Introducing field digital data collection systems into seasonal malaria chemoprevention campaigns: opportunities for robust evidence development and national e-health strategies.

Seasonal malaria chemoprevention (SMC) is a World Health Organization-recommended intervention to protect children under the age of 5 in Africa's Sahel region. While SMC remains highly effective in decreasing malaria cases, implementing countries face several challenges regarding collecting quality data; monitoring coverage and compliance and overcoming delays in campaigns due to late payment to field distributors.To address these challenges, the National Malaria Control Programmes of Benin, The Gambia, Ghana and Nigeria introduced digital data collection (DDC) tools to support their SMC campaigns. To facilitate cross-country learning, this paper investigates the impact of using DDCs in SMC campaigns by comparing country responses.Country experience suggests that in comparison to paper-based data collection systems, using DDC tools help to overcome data quality and operational challenges; cloud-based features also made data more accessible. Thus, scaling up DDC tools and linking them with routine national health management systems could help generate robust evidence for malaria policy development and programming. Of note, evidence from Benin showed that using digital tools reduced the time to pay staff and volunteers by 5 weeks. In Benin's experience, DDC also offered cost benefits (1.5 times cheaper) versus the use of paper-based tools.The authors note that no application offers greater benefits than the other-countries will select a technology that best suits their needs. Several applications are currently being used and newer ones are also being developed. Another option is to develop in-house applications that can be adjusted to local health programmes.Cost-effectiveness studies to inform on whether DDCs offer cost advantages would be beneficial. More studies on DDC are needed from SMC-implementing countries to identify additional benefits and drawbacks of digital applications. These will similarly help national malaria policy and programming efforts.

The use of video job-aids to improve the quality of seasonal malaria chemoprevention delivery.

Mobile phones are increasingly used in community health programmes, but the use of video job-aids that can be displayed on smart phones has not been widely exploited. We investigated the use of video job-aids to support the delivery of seasonal malaria chemoprevention (SMC) in countries in West and Central Africa. The study was prompted by the need for training tools that could be used in a socially distanced manner during the COVID-19 pandemic. Animated videos were developed in English, French, Portuguese, Fula and Hausa, illustrating key steps for administering SMC safely, including wearing masks, washing hands, and social distancing. Through a consultative process with the national malaria programmes of countries using SMC, successive versions of the script and videos were reviewed to ensure accurate and relevant content. Online workshops were held with programme managers to plan how to use the videos in SMC staff training and supervision, and the use of the videos was evaluated in Guinea through focus groups and in-depth interviews with drug distributors and other staff involved in SMC delivery and through direct observations of SMC administration. Programme managers found the videos useful as they reinforce messages, can be viewed at any time and repeatedly, and when used during training sessions, provide a focus of discussion and support for trainers and help retain messages. Managers requested that local specificities of SMC delivery in their setting be included in tailored versions of the video for their country, and videos were required to be narrated in a variety of local languages. In Guinea, SMC drug distributors found the video covered the all the essential steps and found the video easy to understand. However, not all key messages were followed as some of the safety measures, social distancing and wearing masks, were perceived by some as creating mistrust amongst communities. Video job-aids can potentially provide an efficient means of reaching large numbers of drug distributors with guidance for safe and effective distribution of SMC. Not all distributors use android phones, but SMC programmes are increasingly providing drug distributors with android devices to track delivery, and personal ownership of smartphones in sub-Saharan Africa is growing. The use of video job-aids for community health workers to improve the quality delivery of SMC, or of other primary health care interventions, should be more widely evaluated.

Plasmodium falciparum K13 mutations in Africa and Asia impact artemisinin resistance and parasite fitness.

The emergence of mutant K13-mediated artemisinin (ART) resistance in Plasmodium falciparum malaria parasites has led to widespread treatment failures across Southeast Asia. In Africa, K13-propeller genotyping confirms the emergence of the R561H mutation in Rwanda and highlights the continuing dominance of wild-type K13 elsewhere. Using gene editing, we show that R561H, along with C580Y and M579I, confer elevated in vitro ART resistance in some African strains, contrasting with minimal changes in ART susceptibility in others. C580Y and M579I cause substantial fitness costs, which may slow their dissemination in high-transmission settings, in contrast with R561H that in African 3D7 parasites is fitness neutral. In Cambodia, K13 genotyping highlights the increasing spatio-temporal dominance of C580Y. Editing multiple K13 mutations into a panel of Southeast Asian strains reveals that only the R561H variant yields ART resistance comparable to C580Y. In Asian Dd2 parasites C580Y shows no fitness cost, in contrast with most other K13 mutations tested, including R561H. Editing of point mutations in ferredoxin or mdr2, earlier associated with resistance, has no impact on ART susceptibility or parasite fitness. These data underline the complex interplay between K13 mutations, parasite survival, growth and genetic background in contributing to the spread of ART resistance.