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21. Acta Trop. 2012 Aug;123(2):117-22. doi: 10.1016/j.actatropica.2012.04.010. Epub 2012 Apr 28. ITN protection, MSP1 antibody levels and malaria episodes in young children of rural Burkina Faso. Kynast-Wolf G, Wakilzadeh W, Coulibaly B, Schnitzler P, Traoré C, Becher H, Müller O. Institute of Public Health, Ruprecht-Karls-University Heidelberg, Germany. [email protected] Malaria blood-stage vaccines are in an early phase of clinical development with MSP1 being a major antigen candidate. There are limited data on the protective efficacy of antibodies against subunits of MSP1 in the malaria endemic areas of sub-Saharan Africa. This prospective cohort study was nested into a large insecticide-treated mosquito net (ITN) trial during which neonates were individually randomised to ITN protection from birth vs. protection from month six onwards in rural Burkina Faso. A sub sample of 120 children from three villages was followed for 10 months with six measurements of MSP1(42) antibodies (ELISA based on recombinant 42kDa fragment) and daily assessment of malaria episodes. Time to the next malaria episode was determined in relation to MSP1(42) antibody titres. MSP1(42) antibody titres were dependent on age, season, ITN-group, number of previous malaria episodes and parasitaemia. There were no significant differences in time until the next malaria episode in children with low compared to children with high MSP1(42) antibody titres at any point in time (101 vs. 97 days in May, p=0.6; 58 vs. 84 days in September, p=0.3; 144 vs. 161 days in March, p=0.5). The findings of this study support the short-lived nature of the humoral immune response in infants of malaria endemic areas. The study

Transcript of Biblio - Pubmed

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21. Acta Trop. 2012 Aug;123(2):117-22. doi: 10.1016/j.actatropica.2012.04.010. Epub2012 Apr 28.

ITN protection, MSP1 antibody levels and malaria episodes in young children ofrural Burkina Faso.

Kynast-Wolf G, Wakilzadeh W, Coulibaly B, Schnitzler P, Traoré C, Becher H,Müller O.

Institute of Public Health, Ruprecht-Karls-University Heidelberg, [email protected]

Malaria blood-stage vaccines are in an early phase of clinical development withMSP1 being a major antigen candidate. There are limited data on the protectiveefficacy of antibodies against subunits of MSP1 in the malaria endemic areas ofsub-Saharan Africa. This prospective cohort study was nested into a largeinsecticide-treated mosquito net (ITN) trial during which neonates wereindividually randomised to ITN protection from birth vs. protection from monthsix onwards in rural Burkina Faso. A sub sample of 120 children from threevillages was followed for 10 months with six measurements of MSP1(42) antibodies (ELISA based on recombinant 42kDa fragment) and daily assessment of malariaepisodes. Time to the next malaria episode was determined in relation to MSP1(42)antibody titres. MSP1(42) antibody titres were dependent on age, season,ITN-group, number of previous malaria episodes and parasitaemia. There were nosignificant differences in time until the next malaria episode in children withlow compared to children with high MSP1(42) antibody titres at any point in time (101 vs. 97 days in May, p=0.6; 58 vs. 84 days in September, p=0.3; 144 vs. 161days in March, p=0.5). The findings of this study support the short-lived nature of the humoral immune response in infants of malaria endemic areas. The studyprovides no evidence for antibodies against a subunit of MSP1 being protectiveagainst new malaria episodes in infants.

Copyright © 2012 Elsevier B.V. All rights reserved.

PMID: 22569564 [PubMed - indexed for MEDLINE]

22. BMC Public Health. 2012 May 22;12:315. doi: 10.1186/1471-2458-12-315.

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Examining equity in access to long-lasting insecticide nets and artemisinin-basedcombination therapy in Anambra State, Nigeria.

Mbachu CO, Onwujekwe OE, Uzochukwu BS, Uchegbu E, Oranuba J, Ilika AL.

Health Policy Research Group, Department of Pharmacology and Therapeutics,College of Medicine, University of Nigeria, and Department of Community Medicine,University of Nigeria Teaching Hospital, Enugu, Enugu State, [email protected]

BACKGROUND: In order to achieve universal health coverage, the government ofAnambra State, southeast Nigeria has distributed free Long-lasting Insecticidetreated Nets (LLINs) to the general population and delivered freeArtemisinin-based Combination Therapy (ACT) to pregnant women and children lessthan 5 years. However, the levels of coverage with LLINS and ACTs is not clear,especially coverage of different socio-economic status (SES) population groups.This study was carried out to determine the level of coverage and access to LLINsand ACTs amongst different SES groups.METHODS: A questionnaire was used to collect data from randomly selectedhouseholds in 19 local government areas of the State. Selected households had apregnant woman and/or a child less than 5 years. The lot quality assurancesampling (LQAS) methodology was used in sampling. The questionnaire explored the availability and utilization of LLINs and ACTs from 2394 households. Anasset-based SES index was used to examine the level of access of LLINS and ACTsto different SES quintiles.RESULTS: It was found that 80.5% of the households had an LLIN and 64.4% of thehouseholds stated that they actually used the nets the previous night. Thefindings showed that 42.3% of pregnant women who had fever within the past month received ACTs, while 37.5% of children<5 years old who had malaria in the pastmonth had received ACTs. There was equity in ownership of nets for the range 1-5 nets per household. No significant SES difference was found in use of ACTs fortreatment of malaria in children under five years old and in pregnant women.CONCLUSIONS: The free distribution of LLINs and ACTs increased household coverageof both malaria control interventions and bridged the equity gap in access to

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them among the most vulnerable groups.

PMCID: PMC3358243PMID: 22545723 [PubMed - indexed for MEDLINE]

23. AIDS Care. 2012;24(12):1559-64. doi: 10.1080/09540121.2012.674094. Epub 2012 Apr 26.

Prevalence and correlates of insecticide-treated bednet use among HIV-1-infected adults in Kenya.

Nnedu ON, John-Stewart GC, Singa BO, Piper B, Otieno PA, Guidry A, Richardson BA,Walson J.

Department of Medicine, Section Infectious Diseases, Tulane University, NewOrleans, LA, USA. [email protected]

HIV-1-infected adults are at increased risk for malaria. Insecticide-treatedbednets protect individuals from malaria. Little is known about correlates ofownership and use of bednets among HIV-1-infected individuals. We conducted across-sectional survey of 388 HIV-1-infected adults recruited from three sites inKenya (Kilifi, Kisii, and Kisumu) to determine factors associated with ownership and use of optimal bednets. We defined an optimal bednet as an untorn,insecticide-treated bednet. Of 388 participants, 134(34.5%) reported owning anoptimal bednet. Of those that owned optimal bednets, most (76.9%) reported using it daily. In a multivariate model, higher socioeconomic status as defined aspostsecondary education [OR = 2.8 (95% CI: 1.3-6.4), p = 0.01] and living in apermanent home [OR = 1.7(1.03-2.9), p = 0.04] were significantly associated with optimal bednet ownership. Among individuals who owned bednets, employedindividuals were less likely [OR = 0.2(0.04-0.8), p = 0.01] and participants fromKilifi were more likely to use bednets [OR = 2.9 (95% CI 1.04-8.1), p = 0.04] in univariate analysis. Participants from Kilifi had the least education, lowestincome, and lowest rate of employment. Our findings suggest that lowersocioeconomic status is a barrier to ownership of an optimal bednet. However,consistent use is high once individuals are in possession of an optimal bednet.Increasing access to optimal bednets will lead to high uptake and use.

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PMID: 22533793 [PubMed - indexed for MEDLINE]

24. Malar J. 2012 Apr 25;11:127. doi: 10.1186/1475-2875-11-127.

Assessment of the effect of insecticide-treated nets and indoor residual sprayingfor malaria control in three rural kebeles of Adami Tulu District, South Central Ethiopia.

Bekele D, Belyhun Y, Petros B, Deressa W.

Natural and Computational Sciences, Biology Department, Debre Markos University, Debre Markos, Ethiopia.

BACKGROUND: In the Adami Tulu District, indoor residual spraying (IRS) andinsecticide-treated nets (ITNs) has been the main tool used to control malaria.The purpose of this study was to assess the effect of IRS and ITNs controlstrategies in Aneno Shisho kebele (lowest administrative unit of Ethiopia)compared with Kamo Gerbi (supplied ITN only) and Jela Aluto (no IRS and ITNs),with regards to the prevalence of malaria and mosquito density.METHODS: Cross-sectional surveys were conducted after heavy rains(October/November, 2006) and during the sporadic rains (April, 2007) in the threekebeles of Adami Tulu District. Malaria infection was measured by means of thick and thin film. Monthly collection of adult mosquitoes from October-December 2006 and April-May 2007 and sporozoite enzyme-linked immunosorbent assay (ELISA) onthe collected mosquitoes were detected. Data related to the knowledge of mode of malaria transmission and its control measures were collected. Data collected onparasitological and knowledge, attitude and practice (KAP) surveys were managedand analysed using a statistical computer program SPSS version 13.0. A P-value<0.05 was considered to be statistically significant.RESULTS: The overall prevalence of malaria was 8.6% in Jela Aluto, 4.4% in KamoGerbi and 1.3% in Aneno Shisho in the two season surveys. The vector, Anophelesgambiae s.l., Anopheles pharoensis and Anopheles coustani were recorded. However,sporozoite ELISA on mosquito collections detected no infection. The difference inoverall malaria prevalence and mosquito density between the three kebeles wassignificant (P<0.05).

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CONCLUSIONS: The present study has provided some evidence for the success ofITNs/IRS combined malaria control measures in Aneno Shisho kebele in Adami TuluDistrict. Therefore, the combined ITNs/IRS malaria control measures must beexpanded to cover all kebeles in the District of Ethiopia.

PMCID: PMC3407491PMID: 22533789 [PubMed - indexed for MEDLINE]

25. Trop Med Int Health. 2012 Jun;17(6):733-41. doi:10.1111/j.1365-3156.2012.02990.x. Epub 2012 Apr 23.

Long-term effects of malaria prevention with insecticide-treated mosquito nets onmorbidity and mortality in African children: randomised controlled trial.

Louis VR, Bals J, Tiendrebéogo J, Bountogo M, Ramroth H, De Allegri M, Traoré C, Beiersmann C, Coulibaly B, Yé M, Jahn A, Becher H, Müller O.

Institute of Public Health, Ruprecht-Karls-University, Heidelberg, Germany.

OBJECTIVE: The objective is to investigate the effect of malaria control withinsecticide-treated mosquito nets (ITNs) regarding possible higher mortality inchildren protected during early infancy, due to interference with immunitydevelopment, and to assess long-term effects on malaria prevalence and morbidity.METHODS: Between 2000 and 2002, a birth cohort was enrolled in 41 villages of amalaria holoendemic area in north-western Burkina Faso. All neonates (n = 3387)were individually randomised to ITN protection from birth (group A) vs. ITNprotection from age 6 months (group B). Primary outcome was all-cause mortality. In 2009, a survey took place in six sentinel villages, and in 2010, a census was conducted in all study villages.RESULTS: After a median follow-up time of 8.3 years, 443/3387 (13.1%) childrenhad migrated out of the area and 484/2944 (16.4%) had died, mostly at home.Long-term compliance with ITN protection was good. There were no differences inmortality between study groups (248 deaths in group A, 236 deaths in group B;rate ratio 1.05, 95% CI: 0.889-1.237, P = 0.574). The survey conducted brieflyafter the rainy season in 2009 showed that more than 80% of study children

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carried asexual malaria parasites and up to 20% had clinical malaria.CONCLUSION: Insecticide-treated mosquito net protection in early infancy is not arisk factor for mortality. Individual ITN protection does not sufficiently reducemalaria prevalence in high-transmission areas. Achieving universal ITN coverageremains a major challenge for malaria prevention in Africa.

© 2012 Blackwell Publishing Ltd.

PMID: 22519853 [PubMed - indexed for MEDLINE]

26. Glob Health Action. 2012;5:11619. doi: 10.3402/gha.v5i0.11619. Epub 2012 Apr 16.

The impact of indoor residual spraying on malaria incidence in East Shoa Zone,Ethiopia.

Hamusse SD, Balcha TT, Belachew T.

Oromia Regional Health Bureau, Addis Ababa, Ethiopia. [email protected]

BACKGROUND: In Ethiopia, nearly 70% of the population resides in areas prone tomalaria infection. The objective of this study is to evaluate the impact ofindoor residual spraying (IRS) on the incidence of malaria in East Shoa Zone ofEthiopia.METHODS: Data from the registers of malaria cases at Debrezeit Malaria ControlCenter in East Shoa Zone of Ethiopia were collected and analyzed. Records of 22villages with no previous rounds of spraying that were entirely covered with IRS using DDT during the peak malaria transmission season of 2001 and 2002 and other 22 adjacent villages with similar malaria incidence but remained unsprayed wereused for the analyses.RESULTS: The incidence of malaria in 2011 and 2002 among the sprayed villages waslower than the respective preceding years for both Plasmodium species (incidence rate ratio 0.60; CI 0.35 to 0.95; p < 0.0001). After the focal spray, there wassignificant reduction in malaria incidence in the villages sprayed. Spraying was associated with a 62% reduction in malaria incidence.CONCLUSIONS: This study demonstrated that IRS with DDT was effective in reducing malaria incidence in highland epidemic-prone areas in the East Shoa Zone of

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Ethiopia. A larger scale study should evaluate the effectiveness of DDT inreducing malaria incidence against its environmental impact and alternativestrategies for malaria prevention.

PMCID: PMC3329214PMID: 22514514 [PubMed - indexed for MEDLINE]

27. Soc Sci Med. 2012 Jul;75(1):138-47. doi: 10.1016/j.socscimed.2012.02.035. Epub2012 Mar 28.

A perverse 'net' effect? Health insurance and ex-ante moral hazard in Ghana.

Yilma Z, van Kempen L, de Hoop T.

International Institute of Social Studies, Erasmus University Rotterdam, TheNetherlands. [email protected]

Incentive problems in insurance markets are well-established in economic theory. One of these incentive problems is related to reduced prevention effortsfollowing insurance coverage (ex-ante moral hazard). This prediction is yet to betested empirically with regard to health insurance, as the health domain is oftenconsidered relatively immune to perverse incentives, despite its validation inother insurance markets that entail adverse shocks. This paper tests for thepresence of ex-ante moral hazard with reference to malaria prevention in Ghana.We investigate whether enrollment in the country's National Health InsuranceScheme (NHIS) negatively affects ownership and use of insecticide-treated bednets (ITNs). We use a panel of 400 households in the Brong Ahafo region for this purpose and employ a propensity-adjusted household fixed effects model. Ourresults suggest that ex-ante moral hazard is present, especially when the levelof effort and cost required for prevention is high. Implications of perverseincentive effects for the NHIS are briefly outlined.

Copyright © 2012 Elsevier Ltd. All rights reserved.

PMID: 22507951 [PubMed - indexed for MEDLINE]

28. Am J Trop Med Hyg. 2012 Apr;86(4):649-55. doi: 10.4269/ajtmh.2012.11-0414.

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Collapse of Anopheles darlingi populations in Suriname after introduction ofinsecticide-treated nets (ITNs); malaria down to near elimination level.

Hiwat H, Mitro S, Samjhawan A, Sardjoe P, Soekhoe T, Takken W.

Laboratory of Entomology, Wageningen University and Research Centre, Wageningen, The Netherlands. [email protected]

A longitudinal study of malaria vectors was carried out in three villages inSuriname between 2006 and 2010. During 13,392 man hours of collections, 3,180mosquitoes were collected, of which 33.7% were anophelines. Of these, Anophelesdarlingi accounted for 88.1%, and An. nuneztovari accounted for 11.1%. Thehighest mean An. darlingi human biting rate (HBR) observed per survey was 1.43bites/man per hour outdoor and 1.09 bites/man per hour indoor; 2 An. darlingi of the 683 tested were infected with Plasmodium falciparum. The anopheline HBRdecreased to zero after the onset of malaria intervention activities, includinginsecticide-treated net (ITN) distribution, in 2006. Malaria transmissiondecreased to pre-elimination levels. It is concluded that the combination of ITN and climatic events has led to the collapse of malaria vector populations in the study sites in the interior of the country. The results are discussed in relationto the stability of malaria transmission in areas with low-density humanpopulations.

PMCID: PMC3403763 [Available on 2013/4/1]PMID: 22492150 [PubMed - indexed for MEDLINE]

29. Malar J. 2012 Mar 30;11:99. doi: 10.1186/1475-2875-11-99.

The effect of household heads training on long-lasting insecticide-treated bednets utilization: a cluster randomized controlled trial in Ethiopia.

Deribew A, Birhanu Z, Sena L, Dejene T, Reda AA, Sudhakar M, Alemseged F, TessemaF, Zeynudin A, Biadgilign S, Deribe K.

Department of Epidemiology, Jimma University, Jimma, [email protected]

BACKGROUND: Long-lasting insecticide-treated bed nets (LLITN) have demonstrated

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significant impact in reducing malaria-related childhood morbidity and mortality.However, utilization of LLITN by under-five children is not satisfactory in many sub-Saharan African countries due to behavioural barriers. Previous studies hadfocused on the coverage and ownership of LLITN. The effect of skill-basedtraining for household heads on LLITN utilization had not yet been investigated. A cluster-randomized trial on the effect of training of household heads on theuse of LLITN was done in Ethiopia to fill this knowledge gap.METHODS: The study included 22 (11 intervention and 11 control) villages insouthwest Ethiopia. The intervention consisted of tailored training of household heads about the proper use of LLITN and community network system. All households in each group received free LLITN. Data were collected at baseline, six and 12months of the follow up periods. Utilization of LLITN in the control andintervention villages was compared at baseline and follow up periods.RESULTS: A total of 21,673; 14,735 and 13,758 individuals were included atbaseline, sixth and twelfth months of the project period. At the baseline survey,47.9% of individuals in the intervention villages and 68.4% in the controlvillages reported that they had utilized LLITN the night before the survey. Atthe six month, 81.0% of individuals in the intervention villages and 79.3% in thecontrol villages had utilized LLITN. The utilization of LLITN in all age groupsin the intervention villages was increased by 17.7 percentage point (95% CI9.7-25.6) at sixth month and by 31.0 percentage point (95% CI 16.9-45.1) at thetwelfth month. Among under-five children, the LLITN utilization increased by 31.6percentage point (95% CI 17.3-45.8) at the sixth month and 38.4 percentage point (95% CI 12.1-64.7) at the twelfth months of the project period.CONCLUSION: Household level skill-based training has demonstrated a markedpositive effect in the utilization of LLITN. The effect of the interventionsteadily increased overtime. Therefore, distribution of LLITN should beaccompanied by a skill-based training of household heads to improve itsutilization. TRAIL REGISTRATION: Australian New Zealand Clinical Trials Registry (ACTR number: ACTRN12610000035022).

PMCID: PMC3338089PMID: 22463488 [PubMed - indexed for MEDLINE]

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30. BMC Pregnancy Childbirth. 2012 Mar 29;12:21. doi: 10.1186/1471-2393-12-21.

Utilization of insecticide treated nets during pregnancy among postpartum womenin Ibadan, Nigeria: a cross-sectional study.

Aluko JO, Oluwatosin AO.

Nurse/Midwife/Public Health Nurse Tutors Programme, University College Hospital, Orita-mefa, Ibadan, Nigeria. [email protected]

BACKGROUND: Pregnant women are susceptible to symptomatic malaria due to invasionof the placenta by plasmodium. Malaria increases the risk of adverse pregnancyoutcomes for mothers, the foetuses and newborns. The effective use of InsecticideTreated Nets (ITNs) would be of benefit to these vulnerable women. Previousstudies have focused on prenatal-women but this study sought to explore theactual trend of utilization of the proven strategy across all the pregnancystages among postpartum women in Ibadan.METHODS: This cross-sectional survey utilized a validated structuredquestionnaire for data collection. A calculated sample of 335 postpartum womenwas proportionately recruited from three fee-paying facilities within Ibadan,Nigeria using a simple random sampling technique. These hospitals have highclient flow for maternity cases and are known for provision of care undertraditional ANC model. The data collected were analyzed using descriptive andinferential statistics by means of Statistical Package of Social Sciences (SPSS) version 15. The level of significance was set at = 0.05.RESULTS: The women's age ranged between 18 and 47 years, mean age was 29.4 ± 0.8 years. Various irregularities marked the traditional model of ANC provided at thesettings and no exposure to preconception care. Also, 276 (82.4%) had heard ofITNs. Antenatal clinics formed the major source of information. Low utilizationand compliance rates were observed. One hundred and twenty-seven (37.9%) of thewomen had high knowledge of Malaria in Pregnancy (MIP) but only 70 (20.9%)demonstrated positive attitude towards the use of ITNs. Participants' educationalstatus, family types, employment and residential areas significantly influencedITNs utilization.

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CONCLUSIONS: The women knew and learned about ITNs from ANC visits. Majority ofthe women did not own ITNs because of lack of access to free distribution. Theexisting traditional model of ANC was marked by irregularities and none of thewomen was exposed to preconception care. In addition, negative attitude in spite of increased knowledge of MIP was observed among the women. Therefore, evaluationof free distribution of ITNs is recommended. Integration of focused ANC andpreconception care are advocated to promote early access to health information.

PMCID: PMC3352125PMID: 22458645 [PubMed - indexed for MEDLINE]

31. Malar J. 2012 Mar 28;11:94. doi: 10.1186/1475-2875-11-94.

Lives saved from malaria prevention in Africa--evidence to sustain cost-effectivegains.

Korenromp EL.

Global Fund to Fight AIDS, Tuberculosis and Malaria, Vernier, Geneva CH-1214,Switzerland. [email protected]

Lives saved have become a standard metric to express health benefits acrossinterventions and diseases. Recent estimates of malaria-attributable under-fivedeaths prevented using the Lives Saved tool (LiST), extrapolating effectivenessestimates from community-randomized trials of scale-up of insecticide-treatednets (ITNs) in the 1990s, confirm the substantial impact and goodcost-effectiveness that ITNs have achieved in high-endemic sub-Saharan Africa. Aneven higher cost-effectiveness would likely have been found if the modelling had included the additional indirect mortality impact of ITNs on preventing deathsfrom other common child illnesses, to which malaria contributes as a risk factor.As conventional ITNs are being replaced by long-lasting insecticidal nets andscale-up is expanded to target universal coverage for full, all-age populationsat risk, enhanced transmission reduction may--above certain thresholds--enhancethe mortality impact beyond that observed in the trials of the 1990s. On the

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other hand, lives saved by ITNs might fall if improved malaria case managementwith artemisinin-based combination therapy averts the deaths that ITNs wouldotherwise prevent.Validation and updating of LiST's simple assumption of auniversal, fixed coverage-to-mortality-reduction ratio will require enhancednational programme and impact monitoring and evaluation. Key indicators for time trend analysis include malaria-related mortality from population-based surveysand vital registration, vector control and treatment coverage from surveys, andparasitologically-confirmed malaria cases and deaths recorded in healthfacilities. Indispensable is triangulation with dynamic transmission models,fitted to long-term trend data on vector, parasite and human populations oversuccessive phases of malaria control and elimination.Sound, locally optimizedbudget allocation including on monitoring and evaluation priorities will benefit much if policy makers and programme planners use planning tools such as LiST -even when predictions are less certain than often understood. The ultimatesuccess of LiST for supporting malaria prevention may be to prove its linearpredictions less and less relevant.

PMCID: PMC3373378PMID: 22455309 [PubMed - indexed for MEDLINE]

32. PLoS One. 2012;7(3):e31481. doi: 10.1371/journal.pone.0031481. Epub 2012 Mar 16.

Species shifts in the Anopheles gambiae complex: do LLINs successfully controlAnopheles arabiensis?

Kitau J, Oxborough RM, Tungu PK, Matowo J, Malima RC, Magesa SM, Bruce J, MoshaFW, Rowland MW.

Kilimanjaro Christian Medical College, Tumaini University, Moshi, [email protected]

INTRODUCTION: High coverage of conventional and long-lasting insecticide treated nets (ITNs and LLINs) in parts of E Africa are associated with reductions inlocal malaria burdens. Shifts in malaria vector species ratio have coincided with

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the scale-up suggesting that some species are being controlled by ITNs/LLINsbetter than others.METHODS: Between 2005-2006 six experimental hut trials of ITNs and LLINs wereconducted in parallel at two field stations in northeastern Tanzania; the firststation was in Lower Moshi Rice Irrigation Zone, an area where An. arabiensispredominates, and the second was in coastal Muheza, where An. gambiae and An.funestus predominate. Five pyrethroids and one carbamate insecticide wereevaluated on nets in terms of insecticide-induced mortality, blood-feedinginhibition and exiting rates.RESULTS: In the experimental hut trials mortality of An. arabiensis wasconsistently lower than that of An. gambiae and An. funestus. The mortality ratesin trials with pyrethroid-treated nets ranged from 25-52% for An. arabiensis,63-88% for An. gambiae s.s. and 53-78% for An. funestus. All pyrethroid-treatednets provided considerable protection for the occupants, despite beingdeliberately holed, with blood-feeding inhibition (percentage reduction in bitingrates) being consistent between species. Veranda exiting rates did not differbetween species. Percentage mortality of mosquitoes tested in cone bioassays onnetting was similar for An. gambiae and An. arabiensis.CONCLUSIONS: LLINs and ITNs treated with pyrethroids were more effective atkilling An. gambiae and An. funestus than An. arabiensis. This could be a majorcontributing factor to the species shifts observed in East Africa following scaleup of LLINs. With continued expansion of LLIN coverage in Africa An. arabiensisis likely to remain responsible for residual malaria transmission, and speciesshifts might be reported over larger areas. Supplementary control measures toLLINs may be necessary to control this vector species.

PMCID: PMC3306310PMID: 22438864 [PubMed - indexed for MEDLINE]

33. Med Mal Infect. 2012 Mar;42(3):114-8. doi: 10.1016/j.medmal.2012.01.010. Epub2012 Mar 7.

Assessment of microbial larvicide spraying with Bacillus thuringiensisisraelensis, for the prevention of malaria.

Kinde-Gazard D, Baglo T.

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Faculté des Sciences de la Santé de l'Université d'Abomey-Calavi 03, BP 1428Cotonou, Benin. [email protected]

OBJECTIVES: The aim of this study was to assess the contribution of microbiallarvicide spraying, Bacillus thuringiensis israelensis, as prevention strategyagainst malaria.METHODS: An experimental study consisted in spraying B. thuringiensis israelensisin a district during 1 year has been conducted. Another district (control) wasnot sprayed. Eight hundred and two children were evaluated, thick drop and swabexamination was performed for those presenting with fever. The larval density wascalculated in their habitats as well as larvicide remanence. Capture ofmosquitoes with human bait allowed determining human exposure to bites at night, and identifying anopheles after dissection.RESULTS: The incidence of pediatric malaria was 13.8% in the sprayed district and31.4% in the control district. The parasitic load ranged from 2000 to 42,000parasites/μL in the sprayed district and 2000 to 576,000 parasites/μL in thecontrol district. Plasmodium falciparum was the most frequent (97.8%) plasmodial species. In the control district, at least 20 larvae by liter of water werecounted; anopheles larvae were found in 11 larval habitats out of 15 (73.33%).The human exposure to anopheles bites at night was 14.25 in the sprayed district and 33.13 in the control district. The remanence of B. thuringiensis israelensis was estimated at 9 days in the sprayed district.CONCLUSION: The larvicide B. thuringiensis israelensis may be used in vectorcontrol strategy for the prevention of malaria.

