-of-charge.

Tests of Olyset nets by bioassay and in experimental huts.

BACKGROUND: Olyset nets are a type of long-lasting insecticidal net made of polyethylene fibre with permethrin incorporated into it and with a 4 mm mesh size. BIOASSAYS: Olyset netting was wrapped around a wire frame and the mosquitoes were released inside for bioassays. There was significantly faster knockdown and higher percent mortality than bioassays with the netting attached to a WHO cone with a piece of cardboard on the other side of the net to prevent escapes through the large mesh. It is suggested that with the latter method some mosquitoes place their tarsae through the mesh on to the cardboard, thus avoiding insecticide contact. TRIALS IN EXPERIMENTAL HUTS: Four mm mesh nets were compared with conventional 1.5 mm mesh nets treated with permethrin. In further trials in huts Olyset nets which were either unwashed or five times washed, with or without subsequent heating, and a Olyset net which had been in domestic use for four years or a new Olyset net were compared with a net treated with bifenthrin. RESULTS & CONCLUSION: In all cases Anopheles biting on sleepers under the nets was reduced and Anopheles mortality was increased by the use of the insecticidal nets. No significant impact of washing or heating was detected and an Olyset net was as good as new after four years use, but did not cause as much mosquito mortality as bifenthrin treated nets.

Bancroftian filariasis: patterns of vector abundance and transmission in two East African communities with different levels of endemicity.

Intensive monitoring of Wuchereria bancrofti vector abundance and transmission intensity was carried out in two communities, one with high-level endemicity for bancroftian filariasis (Masaika, Tanzania) and the other with low-level (Kingwede, Kenya), on the East African coast. Mosquitoes were collected in light traps, from 50 randomly selected households in each community, once weekly for 1 year. They were identified, dissected and checked for parity and filarial larvae. Anopheles gambiae s. l., An. funestus and Culex quinquefasciatus transmitted W. bancrofti in the two communities but the importance of each of these taxa differed between the communities and by season. The overall vector densities and transmission intensities were significantly higher in Masaika than in Kingwede (the annual biting rate by 3.7 times and the annual transmission potential by 14.6 times), primarily because of differences in the available breeding sites for the vectors and in the vectorial capacity of the predominant vector species. A marked seasonal variation in vector abundance and transmission potential contributed to the complex transmission pattern in the communities. Generally, these indices were higher during and shortly after the rainy seasons than at other times of the year. Considerable differences in W. bancrofti transmission were thus observed between communities within a relatively small geographical area (mainly because of environmentally-determined differences in vector habitats), and these were reflected in the marked differences in infection level in the human populations. The variation in vector abundance, vector composition and transmission intensity in the two communities is discussed in respect to its cause, its effects, and its significance to those attempting to control bancroftian filariasis.

Transmission intensity and the immunoepidemiology of bancroftian filariasis in East Africa.

Previous attempts to determine the interactions between filariasis transmission intensity, infection and chronic disease have been limited by a lack of a theoretical framework that allows the explicit examination of mechanisms that may link these variables at the community level. Here, we show how deterministic mathematical models, in conjunction with analyses of standardized field data from communities with varying parasite transmission intensities, can provide a particularly powerful framework for investigating this topic. These models were based on adult worm population dynamics, worm initiated chronic disease and two major forms of acquired immunity (larval- versus adult-worm generated) explicitly linked to community transmission intensity as measured by the Annual Transmission Potential (ATP). They were then fitted to data from low, moderate and moderately high transmission communities from East Africa to determine the mechanistic relationships between transmission, infection and observed filarial morbidity. The results indicate a profound effect of transmission intensity on patent infection and chronic disease, and on the generation and impact of immunity on these variables. For infection, the analysis indicates that in areas of higher parasite transmission, community-specific microfilarial rates may increase proportionately with transmission intensity until moderated by the generation of herd immunity. This supports recent suggestions that acquired immunity in filariasis is transmission driven and may be significant only in areas of high transmission. In East Africa, this transmission threshold is likely to be higher than an ATP of at least 100. A new finding from the analysis of the disease data is that per capita worm pathogenicity could increase with transmission intensity such that the prevalences of both hydrocele and lymphoedema, even without immunopathological involvement, may increase disproportionately with transmission intensity. For lymphoedema, this rise may be further accelerated with the onset of immunopathology. An intriguing finding is that there may be at least two types of immunity operating in filariasis: one implicated in anti-infection immunity and generated by past experience of adult worms, the other involved in immune-mediated pathology and based on cumulative experience of infective larvae. If confirmed, these findings have important implications for the new global initiative to achieve control of this disease.

Wuchereria bancrofti in a community with seasonal transmission: stability of microfilaraemia, antigenaemia and filarial-specific antibody concentrations.

