Pre-referral Rectal Artesunate Treatment by Community-Based Treatment Providers in Ghana, Guinea-Bissau, Tanzania, and Uganda (Study 18): A Cluster-Randomized Trial.

BACKGROUND: If malaria patients who cannot be treated orally are several hours from facilities for injections, rectal artesunate prior to hospital referral can prevent death and disability. The goal is to reduce death from malaria by having rectal artesunate treatment available and used. How best to do this remains unknown. METHODS: Villages remote from a health facility were randomized to different community-based treatment providers trained to provide rectal artesunate in Ghana, Guinea-Bissau, Tanzania, and Uganda. Prereferral rectal artesunate treatment was provided in 272 villages: 109 through community-based health workers (CHWs), 112 via trained mothers (MUMs), 25 via trained traditional healers (THs), and 26 through trained community-chosen personnel (COMs); episodes eligible for rectal artesunate were established through regular household surveys of febrile illnesses recording symptoms eligible for prereferral treatment. Differences in treatment coverage with rectal artesunate in children aged <5 years in MUM vs CHW (standard-of-care) villages were assessed using the odds ratio (OR); the predictive probability of treatment was derived from a logistic regression analysis, adjusting for heterogeneity between clusters (villages) using random effects. RESULTS: Over 19 months, 54 013 children had 102 504 febrile episodes, of which 32% (31 817 episodes) had symptoms eligible for prereferral therapy; 14% (4460) children received treatment. Episodes with altered consciousness, coma, or convulsions constituted 36.6% of all episodes in treated children. The overall OR of treatment between MUM vs CHW villages, adjusting for country, was 1.84 (95% confidence interval [CI], 1.20-2.83; P = .005). Adjusting for heterogeneity, this translated into a 1.67 higher average probability of a child being treated in MUM vs CHW villages. Referral compliance was 81% and significantly higher with CHWs vs MUMs: 87% vs 82% (risk ratio [RR], 1.1 [95% CI, 1.0-1.1]; P < .0001). There were more deaths in the TH cluster than elsewhere (RR, 2.7 [95% CI, 1.4-5.6]; P = .0040). CONCLUSIONS: Prereferral episodes were almost one-third of all febrile episodes. More than one-third of patients treated had convulsions, altered consciousness, or coma. Mothers were effective in treating patients, and achieved higher coverage than other providers. Treatment access was low. CLINICAL TRIALS REGISTRATION: ISRCTN58046240.

Malaria indicator survey 2009, South Sudan: baseline results at household level.

BACKGROUND: South Sudan has borne the brunt of years of chronic warfare and probably has the highest malaria burden in sub-Saharan Africa. Malaria is the leading cause of morbidity and mortality in the country. This nationally representative survey aimed to provide data on malaria indicators at household level across the country. METHODS: In 2009, data were collected using a two-stage random cluster sample of 2,797 households in 150 census enumeration areas during a Malaria Indicator Survey (MIS) in South Sudan. The survey determined parasite and anaemia prevalence in vulnerable population groups and evaluated coverage, use and access to malaria control services. Standardized Roll Back Malaria Monitoring and Evaluation Reference Group (RBM-MERG) MIS household and women's questionnaires were adapted to the local situation and used for collection of data that were analysed and summarized using descriptive statistics. RESULTS: The results of this survey showed that 59.3% (95% CI: 57.5-61.1) of households owned at least one mosquito net. The proportion of the population with access to an ITN in their household was 49.7% (95% CI: 48.2-51.2). The utilization of insecticide-treated nets was low; 25.3% (95% CI: 23.9-26.7) for children under five (U5) and 35.9% (95% CI: 31.9-40.2) of pregnant women (OR: 1.66 (1.36-2.01); P =0.175). Prevalence of infection was 24.5% (95% CI: 23.0-26.1) in children U5 and 9.9% (95% CI: 7.4-13.1) in pregnant women. About two thirds (64%) of children U5 and 46% of pregnant women were anaemic. Only 2% of households were covered by indoor residual spraying (IRS) the previous year. Data shows that 58% reported that malaria is transmitted by mosquitoes, 34% mentioned that the use of mosquito nets could prevent malaria, 41% knew the correct treatment for malaria, and 52% of the children received treatment at a health facility. CONCLUSION: The observed high malaria prevalence could be due to low levels of coverage and utilization of interventions coupled with low knowledge levels. Therefore, access and utilization of malaria control tools should be increased through scaling up coverage and improving behaviour change communication.

Addressing malaria vector control challenges in South Sudan: proposed recommendations.

Upon the signing of the Comprehensive Peace Agreement in 2005, the Republic of South Sudan (RSS) has faced a lot of challenges, such as a lack of infrastructure, human resources and an enormous burden of vector borne diseases including malaria. While a national malaria strategic plan 2006-2011 was developed, the vector control component has remained relatively weak. The strategy endorses the distribution of long-lasting insecticidal nets (LLINs) as the frontline intervention with other interventions recommended only when technical and institutional capacity is available. In 2006, a draft integrated vector management (IVM) strategic plan 2007-2012 was developed but never implemented, resulting in minimal coordination, implementation and coverage of malaria vector control tools including their inherent impact. To address this challenge, the vector control team of the National Malaria Control Programme (NMCP) is being strengthened. With the objective of building national capacity and technical collaboration for effective implementation of the IVM strategy, a national malaria vector control conference was held from 15-17th October 2012 in Juba. A range of NMCP partners, state ministries, acadaemia, private sector, national and international non-governmental organizations, including regional and global policymakers attended the meeting. The conference represented a major milestone and made recommendations revolving around the five key elements of the IVM approach. The meeting endorsed that vector control efforts in RSS be augmented with other interventions within the confines of the IVM strategy as a national approach, with strong adherence to its key elements.

Impact of malaria morbidity on gross domestic product in Uganda.

BACKGROUND: The burden of malaria is a key challenge to both human and economic development in malaria endemic countries. The impact of malaria can be categorized from three dimensions, namely: health, social and economic. The objective of this study was to estimate the impact of malaria morbidity on gross domestic product (GDP) of Uganda. METHODS: The impact of malaria morbidity on GDP of Uganda was estimated using double-log econometric model. The 1997-2003 time series macro-data used in the analysis were for 28 quarters, i.e. 7 years times 4 quarters per year. It was obtained from national and international secondary sources. RESULTS: The slope coefficient for Malaria Index (M) was -0.00767; which indicates that when malaria morbidity increases by one unit, while holding all other explanatory variables constant, per capita GDP decreases by US$0.00767 per year. In 2003 Uganda lost US$ 49,825,003 of GDP due to malaria morbidity. Dividing the total loss of US$49.8 million by a population of 25,827,000 yields a loss in GDP of US$1.93 per person in Uganda in 2003. CONCLUSION: Malaria morbidity results in a substantive loss in GDP of Uganda. The high burden of malaria leads to decreased long-term economic growth, and works against poverty eradication efforts and socioeconomic development of the country.