Copyright © 2012 Elsevier Masson SAS. All rights reserved.

PMID: 22405513 [PubMed - indexed for MEDLINE]

34. PLoS One. 2012;7(2):e31409. doi: 10.1371/journal.pone.0031409. Epub 2012 Feb 20.

High prevalence of malaria in Zambezia, Mozambique: the protective effect of IRS versus increased risks due to pig-keeping and house construction.

Temu EA, Coleman M, Abilio AP, Kleinschmidt I.

London School of Hygiene and Tropical Medicine, London, United Kingdom.

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BACKGROUND: African countries are scaling up malaria interventions, especiallyinsecticide treated nets (ITN) and indoor residual spraying (IRS), for whichambitious coverage targets have been set. In spite of these efforts infectionprevalence remains high in many parts of the continent. This study investigatedrisk factors for malaria infection in children using three malaria indicatorsurveys from Zambezia province, Mozambique. The impact of IRS and ITNs, theeffects of keeping farm animals and of the construction material of roofs ofhouses and other potential risk factors associated with malaria infection inchildren were assessed.METHODS: Cross-sectional community-based surveys were conducted in October of2006, 2007 and 2008. A total of 8338 children (ages 1-15 years) from 2748households were included in the study. All children were screened for malaria by rapid diagnostic tests. Caregiver interviews were used to assess householddemographic and wealth characteristics and ITN and IRS coverage. Associationsbetween malaria infection, vector control interventions and potential riskfactors were assessed.RESULTS: Overall, the prevalence of malaria infection was 47.8% (95%CI:38.7%-57.1%) in children 1-15 years of age, less than a quarter of children(23.1%, 95%CI: 19.1%-27.6%) were sleeping under ITN and almost two thirds wereliving in IRS treated houses (coverage 65.4%, 95%CI: 51.5%-77.0%). Protectivefactors that were independently associated with malaria infection were: sleeping in an IRS house without sleeping under ITN (Odds Ratio (OR)= 0.6; 95%CI:0.4-0.9); additional protection due to sleeping under ITN in an IRS treated house(OR = 0.5; 95%CI: 0.3-0.7) versus sleeping in an unsprayed house without a ITN;and parental education (primary/secondary: OR = 0.6; 95%CI: 0.5-0.7) versusparents with no education. Increased risk of infection was associated with:current fever (OR = 1.2; 95%CI: 1.0-1.5) versus no fever; pig keeping (OR = 3.2; 95%CI: 2.1-4.9) versus not keeping pigs; living in houses with a grass roof(OR = 1.7; 95%CI: 1.3-2.4) versus other roofing materials and bigger householdsize (8-15 people: OR = 1.6; 95%CI: 1.3-2.1) versus small households (1-4persons).

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CONCLUSION: Malaria infection among children under 15 years of age in Zambeziaremained high but conventional malaria vector control methods, in particular IRS,provided effective means of protection. Household ownership of farm animals,particularly pigs, and living in houses with a grass roof were independentlyassociated with increased risk of infection, even after allowing for householdwealth. To reduce the burden of malaria, national control programs need to ensurehigh coverage of effective IRS and promote the use of ITNs, particularly inhouseholds with elevated risks of infection, such as those keeping farm animals, and those with grass roofs.

PMCID: PMC3282725PMID: 22363640 [PubMed - indexed for MEDLINE]

35. Cochrane Database Syst Rev. 2012 Feb 15;2:CD003756. doi:10.1002/14651858.CD003756.pub4.

Intermittent preventive treatment for malaria in children living in areas withseasonal transmission.

Meremikwu MM, Donegan S, Sinclair D, Esu E, Oringanje C.

Department of Paediatrics, University of Calabar Teaching Hospital, Calabar,Nigeria. [email protected].

Update of Cochrane Database Syst Rev. 2008;(2):CD003756.

BACKGROUND: In malaria endemic areas, pre-school children are at high risk ofsevere and repeated malaria illness. One possible public health strategy, knownas Intermittent Preventive Treatment in children (IPTc), is to treat all childrenfor malaria at regular intervals during the transmission season, regardless ofwhether they are infected or not.OBJECTIVES: To evaluate the effects of IPTc to prevent malaria in preschoolchildren living in endemic areas with seasonal malaria transmission.SEARCH METHODS: We searched the Cochrane Infectious Diseases Group SpecializedRegister (July 2011), CENTRAL (The Cochrane Library 2011, Issue 6), MEDLINE (1966to July 2011), EMBASE (1974 to July 2011), LILACS (1982 to July 2011), mRCT (July

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2011), and reference lists of identified trials. We also contacted researchersworking in the field for unpublished and ongoing trials.SELECTION CRITERIA: Individually randomized and cluster-randomized controlledtrials of full therapeutic dose of antimalarial or antimalarial drug combinationsgiven at regular intervals compared with placebo or no preventive treatment inchildren aged six years or less living in an area with seasonal malariatransmission.DATA COLLECTION AND ANALYSIS: Two authors independently assessed eligibility,extracted data and assessed the risk of bias in the trials. Data weremeta-analysed and measures of effects (ie rate ratio, risk ratio and meandifference) are presented with 95% confidence intervals (CIs). The quality ofevidence was assessed using the GRADE methods.MAIN RESULTS: Seven trials (12,589 participants), including onecluster-randomized trial, met the inclusion criteria. All were conducted in West Africa, and six of seven trials were restricted to children aged less than 5years.IPTc prevents approximately three quarters of all clinical malaria episodes(rate ratio 0.26; 95% CI 0.17 to 0.38; 9321 participants, six trials, highquality evidence), and a similar proportion of severe malaria episodes (rateratio 0.27, 95% CI 0.10 to 0.76; 5964 participants, two trials, high qualityevidence). These effects remain present even where insecticide treated net (ITN) usage is high (two trials, 5964 participants, high quality evidence).IPTcprobably produces a small reduction in all-cause mortality consistent with theeffect on severe malaria, but the trials were underpowered to reach statisticalsignificance (risk ratio 0.66, 95% CI 0.31 to 1.39, moderate qualityevidence).The effect on anaemia varied between studies, but the risk ofmoderately severe anaemia is probably lower with IPTc (risk ratio 0.71, 95% CI0.52 to 0.98; 8805 participants, five trials, moderate quality evidence).Serious drug-related adverse events, if they occur, are probably rare, with none reportedin the six trials (9533 participants, six trials, moderate quality evidence).Amodiaquine plus sulphadoxine-pyrimethamine is the most studied drug combination for seasonal chemoprevention. Although effective, it causes increased vomiting inthis age-group (risk ratio 2.78, 95% CI 2.31 to 3.35; two trials, 3544participants, high quality evidence).When antimalarial IPTc was stopped, norebound increase in malaria was observed in the three trials which continued

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follow-up for one season after IPTc.AUTHORS' CONCLUSIONS: In areas with seasonal malaria transmission, givingantimalarial drugs to preschool children (age < 6 years) as IPTc during themalaria transmission season markedly reduces episodes of clinical malaria,including severe malaria. This benefit occurs even in areas where insecticidetreated net usage is high.

PMID: 22336792 [PubMed - indexed for MEDLINE]

36. J Community Health. 2012 Oct;37(5):1006-14. doi: 10.1007/s10900-012-9546-z.

Factors associated with utilization of insecticide-treated nets in childrenseeking health care at a Ugandan hospital: perspective of child caregivers.

Nankinga Z, Muliira JK, Kalyango J, Nankabirwa J, Kiwuwa S, Njama-Meya D,Karamagi C.

Department of Nursing, School of Health Sciences, Makerere University, P. O. Box 7072, Kampala, Uganda. [email protected]

In Uganda malaria causes more morbidity and mortality than any other disease and children below 5 years contribute the biggest percentage of malaria relatedmortality. Insecticide treated nets (ITNs) are currently one of the most costeffective option for reducing malaria-related morbidity and mortality, howeverthe factors affecting their utilization in Uganda are still not well understood. This study examined the prevalence and factors associated with ITN utilizationamong children of age 0-12 years seeking health care from a Ugandan hospitalusing caregiver's reports. A cross sectional design was used to collect datausing a semi-structured questionnaire from 418 participants. Binary logisticregression was employed to determine predictors of ITN utilization. Results show that the prevalence of ITN utilization among children seeking health care was34.2%. ITN utilization was higher among children of age <5 years [37.0, 95% CI31.81-42.21] as compared to children aged ≥5 years [22.9, 95% CI 13.77-32.01].Source of mosquito net (OR = 13.53, 95% CI = 6.47-28.27), formal employment by

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head of household (OR = 6.00, 95% CI = 1.95-18.48), sharing a bed with parent (s)(OR = 2.61, 95% CI = 1.21-5.63) and number of children below 12 years in ahousehold (OR = 0.80, 95% CI = 0.65-0.99), were significant predictors ofutilization. ITN utilization among children was below the set national target.The predictors identified by this study reveal opportunities that can be takenadvantage of by malaria control programs to achieve the desired rates ofutilization and subsequently malaria prevention in children.

PMID: 22323100 [PubMed - indexed for MEDLINE]

37. BMC Public Health. 2012 Feb 6;12:105. doi: 10.1186/1471-2458-12-105.

Determinants of insecticide-treated net ownership and utilization among pregnant women in Nigeria.

Ankomah A, Adebayo SB, Arogundade ED, Anyanti J, Nwokolo E, Ladipo O, MeremikwuMM.

College of Medical Sciences, University of Calabar, Calabar, Nigeria.

BACKGROUND: Malaria during pregnancy is a major public health problem in Nigeria leading to increase in the risk of maternal mortality, low birth weight andinfant mortality. This paper is aimed at highlighting key predictors of theownership of insecticide treated nets (ITNs) and its use among pregnant women in Nigeria.METHODS: A total of 2348 pregnant women were selected by a multi-stageprobability sampling technique. Structured interview schedule was used to elicit information on socio-demographic characteristics, ITN ownership, use, knowledge, behaviour and practices. Logistic regression was used to detect predictors of twoindicators: ITN ownership, and ITN use in pregnancy among those who owned ITNs.RESULTS: ITN ownership was low; only 28.8% owned ITNs. Key predictors of ITNownership included women who knew that ITNs prevent malaria (OR = 3.85; p <0001); and registration at antenatal clinics (OR = 1.34; p = 0.003). The use ofITNs was equally low with only 7.5% of all pregnant women, and 25.7% of allpregnant women who owned ITNs sleeping under a net. The predictors of ITN use in pregnancy among women who owned ITNs (N = 677) identified by logistic regression

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were: urban residence (OR = 1.87; p = 0.001); knowledge that ITNs prevent malaria(OR = 2.93; p < 0001) and not holding misconceptions about malaria prevention (OR= 1.56; p = 0.036). Educational level was not significantly related to any of thetwo outcome variables. Although registration at ANC is significantly associatedwith ownership of a bednet (perhaps through free ITN distribution) this does not translate to significant use of ITNs.CONCLUSIONS: ITN use lagged well behind ITN ownership. This seems to suggest thatthe current mass distribution of ITNs at antenatal facilities and communitylevels may not necessarily lead to use unless it is accompanied by behaviourchange interventions that address the community level perceptions, misconceptionsand positively position ITN as an effective prevention device to prevent malaria.

PMCID: PMC3340311PMID: 22309768 [PubMed - indexed for MEDLINE]

38. Malar J. 2012 Feb 1;11:32. doi: 10.1186/1475-2875-11-32.

Can universal insecticide-treated net campaigns achieve equity in coverage anduse? the case of northern Nigeria.

Ye Y, Patton E, Kilian A, Dovey S, Eckert E.

ICF International, 11785 Beltsville Drive, Suite 300, Calverton, MD 20705, [email protected]

BACKGROUND: Insecticide-treated nets (ITNs) are effective tools for malariaprevention and can significantly reduce severe disease and mortality due tomalaria, especially among children under five in endemic areas. However, ITNcoverage and use remain low and inequitable among different socio-economic groupsin sub-Saharan Africa, particularly in Nigeria. Several strategies have beenproposed to increase coverage and use and reduce inequity in Nigeria, includingfree distribution campaigns recently conducted by the Nigerian federalgovernment. Using data from the first post-campaign survey, the authorsinvestigated the effect of the mass free distribution campaigns in achievingequity in household ownership and use of ITNs.METHODS: A post-campaign survey was undertaken in November 2009 in northern

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Nigeria to assess the effect of the campaigns in addressing equity acrossdifferent socio-economic groups. The survey included 987 households randomlyselected from 60 clusters in Kano state. Using logistic regression and the Lorenzconcentration curve and index, the authors assessed equity in ITN coverage anduse.RESULTS: ITN ownership coverage increased from 10% before the campaigns to 70%-a more than fivefold increase. The campaigns reduced the ownership coverage gap by 75%, effectively reaching parity among wealth quintiles (Concentration index0.02, 95% CI (-0.02 ; 0.05) versus 0.21 95%CI (0.08 ; 0.34) before thecampaigns). ITN use (individuals reporting having slept under an ITN the nightbefore the survey visit) among individuals from households owning at least oneITN, was 53.1% with no statistically significant difference between the lowest,second, third and fourth wealth quintiles and the highest wealth quintile(lowest: odds ratio (OR) 0.87, 95% confidence interval (CI) (0.67 ; 1.13);second: OR 0.85, 95% CI (0.66 ; 1.24); third: OR 1.10 95% CI (0.86 ; 1.4) andfourth OR 0.91 95% CI (0.72 ; 1.15).CONCLUSION: The campaign had a significant impact by increasing ITN coverage and reducing inequity in ownership and use. Free ITN distribution campaigns should besustained to increase equitable coverage. These campaigns should be supplemented with other ITN distribution strategies to cover newborns and replace aging nets.

PMCID: PMC3312823PMID: 22297189 [PubMed - indexed for MEDLINE]

39. Trop Med Int Health. 2012 Apr;17(4):430-7. doi: 10.1111/j.1365-3156.2011.02953.x.Epub 2012 Jan 24.

Improved equity in measles vaccination from integrating insecticide-treatedbednets in a vaccination campaign, Madagascar.

Goodson JL, Kulkarni MA, Vanden Eng JL, Wannemuehler KA, Cotte AH, Desrochers RE,Randriamanalina B, Luman ET.

Global Immunization Division, Centers for Disease Control and Prevention,Atlanta, GA 30333, USA. [email protected]

OBJECTIVE: To evaluate the effect of integrating ITN distribution on measles

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vaccination campaign coverage in Madagascar.METHODS: Nationwide cross-sectional survey to estimate measles vaccinationcoverage, nationally, and in districts with and without ITN integration. Toevaluate the effect of ITN integration, propensity score matching was used tocreate comparable samples in ITN and non-ITN districts. Relative risks (RR) and95% confidence intervals (CI) were estimated via log-binomial models. Equityratios, defined as the coverage ratio between the lowest and highest householdwealth quintile (Q), were used to assess equity in measles vaccination coverage.RESULTS: National measles vaccination coverage during the campaign was 66.9% (95%CI 63.0-70.7). Among the propensity score subset, vaccination campaign coveragewas higher in ITN districts (70.8%) than non-ITN districts (59.1%) (RR=1.3, 95%CI 1.1-1.6). Among children in the poorest wealth quintile, vaccination coverage was higher in ITN than in non-ITN districts (Q1; RR=2.4, 95% CI 1.2-4.8) andequity for measles vaccination was greater in ITN districts (equity ratio=1.0,95% CI 0.8-1.3) than in non-ITN districts (equity ratio=0.4, 95% CI 0.2-0.8).CONCLUSION: Integration of ITN distribution with a vaccination campaign mightimprove measles vaccination coverage among the poor, thus providing protectionfor the most vulnerable and difficult to reach children.

© 2012 Blackwell Publishing Ltd.

PMID: 22273490 [PubMed - indexed for MEDLINE]

40. Malar J. 2012 Jan 13;11:20. doi: 10.1186/1475-2875-11-20.

Importance of factors determining the effective lifetime of a mass, long-lasting,insecticidal net distribution: a sensitivity analysis.

Briët OJ, Hardy D, Smith TA.

Department of Epidemiology and Public Health, Swiss Tropical and Public HealthInstitute, Basel, Switzerland. [email protected]

BACKGROUND: Long-lasting insecticidal nets (LLINs) reduce malaria transmission byprotecting individuals from infectious bites, and by reducing mosquito survival.

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In recent years, millions of LLINs have been distributed across sub-SaharanAfrica (SSA). Over time, LLINs decay physically and chemically and are destroyed,making repeated interventions necessary to prevent a resurgence of malaria.Because its effects on transmission are important (more so than the effects ofindividual protection), estimates of the lifetime of mass distribution roundsshould be based on the effective length of epidemiological protection.METHODS: Simulation models, parameterised using available field data, were usedto analyse how the distribution's effective lifetime depends on the transmission setting and on LLIN characteristics. Factors considered were the pre-interventiontransmission level, initial coverage, net attrition, and both physical andchemical decay. An ensemble of 14 stochastic individual-based model variants for malaria in humans was used, combined with a deterministic model for malaria inmosquitoes.RESULTS: The effective lifetime was most sensitive to the pre-interventiontransmission level, with a lifetime of almost 10 years at an entomologicalinoculation rate of two infectious bites per adult per annum (ibpapa), but oflittle more than 2 years at 256 ibpapa. The LLIN attrition rate and theinsecticide decay rate were the next most important parameters. The lifetime was surprisingly insensitive to physical decay parameters, but this could change asphysical integrity gains importance with the emergence and spread of pyrethroidresistance.CONCLUSIONS: The strong dependency of the effective lifetime on thepre-intervention transmission level indicated that the required distributionfrequency may vary more with the local entomological situation than with LLINquality or the characteristics of the distribution system. This highlights theneed for malaria monitoring both before and during intervention programmes,particularly since there are likely to be strong variations between years andover short distances. The majority of SSA's population falls into exposurecategories where the lifetime is relatively long, but because exposure estimates are highly uncertain, it is necessary to consider subsequent interventions beforethe end of the expected effective lifetime based on an imprecise transmission

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measure.

PMCID: PMC3273435PMID: 22244509 [PubMed - indexed for MEDLINE]

41. Malar J. 2012 Jan 11;11:18. doi: 10.1186/1475-2875-11-18.

Distance to health services influences insecticide-treated net possession and useamong six to 59 month-old children in Malawi.

Larson PS, Mathanga DP, Campbell CH Jr, Wilson ML.

Department of Epidemiology, School of Public Health, University of Michigan, 09Observatory, Ann Arbor, MI 48109-2029, USA. [email protected]

BACKGROUND: Health ministries and providers are rapidly scaling upinsecticide-treated nets (ITN) distribution to control malaria, yet possessionand proper use typically remain below targeted levels. In Malawi, healthfacilities (HFs) are currently the principal points of ITN distribution, makingit important to understand how access to these ITN sources affects ownership,possession, and use. The authors evaluated the association between proximity toHFs and ITN possession or use among Malawian children six to 59 months of age.METHODS: A household malaria survey undertaken in eight districts of Malawiduring 2007 was used to characterize ITN possession and use. The location of eachrespondent's household was geocoded as was those of Ministry of Health (MoH) HFs and other health centres. Euclidean distance from each household to the nearestHF was calculated. Patterns of net possession and use were determined throughdescriptive methods. The authors then analysed the significance of distance andITN possession/use through standard statistical tests, including logisticregression.RESULTS: Median distance to HFs was greater among households that did not possessITNs and did not use an ITN the previous evening. Descriptive statistical methodsconfirmed a pattern of decreasing ITN possession and use with increasing distancefrom HFs. Logistic regression showed the same statistically significantassociation of distance to HFs, even when controlling for age and gender of thechild, ratio of nets to children in household, community net possession and use, and household material wealth.

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CONCLUSIONS: Strategies that exclusively distribute ITNs through HFs are likelyto be less effective in increasing possession and use in communities that aremore distant from those health services. Health providers should look towardscommunity-based distribution services that take ITNs directly to communitymembers to more effectively scale up ITN possession and regular use aimed atprotecting children from malaria.

PMCID: PMC3283522PMID: 22236395 [PubMed - indexed for MEDLINE]

42. Malar J. 2012 Jan 11;11:17. doi: 10.1186/1475-2875-11-17.

Target product profiles for protecting against outdoor malaria transmission.

Killeen GF, Moore SJ.

Biomedical and Environmental Thematic Group, Ifakara Health Institute, PO Box 53,Ifakara, Morogoro, United Republic of Tanzania. [email protected]

BACKGROUND: Long-lasting insecticidal nets (LLINs) and indoor residual sprays(IRS) have decimated malaria transmission by killing indoor-feeding mosquitoes.However, complete elimination of malaria transmission with these proven methodsis confounded by vectors that evade pesticide contact by feeding outdoors.METHODS: For any assumed level of indoor coverage and personal protectiveefficacy with insecticidal products, process-explicit malaria transmission modelssuggest that insecticides that repel mosquitoes will achieve less impact upontransmission than those that kill them outright. Here such models are extended toexplore how outdoor use of products containing either contact toxins or spatialrepellents might augment or attenuate impact of high indoor coverage of LLINsrelying primarily upon contact toxicity.RESULTS: LLIN impact could be dramatically enhanced by high coverage with spatialrepellents conferring near-complete personal protection, but only if combinedindoor use of both measures can be avoided where vectors persist that preferfeeding indoors upon humans. While very high levels of coverage and efficacy willbe required for spatial repellents to substantially augment the impact of LLINs

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or IRS, these ambitious targets may well be at least as practically achievable asthe lower requirements for equivalent impact using contact insecticides.CONCLUSIONS: Vapour-phase repellents may be more acceptable, practical andeffective than contact insecticides for preventing outdoor malaria transmissionbecause they need not be applied to skin or clothing and may protect multipleoccupants of spaces outside of treatable structures such as nets or houses.

PMCID: PMC3298720PMID: 22236388 [PubMed - indexed for MEDLINE]

43. Am J Trop Med Hyg. 2012 Jan;86(1):96-8. doi: 10.4269/ajtmh.2012.11-0397.

Rolling Malaria Indicator Surveys (rMIS): a potential district-level malariamonitoring and evaluation (M&E) tool for program managers.

Roca-Feltrer A, Lalloo DG, Phiri K, Terlouw DJ.

Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, [email protected]

Novel malaria monitoring and evaluation (M&E) tools are urgently needed tocomplement the current "gold standard" Malaria Indicator Surveys (MIS). Rapid up scaling of malaria control efforts is resulting in substantial reductions inmalaria burden across sub-Saharan Africa. As transmission goes down, timely,accurate, sub-national, and district level burden estimates are needed to guideincreasingly targeted control efforts in remaining hotspot areas. To test a noveldistrict level M&E tool, we have conducted a continuous ("rolling") MIS (rMIS)since May 2010 covering 50 villages in Chikhwawa district in southern Malawi,essentially adapting an existing cross-sectional evaluation tool into acontinuous monitoring tool. Here, we report on our experience after completingthe first full year of monthly data collection focusing on the methods,operational aspects, and estimated costs of rMIS in a programmatic setting. Thepotential applicability of this promising M&E approach for district-level programmanagers and control efforts is discussed.

PMCID: PMC3247115PMID: 22232457 [PubMed - indexed for MEDLINE]

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44. Malar J. 2012 Jan 9;11:9. doi: 10.1186/1475-2875-11-9.

Malaria control in Bhutan: case study of a country embarking on elimination.

Yangzom T, Gueye CS, Namgay R, Galappaththy GN, Thimasarn K, Gosling R,Murugasampillay S, Dev V.

Vector-Borne Disease Control Programme, Ministry of Health, Royal Government ofBhutan, Gelephu, Bhutan.

BACKGROUND: Bhutan has achieved a major reduction in malaria incidence amidmultiple challenges. This case study seeks to characterize the Bhutan malariacontrol programme over the last 10 years.METHODS: A review of the malaria epidemiology, control strategies, andelimination strategies employed in Bhutan was carried out through a literaturereview of peer-reviewed and grey national and international literature with theaddition of reviewing the surveillance and vector control records of the BhutanVector-Borne Disease Control Programme (VDCP). Data triangulation was used toidentify trends in epidemiology and key strategies and interventions throughanalysis of the VDCP surveillance and programme records and the literaturereview. Enabling and challenging factors were identified through analysis ofsocio-economic and health indicators, corroborated through a review of nationaland international reports and peer-review articles.FINDINGS: Confirmed malaria cases in Bhutan declined by 98.7% from 1994 to 2010. The majority of indigenous cases were due to Plasmodium vivax (59.9%) and adultmales are most at-risk of malaria. Imported cases, or those in foreign nationals,varied over the years, reaching 21.8% of all confirmed cases in 2006. Strategies implemented by the VDCP are likely to be related to the decline in cases over thelast 10 years. Access to malaria diagnosis in treatment was expanded throughoutthe country and evidence-based case management, including the introduction ofartemisinin-based combination therapy (ACT) for P. falciparum, increasingcoverage of high risk areas with Indoor Residual Spraying, insecticide-treatedbed nets, and long-lasting insecticidal nets are likely to have contributed tothe decline alongside enabling factors such as economic development and

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increasing access to health services.CONCLUSION: Bhutan has made significant strides towards elimination and hasadopted a goal of national elimination. A major challenge in the future will beprevention and management of imported malaria infections from neighbouring Indianstates. Bhutan plans to implement screening at border points to preventimportation of malaria and to targeted prevention and surveillance effortstowards at-risk Bhutanese and migrant workers in construction sites.

PMCID: PMC3278342PMID: 22230355 [PubMed - indexed for MEDLINE]

45. Malar J. 2012 Jan 6;11:8. doi: 10.1186/1475-2875-11-8.

The effect of household heads training about the use of treated bed nets on theburden of malaria and anaemia in under-five children: a cluster randomized trial in Ethiopia.

Deribew A, Birhanu Z, Sena L, Dejene T, Reda AA, Sudhakar M, Alemseged F, TessemaF, Zeynudin A, Biadgilign S, Deribe K.