The effect of seasonal transmission on microfilaraemia, antigenaemia and filarial-specific antibody levels in individuals infected with Wuchereria bancrofti was investigated in a follow-up study in an endemic community in north-eastern Tanzania. The subjects were 37 adult male residents who were found to be positive for circulating filarial antigen (CFA) at the beginning of the study (26 of whom were also found microfilaraemic with W. bancrofti at this time). Blood samples were collected from each subject in July 1998, January 1999 and July 1999, during the seasons when transmission intensity was high, low and high, respectively. The mean intensities of microfilaraemia and the mean concentrations of CFA were each slightly higher during the low-transmission season than during the two high-transmission seasons but the differences were not statistically significant (P > 0.05). Similarly, the mean levels of filarial-specific IgG1, IgG2, IgG3, IgG4 or IgE did not differ to a statistically significant degree between the three examination times. Microfilaraemias and the levels of CFA and filarial-specific antibodies all therefore appeared to be remarkably stable and largely unaffected by the seasonal variation in transmission. That no variation in the mean IgG4/IgE ratio was observed over the study period may indicate that the level of resistance to W. bancrofti infection in the study subjects was also unaffected by the transmission season.

Seasonal and spatial variation in natural densovirus infection in Anopheles minimus S.L. in Thailand.

We report the first detection of a mosquito densovirus in anophelines, An. minimus species A and species C, and describe temporal and spatial variation in natural densovirus infection. A total of 814 (136 species A; 678 species C) adult mosquitos, obtained over a one year period from human biting catches at three locations in a village in western Thailand, were PCR tested for densovirus infection. Overall infection prevalence did not differ between species (15.4% species A; 14.5% species C). Infection prevalence showed significant seasonal variation. Some spatial heterogeneity in infection was also noted, with timing of peak infection prevalence varying between sites. PCR-screening of An. minimus s.l. larvae found an overall infection prevalence of 18.8%. Larval infection showed a significant positive association with rainfall recorded two months previous to larval collection. Infection in adult mosquitos showed a moderate relationship to environmental variables, but a significant negative correlation with larval infection in the previous month.

Anopheles arabiensis and An. gambiae chromosomal inversion polymorphism, feeding and resting behaviour in relation to insecticide house-spraying in Tanzania.

Differential responses of the mosquitoes Anopheles arabiensis and An. gambiae sensu stricto to house-spraying with DDT or lambda-cyhalothrin were evaluated in relation to chromosomal inversion polymorphism, feeding and resting behaviour of these malaria vectors in Tanzania. Blood-fed mosquitoes from pit traps outdoors, exit traps on windows and indoor-resting catches were identified cytogenetically and the chromosomal inversion frequencies compared between samples and species. Their outdoor-resting behaviour was assessed by a mark-release-recapture experiment and by determining the proportion of freshly blood-fed individuals in exit traps. The source of bloodmeals was analysed by an ELISA method. Endophagic females of An. arabiensis were more likely than those of An.gambiae to exit from a house on the night of blood-feeding. Only in one out of three villages was there evidence that chromosomally distinct individuals within a species had different preferences for resting sites. There were indications, but not conclusive evidence, that mosquitoes caught indoors or outdoors had a tendency to return to the same type of resting site. In villages sprayed with either insecticide, the mean age of the vector populations was greatly reduced, compared with those in the unsprayed villages. An.arabiensis females exited from DDT sprayed houses after blood-feeding, whereas with lambda-cyhalothrin those exiting were mostly unfed and there was a decline in the human blood index. The excitorepellency of DDT was perceived as a disadvantage, whereas lambda-cyhalothrin apparently had more impact on malaria transmission by An.arabiensis.

The effects of house spraying with DDT or lambda-cyhalothrin against Anopheles arabiensis on measures of malarial morbidity in children in Tanzania.

The effects of house spraying of DDT and lambda-cyhalothrin against populations of Anopheles arabiensis were assessed in children aged between 1 and 10 years with regard to fever episodes and parasite prevalences. DDT and lambda-cyhalothrin treatment did not reduce the prevalence of malaria episodes as defined by fever (temperatures > or = 37.4 degrees C and/or fever reported) combined with high parasitaemia (> or = 100 parasites/200 leucocytes). However, the prevalence of malaria parasitaemia, of the episodes of fever with any level of malaria parasitaemia and of high parasitaemia alone were significantly reduced. Furthermore, the reduction in mean parasite densities was greater in children of the 1-2 years age group for both insecticides and also for children of 3-5 years age group with lambda-cyhalothrin. Measured and/or reported fever and high parasitaemia were correlated and the data indicated that most of the fevers in these children could be attributed to malaria. Using this criterion it is concluded that the population of An. arabiensis responded to both DDT and lambda-cyhalothrin house spraying which in turn also reduced malaria-related morbidity.

Trial of pyrethroid impregnated bednets in an area of Tanzania holoendemic for malaria. Part 3. Effects on the prevalence of malaria parasitaemia and fever.

Children aged 1-10 in five villages were contacted fortnightly. Their axillary temperatures, reports of fevers and blood slides were taken. Following the introduction of permethrin impregnated nets into two estate villages the slide positivity for falciparum malaria declined markedly. In traditional villages the introduction of impregnated nets had less convincing effects than in the estate villages and DDT spraying had no perceptible effect on malaria. Over all villages there was a clear relationship between axillary temperature greater than 37.4 degrees C, reports of fever and high parasitaemia. We defined malaria fever in this way, and found in some cases significant reductions in occurrence of such fever following some time after introduction of permethrin impregnated nets. No such effects were found with lambdacyhalothrin nets or with DDT spraying.