Department of Epidemiology, Jimma University, Jimma, [email protected]

BACKGROUND: Long-lasting insecticide-treated bed nets (LLITN) have demonstrated asignificant effect in reducing malaria-related morbidity and mortality. However, barriers on the utilization of LLITN have hampered the desired outcomes. The aim of this study was to assess the effect of community empowerment on the burden of malaria and anaemia in under-five children in Ethiopia.METHODS: A cluster randomized trial was done in 22 (11 intervention and 11control) villages in south-west Ethiopia. The intervention consisted of tailored training of household heads about the proper use of LLITN and community networksystem. The burden of malaria and anaemia in under-five children was determinedthrough mass blood investigation at baseline, six and 12 months of the projectperiod. Cases of malaria and anaemia were treated based on the national protocol.The burden of malaria and anaemia between the intervention and control villageswas compared using the complex logistic regression model by taking into account

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the clustering effect. Eight Focus group discussions were conducted to complementthe quantitative findings.RESULTS: A total of 2,105 household heads received the intervention and theprevalence of malaria and anaemia was assessed among 2410, 2037 and 2612under-five children at baseline, six and 12 months of the project periodrespectively. During the high transmission/epidemic season, children in theintervention arm were less likely to have malaria as compared to children in the control arm (OR = 0.42; 95%CI: 0.32, 0.57). Symptomatic malaria also steadilydeclined in the intervention villages compared to the control villages in thefollow up periods. Children in the intervention arm were less likely to beanaemic compared to those in the control arm both at the high (OR = 0.84; 95%CI: 0.71, 0.99)) and low (OR = 0.73; 95%CI: 0.60, 0.89) transmission seasons.CONCLUSION: Training of household heads on the utilization of LLITN significantlyreduces the burden of malaria in under-five children. The Ministry of Health ofEthiopia in collaboration with other partners should design similar strategies inhigh-risk areas to control malaria in Ethiopia.TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12610000035022.

PMCID: PMC3274442PMID: 22225997 [PubMed - indexed for MEDLINE]

46. Bull Math Biol. 2012 May;74(5):1098-124. doi: 10.1007/s11538-011-9710-0. Epub2012 Jan 5.

A periodically-forced mathematical model for the seasonal dynamics of malaria in mosquitoes.

Chitnis N, Hardy D, Smith T.

Department of Epidemiology and Public Health, Swiss Tropical and Public HealthInstitute, Basel, Switzerland. [email protected]

We describe and analyze a periodically-forced difference equation model formalaria in mosquitoes that captures the effects of seasonality and allows themosquitoes to feed on a heterogeneous population of hosts. We numerically showthe existence of a unique globally asymptotically stable periodic orbit and

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calculate periodic orbits of field-measurable quantities that measure malariatransmission. We integrate this model with an individual-based stochasticsimulation model for malaria in humans to compare the effects ofinsecticide-treated nets (ITNs) and indoor residual spraying (IRS) in reducingmalaria transmission, prevalence, and incidence. We show that ITNs are moreeffective than IRS in reducing transmission and prevalence though IRS wouldachieve its maximal effects within 2 years while ITNs would need two massdistribution campaigns over several years to do so. Furthermore, the combination of both interventions is more effective than either intervention alone. However, although these interventions reduce transmission and prevalence, they can lead toincreased clinical malaria; and all three malaria indicators return topreintervention levels within 3 years after the interventions are withdrawn.

PMCID: PMC3339865PMID: 22218880 [PubMed - indexed for MEDLINE]

47. Malar J. 2011 Dec 20;10:379. doi: 10.1186/1475-2875-10-379.

Rapid assessment of the performance of malaria control strategies implemented by countries in the Amazon subregion using adequacy criteria: case study.

Flores W, Chang J, Barillas E.

Strengthening Pharmaceutical Systems/Management Sciences for Health, 6a avenida11-77 zona 10, Edificio Punto Diez oficina 1 F Guatemala City, [email protected]

BACKGROUND: The objective of this study was to implement a rapid assessment ofthe performance of four malaria control strategies (indoor spraying,insecticide-treated bed nets, timely diagnosis, and artemisinin-based combinationtherapy) using adequacy criteria. The assessment was carried out in fivecountries of the Amazon subregion (Bolivia, Colombia, Ecuador, Guyana, and Peru).METHODS: A list of criteria in three areas was created for each of the fourstrategies: preliminary research that supports the design and adaptation of thecontrol strategies, coverage of the control strategies and quality of theimplementation of the strategies. The criteria were selected by the research teamand based on the technical guidelines established by the World HealthOrganization. Each criterion included in the four lists was graded relative to

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whether evidence exists that the criterion is satisfied (value 1), not satisfied (value 0) or partially satisfied (value 0.5). The values obtained were added and reported according to a scale of three implementation categories: adequate,intermediate and deficient.RESULTS: Implementation of residual indoor spraying and timely diagnosis wasadequate in one country and intermediate or deficient in the rest.Insecticide-treated bed nets ranged between deficient and intermediate in all thecountries, while implementation of artemisinin-based combination therapy (ACT)was adequate in three countries and intermediate in the other two countriesevaluated.CONCLUSIONS: Although ACT is the strategy with the better implementation in allcountries, major gaps exist in implementation of the other three malaria control strategies in terms of technical criteria, coverage and quality desired. Thecountries must implement action plans to close the gaps in the various criteriaand thereby improve the performance of the interventions. The assessment toolsdeveloped, based on adequacy criteria, are considered useful for a rapidassessment by malaria control authorities in the different countries.

PMCID: PMC3297539PMID: 22185638 [PubMed - indexed for MEDLINE]

48. Bull Soc Pathol Exot. 2012 Feb;105(1):36-9. doi: 10.1007/s13149-011-0193-x. Epub 2011 Dec 16.

[Evaluation of the use of insecticide-treated nets and intermittent preventivetreatment in three health zones in Benin].

[Article in French]

Kinde-Gazard D, Vignon Makong J, Kossou HD, Sossa CJ.

Université d'Abomey-Calavi, Cotonou, Bénin. [email protected]

This study aims to evaluate the results of the Project to Support the Fightagainst Malaria in the departments of Mono and Couffo in Benin oninsecticide-treated nets (ITNs) use by children under 5 years and pregnant women and the coverage by Intermittent Preventive Treatment (IPT) withSulfadoxin-Pyrimethamin (SP). This assessment is made from two household surveys.

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The first at the start up and the second after fifteen months of implementation. The availability of ITN in households and their use by pregnant women andchildren under 5 years have increased respectively from 8, 5 and 4% in 2005 to24, 31 and 16 % in 2006. The percentage of pregnant women under IPT withsulfadoxine-pyrimethamine (SP) is 10% while 21% of pregnant women received atleast one dose of SP. The availability of ITN in households and their use bychildren under 5 years and the prevention of malaria during pregnancy remains aconcern in these health areas. The promotion of long lasting insecticide treated nets with effective communication strategies for behavior change could improvethe results. Research on causes of poor compliance of IPT should be emphasized aswell as strengthening management of drugs in health centers.

PMID: 22180050 [PubMed - indexed for MEDLINE]

49. Malar J. 2011 Dec 13;10:353. doi: 10.1186/1475-2875-10-353.

Larval source management for malaria control in Africa: myths and reality.

Fillinger U, Lindsay SW.

Department of Disease Control, London School of Hygiene and Tropical Medicine,Keppel Street, London WC1E 7HT, UK. [email protected]

As malaria declines in many African countries there is a growing realization thatnew interventions need to be added to the front-line vector control tools oflong-lasting impregnated nets (LLINs) and indoor residual spraying (IRS) thattarget adult mosquitoes indoors. Larval source management (LSM) provides the dualbenefits of not only reducing numbers of house-entering mosquitoes, but,importantly, also those that bite outdoors. Large-scale LSM was a highlyeffective method of malaria control in the first half of the twentieth century,but was largely disbanded in favour of IRS with DDT. Today LSM continues to beused in large-scale mosquito abatement programmes in North America and Europe,but has only recently been tested in a few trials of malaria control incontemporary Africa. The results from these trials show that hand-application of larvicides can reduce transmission by 70-90% in settings where mosquito larvalhabitats are defined but is largely ineffectual where habitats are so extensive

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that not all of them can be covered on foot, such as areas that experiencesubstantial flooding. Importantly recent evidence shows that LSM can be aneffective method of malaria control, especially when combined with LLINs.Nevertheless, there are a number of misconceptions or even myths that hamper the advocacy for LSM by leading international institutions and the uptake of LSM byMalaria Control Programmes. Many argue that LSM is not feasible in Africa due to the high number of small and temporary larval habitats for Anopheles gambiae thatare difficult to find and treat promptly. Reference is often made to theRoss-Macdonald model to reinforce the view that larval control is ineffective.This paper challenges the notion that LSM cannot be successfully used for malariacontrol in African transmission settings by highlighting historical and recentsuccesses, discussing its potential in an integrated vector management approachworking towards malaria elimination and critically reviewing the most commonarguments that are used against the adoption of LSM.

PMCID: PMC3273449PMID: 22166144 [PubMed - indexed for MEDLINE]

50. Malar J. 2011 Dec 13;10:357. doi: 10.1186/1475-2875-10-357.

Free distribution of insecticidal bed nets improves possession and preferentialuse by households and is equitable: findings from two cross-sectional surveys in thirteen malaria endemic districts of Bangladesh.

Ahmed SM, Hossain S, Kabir MM, Roy S.

Research and Evaluation Division, BRAC Centre, 75 Mohakhali, Dhaka Dhaka-1212,Bangladesh. [email protected]

BACKGROUND: BRAC, an indigenous non-governmental development organization (NGO), has been implementing a programme to prevent and control malaria in the 13malaria-endemic districts of Bangladesh since 2007. One of the criticalpreventive interventions is the distribution of insecticidal bed nets(long-lasting insecticide-treated nets, LLINs and insecticide-treated ordinarynets, ITNs) to the community free of cost. This study aimed to assess progress inthe possession, preferential use, and knowledge on use of the LLIN/ITNs including

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the programme's avowed pro-poor inclination one and three and half years afterintervention began.METHODS: A convenient sampling strategy based on malaria endemicity in thedistricts was adopted. First, thirty upazila (sub-district, with a populationaround 250,000)s were selected at random, with high prevalent districtscontributing more upazilas; second, from each upazila, one (2008) to two (2011)villages (covered by insecticidal bed net distribution programme) were selected. From each village, households that had either one under-five child and/or apregnant woman were included in the survey, one household being included onlyonce. Data were collected using a pre-tested structured questionnaire.RESULTS: In all, 3,760 households in 2008 and 7,895 households in 2011 weresurveyed for collecting relevant information. Proportion of households with atleast one LLIN, and at least one LLIN/ITN increased (22-59 to 62-67% and 22-64%to 74-76% respectively) over time, including increase in the mean number ofLLIN/ITNs per household (≤ 1 to 1 +). The programme achieved > 80% coverage insleeping under an LLIN/ITN in the case of under-five children and pregnant women,especially in the high-endemic districts. Knowledge regarding critical time ofhanging the net also increased over time (7-22 to 44-54%), but remained low. The pro-poor inclination of the programme is reflected in the status of relevantindicators according to self-rated poverty status of the households.CONCLUSIONS: There has been a substantial improvement in possession and usage of insecticidal bed nets especially for the two most vulnerable groups (under-fivechildren and pregnant women), including a reduction of gaps between the high and low endemic districts, and the deficit and non-deficit households during thestudy period.

PMCID: PMC3266224PMID: 22165959 [PubMed - indexed for MEDLINE]

51. Malar J. 2011 Dec 13;10:356. doi: 10.1186/1475-2875-10-356.

Impact of insecticide-treated bed nets on malaria transmission indices on thesouth coast of Kenya.

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Mutuku FM, King CH, Mungai P, Mbogo C, Mwangangi J, Muchiri EM, Walker ED, KitronU.

Department of Environmental Studies, Emory University, Atlanta, Georgia, [email protected]

BACKGROUND: Besides significantly reducing malaria vector densities, prolongedusage of bed nets has been linked to decline of Anopheles gambiae s.s. relativeto Anopheles arabiensis, changes in host feeding preference of malaria vectors,and behavioural shifts to exophagy (outdoor biting) for the two important malariavectors in Africa, An. gambiae s.l. and Anopheles funestus. In southern coastalKenya, bed net use was negligible in 1997-1998 when Anopheles funestus and An.gambiae s.s. were the primary malaria vectors, with An. arabiensis and Anopheles merus playing a secondary role. Since 2001, bed net use has increasedprogressively and reached high levels by 2009-2010 with corresponding decline in malaria transmission.METHODS: To evaluate the impact of the substantial increase in household bed net use within this area on vector density, vector composition, and human-vectorcontact, indoor and outdoor resting mosquitoes were collected in the same region during 2009-2010 using pyrethrum spray catches and clay pots for indoor andoutdoor collections respectively. Information on bed net use per sleeping spaces and factors influencing mosquito density were determined in the same houses usingPoisson regression analysis. Species distribution was determined, and number ofmosquitoes per house, human-biting rates (HBR), and entomological inoculationrate (EIR) were compared to those reported for the same area during 1997-1998,when bed net coverage had been minimal.RESULTS: Compared to 1997-1998, a significant decline in the relative proportion of An. gambiae s.s. among collected mosquitoes was noted, coupled with aproportionate increase of An. arabiensis. Following > 5 years of 60-86% coverage with bed nets, the density, human biting rate and EIR of indoor restingmosquitoes were reduced by more than 92% for An. funestus and by 75% for An.gambiae s.l. In addition, the host feeding choice of both vectors shifted moretoward non-human vertebrates. Besides bed net use, malaria vector abundance was

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also influenced by type of house construction and according to whether one sleepson a bed or a mat (both of these are associated with household wealth). Mosquito density was positively associated with presence of domestic animals.CONCLUSIONS: These entomological indices indicate a much reduced human bitingrate and a diminishing role of An. gambiae s.s. in malaria transmission followinghigh bed net coverage. While increasing bed net coverage beyond the currentlevels may not significantly reduce the transmission potential of An. arabiensis,it is anticipated that increasing or at least sustaining high bed net coveragewill result in a diminished role for An. funestus in malaria transmission.

PMCID: PMC3322380PMID: 22165904 [PubMed - indexed for MEDLINE]

52. Malar J. 2011 Dec 13;10:363. doi: 10.1186/1475-2875-10-363.

Assessing healthcare providers' knowledge and practices relating toinsecticide-treated nets and the prevention of malaria in Ghana, Laos, Senegaland Tanzania.

Hoffman SJ, Guindon GE, Lavis JN, Ndossi GD, Osei EJ, Sidibe MF, Boupha B;Research to Policy & Practice Study Team.

Collaborators: Lavis JN, Guindon G, Cameron D, Hoffman SJ, Shi G, Qiu T, Osei EJ,Dovlo K, Yesudian CA, Ramachandran P, Malek-Afzali H, Dejman M, Falahat K,Baradaran M, Habibi E, Kohanzad H, Nasehi M, Salek S, Akanov AA, Turdaliyeva BS, Hamzina NK, Tulebaev KA, Clazhneva TI, Battakova G, Boupha B, Kounnavong S,Siengsounthone L, Becerra-Posada F, Ramos LA, Mejia I, Akhtar T, Khan MM, Sidibe MF, Sidibe A, Ndiaye D, Ndossi GD, Massaga J, Sadana R, Pang T.

McMaster Health Forum, McMaster University, Hamilton, Ontario, Canada.

BACKGROUND: Research evidence is not always being disseminated to healthcareproviders who need it to inform their clinical practice. This can result in theprovision of ineffective services and an inefficient use of resources, theimplications of which might be felt particularly acutely in low- andmiddle-income countries. Malaria prevention is a particularly compelling domain

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to study evidence/practice gaps given the proven efficacy, cost-effectiveness anddisappointing utilization of insecticide-treated nets (ITNs).METHODS: This study compares what is known about ITNs to the related knowledgeand practices of healthcare providers in four low- and middle-income countries. Anew questionnaire was developed, pilot tested, translated and administered to 497healthcare providers in Ghana (140), Laos (136), Senegal (100) and Tanzania(121). Ten questions tested participants' knowledge and clinical practice relatedto malaria prevention. Additional questions addressed their individualcharacteristics, working context and research-related activities. Ordinallogistic regressions with knowledge and practices as the dependent variable were conducted in addition to descriptive statistics.RESULTS: The survey achieved a 75% response rate (372/497) across Ghana(107/140), Laos (136/136), Senegal (51/100) and Tanzania (78/121). Fewparticipating healthcare providers correctly answered all five knowledgequestions about ITNs (13%) or self-reported performing all five clinicalpractices according to established evidence (2%). Statistically significantfactors associated with higher knowledge within each country included: 1)training in acquiring systematic reviews through the Cochrane Library (OR 2.48,95% CI 1.30-4.73); and 2) ability to read and write English well or very well (OR1.69, 95% CI 1.05-2.70). Statistically significant factors associated with betterclinical practices within each country include: 1) reading scientific journalsfrom their own country (OR 1.67, 95% CI 1.10-2.54); 2) working with researchersto improve their clinical practice or quality of working life (OR 1.44, 95% CI1.04-1.98); 3) training on malaria prevention since their last degree (OR 1.68,95% CI 1.17-2.39); and 4) easy access to the internet (OR 1.52, 95% CI1.08-2.14).CONCLUSIONS: Improving healthcare providers' knowledge and practices is anuntapped opportunity for expanding ITN utilization and preventing malaria. Thisstudy points to several strategies that may help bridge the gap between what isknown from research evidence and the knowledge and practices of healthcareproviders. Training on acquiring systematic reviews and facilitating internetaccess may be particularly helpful.

PMCID: PMC3265439PMID: 22165841 [PubMed - indexed for MEDLINE]

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53. Malar J. 2011 Dec 13;10:354. doi: 10.1186/1475-2875-10-354.

Factors associated with mosquito net use by individuals in households owning netsin Ethiopia.

Graves PM, Ngondi JM, Hwang J, Getachew A, Gebre T, Mosher AW, Patterson AE,Shargie EB, Tadesse Z, Wolkon A, Reithinger R, Emerson PM, Richards FO Jr.

The Carter Center, Atlanta, GA, USA. [email protected]

BACKGROUND: Ownership of insecticidal mosquito nets has dramatically increased inEthiopia since 2006, but the proportion of persons with access to such nets whouse them has declined. It is important to understand individual level net usefactors in the context of the home to modify programmes so as to maximize netuse.METHODS: Generalized linear latent and mixed models (GLLAMM) were used toinvestigate net use using individual level data from people living in net-owning households from two surveys in Ethiopia: baseline 2006 included 12,678individuals from 2,468 households and a sub-sample of the Malaria IndicatorSurvey (MIS) in 2007 included 14,663 individuals from 3,353 households.Individual factors (age, sex, pregnancy); net factors (condition, age, netdensity); household factors (number of rooms [2006] or sleeping spaces [2007],IRS, women's knowledge and school attendance [2007 only], wealth, altitude); and cluster level factors (rural or urban) were investigated in univariate andmulti-variable models for each survey.RESULTS: In 2006, increased net use was associated with: age 25-49 years(adjusted (a) OR = 1.4, 95% confidence interval (CI) 1.2-1.7) compared tochildren U5; female gender (aOR = 1.4; 95% CI 1.2-1.5); fewer nets with holes(Ptrend = 0.002); and increasing net density (Ptrend < 0.001). Reduced net usewas associated with: age 5-24 years (aOR = 0.2; 95% CI 0.2-0.3). In 2007,increased net use was associated with: female gender (aOR = 1.3; 95% CI 1.1-1.6);fewer nets with holes (aOR [all nets in HH good] = 1.6; 95% CI 1.2-2.1);increasing net density (Ptrend < 0.001); increased women's malaria knowledge(Ptrend < 0.001); and urban clusters (aOR = 2.5; 95% CI 1.5-4.1). Reduced net usewas associated with: age 5-24 years (aOR = 0.3; 95% CI 0.2-0.4); number ofsleeping spaces (aOR [per additional space] = 0.6, 95% CI 0.5-0.7); more old nets

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(aOR [all nets in HH older than 12 months] = 0.5; 95% CI 0.3-0.7); and increasinghousehold altitude (Ptrend < 0.001).CONCLUSION: In both surveys, net use was more likely by women, if nets had fewer holes and were at higher net per person density within households. School-agechildren and young adults were much less likely to use a net. Increasingavailability of nets within households (i.e. increasing net density), andimproving net condition while focusing on education and promotion of net use,especially in school-age children and young adults in rural areas, are crucialareas for intervention to ensure maximum net use and consequent reduction ofmalaria transmission.

PMCID: PMC3258293PMID: 22165821 [PubMed - indexed for MEDLINE]

54. Am J Trop Med Hyg. 2011 Dec;85(6):1080-6. doi: 10.4269/ajtmh.2011.10-0684.

The combination of indoor residual spraying and insecticide-treated nets providesadded protection against malaria compared with insecticide-treated nets alone.

Hamel MJ, Otieno P, Bayoh N, Kariuki S, Were V, Marwanga D, Laserson KF,Williamson J, Slutsker L, Gimnig J.

Division of Parasitic Diseases and Malaria, Centers for Disease Control andPrevention, Atlanta, Georgia 30301, USA. [email protected]

Both insecticide-treated bed nets (ITNs) and indoor residual spraying (IRS)reduce malaria in high malaria transmission areas. The combined effect of theseinterventions is unknown. We conducted a non-randomized prospective cohort study to determine protective efficacy of IRS with ITNs (ITN + IRS) compared with ITNs alone (ITN only) in preventing Plasmodium falciparum parasitemia. At baseline,participants provided blood samples for malaria smears, were presumptivelytreated for malaria, and received ITNs. Blood smears were made monthly and atsick visits. In total, 1,804 participants were enrolled. Incidence of P.falciparum parasitemia in the ITN + IRS and ITN only groups was 18 and 44infections per 100 persons-years at risk, respectively (unadjusted rate ratio =0.41; 95% confidence interval [CI] = 0.31-0.56). Adjusted protective efficacy of

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ITN + IRS compared with ITN only was 62% (95% CI = 0.50-0.72). The combination ofIRS and ITN might be a feasible strategy to further reduce malaria transmissionin areas of persistent perennial malaria transmission.

PMCID: PMC3225156 [Available on 2012/12/1]PMID: 22144448 [PubMed - indexed for MEDLINE]

55. Acta Trop. 2012 Mar;121(3):166-74. doi: 10.1016/j.actatropica.2011.11.005. Epub2011 Nov 19.

Sahel, savana, riverine and urban malaria in West Africa: Similar controlpolicies with different outcomes.

Ceesay SJ, Bojang KA, Nwakanma D, Conway DJ, Koita OA, Doumbia SO, Ndiaye D,Coulibaly TF, Diakité M, Traoré SF, Coulibaly M, Ndiaye JL, Sarr O, Gaye O,Konaté L, Sy N, Faye B, Faye O, Sogoba N, Jawara M, Dao A, Poudiougou B, Diawara S, Okebe J, Sangaré L, Abubakar I, Sissako A, Diarra A, Kéita M, Kandeh B, LongCA, Fairhurst RM, Duraisingh M, Perry R, Muskavitch MA, Valim C, Volkman SK,Wirth DF, Krogstad DJ.

International Center for Excellence in Malaria Research in West Africa at theMedical Research Council Laboratories, Fajara, Gambia.

The study sites for the West African ICEMR are in three countries (The Gambia,Senegal, Mali) and are located within 750 km of each other. In addition, theNational Malaria Control Programmes of these countries have virtually identicalpolicies: (1) Artemisinin Combination Therapies (ACTs) for the treatment ofsymptomatic Plasmodium falciparum infection, (2) Long-Lasting Insecticide-treatedbed Nets (LLINs) to reduce the Entomololgic Inoculation Rate (EIR), and (3)sulfadoxine-pyrimethamine for the Intermittent Preventive Treatment of malariaduring pregnancy (IPTp). However, the prevalence of P. falciparum malaria and thestatus of malaria control vary markedly across the four sites with differences inthe duration of the transmission season (from 4-5 to 10-11 months), the intensityof transmission (with EIRs from unmeasurably low to 4-5 per person per month),multiplicity of infection (from a mean of 1.0 to means of 2-5) and the status of

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malaria control (from areas which have virtually no control to areas that are at the threshold of malaria elimination). The most important priority is the need toobtain comparable data on the population-based prevalence, incidence andtransmission of malaria before new candidate interventions or combinations ofinterventions are introduced for malaria control.

Copyright © 2011 Elsevier B.V. All rights reserved.

PMCID: PMC3294051 [Available on 2013/3/1]PMID: 22119584 [PubMed - indexed for MEDLINE]

56. Malar J. 2011 Nov 23;10:344. doi: 10.1186/1475-2875-10-344.

What drives community adherence to indoor residual spraying (IRS) against malariain Manhiça district, rural Mozambique: a qualitative study.

Munguambe K, Pool R, Montgomery C, Bavo C, Nhacolo A, Fiosse L, Sacoor C,Nhalungo D, Mabunda S, Macete E, Alonso P.

Centro de Investigação em Saúde de Manhiça, Rua 12, CP 1929 Manhiça, Mozambique. [email protected]

BACKGROUND: Malaria control remains a challenge in sub-Saharan Africa. In 2006,the World Health Organization (WHO) reinforced the recommendation of indoorresidual spraying (IRS) with dichlorodiphenyltrichloroethane (DDT) to reducemalaria transmission. The National Malaria Control Programme has been reportinghigh coverage rates of IRS in Mozambique. It is important to establish to whatextent these rates are a reflection of community acceptability, and to explorethe factors associated with adherence, in order to recommend suitable approaches for interventions of this nature.OBJECTIVE: To understand the implementation process, reception and acceptability of the IRS program in Manhiça district, Southern Mozambique.METHODS: Qualitative data was collected through in-depth interviews, participant observation of IRS activities, informal interviews, and focus group discussions. Study participants comprised householders, community leaders, health careproviders, sprayers, and community members. Qualitative data analysis was basedon grounded theory. Secondary data from the Manhiça Demographic SurveillanceSystem was used to complement the qualitative data.

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RESULTS: IRS was well received in most neighbourhoods. The overall coverage ratesvaried between 29% and 41% throughout the study period. The factors related toadherence to IRS were: immediate impact on insects in general, trust andobedience in the health authority, community leaders' influence, and acquaintancewith the sprayers. Fighting malaria was not an important motivation for IRSadherence. There was a perception of limited efficacy of IRS against mosquitoes, but this did not affect adherence. Non-adherence to the intervention was mainlydue to the unavailability of key householders, disagreement with the procedures, and the perception that spraying increased the burden of insects. Mostrespondents strongly favoured bed nets over IRS.CONCLUSION: The study suggests that the contribution of IRS to malaria andmosquito control is not entirely perceived by the beneficiaries, and that otheras cost effective interventions such as insecticide-treated nets are favouredover IRS. Adherence to IRS was found to be influenced by socio-political factors.There is a need to redefine the community sensitization approaches in order tomake IRS a genuinely participative, acceptable, and sustainable programme.

PMCID: PMC3339361PMID: 22111698 [PubMed - indexed for MEDLINE]

57. PLoS One. 2011;6(11):e27516. doi: 10.1371/journal.pone.0027516. Epub 2011 Nov 11.

Infections in infants during the first 12 months of life: role of placentalmalaria and environmental factors.

Le Port A, Watier L, Cottrell G, Ouédraogo S, Dechavanne C, Pierrat C, Rachas A, Bouscaillou J, Bouraima A, Massougbodji A, Fayomi B, Thiébaut A, Chandre F,Migot-Nabias F, Martin-Prevel Y, Garcia A, Cot M.

UMR216 Mère et enfant face aux infections tropicales, Institut de Recherche pour le Développement, Paris, France. [email protected]

BACKGROUND: The association between placental malaria (PM) and first peripheralparasitaemias in early infancy was assessed in Tori Bossito, a rural area ofBenin with a careful attention on transmission factors at an individual level.

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METHODOLOGY: Statistical analysis was performed on 550 infants followed weeklyfrom birth to 12 months. Malaria transmission was assessed by anopheles humanlanding catches every 6 weeks in 36 sampling houses and season defined byrainfall. Each child was located by GPS and assigned to the closest anophelessampling house. Data were analysed by survival Cox models, stratified on thepossession of insecticide-treated mosquito nets (ITNs) at enrolment.PRINCIPAL FINDINGS: Among infants sleeping in a house with an ITN, PM was foundto be highly associated to first malaria infections, after adjusting on season,number of anopheles, antenatal care (ANC) visits and maternal severe anaemia.Infants born from a malaria infected placenta had a 2.13 fold increased risk topresent a first malaria infection than those born from a non infected placenta([1.24-3.67], p<0.01) when sleeping in a house with an ITN. The risk to present afirst malaria infection was increased by 3.2 to 6.5, according to the level ofanopheles exposure (moderate or high levels, compared to the absence ofanopheles).CONCLUSIONS: First malaria infections in early childhood can be attributedsimultaneously to both PM and high levels of exposure to infected anopheles.Protective measures as Intermittent Preventive Treatment during pregnancy (IPTp) and ITNs, targeted on both mothers and infants should be reinforced, as well asthe research on new drugs and insecticides. In parallel, investigations onplacental malaria have to be strengthened to better understand the mechanismsinvolved, and thus to protect adequately the infants high risk group.

PMCID: PMC3214070PMID: 22096588 [PubMed - indexed for MEDLINE]

58. PLoS One. 2011;6(11):e26746. doi: 10.1371/journal.pone.0026746. Epub 2011 Nov 11.

Effect of transmission reduction by insecticide-treated bednets (ITNs) onantimalarial drug resistance in western Kenya.

Shah M, Kariuki S, Vanden Eng J, Blackstock AJ, Garner K, Gatei W, Gimnig JE,Lindblade K, Terlouw D, ter Kuile F, Hawley WA, Phillips-Howard P, Nahlen B,Walker E, Hamel MJ, Slutsker L, Shi YP.

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Division of Parasitic Diseases and Malaria, Center for Global Health, Centers forDisease Control and Prevention, Atlanta, Georgia, United States of America.

Despite the clear public health benefit of insecticide-treated bednets (ITNs),the impact of malaria transmission-reduction by vector control on the spread ofdrug resistance is not well understood. In the present study, the effect ofsustained transmission reduction by ITNs on the prevalence of Plasmodiumfalciparum gene mutations associated with resistance to the antimalarial drugssulfadoxine-pyrimethamine (SP) and chloroquine (CQ) in children under the age of five years was investigated during an ITN trial in Asembo area, western Kenya.During the ITN trial, the national first line antimalarial treatment changed fromCQ to SP. Smear-positive samples collected from cross sectional surveys prior to ITN introduction (baseline, n = 250) and five years post-ITN intervention (year 5survey, n = 242) were genotyped for single nucleotide polymorphisms (SNPs) atdhfr-51, 59, 108, 164 and dhps-437, 540 (SP resistance), and pfcrt-76 andpfmdr1-86 (CQ resistance). The association between the drug resistance mutations and epidemiological variables was evaluated. There were significant increases in the prevalence of SP dhps mutations and the dhfr/dhps quintuple mutant, and asignificant reduction in the proportion of mixed infections detected at dhfr-51, 59 and dhps-437, 540 SNPs from baseline to the year 5 survey. There was no changein the high prevalence of pfcrt-76 and pfmdr1-86 mutations. Multivariableregression analysis further showed that current antifolate use and year of surveywere significantly associated with more SP drug resistance mutations. Theseresults suggest that increased antifolate drug use due to drug policy changelikely led to the high prevalence of SP mutations 5 years post-ITN interventionand reduced transmission had no apparent effect on the existing high prevalenceof CQ mutations. There is no evidence from the current study that sustainedtransmission reduction by ITNs reduces the prevalence of genes associated withmalaria drug resistance.

PMCID: PMC3214025PMID: 22096496 [PubMed - indexed for MEDLINE]

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59. Educ Health (Abingdon). 2011 Aug;24(2):474. Epub 2011 Jul 22.

A community health worker program for the prevention of malaria in eastern Kenya.

Stromberg DG, Frederiksen J, Hruschka J, Tomedi A, Mwanthi M.

University of New Mexico Albuquerque, New Mexico, USA. [email protected]

OBJECTIVE: To assess whether the development and implementation of a communityhealth worker (CHW) project in rural Kenya was associated with an increase inknowledge about malaria and the use of insecticide-treated nets (ITNs) inchildren under five years of age.METHODS: A baseline knowledge and behavior questionnaire, adopted from the KenyanDemographic Health Survey, was conducted in August 2007 by Kenyan healthofficials in 75 villages. Two CHWs were chosen from each village and trained inappropriate use of ITNs. The CHWs provided educational sessions and ITNs tomothers in their respective villages. A follow-up survey was conducted in March2008 of all families with children less than five years of age within randomlyselected villages. The main questions addressed during the follow-up surveyincluded knowledge about malaria and the practice of correctly using ITNs.FINDINGS: There were 267 surveys compiled for knowledge assessment before theintervention and 340 in the post-intervention analysis with an approximate 99%family participation rate. Of the families surveyed, 81% correctly knew the causefor malaria before the study and 93% after the CHW intervention (p < 0.01). Ofthose surveyed before the intervention, 70% owned and correctly used mosquitonets compared with 88% after the CHW intervention (p < 0.01).CONCLUSIONS: There was a significant increase in knowledge about malaria and use of ITNs after the implementation of the CHW program.

PMID: 22081652 [PubMed - indexed for MEDLINE]

60. Malar J. 2011 Nov 13;10:341. doi: 10.1186/1475-2875-10-341.

Who attends antenatal care and expanded programme on immunization services inChad, Mali and Niger? The implications for insecticide-treated net delivery.

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Carlson M, Smith Paintain L, Bruce J, Webster J, Lines J.

Department of Disease Control, London School of Hygiene and Tropical Medicine,Keppel Street, London WC1E 7HT, UK. [email protected]

BACKGROUND: Malaria remains one of the largest public health problems facing the developing world. Insecticide-treated nets (ITNs) are an effective interventionagainst malaria. ITN delivery through routine health services, such as antenatal care (ANC) and childhood vaccination (EPI), is a promising channel of delivery toreach individuals with the highest risk (pregnant women and children under fiveyears old). Decisions on whether to deliver ITNs through both channels dependsupon the reach of each of these systems, whether these are independent and theeffectiveness and cost effectiveness of each. Predictors of women attending ANCand EPI separately have been studied, but the predictors of those who attendneither service have not been identified.METHODS: Data from Chad, Mali and Niger demographic and health surveys (DHS) wereanalyzed to determine risk factors for attending neither service. A conceptualframework for preventative health care-seeking behaviour was created toillustrate the hierarchical relationships between the potential risk factors. Theindependence of attending both ANC and EPI was investigated. A multivariate modelof predictors for non-attendance was developed using logistic regression.RESULTS: ANC and EPI attendance were found to be strongly associated in all threecountries. However, 47% of mothers in Chad, 12% in Mali and 36% in Niger did not attend either ANC or EPI. Region, mother's education and partner's education werepredictors of non-attendance in all three countries. Wealth index, ethnicity, andoccupation were associated with non-attendance in Mali and Niger. Otherpredictors included religion, healthcare autonomy, household size and number ofchildren under five.CONCLUSIONS: Attendance of ANC and EPI are not independent and therefore themajority of pregnant women in these countries will have the opportunity toreceive ITNs through both services. Although attendance at ANC and EPI are notindependent, delivery through both systems may still add incrementally todelivery through one alone. Therefore, there is potential to increase theproportion of women and children receiving ITNs by delivering through both of

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these channels. However, modelling is required to determine the level ofattendance and incremental potential at which it's cost effective to deliverthrough both services.

41. Malar J. 2012 Jan 11;11:18. doi: 10.1186/1475-2875-11-18.

Distance to health services influences insecticide-treated net possession and useamong six to 59 month-old children in Malawi.

Larson PS, Mathanga DP, Campbell CH Jr, Wilson ML.

Department of Epidemiology, School of Public Health, University of Michigan, 09Observatory, Ann Arbor, MI 48109-2029, USA. [email protected]

BACKGROUND: Health ministries and providers are rapidly scaling upinsecticide-treated nets (ITN) distribution to control malaria, yet possessionand proper use typically remain below targeted levels. In Malawi, healthfacilities (HFs) are currently the principal points of ITN distribution, makingit important to understand how access to these ITN sources affects ownership,possession, and use. The authors evaluated the association between proximity toHFs and ITN possession or use among Malawian children six to 59 months of age.METHODS: A household malaria survey undertaken in eight districts of Malawiduring 2007 was used to characterize ITN possession and use. The location of eachrespondent's household was geocoded as was those of Ministry of Health (MoH) HFs and other health centres. Euclidean distance from each household to the nearestHF was calculated. Patterns of net possession and use were determined throughdescriptive methods. The authors then analysed the significance of distance andITN possession/use through standard statistical tests, including logisticregression.RESULTS: Median distance to HFs was greater among households that did not possessITNs and did not use an ITN the previous evening. Descriptive statistical methodsconfirmed a pattern of decreasing ITN possession and use with increasing distancefrom HFs. Logistic regression showed the same statistically significantassociation of distance to HFs, even when controlling for age and gender of thechild, ratio of nets to children in household, community net possession and use, and household material wealth.CONCLUSIONS: Strategies that exclusively distribute ITNs through HFs are likely

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to be less effective in increasing possession and use in communities that aremore distant from those health services. Health providers should look towardscommunity-based distribution services that take ITNs directly to communitymembers to more effectively scale up ITN possession and regular use aimed atprotecting children from malaria.

PMCID: PMC3283522PMID: 22236395 [PubMed - indexed for MEDLINE]

42. Malar J. 2012 Jan 11;11:17. doi: 10.1186/1475-2875-11-17.

Target product profiles for protecting against outdoor malaria transmission.

Killeen GF, Moore SJ.

Biomedical and Environmental Thematic Group, Ifakara Health Institute, PO Box 53,Ifakara, Morogoro, United Republic of Tanzania. [email protected]

BACKGROUND: Long-lasting insecticidal nets (LLINs) and indoor residual sprays(IRS) have decimated malaria transmission by killing indoor-feeding mosquitoes.However, complete elimination of malaria transmission with these proven methodsis confounded by vectors that evade pesticide contact by feeding outdoors.METHODS: For any assumed level of indoor coverage and personal protectiveefficacy with insecticidal products, process-explicit malaria transmission modelssuggest that insecticides that repel mosquitoes will achieve less impact upontransmission than those that kill them outright. Here such models are extended toexplore how outdoor use of products containing either contact toxins or spatialrepellents might augment or attenuate impact of high indoor coverage of LLINsrelying primarily upon contact toxicity.RESULTS: LLIN impact could be dramatically enhanced by high coverage with spatialrepellents conferring near-complete personal protection, but only if combinedindoor use of both measures can be avoided where vectors persist that preferfeeding indoors upon humans. While very high levels of coverage and efficacy willbe required for spatial repellents to substantially augment the impact of LLINsor IRS, these ambitious targets may well be at least as practically achievable as

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the lower requirements for equivalent impact using contact insecticides.CONCLUSIONS: Vapour-phase repellents may be more acceptable, practical andeffective than contact insecticides for preventing outdoor malaria transmissionbecause they need not be applied to skin or clothing and may protect multipleoccupants of spaces outside of treatable structures such as nets or houses.

PMCID: PMC3298720PMID: 22236388 [PubMed - indexed for MEDLINE]

43. Am J Trop Med Hyg. 2012 Jan;86(1):96-8. doi: 10.4269/ajtmh.2012.11-0397.

Rolling Malaria Indicator Surveys (rMIS): a potential district-level malariamonitoring and evaluation (M&E) tool for program managers.

Roca-Feltrer A, Lalloo DG, Phiri K, Terlouw DJ.

Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, [email protected]

Novel malaria monitoring and evaluation (M&E) tools are urgently needed tocomplement the current "gold standard" Malaria Indicator Surveys (MIS). Rapid up scaling of malaria control efforts is resulting in substantial reductions inmalaria burden across sub-Saharan Africa. As transmission goes down, timely,accurate, sub-national, and district level burden estimates are needed to guideincreasingly targeted control efforts in remaining hotspot areas. To test a noveldistrict level M&E tool, we have conducted a continuous ("rolling") MIS (rMIS)since May 2010 covering 50 villages in Chikhwawa district in southern Malawi,essentially adapting an existing cross-sectional evaluation tool into acontinuous monitoring tool. Here, we report on our experience after completingthe first full year of monthly data collection focusing on the methods,operational aspects, and estimated costs of rMIS in a programmatic setting. Thepotential applicability of this promising M&E approach for district-level programmanagers and control efforts is discussed.

PMCID: PMC3247115PMID: 22232457 [PubMed - indexed for MEDLINE]

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44. Malar J. 2012 Jan 9;11:9. doi: 10.1186/1475-2875-11-9.

Malaria control in Bhutan: case study of a country embarking on elimination.

Yangzom T, Gueye CS, Namgay R, Galappaththy GN, Thimasarn K, Gosling R,Murugasampillay S, Dev V.

Vector-Borne Disease Control Programme, Ministry of Health, Royal Government ofBhutan, Gelephu, Bhutan.

BACKGROUND: Bhutan has achieved a major reduction in malaria incidence amidmultiple challenges. This case study seeks to characterize the Bhutan malariacontrol programme over the last 10 years.METHODS: A review of the malaria epidemiology, control strategies, andelimination strategies employed in Bhutan was carried out through a literaturereview of peer-reviewed and grey national and international literature with theaddition of reviewing the surveillance and vector control records of the BhutanVector-Borne Disease Control Programme (VDCP). Data triangulation was used toidentify trends in epidemiology and key strategies and interventions throughanalysis of the VDCP surveillance and programme records and the literaturereview. Enabling and challenging factors were identified through analysis ofsocio-economic and health indicators, corroborated through a review of nationaland international reports and peer-review articles.FINDINGS: Confirmed malaria cases in Bhutan declined by 98.7% from 1994 to 2010. The majority of indigenous cases were due to Plasmodium vivax (59.9%) and adultmales are most at-risk of malaria. Imported cases, or those in foreign nationals,varied over the years, reaching 21.8% of all confirmed cases in 2006. Strategies implemented by the VDCP are likely to be related to the decline in cases over thelast 10 years. Access to malaria diagnosis in treatment was expanded throughoutthe country and evidence-based case management, including the introduction ofartemisinin-based combination therapy (ACT) for P. falciparum, increasingcoverage of high risk areas with Indoor Residual Spraying, insecticide-treatedbed nets, and long-lasting insecticidal nets are likely to have contributed tothe decline alongside enabling factors such as economic development andincreasing access to health services.

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CONCLUSION: Bhutan has made significant strides towards elimination and hasadopted a goal of national elimination. A major challenge in the future will beprevention and management of imported malaria infections from neighbouring Indianstates. Bhutan plans to implement screening at border points to preventimportation of malaria and to targeted prevention and surveillance effortstowards at-risk Bhutanese and migrant workers in construction sites.

PMCID: PMC3278342PMID: 22230355 [PubMed - indexed for MEDLINE]

45. Malar J. 2012 Jan 6;11:8. doi: 10.1186/1475-2875-11-8.

The effect of household heads training about the use of treated bed nets on theburden of malaria and anaemia in under-five children: a cluster randomized trial in Ethiopia.

Deribew A, Birhanu Z, Sena L, Dejene T, Reda AA, Sudhakar M, Alemseged F, TessemaF, Zeynudin A, Biadgilign S, Deribe K.

Department of Epidemiology, Jimma University, Jimma, [email protected]

BACKGROUND: Long-lasting insecticide-treated bed nets (LLITN) have demonstrated asignificant effect in reducing malaria-related morbidity and mortality. However, barriers on the utilization of LLITN have hampered the desired outcomes. The aim of this study was to assess the effect of community empowerment on the burden of malaria and anaemia in under-five children in Ethiopia.METHODS: A cluster randomized trial was done in 22 (11 intervention and 11control) villages in south-west Ethiopia. The intervention consisted of tailored training of household heads about the proper use of LLITN and community networksystem. The burden of malaria and anaemia in under-five children was determinedthrough mass blood investigation at baseline, six and 12 months of the projectperiod. Cases of malaria and anaemia were treated based on the national protocol.The burden of malaria and anaemia between the intervention and control villageswas compared using the complex logistic regression model by taking into accountthe clustering effect. Eight Focus group discussions were conducted to complement

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the quantitative findings.RESULTS: A total of 2,105 household heads received the intervention and theprevalence of malaria and anaemia was assessed among 2410, 2037 and 2612under-five children at baseline, six and 12 months of the project periodrespectively. During the high transmission/epidemic season, children in theintervention arm were less likely to have malaria as compared to children in the control arm (OR = 0.42; 95%CI: 0.32, 0.57). Symptomatic malaria also steadilydeclined in the intervention villages compared to the control villages in thefollow up periods. Children in the intervention arm were less likely to beanaemic compared to those in the control arm both at the high (OR = 0.84; 95%CI: 0.71, 0.99)) and low (OR = 0.73; 95%CI: 0.60, 0.89) transmission seasons.CONCLUSION: Training of household heads on the utilization of LLITN significantlyreduces the burden of malaria in under-five children. The Ministry of Health ofEthiopia in collaboration with other partners should design similar strategies inhigh-risk areas to control malaria in Ethiopia.TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12610000035022.

PMCID: PMC3274442PMID: 22225997 [PubMed - indexed for MEDLINE]

46. Bull Math Biol. 2012 May;74(5):1098-124. doi: 10.1007/s11538-011-9710-0. Epub2012 Jan 5.

A periodically-forced mathematical model for the seasonal dynamics of malaria in mosquitoes.

Chitnis N, Hardy D, Smith T.

Department of Epidemiology and Public Health, Swiss Tropical and Public HealthInstitute, Basel, Switzerland. [email protected]

We describe and analyze a periodically-forced difference equation model formalaria in mosquitoes that captures the effects of seasonality and allows themosquitoes to feed on a heterogeneous population of hosts. We numerically showthe existence of a unique globally asymptotically stable periodic orbit andcalculate periodic orbits of field-measurable quantities that measure malaria

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transmission. We integrate this model with an individual-based stochasticsimulation model for malaria in humans to compare the effects ofinsecticide-treated nets (ITNs) and indoor residual spraying (IRS) in reducingmalaria transmission, prevalence, and incidence. We show that ITNs are moreeffective than IRS in reducing transmission and prevalence though IRS wouldachieve its maximal effects within 2 years while ITNs would need two massdistribution campaigns over several years to do so. Furthermore, the combination of both interventions is more effective than either intervention alone. However, although these interventions reduce transmission and prevalence, they can lead toincreased clinical malaria; and all three malaria indicators return topreintervention levels within 3 years after the interventions are withdrawn.

PMCID: PMC3339865PMID: 22218880 [PubMed - indexed for MEDLINE]

47. Malar J. 2011 Dec 20;10:379. doi: 10.1186/1475-2875-10-379.

Rapid assessment of the performance of malaria control strategies implemented by countries in the Amazon subregion using adequacy criteria: case study.

Flores W, Chang J, Barillas E.

Strengthening Pharmaceutical Systems/Management Sciences for Health, 6a avenida11-77 zona 10, Edificio Punto Diez oficina 1 F Guatemala City, [email protected]

BACKGROUND: The objective of this study was to implement a rapid assessment ofthe performance of four malaria control strategies (indoor spraying,insecticide-treated bed nets, timely diagnosis, and artemisinin-based combinationtherapy) using adequacy criteria. The assessment was carried out in fivecountries of the Amazon subregion (Bolivia, Colombia, Ecuador, Guyana, and Peru).METHODS: A list of criteria in three areas was created for each of the fourstrategies: preliminary research that supports the design and adaptation of thecontrol strategies, coverage of the control strategies and quality of theimplementation of the strategies. The criteria were selected by the research teamand based on the technical guidelines established by the World HealthOrganization. Each criterion included in the four lists was graded relative towhether evidence exists that the criterion is satisfied (value 1), not satisfied

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(value 0) or partially satisfied (value 0.5). The values obtained were added and reported according to a scale of three implementation categories: adequate,intermediate and deficient.RESULTS: Implementation of residual indoor spraying and timely diagnosis wasadequate in one country and intermediate or deficient in the rest.Insecticide-treated bed nets ranged between deficient and intermediate in all thecountries, while implementation of artemisinin-based combination therapy (ACT)was adequate in three countries and intermediate in the other two countriesevaluated.CONCLUSIONS: Although ACT is the strategy with the better implementation in allcountries, major gaps exist in implementation of the other three malaria control strategies in terms of technical criteria, coverage and quality desired. Thecountries must implement action plans to close the gaps in the various criteriaand thereby improve the performance of the interventions. The assessment toolsdeveloped, based on adequacy criteria, are considered useful for a rapidassessment by malaria control authorities in the different countries.

PMCID: PMC3297539PMID: 22185638 [PubMed - indexed for MEDLINE]

48. Bull Soc Pathol Exot. 2012 Feb;105(1):36-9. doi: 10.1007/s13149-011-0193-x. Epub 2011 Dec 16.

[Evaluation of the use of insecticide-treated nets and intermittent preventivetreatment in three health zones in Benin].

[Article in French]

Kinde-Gazard D, Vignon Makong J, Kossou HD, Sossa CJ.

Université d'Abomey-Calavi, Cotonou, Bénin. [email protected]

This study aims to evaluate the results of the Project to Support the Fightagainst Malaria in the departments of Mono and Couffo in Benin oninsecticide-treated nets (ITNs) use by children under 5 years and pregnant women and the coverage by Intermittent Preventive Treatment (IPT) withSulfadoxin-Pyrimethamin (SP). This assessment is made from two household surveys.The first at the start up and the second after fifteen months of implementation. The availability of ITN in households and their use by pregnant women and

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children under 5 years have increased respectively from 8, 5 and 4% in 2005 to24, 31 and 16 % in 2006. The percentage of pregnant women under IPT withsulfadoxine-pyrimethamine (SP) is 10% while 21% of pregnant women received atleast one dose of SP. The availability of ITN in households and their use bychildren under 5 years and the prevention of malaria during pregnancy remains aconcern in these health areas. The promotion of long lasting insecticide treated nets with effective communication strategies for behavior change could improvethe results. Research on causes of poor compliance of IPT should be emphasized aswell as strengthening management of drugs in health centers.

PMID: 22180050 [PubMed - indexed for MEDLINE]

49. Malar J. 2011 Dec 13;10:353. doi: 10.1186/1475-2875-10-353.

Larval source management for malaria control in Africa: myths and reality.

Fillinger U, Lindsay SW.

Department of Disease Control, London School of Hygiene and Tropical Medicine,Keppel Street, London WC1E 7HT, UK. [email protected]

As malaria declines in many African countries there is a growing realization thatnew interventions need to be added to the front-line vector control tools oflong-lasting impregnated nets (LLINs) and indoor residual spraying (IRS) thattarget adult mosquitoes indoors. Larval source management (LSM) provides the dualbenefits of not only reducing numbers of house-entering mosquitoes, but,importantly, also those that bite outdoors. Large-scale LSM was a highlyeffective method of malaria control in the first half of the twentieth century,but was largely disbanded in favour of IRS with DDT. Today LSM continues to beused in large-scale mosquito abatement programmes in North America and Europe,but has only recently been tested in a few trials of malaria control incontemporary Africa. The results from these trials show that hand-application of larvicides can reduce transmission by 70-90% in settings where mosquito larvalhabitats are defined but is largely ineffectual where habitats are so extensivethat not all of them can be covered on foot, such as areas that experience

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substantial flooding. Importantly recent evidence shows that LSM can be aneffective method of malaria control, especially when combined with LLINs.Nevertheless, there are a number of misconceptions or even myths that hamper the advocacy for LSM by leading international institutions and the uptake of LSM byMalaria Control Programmes. Many argue that LSM is not feasible in Africa due to the high number of small and temporary larval habitats for Anopheles gambiae thatare difficult to find and treat promptly. Reference is often made to theRoss-Macdonald model to reinforce the view that larval control is ineffective.This paper challenges the notion that LSM cannot be successfully used for malariacontrol in African transmission settings by highlighting historical and recentsuccesses, discussing its potential in an integrated vector management approachworking towards malaria elimination and critically reviewing the most commonarguments that are used against the adoption of LSM.

PMCID: PMC3273449PMID: 22166144 [PubMed - indexed for MEDLINE]

50. Malar J. 2011 Dec 13;10:357. doi: 10.1186/1475-2875-10-357.

Free distribution of insecticidal bed nets improves possession and preferentialuse by households and is equitable: findings from two cross-sectional surveys in thirteen malaria endemic districts of Bangladesh.

Ahmed SM, Hossain S, Kabir MM, Roy S.

Research and Evaluation Division, BRAC Centre, 75 Mohakhali, Dhaka Dhaka-1212,Bangladesh. [email protected]

BACKGROUND: BRAC, an indigenous non-governmental development organization (NGO), has been implementing a programme to prevent and control malaria in the 13malaria-endemic districts of Bangladesh since 2007. One of the criticalpreventive interventions is the distribution of insecticidal bed nets(long-lasting insecticide-treated nets, LLINs and insecticide-treated ordinarynets, ITNs) to the community free of cost. This study aimed to assess progress inthe possession, preferential use, and knowledge on use of the LLIN/ITNs includingthe programme's avowed pro-poor inclination one and three and half years afterintervention began.

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METHODS: A convenient sampling strategy based on malaria endemicity in thedistricts was adopted. First, thirty upazila (sub-district, with a populationaround 250,000)s were selected at random, with high prevalent districtscontributing more upazilas; second, from each upazila, one (2008) to two (2011)villages (covered by insecticidal bed net distribution programme) were selected. From each village, households that had either one under-five child and/or apregnant woman were included in the survey, one household being included onlyonce. Data were collected using a pre-tested structured questionnaire.RESULTS: In all, 3,760 households in 2008 and 7,895 households in 2011 weresurveyed for collecting relevant information. Proportion of households with atleast one LLIN, and at least one LLIN/ITN increased (22-59 to 62-67% and 22-64%to 74-76% respectively) over time, including increase in the mean number ofLLIN/ITNs per household (≤ 1 to 1 +). The programme achieved > 80% coverage insleeping under an LLIN/ITN in the case of under-five children and pregnant women,especially in the high-endemic districts. Knowledge regarding critical time ofhanging the net also increased over time (7-22 to 44-54%), but remained low. The pro-poor inclination of the programme is reflected in the status of relevantindicators according to self-rated poverty status of the households.CONCLUSIONS: There has been a substantial improvement in possession and usage of insecticidal bed nets especially for the two most vulnerable groups (under-fivechildren and pregnant women), including a reduction of gaps between the high and low endemic districts, and the deficit and non-deficit households during thestudy period.

PMCID: PMC3266224PMID: 22165959 [PubMed - indexed for MEDLINE]

51. Malar J. 2011 Dec 13;10:356. doi: 10.1186/1475-2875-10-356.

Impact of insecticide-treated bed nets on malaria transmission indices on thesouth coast of Kenya.

Mutuku FM, King CH, Mungai P, Mbogo C, Mwangangi J, Muchiri EM, Walker ED, KitronU.

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Department of Environmental Studies, Emory University, Atlanta, Georgia, [email protected]

BACKGROUND: Besides significantly reducing malaria vector densities, prolongedusage of bed nets has been linked to decline of Anopheles gambiae s.s. relativeto Anopheles arabiensis, changes in host feeding preference of malaria vectors,and behavioural shifts to exophagy (outdoor biting) for the two important malariavectors in Africa, An. gambiae s.l. and Anopheles funestus. In southern coastalKenya, bed net use was negligible in 1997-1998 when Anopheles funestus and An.gambiae s.s. were the primary malaria vectors, with An. arabiensis and Anopheles merus playing a secondary role. Since 2001, bed net use has increasedprogressively and reached high levels by 2009-2010 with corresponding decline in malaria transmission.METHODS: To evaluate the impact of the substantial increase in household bed net use within this area on vector density, vector composition, and human-vectorcontact, indoor and outdoor resting mosquitoes were collected in the same region during 2009-2010 using pyrethrum spray catches and clay pots for indoor andoutdoor collections respectively. Information on bed net use per sleeping spaces and factors influencing mosquito density were determined in the same houses usingPoisson regression analysis. Species distribution was determined, and number ofmosquitoes per house, human-biting rates (HBR), and entomological inoculationrate (EIR) were compared to those reported for the same area during 1997-1998,when bed net coverage had been minimal.RESULTS: Compared to 1997-1998, a significant decline in the relative proportion of An. gambiae s.s. among collected mosquitoes was noted, coupled with aproportionate increase of An. arabiensis. Following > 5 years of 60-86% coverage with bed nets, the density, human biting rate and EIR of indoor restingmosquitoes were reduced by more than 92% for An. funestus and by 75% for An.gambiae s.l. In addition, the host feeding choice of both vectors shifted moretoward non-human vertebrates. Besides bed net use, malaria vector abundance wasalso influenced by type of house construction and according to whether one sleepson a bed or a mat (both of these are associated with household wealth). Mosquito

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density was positively associated with presence of domestic animals.CONCLUSIONS: These entomological indices indicate a much reduced human bitingrate and a diminishing role of An. gambiae s.s. in malaria transmission followinghigh bed net coverage. While increasing bed net coverage beyond the currentlevels may not significantly reduce the transmission potential of An. arabiensis,it is anticipated that increasing or at least sustaining high bed net coveragewill result in a diminished role for An. funestus in malaria transmission.

PMCID: PMC3322380PMID: 22165904 [PubMed - indexed for MEDLINE]

52. Malar J. 2011 Dec 13;10:363. doi: 10.1186/1475-2875-10-363.

Assessing healthcare providers' knowledge and practices relating toinsecticide-treated nets and the prevention of malaria in Ghana, Laos, Senegaland Tanzania.

Hoffman SJ, Guindon GE, Lavis JN, Ndossi GD, Osei EJ, Sidibe MF, Boupha B;Research to Policy & Practice Study Team.

Collaborators: Lavis JN, Guindon G, Cameron D, Hoffman SJ, Shi G, Qiu T, Osei EJ,Dovlo K, Yesudian CA, Ramachandran P, Malek-Afzali H, Dejman M, Falahat K,Baradaran M, Habibi E, Kohanzad H, Nasehi M, Salek S, Akanov AA, Turdaliyeva BS, Hamzina NK, Tulebaev KA, Clazhneva TI, Battakova G, Boupha B, Kounnavong S,Siengsounthone L, Becerra-Posada F, Ramos LA, Mejia I, Akhtar T, Khan MM, Sidibe MF, Sidibe A, Ndiaye D, Ndossi GD, Massaga J, Sadana R, Pang T.

McMaster Health Forum, McMaster University, Hamilton, Ontario, Canada.

BACKGROUND: Research evidence is not always being disseminated to healthcareproviders who need it to inform their clinical practice. This can result in theprovision of ineffective services and an inefficient use of resources, theimplications of which might be felt particularly acutely in low- andmiddle-income countries. Malaria prevention is a particularly compelling domainto study evidence/practice gaps given the proven efficacy, cost-effectiveness anddisappointing utilization of insecticide-treated nets (ITNs).METHODS: This study compares what is known about ITNs to the related knowledge

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and practices of healthcare providers in four low- and middle-income countries. Anew questionnaire was developed, pilot tested, translated and administered to 497healthcare providers in Ghana (140), Laos (136), Senegal (100) and Tanzania(121). Ten questions tested participants' knowledge and clinical practice relatedto malaria prevention. Additional questions addressed their individualcharacteristics, working context and research-related activities. Ordinallogistic regressions with knowledge and practices as the dependent variable were conducted in addition to descriptive statistics.RESULTS: The survey achieved a 75% response rate (372/497) across Ghana(107/140), Laos (136/136), Senegal (51/100) and Tanzania (78/121). Fewparticipating healthcare providers correctly answered all five knowledgequestions about ITNs (13%) or self-reported performing all five clinicalpractices according to established evidence (2%). Statistically significantfactors associated with higher knowledge within each country included: 1)training in acquiring systematic reviews through the Cochrane Library (OR 2.48,95% CI 1.30-4.73); and 2) ability to read and write English well or very well (OR1.69, 95% CI 1.05-2.70). Statistically significant factors associated with betterclinical practices within each country include: 1) reading scientific journalsfrom their own country (OR 1.67, 95% CI 1.10-2.54); 2) working with researchersto improve their clinical practice or quality of working life (OR 1.44, 95% CI1.04-1.98); 3) training on malaria prevention since their last degree (OR 1.68,95% CI 1.17-2.39); and 4) easy access to the internet (OR 1.52, 95% CI1.08-2.14).CONCLUSIONS: Improving healthcare providers' knowledge and practices is anuntapped opportunity for expanding ITN utilization and preventing malaria. Thisstudy points to several strategies that may help bridge the gap between what isknown from research evidence and the knowledge and practices of healthcareproviders. Training on acquiring systematic reviews and facilitating internetaccess may be particularly helpful.

PMCID: PMC3265439PMID: 22165841 [PubMed - indexed for MEDLINE]

53. Malar J. 2011 Dec 13;10:354. doi: 10.1186/1475-2875-10-354.

Factors associated with mosquito net use by individuals in households owning netsin Ethiopia.

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Graves PM, Ngondi JM, Hwang J, Getachew A, Gebre T, Mosher AW, Patterson AE,Shargie EB, Tadesse Z, Wolkon A, Reithinger R, Emerson PM, Richards FO Jr.

The Carter Center, Atlanta, GA, USA. [email protected]

BACKGROUND: Ownership of insecticidal mosquito nets has dramatically increased inEthiopia since 2006, but the proportion of persons with access to such nets whouse them has declined. It is important to understand individual level net usefactors in the context of the home to modify programmes so as to maximize netuse.METHODS: Generalized linear latent and mixed models (GLLAMM) were used toinvestigate net use using individual level data from people living in net-owning households from two surveys in Ethiopia: baseline 2006 included 12,678individuals from 2,468 households and a sub-sample of the Malaria IndicatorSurvey (MIS) in 2007 included 14,663 individuals from 3,353 households.Individual factors (age, sex, pregnancy); net factors (condition, age, netdensity); household factors (number of rooms [2006] or sleeping spaces [2007],IRS, women's knowledge and school attendance [2007 only], wealth, altitude); and cluster level factors (rural or urban) were investigated in univariate andmulti-variable models for each survey.RESULTS: In 2006, increased net use was associated with: age 25-49 years(adjusted (a) OR = 1.4, 95% confidence interval (CI) 1.2-1.7) compared tochildren U5; female gender (aOR = 1.4; 95% CI 1.2-1.5); fewer nets with holes(Ptrend = 0.002); and increasing net density (Ptrend < 0.001). Reduced net usewas associated with: age 5-24 years (aOR = 0.2; 95% CI 0.2-0.3). In 2007,increased net use was associated with: female gender (aOR = 1.3; 95% CI 1.1-1.6);fewer nets with holes (aOR [all nets in HH good] = 1.6; 95% CI 1.2-2.1);increasing net density (Ptrend < 0.001); increased women's malaria knowledge(Ptrend < 0.001); and urban clusters (aOR = 2.5; 95% CI 1.5-4.1). Reduced net usewas associated with: age 5-24 years (aOR = 0.3; 95% CI 0.2-0.4); number ofsleeping spaces (aOR [per additional space] = 0.6, 95% CI 0.5-0.7); more old nets(aOR [all nets in HH older than 12 months] = 0.5; 95% CI 0.3-0.7); and increasinghousehold altitude (Ptrend < 0.001).CONCLUSION: In both surveys, net use was more likely by women, if nets had fewer

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holes and were at higher net per person density within households. School-agechildren and young adults were much less likely to use a net. Increasingavailability of nets within households (i.e. increasing net density), andimproving net condition while focusing on education and promotion of net use,especially in school-age children and young adults in rural areas, are crucialareas for intervention to ensure maximum net use and consequent reduction ofmalaria transmission.

PMCID: PMC3258293PMID: 22165821 [PubMed - indexed for MEDLINE]

54. Am J Trop Med Hyg. 2011 Dec;85(6):1080-6. doi: 10.4269/ajtmh.2011.10-0684.

The combination of indoor residual spraying and insecticide-treated nets providesadded protection against malaria compared with insecticide-treated nets alone.

Hamel MJ, Otieno P, Bayoh N, Kariuki S, Were V, Marwanga D, Laserson KF,Williamson J, Slutsker L, Gimnig J.

Division of Parasitic Diseases and Malaria, Centers for Disease Control andPrevention, Atlanta, Georgia 30301, USA. [email protected]

Both insecticide-treated bed nets (ITNs) and indoor residual spraying (IRS)reduce malaria in high malaria transmission areas. The combined effect of theseinterventions is unknown. We conducted a non-randomized prospective cohort study to determine protective efficacy of IRS with ITNs (ITN + IRS) compared with ITNs alone (ITN only) in preventing Plasmodium falciparum parasitemia. At baseline,participants provided blood samples for malaria smears, were presumptivelytreated for malaria, and received ITNs. Blood smears were made monthly and atsick visits. In total, 1,804 participants were enrolled. Incidence of P.falciparum parasitemia in the ITN + IRS and ITN only groups was 18 and 44infections per 100 persons-years at risk, respectively (unadjusted rate ratio =0.41; 95% confidence interval [CI] = 0.31-0.56). Adjusted protective efficacy of ITN + IRS compared with ITN only was 62% (95% CI = 0.50-0.72). The combination ofIRS and ITN might be a feasible strategy to further reduce malaria transmissionin areas of persistent perennial malaria transmission.

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PMCID: PMC3225156 [Available on 2012/12/1]PMID: 22144448 [PubMed - indexed for MEDLINE]

55. Acta Trop. 2012 Mar;121(3):166-74. doi: 10.1016/j.actatropica.2011.11.005. Epub2011 Nov 19.

Sahel, savana, riverine and urban malaria in West Africa: Similar controlpolicies with different outcomes.

Ceesay SJ, Bojang KA, Nwakanma D, Conway DJ, Koita OA, Doumbia SO, Ndiaye D,Coulibaly TF, Diakité M, Traoré SF, Coulibaly M, Ndiaye JL, Sarr O, Gaye O,Konaté L, Sy N, Faye B, Faye O, Sogoba N, Jawara M, Dao A, Poudiougou B, Diawara S, Okebe J, Sangaré L, Abubakar I, Sissako A, Diarra A, Kéita M, Kandeh B, LongCA, Fairhurst RM, Duraisingh M, Perry R, Muskavitch MA, Valim C, Volkman SK,Wirth DF, Krogstad DJ.

International Center for Excellence in Malaria Research in West Africa at theMedical Research Council Laboratories, Fajara, Gambia.

The study sites for the West African ICEMR are in three countries (The Gambia,Senegal, Mali) and are located within 750 km of each other. In addition, theNational Malaria Control Programmes of these countries have virtually identicalpolicies: (1) Artemisinin Combination Therapies (ACTs) for the treatment ofsymptomatic Plasmodium falciparum infection, (2) Long-Lasting Insecticide-treatedbed Nets (LLINs) to reduce the Entomololgic Inoculation Rate (EIR), and (3)sulfadoxine-pyrimethamine for the Intermittent Preventive Treatment of malariaduring pregnancy (IPTp). However, the prevalence of P. falciparum malaria and thestatus of malaria control vary markedly across the four sites with differences inthe duration of the transmission season (from 4-5 to 10-11 months), the intensityof transmission (with EIRs from unmeasurably low to 4-5 per person per month),multiplicity of infection (from a mean of 1.0 to means of 2-5) and the status of malaria control (from areas which have virtually no control to areas that are at the threshold of malaria elimination). The most important priority is the need toobtain comparable data on the population-based prevalence, incidence and

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transmission of malaria before new candidate interventions or combinations ofinterventions are introduced for malaria control.

Copyright © 2011 Elsevier B.V. All rights reserved.

PMCID: PMC3294051 [Available on 2013/3/1]PMID: 22119584 [PubMed - indexed for MEDLINE]

56. Malar J. 2011 Nov 23;10:344. doi: 10.1186/1475-2875-10-344.

What drives community adherence to indoor residual spraying (IRS) against malariain Manhiça district, rural Mozambique: a qualitative study.

Munguambe K, Pool R, Montgomery C, Bavo C, Nhacolo A, Fiosse L, Sacoor C,Nhalungo D, Mabunda S, Macete E, Alonso P.

Centro de Investigação em Saúde de Manhiça, Rua 12, CP 1929 Manhiça, Mozambique. [email protected]

BACKGROUND: Malaria control remains a challenge in sub-Saharan Africa. In 2006,the World Health Organization (WHO) reinforced the recommendation of indoorresidual spraying (IRS) with dichlorodiphenyltrichloroethane (DDT) to reducemalaria transmission. The National Malaria Control Programme has been reportinghigh coverage rates of IRS in Mozambique. It is important to establish to whatextent these rates are a reflection of community acceptability, and to explorethe factors associated with adherence, in order to recommend suitable approaches for interventions of this nature.OBJECTIVE: To understand the implementation process, reception and acceptability of the IRS program in Manhiça district, Southern Mozambique.METHODS: Qualitative data was collected through in-depth interviews, participant observation of IRS activities, informal interviews, and focus group discussions. Study participants comprised householders, community leaders, health careproviders, sprayers, and community members. Qualitative data analysis was basedon grounded theory. Secondary data from the Manhiça Demographic SurveillanceSystem was used to complement the qualitative data.RESULTS: IRS was well received in most neighbourhoods. The overall coverage ratesvaried between 29% and 41% throughout the study period. The factors related toadherence to IRS were: immediate impact on insects in general, trust and

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obedience in the health authority, community leaders' influence, and acquaintancewith the sprayers. Fighting malaria was not an important motivation for IRSadherence. There was a perception of limited efficacy of IRS against mosquitoes, but this did not affect adherence. Non-adherence to the intervention was mainlydue to the unavailability of key householders, disagreement with the procedures, and the perception that spraying increased the burden of insects. Mostrespondents strongly favoured bed nets over IRS.CONCLUSION: The study suggests that the contribution of IRS to malaria andmosquito control is not entirely perceived by the beneficiaries, and that otheras cost effective interventions such as insecticide-treated nets are favouredover IRS. Adherence to IRS was found to be influenced by socio-political factors.There is a need to redefine the community sensitization approaches in order tomake IRS a genuinely participative, acceptable, and sustainable programme.

PMCID: PMC3339361PMID: 22111698 [PubMed - indexed for MEDLINE]

57. PLoS One. 2011;6(11):e27516. doi: 10.1371/journal.pone.0027516. Epub 2011 Nov 11.

Infections in infants during the first 12 months of life: role of placentalmalaria and environmental factors.

Le Port A, Watier L, Cottrell G, Ouédraogo S, Dechavanne C, Pierrat C, Rachas A, Bouscaillou J, Bouraima A, Massougbodji A, Fayomi B, Thiébaut A, Chandre F,Migot-Nabias F, Martin-Prevel Y, Garcia A, Cot M.

UMR216 Mère et enfant face aux infections tropicales, Institut de Recherche pour le Développement, Paris, France. [email protected]

BACKGROUND: The association between placental malaria (PM) and first peripheralparasitaemias in early infancy was assessed in Tori Bossito, a rural area ofBenin with a careful attention on transmission factors at an individual level.METHODOLOGY: Statistical analysis was performed on 550 infants followed weeklyfrom birth to 12 months. Malaria transmission was assessed by anopheles humanlanding catches every 6 weeks in 36 sampling houses and season defined by

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rainfall. Each child was located by GPS and assigned to the closest anophelessampling house. Data were analysed by survival Cox models, stratified on thepossession of insecticide-treated mosquito nets (ITNs) at enrolment.PRINCIPAL FINDINGS: Among infants sleeping in a house with an ITN, PM was foundto be highly associated to first malaria infections, after adjusting on season,number of anopheles, antenatal care (ANC) visits and maternal severe anaemia.Infants born from a malaria infected placenta had a 2.13 fold increased risk topresent a first malaria infection than those born from a non infected placenta([1.24-3.67], p<0.01) when sleeping in a house with an ITN. The risk to present afirst malaria infection was increased by 3.2 to 6.5, according to the level ofanopheles exposure (moderate or high levels, compared to the absence ofanopheles).CONCLUSIONS: First malaria infections in early childhood can be attributedsimultaneously to both PM and high levels of exposure to infected anopheles.Protective measures as Intermittent Preventive Treatment during pregnancy (IPTp) and ITNs, targeted on both mothers and infants should be reinforced, as well asthe research on new drugs and insecticides. In parallel, investigations onplacental malaria have to be strengthened to better understand the mechanismsinvolved, and thus to protect adequately the infants high risk group.

PMCID: PMC3214070PMID: 22096588 [PubMed - indexed for MEDLINE]

58. PLoS One. 2011;6(11):e26746. doi: 10.1371/journal.pone.0026746. Epub 2011 Nov 11.

Effect of transmission reduction by insecticide-treated bednets (ITNs) onantimalarial drug resistance in western Kenya.

Shah M, Kariuki S, Vanden Eng J, Blackstock AJ, Garner K, Gatei W, Gimnig JE,Lindblade K, Terlouw D, ter Kuile F, Hawley WA, Phillips-Howard P, Nahlen B,Walker E, Hamel MJ, Slutsker L, Shi YP.

Division of Parasitic Diseases and Malaria, Center for Global Health, Centers forDisease Control and Prevention, Atlanta, Georgia, United States of America.

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Despite the clear public health benefit of insecticide-treated bednets (ITNs),the impact of malaria transmission-reduction by vector control on the spread ofdrug resistance is not well understood. In the present study, the effect ofsustained transmission reduction by ITNs on the prevalence of Plasmodiumfalciparum gene mutations associated with resistance to the antimalarial drugssulfadoxine-pyrimethamine (SP) and chloroquine (CQ) in children under the age of five years was investigated during an ITN trial in Asembo area, western Kenya.During the ITN trial, the national first line antimalarial treatment changed fromCQ to SP. Smear-positive samples collected from cross sectional surveys prior to ITN introduction (baseline, n = 250) and five years post-ITN intervention (year 5survey, n = 242) were genotyped for single nucleotide polymorphisms (SNPs) atdhfr-51, 59, 108, 164 and dhps-437, 540 (SP resistance), and pfcrt-76 andpfmdr1-86 (CQ resistance). The association between the drug resistance mutations and epidemiological variables was evaluated. There were significant increases in the prevalence of SP dhps mutations and the dhfr/dhps quintuple mutant, and asignificant reduction in the proportion of mixed infections detected at dhfr-51, 59 and dhps-437, 540 SNPs from baseline to the year 5 survey. There was no changein the high prevalence of pfcrt-76 and pfmdr1-86 mutations. Multivariableregression analysis further showed that current antifolate use and year of surveywere significantly associated with more SP drug resistance mutations. Theseresults suggest that increased antifolate drug use due to drug policy changelikely led to the high prevalence of SP mutations 5 years post-ITN interventionand reduced transmission had no apparent effect on the existing high prevalenceof CQ mutations. There is no evidence from the current study that sustainedtransmission reduction by ITNs reduces the prevalence of genes associated withmalaria drug resistance.

PMCID: PMC3214025PMID: 22096496 [PubMed - indexed for MEDLINE]

59. Educ Health (Abingdon). 2011 Aug;24(2):474. Epub 2011 Jul 22.

A community health worker program for the prevention of malaria in eastern Kenya.

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Stromberg DG, Frederiksen J, Hruschka J, Tomedi A, Mwanthi M.

University of New Mexico Albuquerque, New Mexico, USA. [email protected]

OBJECTIVE: To assess whether the development and implementation of a communityhealth worker (CHW) project in rural Kenya was associated with an increase inknowledge about malaria and the use of insecticide-treated nets (ITNs) inchildren under five years of age.METHODS: A baseline knowledge and behavior questionnaire, adopted from the KenyanDemographic Health Survey, was conducted in August 2007 by Kenyan healthofficials in 75 villages. Two CHWs were chosen from each village and trained inappropriate use of ITNs. The CHWs provided educational sessions and ITNs tomothers in their respective villages. A follow-up survey was conducted in March2008 of all families with children less than five years of age within randomlyselected villages. The main questions addressed during the follow-up surveyincluded knowledge about malaria and the practice of correctly using ITNs.FINDINGS: There were 267 surveys compiled for knowledge assessment before theintervention and 340 in the post-intervention analysis with an approximate 99%family participation rate. Of the families surveyed, 81% correctly knew the causefor malaria before the study and 93% after the CHW intervention (p < 0.01). Ofthose surveyed before the intervention, 70% owned and correctly used mosquitonets compared with 88% after the CHW intervention (p < 0.01).CONCLUSIONS: There was a significant increase in knowledge about malaria and use of ITNs after the implementation of the CHW program.

PMID: 22081652 [PubMed - indexed for MEDLINE]

60. Malar J. 2011 Nov 13;10:341. doi: 10.1186/1475-2875-10-341.

Who attends antenatal care and expanded programme on immunization services inChad, Mali and Niger? The implications for insecticide-treated net delivery.

Carlson M, Smith Paintain L, Bruce J, Webster J, Lines J.

Department of Disease Control, London School of Hygiene and Tropical Medicine,Keppel Street, London WC1E 7HT, UK. [email protected]

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BACKGROUND: Malaria remains one of the largest public health problems facing the developing world. Insecticide-treated nets (ITNs) are an effective interventionagainst malaria. ITN delivery through routine health services, such as antenatal care (ANC) and childhood vaccination (EPI), is a promising channel of delivery toreach individuals with the highest risk (pregnant women and children under fiveyears old). Decisions on whether to deliver ITNs through both channels dependsupon the reach of each of these systems, whether these are independent and theeffectiveness and cost effectiveness of each. Predictors of women attending ANCand EPI separately have been studied, but the predictors of those who attendneither service have not been identified.METHODS: Data from Chad, Mali and Niger demographic and health surveys (DHS) wereanalyzed to determine risk factors for attending neither service. A conceptualframework for preventative health care-seeking behaviour was created toillustrate the hierarchical relationships between the potential risk factors. Theindependence of attending both ANC and EPI was investigated. A multivariate modelof predictors for non-attendance was developed using logistic regression.RESULTS: ANC and EPI attendance were found to be strongly associated in all threecountries. However, 47% of mothers in Chad, 12% in Mali and 36% in Niger did not attend either ANC or EPI. Region, mother's education and partner's education werepredictors of non-attendance in all three countries. Wealth index, ethnicity, andoccupation were associated with non-attendance in Mali and Niger. Otherpredictors included religion, healthcare autonomy, household size and number ofchildren under five.CONCLUSIONS: Attendance of ANC and EPI are not independent and therefore themajority of pregnant women in these countries will have the opportunity toreceive ITNs through both services. Although attendance at ANC and EPI are notindependent, delivery through both systems may still add incrementally todelivery through one alone. Therefore, there is potential to increase theproportion of women and children receiving ITNs by delivering through both ofthese channels. However, modelling is required to determine the level ofattendance and incremental potential at which it's cost effective to deliverthrough both services.

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81. J Health Popul Nutr. 2011 Jun;29(3):200-6.

Factors influencing people's willingness-to-buy insecticide-treated bednets inArbaminch Zuria District, southern Ethiopia.

Gebresilassie FE, Mariam DH.

CDC-Ethiopia, P.O. Box 11531, Addis Ababa, Ethiopia. [email protected]

Promoting self-financing healthcare helps restore efficiency and equity tonational health systems. This study was conducted in malaria-endemic areas ofsouthern Ethiopia to assess the bednet possession of the community, determine thepeople's willingness-to-pay for insecticide-treated bednets (ITNs), and identify what factors influence it. The study provided relevant information for programme planners and policymakers for evidence-based decision-making. This quantitativecross-sectional community-based study was conducted in four selected malariousKebeles of Arbaminch Zuria district using a pretested interview-administeredstructured questionnaire. In total, 982 household heads were interviewed. Thecommunity's willingness-to-pay was assessed by contingent valuation, techniqueusing binary with follow-up method. The advantage, the distribution, and thepayment mechanism were explained, and three different qualities of ITN were shownby constructing a hypothetical market scenario. Of the 982 respondents, 466(47.5%) households had at least one functional bednet. Of 849 children aged less than five years in the 982 households, 185 (21.8%) slept under a net the nightpreceding the survey. The results of the study revealed that around 86% of therespondents were willing to buy ITNs. The average maximum willingness-to-pay for three different types of bednets was statistically different. The maximum amount the people were willing to pay was US$ 3.3 for a blue conical ITN, US$ 3.2 for a white conical one, and US$ 1.7 for a blue rectangular ITN. The community'swillingness-to-pay was significantly affected by gender, educational status,perceived benefit of ITN, previous source of bednet, and characteristics ofbednet. The results showed that a significant proportion of the community people

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were willing to pay for ITNs. Therefore, introducing a subsidized ITN marketrather than free distribution for all should be considered to ensuresustainability and self-reliance in the prevention and control of malaria.

PMCID: PMC3131120PMID: 21766555 [PubMed - indexed for MEDLINE]

82. Acta Trop. 2012 Mar;121(3):212-7. doi: 10.1016/j.actatropica.2011.06.017. Epub2011 Jul 8.

Malaria control in Malawi: current status and directions for the future.

Mathanga DP, Walker ED, Wilson ML, Ali D, Taylor TE, Laufer MK.

Department of Community Health, University of Malawi College of Medicine,Blantyre, Malawi. [email protected]

The last decade has seen an increase in investment and concerted efforts by theMalawi Ministry of Health and partners to control malaria disease. This reportsummarizes what is known about the burden of malaria and the strategies beingimplemented to control it in Malawi. Over the past 5 years, roll out of treatmentand prevention efforts have been successful in the country, as demonstrated byincreased use of insecticide treated nets, improved access to prompt andeffective treatment and the initiation of pilot studies of indoor residualspraying. However, unlike other countries in the region, the recent data have notsuggested a decrease in the burden of disease. We describe the environment inwhich the activities of Malawi's International Center for Excellence in MalariaResearch (ICEMR) will be carried out and provide the rationale for the clinical, entomological and molecular studies. Our approach is to establish consistent,stainable data collection systems that are embedded within the public healthsector. Through standardized and long-term studies of hosts, parasites andvectors, we hope to contribute to assessment of malaria disease burden, theappropriate application of interventions and policies and provide both the datacollection and the health care infrastructure to ultimately eliminate thedisease.

Copyright © 2011 Elsevier B.V. All rights reserved.

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PMID: 21763670 [PubMed - indexed for MEDLINE]

83. Acta Trop. 2012 Mar;121(3):202-6. doi: 10.1016/j.actatropica.2011.06.012. Epub2011 Jul 2.

Malaria epidemiology and control in Southern Africa.

Mharakurwa S, Thuma PE, Norris DE, Mulenga M, Chalwe V, Chipeta J, Munyati S,Mutambu S, Mason PR; Southern Africa ICEMR Team.

Collaborators: Agre P, Glass G, Hackman A, Kobayashi T, Louis TA, Moss WJ, Scott A, Shields T, Shiff C, Gwanzura L, Coetzee M.

Johns Hopkins Malaria Research Institute, Bloomberg School of Public Health,Johns Hopkins University, Baltimore, MD 21205, USA. [email protected]

The burden of malaria has decreased dramatically within the past several years inparts of sub-Saharan Africa, following the scale-up of interventions supported bythe Roll Back Malaria Partnership, the President's Malaria Initiative and otherpartners. It is important to appreciate that the reductions in malaria have notbeen uniform between and within countries, with some areas experiencingresurgence instead. Furthermore, while interventions have greatly reduced theburden of malaria in many countries, it is also recognized that the malariadecline pre-dated widespread intervention efforts, at least in some cases wheredata are available. This raises more questions as what other factors may havebeen contributing to the reduction in malaria transmission and to what extent.The International Center of Excellence for Malaria Research (ICEMR) in SouthernAfrica aims to better understand the underlying malaria epidemiology, vectorecology and parasite genomics using three contrasting settings of malariatransmission in Zambia and Zimbabwe: an area of successful malaria control, anarea of resurgent malaria and an area where interventions have not beeneffective. The Southern Africa ICEMR will capitalize on the opportunity toinvestigate the complexities of malaria transmission while adapting tointervention and establish the evidence-base to guide effective and sustainablemalaria intervention strategies. Key approaches to attain this goal for theregion will include close collaboration with national malaria control programs

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and contribution to capacity building at the individual, institutional andnational levels.

Copyright © 2011 Elsevier B.V. All rights reserved.

PMCID: PMC3214248 [Available on 2013/3/1]PMID: 21756864 [PubMed - indexed for MEDLINE]

84. Acta Trop. 2012 Mar;121(3):196-201. doi: 10.1016/j.actatropica.2011.06.013. Epub 2011 Jul 2.

Malaria in Uganda: challenges to control on the long road to elimination. II. Thepath forward.

Talisuna A, Adibaku S, Dorsey G, Kamya MR, Rosenthal PJ.

Infectious Diseases Research Collaboration, Kampala, Uganda.

In the recent past there have been several reports of successes in malariacontrol, leading some public health experts to conclude that Africa is witnessingan epidemiological transition, from an era of failed malaria control toprogression from successful control to elimination. Successes in control havebeen attributed to increased international donor support leading to increasedintervention coverage. However, these changes are not uniform across Africa. InUganda, where baseline transmission is very high and intervention coverage notyet to scale, the malaria burden is not declining and has even likely increasedin the last decade. In this article we present perspectives for the future forUganda and other malaria endemic countries with high baseline transmissionintensity and significant health system challenges. For these high burden areas, malaria elimination is currently not feasible, and early elimination programs areinappropriate, as they would further fragment already fragmented and inefficient malaria control systems. Rather, health impacts will be maximized by aiming toachieve universal coverage of proven interventions in the context of astrengthened health system.

Copyright © 2011 Elsevier B.V. All rights reserved.

PMCID: PMC3439212 [Available on 2013/3/1]PMID: 21756863 [PubMed - indexed for MEDLINE]

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85. Malar J. 2011 Jun 22;10:170. doi: 10.1186/1475-2875-10-170.

Relationship between care-givers' misconceptions and non-use of ITNs byunder-five Nigerian children.

Arogundade ED, Adebayo SB, Anyanti J, Nwokolo E, Ladipo O, Ankomah A, MeremikwuMM.

Department of Paediatrics, University of Calabar, Calabar, Nigeria.

BACKGROUND: Malaria has been a major public health problem in Nigeria and manyother sub-Saharan African countries. Insecticide-treated nets have shown to becost-effective in the prevention of malaria, but the number of people thatactually use these nets has remained generally low. Studies that explore thedeterminants of use of ITN are desirable.METHODS: Structured questionnaires based on thematic areas were administered bytrained interviewers to 7,223 care-givers of under-five children selected fromall the six geo-political zones of Nigeria. Bivariate analysis and multinomiallogit model were used to identify possible determinants of use of ITN.RESULTS: Bivariate analysis showed that under-five children whose care-givers hadsome misconceptions about causes and prevention of malaria were significantlyless likely to use ITN even though the household may own a net (p < 0.0001).Education and correct knowledge about modes of prevention of malaria, knowingthat malaria is dangerous and malaria can kill were also significantly associatedwith use of ITN (p < 0.0001). Knowledge of symptoms of malaria did not influence use of ITN. Association of non-use of ITN with misconceptions about prevention ofmalaria persisted with logistic regression (Odds ratio 0.847; 95% CI 0.747 to0.960).CONCLUSIONS: Misconceptions about causes and prevention of malaria by caregivers adversely influence the use ITN by under-five children. Appropriate communicationstrategies should correct these misconceptions.

PMCID: PMC3146898PMID: 21696622 [PubMed - indexed for MEDLINE]

86. PLoS One. 2011;6(6):e20805. doi: 10.1371/journal.pone.0020805. Epub 2011 Jun 14.

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A sub-microscopic gametocyte reservoir can sustain malaria transmission.

Karl S, Gurarie D, Zimmerman PA, King CH, St Pierre TG, Davis TM.

School of Physics, The University of Western Australia, Crawley, WesternAustralia, Australia. [email protected]

BACKGROUND: Novel diagnostic tools, including PCR and high field gradientmagnetic fractionation (HFGMF), have improved detection of asexual Plasmodiumfalciparum parasites and especially infectious gametocytes in human blood. These techniques indicate a significant number of people carry gametocyte densitiesthat fall below the conventional threshold of detection achieved by standardlight microscopy (LM).METHODOLOGY/PRINCIPAL FINDINGS: To determine how low-level gametocytemia mayaffect transmission in present large-scale efforts for P. falciparum control inendemic areas, we developed a refinement of the classical Ross-Macdonald model ofmalaria transmission by introducing multiple infective compartments to model the potential impact of highly prevalent, low gametocytaemic reservoirs in thepopulation. Models were calibrated using field-based data and several numericalexperiments were conducted to assess the effect of high and low gametocytemia on P. falciparum transmission and control. Special consideration was given to theimpact of long-lasting insecticide-treated bed nets (LLIN), presently considered the most efficient way to prevent transmission, and particularly LLIN coveragesimilar to goals targeted by the Roll Back Malaria and Global Fund malariacontrol campaigns. Our analyses indicate that models which include onlymoderate-to-high gametocytemia (detectable by LM) predict finite eradicationtimes after LLIN introduction. Models that include a low gametocytemia reservoir (requiring PCR or HFGMF detection) predict much more stable, persistenttransmission. Our modeled outcomes result in significantly different estimatesfor the level and duration of control needed to achieve malaria elimination ifsubmicroscopic gametocytes are included.CONCLUSIONS/SIGNIFICANCE: It will be very important to complement current methodsof surveillance with enhanced diagnostic techniques to detect asexual parasitesand gametocytes to more accurately plan, monitor and guide malaria control

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programs aimed at eliminating malaria.

PMCID: PMC3114851PMID: 21695129 [PubMed - indexed for MEDLINE]

87. Soc Sci Med. 2011 Jul;73(1):160-8. doi: 10.1016/j.socscimed.2011.04.028. Epub2011 May 27.

Price subsidies and the market for mosquito nets in developing countries: A studyof Tanzania's discount voucher scheme.

Gingrich CD, Hanson K, Marchant T, Mulligan JA, Mponda H.

Department of Business and Economics, Eastern Mennonite University, Harrisonburg,VA 22802, USA. [email protected]

This study uses a partial equilibrium simulation model to explore how pricesubsidies for insecticide-treated mosquito nets (ITNs) affect households'purchases of ITNs. The model describes the ITN market in a typical developingcountry and is applied to the situation in Tanzania, where the Tanzania National Voucher Scheme (TNVS) provides a targeted subsidy to vulnerable population groupsby means of a discount voucher. The data for this study come from anationally-representative household survey completed July-August 2006 coveringover 4300 households in 21 districts. The simulation results show the impact ofthe voucher program on ITN coverage among target households, namely those thatexperienced the birth of a child. More specifically, the share of targethouseholds purchasing an ITN increased from 18 to 62 percent because of thediscount voucher. The model also suggests that the voucher program could causethe retail ITN price to rise due to an overall increase in demand. As a result,ITN purchases by households without a voucher may actually decline. Thesimulation model suggests that additional increases toward the stated goal of 80 percent ITN coverage for pregnant women and children could best be achievedthrough a combination of "catch up" mass distribution programs and expanding the target group for the voucher program to cover additional households. The modelcan be employed in other countries considering use of a targeted price subsidyfor ITNs, and could be adapted to assess the impact of subsidies for other publichealth commodities.

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Copyright © 2011 Elsevier Ltd. All rights reserved.

PMID: 21684054 [PubMed - indexed for MEDLINE]

88. Parasit Vectors. 2011 Jun 18;4:113. doi: 10.1186/1756-3305-4-113.

Insecticide-treated net (ITN) ownership, usage, and malaria transmission in thehighlands of western Kenya.

Atieli HE, Zhou G, Afrane Y, Lee MC, Mwanzo I, Githeko AK, Yan G.

Climate and Human Health Research Unit, Centre for Global Health Research, Kenya Medical Research Institute, PO Box 1578-40100, Kisumu, Kenya. [email protected]

BACKGROUND: Insecticide-treated bed nets (ITNs) are known to be highly effective in reducing malaria morbidity and mortality. However, usage varies amonghouseholds, and such variations in actual usage may seriously limit the potentialimpact of nets and cause spatial heterogeneity on malaria transmission. Thisstudy examined ITN ownership and underlying factors for among-household variationin use, and malaria transmission in two highland regions of western Kenya.METHODS: Cross-sectional surveys were conducted on ITN ownership (possession),compliance (actual usage among those who own ITNs), and malaria infections inoccupants of randomly sampled houses in the dry and the rainy seasons of 2009.RESULTS: Despite ITN ownership reaching more than 71%, compliance was low at56.3%. The compliance rate was significantly higher during the rainy seasoncompared with the dry season (62% vs. 49.6%). Both malaria parasite prevalence(11.8% vs. 5.1%) and vector densities (1.0 vs.0.4 female/house/night) weresignificantly higher during the rainy season than during the dry season. Otherimportant factors affecting the use of ITNs include: a household education level of at least primary school level, significantly high numbers of nuisancemosquitoes, and low indoor temperatures. Malaria prevalence in the rainy seasonwas about 30% lower in ITN users than in non-ITN users, but this percentage wasnot significantly different during the dry season.CONCLUSION: In malaria hypo-mesoendemic highland regions of western Kenya, the

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gap between ITNownership and usage is generally high with greater usage recorded during the high transmission season. Because of the low compliance among thosewho own ITNs, there is a need to sensitize households on sustained use of ITNs inorder to optimize their role as a malaria control tool.

PMCID: PMC3135563PMID: 21682919 [PubMed - indexed for MEDLINE]

89. Acta Trop. 2011 Aug;119(2-3):172-7. doi: 10.1016/j.actatropica.2011.05.013. Epub 2011 Jun 6.

Laboratory wash-resistance and field evaluation of deltamethrin incorporatedlong-lasting polyethylene netting (Netprotect(®)) against malaria transmission inAssam, north-east India.

Dev V, Phookan S, Padhan K, Tewari GG, Khound K.

National Institute of Malaria Research, Assam, India. [email protected]

North-east India is co-endemic for Plasmodium falciparum and P. vivax malaria,and disease transmission is perennial and persistent. This study reports theresults of a field-based village scale trial of deltamethrin incorporatedlong-lasting polyethylene netting (Netprotect(®)) conducted in P. falciparumpredominant pocket of Assam, north-east India to assess operational feasibility, acceptability and sustainability against disease vectors and malariatransmission. The study monitored the residual efficacy of the long-lasting netin relation to serial washings in the laboratory and malaria prevalence inexperimental villages for the first year of investigations from September 2008 toJune 2009. The mosquito vector populations of Anopheles minimus were observed to be highly susceptible to deltamethrin (0.05%), and follow up investigationsrevealed that the vector mosquito had virtually disappeared in Netprotect(®)intervention villages. Concurrently, there was consistent decline in malariacases in Netprotect(®) villages and transmission reduction was statisticallysignificant compared to untreated net (net without insecticide) and no-netcontrol villages for the corresponding study period. The contact cone-bioassay

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investigations against malaria transmitting mosquito species revealed that thebioavailability of the insecticide on the net fiber was persistent up to 20thserial wash resulting in ≥80% mortality. Community compliance and acceptance werehigh, and users reported decreased nuisance due to biting mosquitoes. It wasconcluded that deltamethrin incorporated polyethylene long-lasting netting wassafe, wash-resistant, and assessed to be an operationally feasible,community-based intervention for sustainable management of disease vectors toprevent malaria transmission.

Copyright © 2011 Elsevier B.V. All rights reserved.

PMID: 21679681 [PubMed - indexed for MEDLINE]

90. World Health Popul. 2011;12(3):42-51.

Assessing the progress of malaria control in Nigeria.

Amzat J.

Department of Sociology, Usmanu Danfodiyo University, Sokoto, [email protected]

One third of the world's malaria deaths occur in Nigeria. It is doubtful whether Nigeria will meet the malaria control target of the Millennium Development Goals by 2015, having failed to meet the Abuja target to halve the burden of malaria by2010. This paper assesses the current malaria burden and progress toward malaria control. Substantial data were obtained from the 2008 Nigeria Demographic andHealth Survey and other secondary sources. Data showed that the malaria burden isstill enormous because of inadequate control efforts. In 2008, only 17% ofNigerians owned at least one net, compared with 12% in 2003. Eight percent owned an insecticide-treated mosquito net (ITN), but only 6% of under-five children and5% of pregnant women slept under an ITN. Only one third of under-five childrenwith fever received antimalarial drugs, while one fifth of pregnant women tookantimalarial drugs for prevention. Chloroquine is still the most common drug usedin malaria treatment, despite its ban in first-line treatment since 2005. Thepaper concludes that scaling up home management of malaria and a

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community-centred approach to ITN and artemisinin-based combination therapyprovisioning should be prioritized.

PMID: 21677528 [PubMed - indexed for MEDLINE]

91. World Health Popul. 2011;12(3):13-22.

Knowledge of malaria and preventive measures among pregnant women attendingantenatal clinics in a rural local government area in Southwestern Nigeria.

Akinleye SO, Ajayi IO.

Department of Epidemiology, Medical Statistics and Environmental Health, College of Medicine, University of Ibadan, Nigeria. [email protected]

OBJECTIVE: This study determined the level of knowledge of malaria and preventivemeasures among pregnant women and its influence on the uptake of preventivemeasures.METHODS: A cross-sectional survey was carried out among 209 participants selectedfrom pregnant women attending antenatal clinics in primary healthcare centres in Irepodun/Ifelodun, a local government area in Ekiti state, Nigeria.RESULTS: Knowledge of malaria was found to be very good, average and poor amongtwo (1.0%), 165 (78.9%) and 42 (20.1%) respondents, respectively. Of the 109(52.2%) respondents who had heard about intermittent preventive treatment, eight (7.3%) scored "very good" on knowledge, while 53 (48.6%) and 48 (44.1%) scored"average" and "poor," respectively. Of the 144 (68.9%) respondents who had heard about insecticide-treated nets, 95 (66.0%) scored "good" on knowledge, while 49(34.0%) scored "poor." Factors that significantly influenced knowledge aboutmalaria were occupation, level of education, months at first appearance atantenatal clinic and transportation cost. Knowledge significantly influenceduptake of insecticide-treated nets and intermittent preventive treatment inpregnancy ( p < .05).CONCLUSION: There is a need to intensify efforts to provide health education onmalaria and preventive measures as well as to encourage preventive practicesamong pregnant women.

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PMID: 21677525 [PubMed - indexed for MEDLINE]

92. Trials. 2011 Jun 10;12:147. doi: 10.1186/1745-6215-12-147.

To assess whether indoor residual spraying can provide additional protectionagainst clinical malaria over current best practice of long-lasting insecticidal mosquito nets in The Gambia: study protocol for a two-armed cluster-randomisedtrial.

Pinder M, Jawara M, Jarju LB, Kandeh B, Jeffries D, Lluberas MF, Mueller J,Parker D, Bojang K, Conway DJ, Lindsay SW.

London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT,UK.

BACKGROUND: Recently, there has been mounting interest in scaling-up vectorcontrol against malaria in Africa. It needs to be determined if indoor residualspraying (IRS with DDT) will provide significant marginal protection againstmalaria over current best practice of long-lasting insecticidal nets (LLINs) and prompt treatment in a controlled trial, given that DDT is currently the mostpersistent insecticide for IRS.METHODS: A 2 armed cluster-randomised controlled trial will be conducted toassess whether DDT IRS and LLINs combined provide better protection againstclinical malaria in children than LLINs alone in rural Gambia. Each cluster will be a village, or a group of small adjacent villages; all clusters will receiveLLINs and half will receive IRS in addition. Study children, aged 6 months to 13 years, will be enrolled from all clusters and followed for clinical malaria usingpassive case detection to estimate malaria incidence for 2 malaria transmissionseasons in 2010 and 2011. This will be the primary endpoint. Exposure to malaria parasites will be assessed using light and exit traps followed by detection ofAnopheles gambiae species and sporozoite infection. Study children will besurveyed at the end of each transmission season to estimate the prevalence ofPlasmodium falciparum infection and the prevalence of anaemia.DISCUSSION: Practical issues concerning intervention implementation, as well as

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the potential benefits and risks of the study, are discussed.TRIAL REGISTRATION: ISRCTN01738840 - Spraying And Nets Towards malariaElimination (SANTE).

PMCID: PMC3121610PMID: 21663656 [PubMed - indexed for MEDLINE]

93. Health Policy Plan. 2012 Jul;27(4):316-25. doi: 10.1093/heapol/czr042. Epub 2011 Jun 6.

Determinants of hanging and use of ITNs in the context of near universal coveragein Zambia.

Macintyre K, Littrell M, Keating J, Hamainza B, Miller J, Eisele TP.

Department of International Health and Development, Tulane University, NewOrleans, LA, USA. [email protected]

Roll Back Malaria recently recommended a policy of universal coverage withinsecticide-treated nets (ITNs) so that all age groups can benefit fromprotection against malaria. Countries adopting the 'universal access' policyinclude Zambia. Policy implementation in many settings involves mass distributionof free ITNs to achieve a measure of universal coverage. This study examines ITN deployment and use in the context of mass distribution efforts towards achieving universal coverage in a malaria-endemic district in Zambia. We use multiplelogistic regression to identify predictors of ITN deployment and use by anyone inthe household and by children under five. Among ITN-owning households with achild under five, 69% used at least one ITN the night before the survey. Abouthalf of those children (54%) in ITN-owning households were covered the previousnight. A strong and consistent predictor of use is household deployment of atleast one ITN. Just over half of all ITNs were observed hanging, and reported useof nets for purposes other than malaria prevention was only 3%. Netcharacteristics, including shape, colour and whether or not the ITN waspurchased, were not associated with net deployment. However, ITNs in poorcondition are more likely to be observed hanging than ITNs in new or goodcondition. In the context of free mass distribution of ITNs, behaviour changecommunication and activities are necessary to improve use. Results suggestcampaigns and messages that persuade recipients to hang up their ITNs would

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contribute towards closing the gap between ownership and use.

PMID: 21652576 [PubMed - indexed for MEDLINE]

94. Malar J. 2011 Jun 8;10:157. doi: 10.1186/1475-2875-10-157.

Best practices for an insecticide-treated bed net distribution programme insub-Saharan eastern Africa.

Sexton AR.

Graduate School of Public Health, College of Health and Human Services, San DiegoState University, 5500 Campanile Drive, San Diego, CA 92182-4162, [email protected]

Insecticide-treated bed nets are the preeminent malaria control means; thoughthere is no consensus as to a best practice for large-scale insecticide-treatedbed net distribution. In order to determine the paramount distribution method,this review assessed literature on recent insecticide treated bed netdistribution programmes throughout sub-Saharan Eastern Africa. Inclusion criteriawere that the study had taken place in sub-Saharan Eastern Africa, targetedmalaria prevention and control, and occurred between 1996 and 2007. Forty-twostudies were identified and reviewed. The results indicate that distributionframeworks varied greatly; and consequently so did outcomes ofinsecticide-treated bed net use. Studies revealed consistent inequities betweenurban and rural populations; which were most effectively alleviated through afree insecticide-treated bed net delivery and distribution framework. However,cost sharing through subsidies was shown to increase programme sustainability,which may lead to more long-term coverage. Thus, distribution should employ acatch up/keep up programme strategy. The catch-up programme rapidly scales upcoverage, while the keep-up programme maintains coverage levels. Futuredirections for malaria should include progress toward distribution oflong-lasting insecticide-treated nets.

PMCID: PMC3121652PMID: 21651815 [PubMed - indexed for MEDLINE]

95. Am J Trop Med Hyg. 2011 Jun;84(6):951-6. doi: 10.4269/ajtmh.2011.11-0016.

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Net risk: a risk assessment of long-lasting insecticide bed nets used for malariamanagement.

Peterson RK, Barber LM, Schleier JJ 3rd.

Department of Land Resources and Environmental Sciences, Montana StateUniversity, Bozeman, MT 59717, USA. [email protected]

Despite the demonstrated ability of bed nets that have been factory-impregnatedwith long-lasting insecticides (LLINs) to protect people from malaria and despitethe ambitious plans for their widespread use, the health risks from the LLINsthemselves have not been adequately investigated and reported in thepeer-reviewed science literature. Here, we use a probabilistic risk assessmentapproach to estimate the risks to Africans from inhalation, dermal, and oralexposures to the newer LLINs with permethrin, α-cypermethrin, or deltamethrin as the insecticide active ingredient. We estimated exposures to LLINs using 17 agegroups to incorporate different body weights and sleeping behaviors. Riskquotients (exposure divided by toxic threshold) at the 50th and 90th percentiles for non-cancer risks were < 1.0 for lifetime adjusted risk and all youth andadult age groups. Risk quotients for infants and toddlers (0-3 years) and childgroups from 3 to 10 years were ≥ 1.0 for specific bed nets.

PMCID: PMC3110360PMID: 21633033 [PubMed - indexed for MEDLINE]

96. PLoS One. 2011;6(5):e20179. doi: 10.1371/journal.pone.0020179. Epub 2011 May 24.

The potential contribution of mass treatment to the control of Plasmodiumfalciparum malaria.

Okell LC, Griffin JT, Kleinschmidt I, Hollingsworth TD, Churcher TS, White MJ,Bousema T, Drakeley CJ, Ghani AC.

Department of Infectious Disease Epidemiology, MRC Centre for Outbreak Analysisand Modeling, Imperial College London, London, United [email protected]

Mass treatment as a means to reducing P. falciparum malaria transmission was usedduring the first global malaria eradication campaign and is increasingly beingconsidered for current control programmes. We used a previously developed

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mathematical transmission model to explore both the short and long-term impact ofpossible mass treatment strategies in different scenarios of endemictransmission. Mass treatment is predicted to provide a longer-term benefit inareas with lower malaria transmission, with reduced transmission levels for atleast 2 years after mass treatment is ended in a scenario where the baselineslide-prevalence is 5%, compared to less than one year in a scenario withbaseline slide-prevalence at 50%. However, repeated annual mass treatment at 80% coverage could achieve around 25% reduction in infectious bites inmoderate-to-high transmission settings if sustained. Using vector control couldreduce transmission to levels at which mass treatment has a longer-term impact.In a limited number of settings (which have isolated transmission in smallpopulations of 1000-10,000 with low-to-medium levels of baseline transmission) wefind that five closely spaced rounds of mass treatment combined with vectorcontrol could make at least temporary elimination a feasible goal. We alsoestimate the effects of using gametocytocidal treatments such as primaquine andof restricting treatment to parasite-positive individuals. In conclusion, masstreatment needs to be repeated or combined with other interventions for long-termimpact in many endemic settings. The benefits of mass treatment need to becarefully weighed against the risks of increasing drug selection pressure.

PMCID: PMC3101232PMID: 21629651 [PubMed - indexed for MEDLINE]

97. Parasit Vectors. 2011 May 25;4:90. doi: 10.1186/1756-3305-4-90.

Sustained reduction in prevalence of lymphatic filariasis infection in spite ofmissed rounds of mass drug administration in an area under mosquito nets formalaria control.

Njenga SM, Mwandawiro CS, Wamae CN, Mukoko DA, Omar AA, Shimada M, Bockarie MJ,Molyneux DH.

Kenya Medical Research Institute (KEMRI), Nairobi, Kenya. [email protected]

BACKGROUND: The Global Programme to Eliminate Lymphatic Filariasis (GPELF) was

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established by the World Health Organisation (WHO) in 2000 with the goal ofeliminating lymphatic filariasis (LF) as a public health problem globally by2020. Mass drug administration (MDA) of antifilarial drugs is the principalstrategy recommended for global elimination. Kenya launched a National Programme for Elimination of Lymphatic Filariasis (NPELF) in Coast Region in 2002. Duringthe same year a longitudinal research project to monitor trends of LF infectionduring MDA started in a highly endemic area in Malindi District. High coverage ofinsecticide treated nets (ITNs) in the coastal region has been associated withdramatic decline in hospital admissions due to malaria; high usage of ITNs isalso expected to have an impact on LF infection, also transmitted by mosquitoes.RESULTS: Four rounds of MDA with diethylcarbamazine citrate (DEC) and albendazolewere given to 8 study villages over an 8-year period. Although annual MDA was notadministered for several years the overall prevalence of microfilariae declinedsignificantly from 20.9% in 2002 to 0.9% in 2009. Similarly, the prevalence offilarial antigenaemia declined from 34.6% in 2002 to 10.8% in 2009. All theexamined children born since the start of the programme were negative forfilarial antigen in 2009.CONCLUSIONS: Despite the fact that the study villages missed MDA in some of theyears, significant reductions in infection prevalence and intensity were observedat each survey. More importantly, there were no rebounds in infection prevalence between treatment rounds. However, because of confounding variables such asinsecticide-treated bed nets (ITNs), it is difficult to attribute the reductionto MDA alone as ITNs can lead to a significant reduction in exposure tofilariasis vectors. The results indicate that national LF elimination programmes should be encouraged to continue provision of MDA albeit constraints that maylead to missing of MDA in some years.

PMCID: PMC3125382PMID: 21612649 [PubMed - indexed for MEDLINE]

98. Am J Public Health. 2011 Dec;101(12):2333-41. doi: 10.2105/AJPH.2010.300068. Epub2011 May 12.

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Impact of a malaria-control project in Benin that included the integratedmanagement of childhood illness strategy.

Rowe AK, Onikpo F, Lama M, Osterholt DM, Deming MS.

Division of Parasitic Diseases, Centers for Disease Control and Prevention,Atlanta, GA 30341-3724, USA. [email protected]

OBJECTIVES: To estimate the impact of the Integrated Management of ChildhoodIllness (IMCI) strategy on early-childhood mortality, we evaluated amalaria-control project in Benin that implemented IMCI and promotedinsecticide-treated nets (ITNs).METHODS: We conducted a before-and-after intervention study that included anonrandomized comparison group. We used the preceding birth technique to measure early-childhood mortality (risk of dying before age 30 months), and we usedhealth facility surveys and household surveys to measure process indicators.RESULTS: Most process indicators improved in the area covered by theintervention. Notably, because ITNs were also promoted in the comparison areachildren's ITN use increased by about 20 percentage points in both areas.Regarding early-childhood mortality, the trend from baseline (1999-2001) tofollow-up (2002-2004) for the intervention area (13.0% decrease; P < .001) was14.1% (P < .001) lower than was the trend for the comparison area (1.3% increase;P = .46).CONCLUSIONS: Mortality decreased in the intervention area after IMCI and ITNpromotion. ITN use increased similarly in both study areas, so the mortalityimpact of ITNs in the 2 areas might have canceled each other out. Thus, themortality reduction could have been primarily attributable to IMCI's effect onhealth care quality and care-seeking.

PMID: 21566036 [PubMed - indexed for MEDLINE]

99. Acta Trop. 2011 Aug;119(2-3):107-13. doi: 10.1016/j.actatropica.2011.04.015. Epub2011 May 4.

Evaluating indoor residual spray for reducing malaria infection prevalence inEritrea: results from a community randomized control trial.

Keating J, Locatelli A, Gebremichael A, Ghebremeskel T, Mufunda J, Mihreteab S,Berhane D, Carneiro P.

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Department of International Health and Development, Tulane University School ofPublic Health and Tropical Medicine, New Orleans, LA 70112, United [email protected]

This paper examines the relationship between indoor residual spray (IRS) andmalaria parasite infection in Gash Barka Zone, Eritrea, an area with nearuniversal coverage of insecticide treated bednets (ITN) and already low malariaparasite prevalence. A community randomized control trial was conducted in 2009. Malaria parasite infection prevalence was 0.5% [95% confidence interval (CI):0.37-0.78%], with no significant difference detected between treatment andcontrol areas. ITN possession remains high, with over 70% of households reportingITN ownership [95% CI: 68.4-72.9]. ITN use among individuals within ITN-owninghouseholds was just under half [46.7% (95% CI: 45.4-48.0)]. Slight differences inITN possession and use were detected between treatment and control areas. Therewas no significant difference in malaria parasite infection prevalence amongindividuals in households with ≥1 ITN compared to those in households withoutITNs, nor among individuals reporting ITN use. Among individuals in ITN-owninghouseholds, sleeping under an ITN offered no statistically significant protectionfrom malaria parasite infection. Community participation in environmental andlarval habitat management activities was low: 17.9% (95% CI: 16.0-19.7). It islikely that IRS, larval habitat management and ITN distribution alone may beinsufficient to interrupt transmission without corresponding high ITN use,sustained IRS application in areas where infections are clustered, and promptlyseeking laboratory diagnosis and treatment of all fevers. Eritrea is ready forelimination, irrespective of inconclusive impact evaluation results.

Copyright © 2011 Elsevier B.V. All rights reserved.

PMID: 21565149 [PubMed - indexed for MEDLINE]

100. Trans R Soc Trop Med Hyg. 2011 Jun;105(6):327-32. doi:10.1016/j.trstmh.2011.02.008. Epub 2011 May 6.

Malaria control in a forest fringe area of Assam, India: a pilot study.

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Dutta P, Khan AM, Khan SA, Borah J, Sharma CK, Mahanta J.

Regional Medical Research Centre (ICMR), Northeastern Region, Dibrugarh 786001,Assam, India. [email protected]

A study was conducted to evaluate the preventive efficacy of insecticide-treated mosquito nets (ITMNs) and mosquito repellent (MR) in a malaria-endemic foothillarea of Assam, India, with forest ecosystem. During the first year, a survey was conducted in four demarcated sectors (A-D) to observe the malaria endemicity and vector prevalence patterns before implementing intervention measures. All foursectors were endemic for malaria. The prevalence of established malaria vectorssuch as Anopheles dirus, A. minimus and A. philippinensis was observed. Duringthe second year, intervention measures were implemented in the four sectors asfollows: A, ITMN + MR; B, ITMN; C, MR; D, no intervention. The most effectiveintervention was in sector A, followed by sectors B and C. Sectors A and Bexhibited significantly higher (P < 0.001) malaria protective efficacy duringboth the first and second years of intervention compared with sector D. The totalvector population in the three intervention sectors decreased significantlycompared with that of the non-intervention one.Information-education-communication activities motivated the residents toparticipate actively in the intervention programme. The finding could be aneffective model for containment of high malaria morbidity in inaccessible forest fringe areas of the northeastern region of India.

Copyright © 2011 Royal Society of Tropical Medicine and Hygiene. Published byElsevier Ltd. All rights reserved.

101. Med Trop (Mars). 2010 Dec;70(5-6):479-84.

[Malaria transmission in an area of high coverage with long lasting insecticidal nets in central Côte d'Ivoire].

[Article in French]

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Koudou BG, Ouattara FA, Edi AV, Nsanzabana C, Tia E, Tchicaya ES, Tanner M,Bonfoh B, Dagnogo M, Utzinger J.

Centre suisse de recherches scientifiques en Côte d'Ivoire, Abidjan, Côted'Ivoire. [email protected]

The purpose of this study was to assess malaria transmission in an area of highcoverage with long-lasting insecticidal nets (LLINs) in central Côte d'Ivoire.Two four-day larva collections were carried out in April and July 2008. Adultmosquito samples were collected by conducting human bait catches during a totalof 80 man-nights. Vector infection rates were determined using an ELISAcircumsporozoite antibody test. A total of 1582 mosquitoes were captured.Mansonia was the dominant genus in the culcidian fauna followed by Anopheles thatwas dominant in the anopheline fauna. The only Plasmodium vector was An. gambiae s.l. The high household bednet coverage rate probably accounted for therelatively low biting rate: 0.75 to 4.15 bites per person per night (b/p/n).Households not using bednets appear to have benefited from a passive protectioneffect associated with high LLIN coverage. Biting and entomological inoculationrates were 2.25 to 4.1 b/p/n (range) and 0.184 ib/p/n respectively in households that did not use LLINs and 0.75 to 4.15 b/p/n (range) and 0.341 ib/p/nrespectively in households using LLINs.

PMID: 21520651 [PubMed - indexed for MEDLINE]

102. MMWR Morb Mortal Wkly Rep. 2011 Apr 22;60(15):476-80.

Grand rounds: The opportunity for and challenges to malaria eradication.

Centers for Disease Control and Prevention (CDC).

In 2009, malaria, a disease transmitted by the bite of an infective Anophelesmosquito, caused an estimated 225 million clinical cases and 781,000 deathsworldwide, of which more than 90% occurred in children aged <5 years in Africa.Approximately half of the world's population, or 3 billion persons, are at riskfor acquiring the illness. Malaria is transmitted most intensely in central andwestern Africa, where in some areas >40% of children aged <10 years are infected and residents can be bitten by more than one infective mosquito every day of the year.

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PMID: 21508924 [PubMed - indexed for MEDLINE]

103. Malar J. 2011 Apr 20;10:98. doi: 10.1186/1475-2875-10-98.

Malaria risk factors in north-east Tanzania.

Winskill P, Rowland M, Mtove G, Malima RC, Kirby MJ.

London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK. [email protected]

BACKGROUND: Understanding the factors which determine a household's orindividual's risk of malaria infection is important for targeting controlinterventions at all intensities of transmission. Malaria ecology in Tanzaniaappears to have reduced over recent years. This study investigated potential riskfactors and clustering in face of changing infection dynamics.METHODS: Household survey data were collected in villages of rural Muhezadistrict. Children aged between six months and thirteen years were tested forpresence of malaria parasites using microscopy. A multivariable logisticregression model was constructed to identify significant risk factors forchildren. Geographical information systems combined with global positioning data and spatial scan statistic analysis were used to identify clusters of malaria.RESULTS: Using an insecticide-treated mosquito net of any type proved to behighly protective against malaria (OR 0.75, 95% CI 0.59-0.96). Children aged fiveto thirteen years were at higher risk of having malaria than those aged underfive years (OR 1.71, 95% CI 1.01-2.91). The odds of malaria were less for femaleswhen compared to males (OR 0.62, 95% CI 0.39-0.98). Two spatial clusters ofsignificantly increased malaria risk were identified in two out of five villages.CONCLUSIONS: This study provides evidence that recent declines in malariatransmission and prevalence may shift the age groups at risk of malaria infectionto older children. Risk factor analysis provides support for universal coverageand targeting of long-lasting insecticide-treated nets (LLINs) to all age groups.Clustering of cases indicates heterogeneity of risk. Improved targeting of LLINs or additional supplementary control interventions to high risk clusters mayimprove outcomes and efficiency as malaria transmission continues to fall underintensified control.

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PMCID: PMC3094229PMID: 21507217 [PubMed - indexed for MEDLINE]

104. Med Mal Infect. 2011 Jun;41(6):301-6. doi: 10.1016/j.medmal.2011.02.004. Epub2011 Apr 16.

[Malaria in France: Mainland and territories].

[Article in French]

Tarantola A, Eltges F, Ardillon V, Lernout T, Sissoko D, Kendjo E, Achirafi A,Thiria J, Flamand C, D'Ortenzio E, Cohuet S, Quatresous I, Quenel P, Filleul L,Gastellu-Etchegorry M.

Département international et tropical, institut de veille sanitaire, directionscientifique, 12, rue du Val d'Osne, 94415 Saint-Maurice, [email protected]

Malaria, which was eliminated first from Metropolitan France (mainland andCorsica), then in the French West Indies and the Reunion Island during the 20(th)century, remains endemic in two French territories: French Guiana and the Indian Ocean Mayotte island. Despite differences in the dominating plasmodial speciesand epidemiological patterns, these two territories have achieved markedquantitative improvements (in the reported number of cases and severe cases)thanks to efforts undertaken over the past decade. The situation, however,remains a concern from a qualitative standpoint with the emergence of resistance to antimalarial drugs and logistical and administrative issues which hinderaccess to treatment. Although malaria was eradicated in Metropolitan France half a century ago, competent vectors remain present in part or all of theseterritories and can give rise to limited outbreaks.

Copyright © 2011 Elsevier Masson SAS. All rights reserved.

PMID: 21498013 [PubMed - indexed for MEDLINE]

105. Niger J Clin Pract. 2011 Jan-Mar;14(1):19-22. doi: 10.4103/1119-3077.79234.

The effect of free distribution of insecticide-treated nets on asymptomaticPlasmodium parasitemia in pregnant and nursing mothers in a rural Nigerian

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community.

Anyaehie U, Nwagha UI, Aniebue PN, Nwagha TU.

Department of Physiology/Obstetrics and Gynaecology, College of Medicine,University of Nigeria, Enugu Campus, Nigeria.

INTRODUCTION: Malaria is a major public health problem in Nigeria, with adverseoutcomes on the poor, pregnant women and children living in rural communities. A major component of current intervention in roll back malaria (RBM) initiative is vector control and insecticide-treated nets (ITNs).AIMS AND OBJECTIVE: This research studied the impact of free distribution of ITNson malaria parasitemia in a rural community in Nigeria.MATERIALS AND METHODS: This is a longitudinal survey involving 990 pregnant andnursing mothers who received free ITNs between February 2007 and September 2008. Blood samples were collected at contact, then every 2 months to check for malariaparasites using standard methods.RESULT: There was a sustained but insignificant rise in asymptomatic malariaparasitemia post-distribution of ITNs.CONCLUSION: We conclude that ITN intervention remains important in malariaprophylaxis but must be complemented with awareness campaigns and other vectorcontrol strategies.

PMID: 21493986 [PubMed - indexed for MEDLINE]

106. Malar J. 2011 Apr 13;10:86. doi: 10.1186/1475-2875-10-86.

Success of Senegal's first nationwide distribution of long-lastinginsecticide-treated nets to children under five - contribution toward universalcoverage.

Thwing JI, Perry RT, Townes DA, Diouf MB, Ndiaye S, Thior M.

Malaria Branch, Center for Global Health, Centers for Disease Control andPrevention, Atlanta, GA, USA. [email protected]

BACKGROUND: In 2009, the first national long-lasting insecticide-treated net(LLIN) distribution campaign in Senegal resulted in the distribution of 2.2million LLINs in two phases to children aged 6-59 months. Door-to-door teamsvisited all households to administer vitamin A and mebendazole, and to give acoupon to redeem later for an LLIN.

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METHODS: A nationwide community-based two-stage cluster survey was conducted,with clusters selected within regions by probability proportional to sizesampling, followed by GPS-assisted mapping, simple random selection of householdsin each cluster, and administration of a questionnaire using personal digitalassistants (PDAs). The questionnaire followed the Malaria Indicator Surveyformat, with rosters of household members and bed nets, and questions on campaignparticipation.RESULTS: There were 3,280 households in 112 clusters representing 33,993 people. Most (92.1%) guardians of eligible children had heard about the campaign, theprimary sources being health workers (33.7%), neighbours (26.2%), and radio(22.0%). Of eligible children, 82.4% received mebendazole, 83.8% received vitaminA, and 75.4% received LLINs. Almost all (91.4%) LLINs received during thecampaign remained in the household; of those not remaining, 74.4% had been given away and none were reported sold. At least one insecticide-treated net (ITN) was present in 82.3% of all households, 89.2% of households with a child < 5 yearsand 57.5% of households without a child < 5 years. Just over half (52.4%) of ITNshad been received during the campaign. Considering possible indicators ofuniversal coverage, 39.8% of households owned at least one ITN per two people,21.6% owned at least one ITN per sleeping space and 34.7% of the generalpopulation slept under an ITN the night before the survey. In addition, 45.6% of children < 5 years, and 49.2% of pregnant women had slept under an ITN.CONCLUSIONS: The nationwide integrated LLIN distribution campaign allowedhousehold ITN ownership of one or more ITNs to surpass the RBM target of 80% set for 2010, though additional distribution strategies are needed to reachpopulations missed by the targeted campaign and to reach the universal coveragetargets of one ITN per sleeping space and 80% of the population using an ITN.

PMCID: PMC3083382PMID: 21489278 [PubMed - indexed for MEDLINE]

107. BMC Med. 2011 Apr 13;9:37. doi: 10.1186/1741-7015-9-37.

Increasing malaria hospital admissions in Uganda between 1999 and 2009.

Okiro EA, Bitira D, Mbabazi G, Mpimbaza A, Alegana VA, Talisuna AO, Snow RW.

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Malaria Public Health & Epidemiology Group, Centre for Geographic MedicineResearch - Coast, Kenya Medical Research Institute/Wellcome Trust ResearchProgramme, Nairobi, Kenya. [email protected]

BACKGROUND: Some areas of Africa are witnessing a malaria transition, in part dueto escalated international donor support and intervention coverage. Areas wheredeclining malaria rates have been observed are largely characterized byrelatively low baseline transmission intensity and rapid scaling ofinterventions. Less well described are changing patterns of malaria burden inareas of high parasite transmission and slower increases in control and treatmentaccess.METHODS: Uganda is a country predominantly characterized by intense, perennialmalaria transmission. Monthly pediatric admission data from five Ugandanhospitals and their catchments have been assembled retrospectively across 11years from January 1999 to December 2009. Malaria admission rates adjusted forchanges in population density within defined catchment areas were computed acrossthree time periods that correspond to periods where intervention coverage dataexist and different treatment and prevention policies were operational. Timeseries models were developed adjusting for variations in rainfall and hospitaluse to examine changes in malaria hospitalization over 132 months. The temporalchanges in factors that might explain changes in disease incidence werequalitatively examined sequentially for each hospital setting and comparedbetween hospital settingsRESULTS: In four out of five sites there was a significant increase in malariaadmission rates. Results from time series models indicate a significantmonth-to-month increase in the mean malaria admission rates at four hospitals(trend P < 0.001). At all hospitals malaria admissions had increased from 1999 by47% to 350%. Observed changes in intervention coverage within the catchments ofeach hospital showed a change in insecticide-treated net coverage from <1% in2000 to 33% by 2009 but accompanied by increases in access to nationallyrecommended drugs at only two of the five hospital areas studied.CONCLUSIONS: The declining malaria disease burden in some parts of Africa is not a universal phenomena across the continent. Despite moderate increases in thecoverage of measures to reduce infection and disease without significant

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coincidental increasing access to effective medicines to treat disease may notlead to severe disease burden reductions in high transmission areas of Africa.More data is needed from a wider range of malaria settings to provide an honesttracking progress of the impact of scaled intervention coverage in Africa.

PMCID: PMC3096581PMID: 21486498 [PubMed - indexed for MEDLINE]

108. Malar J. 2011 Apr 9;10:80. doi: 10.1186/1475-2875-10-80.

Increased proportions of outdoor feeding among residual malaria vectorpopulations following increased use of insecticide-treated nets in ruralTanzania.

Russell TL, Govella NJ, Azizi S, Drakeley CJ, Kachur SP, Killeen GF.

Ifakara Health Institute, Biomedical and Environmental Thematic Group, Ifakara,Tanzania. [email protected]

BACKGROUND: Insecticide-treated nets (ITNs) and indoor residual spraying (IRS)represent the front-line tools for malaria vector control globally, but areoptimally effective where the majority of baseline transmission occurs indoors.In the surveyed area of rural southern Tanzania, bed net use steadily increasedover the last decade, reducing malaria transmission intensity by 94%.METHODS: Starting before bed nets were introduced (1997), and then after twomilestones of net use had been reached-75% community-wide use of untreated nets(2004) and then 47% use of ITNs (2009)-hourly biting rates of malaria vectorsfrom the Anopheles gambiae complex and Anopheles funestus group were surveyed.RESULTS: In 1997, An. gambiae s.l. and An. funestus mosquitoes exhibited atendency to bite humans inside houses late at night. For An. gambiae s.l., by2009, nocturnal activity was less (p = 0.0018). At this time, the sibling speciescomposition of the complex had shifted from predominantly An. gambiae s.s. topredominantly An. arabiensis. For An. funestus, by 2009, nocturnal activity wasless (p = 0.0054) as well as the proportion biting indoors (p < 0.0001). At this time, An. funestus s.s. remained the predominant species within this group. As a

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consequence of these altered feeding patterns, the proportion (mean ± standarderror) of human contact with mosquitoes (bites per person per night) occurringindoors dropped from 0.99 ± 0.002 in 1997 to 0.82 ± 0.008 in 2009 for the An.gambiae complex (p = 0.0143) and from 1.00 ± <0.001 to only 0.50 ± 0.048 for the An. funestus complex (p = 0.0004) over the same time period.CONCLUSIONS: High usage of ITNs can dramatically alter African vector populationsso that intense, predominantly indoor transmission is replaced by greatly loweredresidual transmission, a greater proportion of which occurs outdoors. Regardless of the underlying mechanism, the residual, self-sustaining transmission willrespond poorly to further insecticidal measures within houses. Additional vector control tools which target outdoor biting mosquitoes at the adult or immaturestages are required to complement ITNs and IRS.

PMCID: PMC3084176PMID: 21477321 [PubMed - indexed for MEDLINE]

109. Malar J. 2011 Mar 31;10:73. doi: 10.1186/1475-2875-10-73.

Design, implementation and evaluation of a national campaign to distribute ninemillion free LLINs to children under five years of age in Tanzania.

Bonner K, Mwita A, McElroy PD, Omari S, Mzava A, Lengeler C, Kaspar N, Nathan R, Ngegba J, Mtung'e R, Brown N.

National Malaria Control Programme, Ministry of Health and Social Welfare, PO Box9083, Dar es Salaam, Tanzania. [email protected]

BACKGROUND: After a national voucher scheme in 2004 provided pregnant women andinfants with highly subsidized insecticide-treated nets (ITNs), use amongchildren under five years (U5s) in mainland Tanzania increased from 16% in 2004to 26.2% in 2007. In 2008, the Ministry of Health and Social Welfare planned acatch-up campaign to rapidly and equitably deliver a free long-lastinginsecticidal net (LLIN) to every child under five years in Tanzania.METHODS: The ITN Cell, a unit within the National Malaria Control Programme(NMCP), coordinated the campaign on behalf of the Ministry of Health and SocialWelfare. Government contractors trained and facilitated local governmentofficials to supervise village-level volunteers on a registration of all U5s and

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the distribution and issuing of LLINs. The registration results formed the basis for the LLIN order and delivery to village level. Caregivers brought theirregistration coupons to village issuing posts during a three-day period wherethey received LLINs for their U5s. Household surveys in five districts assessedITN ownership and use immediately after the campaign.RESULTS: Nine donors contributed to the national campaign that purchased anddistributed 9.0 million LLINs at an average cost of $7.07 per LLIN, including allcampaign-associated activities. The campaign covered all eight zones of mainland Tanzania, the first region being covered separately during an integrated measles immunization/malaria LLIN distribution in August 2008, and was implemented onezone at a time from March 2009 until May 2010. ITN ownership at household levelincreased from Tanzania's 2008 national average of 45.7% to 63.4%, withsignificant regional variations. ITN use among U5s increased from 28.8% to 64.1%,a 2.2-fold increase, with increases ranging from 22.1-38.3% percentage points in different regions.CONCLUSION: A national-level LLIN distribution strategy that fully engaged local government authorities helped avoid additional burden on the healthcare system.Distribution costs per net were comparable to other public health interventions. Particularly among rural residents, ITN ownership and use increased significantlyfor the intended beneficiaries. The upcoming universal LLIN distribution andfurther behaviour change communication will further improve ITN ownership and usein 2010-2011.

PMCID: PMC3078903PMID: 21453519 [PubMed - indexed for MEDLINE]

110. Acta Trop. 2012 Mar;121(3):184-95. doi: 10.1016/j.actatropica.2011.03.004. Epub2011 Mar 21.

Malaria in Uganda: challenges to control on the long road to elimination: I.Epidemiology and current control efforts.

Yeka A, Gasasira A, Mpimbaza A, Achan J, Nankabirwa J, Nsobya S, Staedke SG,Donnelly MJ, Wabwire-Mangen F, Talisuna A, Dorsey G, Kamya MR, Rosenthal PJ.

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Infectious Diseases Research Collaboration, Kampala, Uganda.

Malaria remains one of the leading health problems of the developing world, andUganda bears a particularly large burden from the disease. Our understanding islimited by a lack of reliable data, but it is clear that the prevalence ofmalaria infection, incidence of disease, and mortality from severe malaria allremain very high. Uganda has made progress in implementing key malaria controlmeasures, in particular distribution of insecticide-impregnated bednets, indoorresidual spraying of insecticides, utilization of artemisinin-based combinationtherapy to treat uncomplicated malaria, and provision of intermittent preventive therapy for pregnant women. However, despite enthusiasm regarding the potentialfor the elimination of malaria in other areas, there is no convincing evidencethat the burden of malaria has decreased in Uganda in recent years. Majorchallenges to malaria control in Uganda include very high malaria transmissionintensity, inadequate health care resources, a weak health system, inadequateunderstanding of malaria epidemiology and the impact of control interventions,increasing resistance of parasites to drugs and of mosquitoes to insecticides,inappropriate case management, inadequate utilization of drugs to preventmalaria, and inadequate epidemic preparedness and response. Despite thesechallenges, prospects for the control of malaria have improved, and withattention to underlying challenges, progress toward the control of malaria inUganda can be expected.

Copyright © 2011 Elsevier B.V. All rights reserved.

PMCID: PMC3156969 [Available on 2013/3/1]PMID: 21420377 [PubMed - indexed for MEDLINE]

111. Acta Trop. 2012 Mar;121(3):227-39. doi: 10.1016/j.actatropica.2011.02.016. Epub2011 Mar 5.

Malaria in the Greater Mekong Subregion: heterogeneity and complexity.

Cui L, Yan G, Sattabongkot J, Cao Y, Chen B, Chen X, Fan Q, Fang Q, JongwutiwesS, Parker D, Sirichaisinthop J, Kyaw MP, Su XZ, Yang H, Yang Z, Wang B, Xu J,Zheng B, Zhong D, Zhou G.

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Department of Entomology, The Pennsylvania State University, University Park,16801, USA. [email protected]

The Greater Mekong Subregion (GMS), comprised of six countries includingCambodia, China's Yunnan Province, Lao PDR, Myanmar (Burma), Thailand andVietnam, is one of the most threatening foci of malaria. Since the initiation of the WHO's Mekong Malaria Program a decade ago, malaria situation in the GMS hasgreatly improved, reflected in the continuous decline in annual malaria incidenceand deaths. However, as many nations are moving towards malaria elimination, the GMS nations still face great challenges. Malaria epidemiology in this regionexhibits enormous geographical heterogeneity with Myanmar and Cambodia remaining high-burden countries. Within each country, malaria distribution is also patchy, exemplified by 'border malaria' and 'forest malaria' with high transmissionoccurring along international borders and in forests or forest fringes,respectively. 'Border malaria' is extremely difficult to monitor, and frequentmalaria introductions by migratory human populations constitute a major threat toneighboring, malaria-eliminating countries. Therefore, coordination betweenneighboring countries is essential for malaria elimination from the entireregion. In addition to these operational difficulties, malaria control in the GMSalso encounters several technological challenges. Contemporary malaria controlmeasures rely heavily on effective chemotherapy and insecticide control of vectormosquitoes. However, the spread of multidrug resistance and potential emergenceof artemisinin resistance in Plasmodium falciparum make resistance management ahigh priority in the GMS. This situation is further worsened by the circulationof counterfeit and substandard artemisinin-related drugs. In most endemic areasof the GMS, P. falciparum and Plasmodium vivax coexist, and in recent malariacontrol history, P. vivax has demonstrated remarkable resilience to controlmeasures. Deployment of the only registered drug (primaquine) for the radicalcure of vivax malaria is severely undermined due to high prevalence ofglucose-6-phosphate dehydrogenase deficiency in target human populations. In the GMS, the dramatically different ecologies, diverse vector systems, andinsecticide resistance render traditional mosquito control less efficient. Here

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we attempt to review the changing malaria epidemiology in the GMS, analyze thevector systems and patterns of malaria transmission, and identify the majorchallenges the malaria control community faces on its way to malaria elimination.

Copyright © 2011 Elsevier B.V. All rights reserved.

PMCID: PMC3132579 [Available on 2013/3/1]PMID: 21382335 [PubMed - indexed for MEDLINE]

112. BMC Infect Dis. 2011 Mar 2;11:57. doi: 10.1186/1471-2334-11-57.

Malaria prevention reduces in-hospital mortality among severely ill tuberculosis patients: a three-step intervention in Bissau, Guinea-Bissau.

Colombatti R, Penazzato M, Bassani F, Vieira CS, Lourenço AA, Vieira F, Teso S,Giaquinto C, Riccardi F.

Clinic of Pediatric Hematology-Oncology, Department of Pediatrics, University of Padova, Padova, Italy. [email protected]

BACKGROUND: Malaria and Tuberculosis (TB) are important causes of morbidity andmortality in Africa. Malaria prevention reduces mortality among HIV patients,pregnant women and children, but its role in TB patients is not clear. In the TB National Reference Center in Guinea-Bissau, admitted patients are in severeclinical conditions and mortality during the rainy season is high. We performed athree-step malaria prevention program to reduce mortality in TB patients duringthe rainy season.METHODS: Since 2005 Permethrin treated bed nets were given to every patient.Since 2006 environmental prevention with permethrin derivates was performed both indoor and outdoor during the rainy season. In 2007 cotrimoxazole prophylaxis wasadded during the rainy season. Care was without charge; health education onmalaria prevention was performed weekly. Primary outcomes were death, discharge, drop-out.RESULTS: 427, 346, 549 patients were admitted in 2005, 2006, 2007, respectively. Mortality dropped from 26.46% in 2005 to 18.76% in 2007 (p-value 0.003), due tothe significant reduction in rainy season mortality (death/discharge ratio: 0.79,

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0.55 and 0.26 in 2005, 2006 and 2007 respectively; p-value 0.001) while dryseason mortality remained constant (0.39, 0.37 and 0.32; p-value 0.647). Costs ofmalaria prevention were limited: 2€/person. No drop-outs were observed. Healtheducation attendance was 96-99%.CONCLUSIONS: Malaria prevention in African tertiary care hospitals seems feasiblewith limited costs. Vector control, personal protection and cotrimoxazoleprophylaxis seem to reduce mortality in severely ill TB patients. Prospectiverandomized trials are needed to confirm our findings in similar settings.

PMCID: PMC3056796PMID: 21366907 [PubMed - indexed for MEDLINE]

113. Southeast Asian J Trop Med Public Health. 2010 Nov;41(6):1297-305.

Progress of partial integration of malaria control with other vector bornediseases control in northern Thailand.

Suwonkerd W, Vryheid R, Suwannachote N.

Vector Borne Disease Section, Office of Disease Prevention and Control No. 10,Chiang Mai, Thailand. [email protected]

Thailand partially integrated the malaria program into the provincial and localPublic Health system starting in 2003 by adding it to the control of other vectorborne diseases and by transferring some activities to the Public HealthDepartment. This study evaluates the results of this transfer on 8 high malariaincidence districts of Mae Hong Son and Chiang Mai Provinces. Indicators weremeasured for all community hospitals, Vector Borne Disease Control Units, (VBDU),health centers (HC), malaria clinics, and malaria posts in 2003 and 2004 duringthe first two years of partial integration. The number of Vector Borne DiseaseControl staff decreased 1.8 - 3%, and their operational budgets decreased 25%.The VBDU staff did all the indoor residual spraying (IRS), insecticide treatednet (ITN) work and entomology surveys, they took 80.6% of the blood films, andtreated 72% of the patients, while Public Health system did the remainder. TheAnnual Parasite Incidence (API) (1 - 10/1,000) and IRS coverage (88 - 100%)remained adequate in most areas during the first years after partial integration,

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but the API increased (to 31.6 - 57.6/1,000) in some populations. The percentage of insecticide treated bed net coverage was adequate in Mae Hong Son (95.4%), butinadequate in Chiang Mai (52.2%). Early diagnosis and prompt treatment (4 - 23days), hospitals reporting disruption of anti-malarial drugs (3 of 7), and healthcenters having all needed equipment, training, and drugs for malaria diagnosis(9%) remain inadequate. If the program is allowed to diminish, malaria couldspread again among the population. Integration of antimalarial activities intothe general Public Health system has only been partially successful. We recommendthe integration process and results should be monitored and evaluated to find andmitigate problems as they occur, and modify the integration process if needed.

PMID: 21329301 [PubMed - indexed for MEDLINE]

114. Afr Health Sci. 2010 Jun;10(2):117-9.

Awareness and use of insecticide-treated bed nets among children attendingoutpatient clinic at UNTH, Enugu - the need for an effective mobilizationprocess.

Edelu BO, Ikefuna AN, Emodi JI, Adimora GN.

Department of Paediatrics, University of Nigeria Teaching Hospital, Ituku-Ozalla,Enugu, Nigeria. [email protected]

BACKGROUND: The promotion of insecticide-treated net (ITN) can be a key approach towards the reduction of morbidity and mortality from malaria.OBJECTIVE: To determine the proportion of mothers using insecticide treated nets for their children and reasons for nonuse.STUDY DESIGN: Prospective hospital-based study.METHOD: Consecutive mothers attending the children's out patient clinic of UNTH, Ituku-Ozalla, Enugu, whose children presented with fever without localizing focuswere interviewed with the aid of an open-ended structured questionnaire.RESULTS: Awareness of ITN was found in 184 (80%) of the 230 mothers interviewed, while only 48 (26.1%) use it for their children. There was statisticallysignificant difference in terms of ITN awareness between the highly educatedmothers and those with lower educational qualification (p = 0.000) but, in terms

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of ITN usage, there was no significant difference between the two groups (p =0.40). Socio economic class did not influence the use of ITN (p = 0.153). Agreater number; 56 (41.2%) have no reason for non-use. Reasons for nonuse includeuse of windows and door nets 22 (16.2%) and not convenient to spread 18 (13.2%).CONCLUSION: There was a high awareness of ITN, which did not influence usage.

PMCID: PMC2956296PMID: 21326961 [PubMed - indexed for MEDLINE]

115. PLoS Med. 2011 Feb 1;8(2):e1000408. doi: 10.1371/journal.pmed.1000408.

Intermittent preventive treatment of malaria provides substantial protectionagainst malaria in children already protected by an insecticide-treated bednet inBurkina Faso: a randomised, double-blind, placebo-controlled trial.

Konaté AT, Yaro JB, Ouédraogo AZ, Diarra A, Gansané A, Soulama I, Kangoyé DT,Kaboré Y, Ouédraogo E, Ouédraogo A, Tiono AB, Ouédraogo IN, Chandramohan D,Cousens S, Milligan PJ, Sirima SB, Greenwood B, Diallo DA.

Centre National de Recherche et de Formation sur Paludisme, Ouagadougou, Burkina Faso.

BACKGROUND: Intermittent preventive treatment of malaria in children (IPTc) is a promising new approach to the control of malaria in areas of seasonal malariatransmission but it is not known if IPTc adds to the protection provided by aninsecticide-treated net (ITN).METHODS AND FINDINGS: An individually randomised, double-blind,placebo-controlled trial of seasonal IPTc was conducted in Burkina Faso inchildren aged 3 to 59 months who were provided with a long-lastinginsecticide-treated bednet (LLIN). Three rounds of treatment with sulphadoxinepyrimethamine plus amodiaquine or placebos were given at monthly intervals duringthe malaria transmission season. Passive surveillance for malaria episodes wasestablished, a cross-sectional survey was conducted at the end of the malariatransmission season, and use of ITNs was monitored during the interventionperiod. Incidence rates of malaria were compared using a Cox regression model and

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generalized linear models were fitted to examine the effect of IPTc on theprevalence of malaria infection, anaemia, and on anthropometric indicators. 3,052children were screened and 3,014 were enrolled in the trial; 1,505 in the controlarm and 1,509 in the intervention arm. Similar proportions of children in the twotreatment arms were reported to sleep under an LLIN during the interventionperiod (93%). The incidence of malaria, defined as fever or history of fever withparasitaemia ≥ 5,000/µl, was 2.88 (95% confidence interval [CI] 2.70-3.06) perchild during the intervention period in the control arm versus 0.87 (95% CI0.78-0.97) in the intervention arm, a protective efficacy (PE) of 70% (95% CI66%-74%) (p<0.001). There was a 69% (95% CI 6%-90%) reduction in incidence ofsevere malaria (p = 0.04) and a 46% (95% CI 7%-69%) (p = 0.03) reduction in theincidence of all-cause hospital admissions. IPTc reduced the prevalence ofmalaria infection at the end of the malaria transmission season by 73% (95% CI68%-77%) (p<0.001) and that of moderately severe anaemia by 56% (95% CI 36%-70%) (p<0.001). IPTc reduced the risks of wasting (risk ratio [RR] = 0.79; 95% CI0.65-1.00) (p = 0.05) and of being underweight (RR = 0.84; 95% CI 0.72-0.99) (p =0.03). Children who received IPTc were 2.8 (95% CI 2.3-3.5) (p<0.001) times more likely to vomit than children who received placebo but no drug-related seriousadverse event was recorded.CONCLUSIONS: IPT of malaria provides substantial protection against malaria inchildren who sleep under an ITN. There is now strong evidence to support theintegration of IPTc into malaria control strategies in areas of seasonal malaria transmission.TRIAL REGISTRATION: ClinicalTrials.govNCT00738946. Please see later in thearticle for the Editors' Summary.

PMCID: PMC3032552PMID: 21304925 [PubMed - indexed for MEDLINE]

116. PLoS Med. 2011 Feb 1;8(2):e1000407. doi: 10.1371/journal.pmed.1000407.

Intermittent preventive treatment of malaria provides substantial protection

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against malaria in children already protected by an insecticide-treated bednet inMali: a randomised, double-blind, placebo-controlled trial.

Dicko A, Diallo AI, Tembine I, Dicko Y, Dara N, Sidibe Y, Santara G, Diawara H,Conaré T, Djimde A, Chandramohan D, Cousens S, Milligan PJ, Diallo DA, Doumbo OK,Greenwood B.

Malaria Research and Training Centre, Faculty of Medicine Pharmacy and Dentistry,University of Bamako, Bamako, Mali. [email protected]

BACKGROUND: Previous studies have shown that in areas of seasonal malariatransmission, intermittent preventive treatment of malaria in children (IPTc),targeting the transmission season, reduces the incidence of clinical malaria.However, these studies were conducted in communities with low coverage withinsecticide-treated nets (ITNs). Whether IPTc provides additional protection tochildren sleeping under an ITN has not been established.METHODS AND FINDINGS: To assess whether IPTc provides additional protection tochildren sleeping under an ITN, we conducted a randomised, double-blind,placebo-controlled trial of IPTc with sulphadoxine pyrimethamine (SP) plusamodiaquine (AQ) in three localities in Kati, Mali. After screening, eligiblechildren aged 3-59 mo were given a long-lasting insecticide-treated net (LLIN)and randomised to receive three rounds of active drugs or placebos. Treatmentswere administered under observation at monthly intervals during the high malaria transmission season in August, September, and October 2008. Adverse events weremonitored immediately after the administration of each course of IPTc andthroughout the follow-up period. The primary endpoint was clinical episodes ofmalaria recorded through passive surveillance by study clinicians available atall times during the follow-up. Cross-sectional surveys were conducted in 150randomly selected children weekly and in all children at the end of the malariatransmission season to assess usage of ITNs and the impact of IPTc on theprevalence of malaria, anaemia, and malnutrition. Cox regression was used tocompare incidence rates between intervention and control arms. The effects ofIPTc on the prevalence of malaria infection and anaemia were estimated usinglogistic regression. 3,065 children were screened and 3,017 (1,508 in the control

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and 1,509 in the intervention arm) were enrolled in the study. 1,485 children(98.5%) in the control arm and 1,481 (98.1%) in the intervention arm completedfollow-up. During the intervention period, the proportion of children reported tohave slept under an ITN was 99.7% in the control and 99.3% in intervention arm (p= 0.45). A total of 672 episodes of clinical malaria defined as fever or ahistory of fever and the presence of at least 5,000 asexual forms of Plasmodiumfalciparum per microlitre (incidence rate of 1.90; 95% confidence interval [CI]1.76-2.05 episodes per person year) were observed in the control arm versus 126(incidence rate of 0.34; 95% CI 0.29-0.41 episodes per person year) in theintervention arm, indicating a protective effect (PE) of 82% (95% CI 78%-85%)(p<0.001) on the primary endpoint. There were 15 episodes of severe malaria inchildren in the control arm compared to two in children in the intervention groupgiving a PE of 87% (95% CI 42%-99%) (p = 0.001). IPTc reduced the prevalence ofmalaria infection by 85% (95% CI 73%-92%) (p<0.001) during the interventionperiod and by 46% (95% CI 31%-68%) (p<0.001) at the end of the interventionperiod. The prevalence of moderate anaemia (haemoglobin [Hb] <8 g/dl) was reducedby 47% (95% CI 15%-67%) (p<0.007) at the end of intervention period. Thefrequencies of adverse events were similar between the two arms. There was nodrug-related serious adverse event.CONCLUSIONS: IPTc given during the malaria transmission season providedsubstantial protection against clinical episodes of malaria, malaria infection,and anaemia in children using an LLIN. SP+AQ was safe and well tolerated. Thesefindings indicate that IPTc could make a valuable contribution to malaria controlin areas of seasonal malaria transmission alongside other interventions.TRIAL REGISTRATION: ClinicalTrials.gov NCT00738946. Please see later in thearticle for the Editors' Summary.

PMCID: PMC3032550PMID: 21304923 [PubMed - indexed for MEDLINE]

117. PLoS Med. 2011 Feb 1;8(2):e1000409. doi: 10.1371/journal.pmed.1000409.

Two strategies for the delivery of IPTc in an area of seasonal malariatransmission in the Gambia: a randomised controlled trial.

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Bojang KA, Akor F, Conteh L, Webb E, Bittaye O, Conway DJ, Jasseh M, Wiseman V,Milligan PJ, Greenwood B.

Medical Research Council Laboratories, Banjul, The Gambia. [email protected]

BACKGROUND: The Expanded Programme on Immunisation (EPI) provides an effectiveway of delivering intermittent preventive treatment for malaria (IPT) to infants.However, it is uncertain how IPT can be delivered most effectively to olderchildren. Therefore, we have compared two approaches to the delivery of IPT toGambian children: distribution by village health workers (VHWs) or throughreproductive and child health (RCH) trekking teams. In rural areas, RCH trekking teams provide most of the health care to children under the age of 5 years in theInfant Welfare Clinic, and provide antenatal care for pregnant women.METHODS AND FINDINGS: During the 2006 malaria transmission season, the catchment populations of 26 RCH trekking clinics in The Gambia, each with 400-500 children 6 years of age and under, were randomly allocated to receive IPT from an RCHtrekking team or from a VHW. Treatment with a single dose of sulfadoxinepyrimethamine (SP) plus three doses of amodiaquine (AQ) were given at monthlyintervals during the malaria transmission season. Morbidity from malaria wasmonitored passively throughout the malaria transmission season in all children,and a random sample of study children from each cluster was examined at the endof the malaria transmission season. The primary study endpoint was the incidence of malaria. Secondary endpoints included coverage of IPTc, mean haemoglobin (Hb) concentration, and the prevalence of asexual malaria parasitaemia at the end ofmalaria transmission period. Financial and economic costs associated with the twodelivery strategies were collected and incremental cost and effects werecompared. A nested case-control study was used to estimate efficacy of IPTtreatment courses. Treatment with SP plus AQ was safe and well tolerated. Therewere 49 cases of malaria with parasitaemia above 5,000/µl in the areas where IPT was delivered through RCH clinics and 21 cases in the areas where IPT wasdelivered by VHWs, (incidence rates 2.8 and 1.2 per 1,000 child months,respectively, rate difference 1.6 [95% confidence interval (CI) -0.24 to 3.5]).

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Delivery through VHWs achieved a substantially higher coverage level of threecourses of IPT than delivery by RCH trekking teams (74% versus 48%, a difference of 27% [95% CI 16%-38%]). For both methods of delivery, coverage was unrelated toindices of wealth, with similar coverage being achieved in the poorest andwealthiest groups. The prevalence of anaemia was low in both arms of the trial atthe end of the transmission season. Efficacy of IPTc against malaria during themonth after each treatment course was 87% (95% CI 54%-96%). Delivery of IPTc byVHWs was less costly in both economic and financial terms than delivery throughRCH trekking teams, resulting in incremental savings of US$872 and US$1,244respectively. The annual economic cost of delivering at least the first dose ofeach course of IPTc was US$3.47 and US$1.63 per child using trekking team andVHWs respectively.CONCLUSIONS: In this setting in The Gambia, delivery of IPTc to children 6 years of age and under by VHWs is more effective and less costly than delivery through RCH trekking clinics.TRIAL REGISTRATION: ClinicalTrials.gov NCT00376155. Please see later in thearticle for the Editors' Summary.

PMCID: PMC3032548PMID: 21304921 [PubMed - indexed for MEDLINE]

118. Popul Stud (Camb). 2011 Mar;65(1):57-71. doi: 10.1080/00324728.2010.544323.

The problems of eligibility and endogenous confounders when assessing themortality impact of a nationwide disease-prevention programme: the case ofinsecticide-treated nets in Togo.

Ishida K, Stupp P, Erskine M, Goldberg H, Morgah K.

Centers for Disease Control and Prevention, Division of Reproductive Health, 4770Buford Hwy NE, Mail Stop K-23, Atlanta, GA 30341, USA. [email protected]

Evaluation of the mortality impact of nationwide disease-prevention efforts iscomplicated by potential endogeneity: programme recipients may have unobservedcharacteristics that simultaneously make them both more likely to becomerecipients and more likely to survive as a result of other health practices. This

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population-based study assesses the mortality impact of a nationwide programmethat distributed insecticide-treated nets (ITNs) to mothers of children aged 9-59months in Togo. By comparing mortality rates before and after the programmeaccording to households' eligibility status, we demonstrate that a one-timeprogramme that restricts eligibility to households with a surviving childexcludes some households with a high risk of child mortality. We then applysimultaneous estimation models to untangle the mortality impact of ITNs from the effects of unobserved confounders and show that among eligible households, livingin a household with ITNs significantly reduces mortality for children aged 20-59 months, even after controlling for endogeneity.

PMID: 21294055 [PubMed - indexed for MEDLINE]

119. Lancet Infect Dis. 2011 Mar;11(3):190-207. doi: 10.1016/S1473-3099(10)70295-4.Epub 2011 Jan 26.

Coverage of malaria protection in pregnant women in sub-Saharan Africa: asynthesis and analysis of national survey data.

van Eijk AM, Hill J, Alegana VA, Kirui V, Gething PW, ter Kuile FO, Snow RW.

Child and Reproductive Health Group, Liverpool School of Tropical Medicine,Liverpool, UK. [email protected]

Comment in Lancet Infect Dis. 2011 Mar;11(3):157-9.

BACKGROUND: Insecticide-treated nets and intermittent preventive treatment withsulfadoxine-pyrimethamine are recommended for the control of malaria duringpregnancy in endemic areas in Africa, but there has been no analysis of coverage data at a subnational level. We aimed to synthesise data from national surveysabout these interventions, accounting for disparities in malaria risk withinnational borders.METHODS: We extracted data for specific strategies for malaria control inpregnant women from national malaria policies from endemic countries in Africa.We identified the most recent national household cluster-sample surveys recordingintermittent preventive treatment with sulfadoxine-pyrimethamine and use of

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insecticide-treated nets. We reconciled data to subnational administrative units to construct a model to estimate the number of pregnant women covered by arecommended intervention in 2007.FINDINGS: 45 (96%) of 47 countries surveyed had a policy for distribution ofinsecticide-treated nets for pregnant women; estimated coverage in 2007 was 4·7million (17%) of 27·7 million pregnancies at risk of malaria in 32 countries withdata. 39 (83%) of 47 countries surveyed had an intermittent preventive treatment policy; in 2007, an estimated 6·4 million (25%) of 25·6 million pregnant womenreceived at least one dose of treatment and 19·8 million (77%) visited anantenatal clinic (31 countries). Estimated coverage was lowest in areas ofhigh-intensity transmission of malaria.INTERPRETATION: Despite success in a few countries, coverage ofinsecticide-treated nets and intermittent preventive treatment in pregnantAfrican women is inadequate; increased efforts towards scale-up are needed.FUNDING: The Malaria in Pregnancy Consortium and Wellcome Trust.

Copyright © 2011 Elsevier Ltd. All rights reserved.

PMCID: PMC3119932PMID: 21273130 [PubMed - indexed for MEDLINE]

120. Am J Trop Med Hyg. 2011 Jan;84(1):152-7. doi: 10.4269/ajtmh.2011.10-0287.

Malaria infection and anemia prevalence in Zambia's Luangwa District: an area of near-universal insecticide-treated mosquito net coverage.

Eisele TP, Miller JM, Moonga HB, Hamainza B, Hutchinson P, Keating J.

Department of International Health and Development, Tulane University School ofPublic Health and Tropical Medicine, New Orleans, Louisiana 70112, [email protected]

We examined the relationship between insecticide-treated mosquito nets (ITNs),malaria parasite infection, and severe anemia prevalence in children in LuangwaDistrict, Zambia, an area with near-universal ITN coverage, at the end of the2008 and 2010 malaria transmission seasons. Malaria parasite infection prevalenceamong children < 5 years old was 9.7% (95% confidence interval [CI] = 8.0-11.4%)

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over both survey years. Prevalence of severe anemia among children 6-59 monthsold was 6.9% (95% CI = 5.4-8.5%) over both survey years. Within this context ofnear-universal ITN coverage, we were unable to detect a significant associationbetween malaria parasite or severe anemia prevalence and ITNs (possession anduse). In addition to maintaining universal ITN coverage, it will be essential forthe malaria control program to achieve high ITN use and laboratory diagnosis and treatment of all fevers among all age groups to further reduce the malaria burdenin this area.

PMCID: PMC3005497

121. Soc Sci Med. 2011 Feb;72(3):408-17. doi: 10.1016/j.socscimed.2010.11.009. Epub2010 Nov 24.

Malaria risk behaviours, socio-cultural practices and rural livelihoods insouthern Tanzania: implications for bednet usage.

Dunn CE, Le Mare A, Makungu C.

Durham University, Department of Geography, Science Site, South Road, Durham DH1 3LE, United Kingdom. [email protected]

Most malaria risk reduction strategies are firmly embedded in biomedicalpractices and public health perspectives. National and international programmesto 'control' malaria are particularly characterised by the promotion of publichealth interventions which converge on the disease vector, the malaria mosquito, notably through the use of indoor household spraying with insecticides, and thedeployment of insecticide-treated bednets (ITNs). With convincing evidence forthe effectiveness of ITNs in reducing the incidence of malaria, controlprogrammes have emphasised the notion of 'scaling-up' bednet coverage. Muchprevious research on people's 'compliance' with bednet programmes has tended tofocus on the quantification of bednet usage and on deriving explanations for'non-compliance' based on household or individual indicators such as wealth, age,gender or educational level, or on climatic factors such as season and

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temperature. However, malaria risk behaviours are also rooted in wider aspects oflocal livelihoods, and socio-cultural beliefs and practices which interplay with the use and, crucially, non-use, of bednets. This paper draws on empirical dataderived from in-depth, one-to-one semi-structured interviews, focus groups andparticipatory methods (mapping and diagramming) with participants in two villagesin rural Tanzania to explore the nature of these practices and vulnerabilities,and their potential impact on malaria exposure risk. Participants includedfarmers and pastoralists, both men and women, as well as village 'officials'. By eliciting local understandings of malaria-related behaviours we explore howmalaria risks are played out in people's everyday lives, and the circumstancesand decision-making which underpin non-usage of bednets. Our findings reveal the importance of shifting sleeping patterns in response to livelihood needs andsocio-cultural practices and events. These arrangements militate against theconsistent and sustained use of the bednet which are called for by public health policies. In particular we demonstrate the importance of the spatial and temporaldimensions of farming practices and the role of conflict over access to sharedland; the impact of livelihood activities on malaria risks for school-agedchildren; risk behaviours during 'special' socio-cultural events such as funeral ceremonies; and routine, outdoor activities around dawn and dusk and the genderednature of these practices.

Copyright © 2010 Elsevier Ltd. All rights reserved.

PMID: 21211875 [PubMed - indexed for MEDLINE]

122. Malar J. 2010 Dec 23;9:372. doi: 10.1186/1475-2875-9-372.

Is staying overnight in a farming hut a risk factor for malaria infection in asetting with insecticide-treated bed nets in rural Laos?

Nonaka D, Laimanivong S, Kobayashi J, Chindavonsa K, Kano S, Vanisaveth V,Yasuoka J, Phompida S, Jimba M.

Department of Community and Global Health, Graduate School of Medicine, the

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University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo, Japan. [email protected]

BACKGROUND: Overnight stays in farming huts are known to pose a risk of malariainfection. However, studies reporting the risk were conducted in the settings of poor net coverage. This study sought to assess whether an overnight stay in afarming hut is associated with an increased risk of malaria infection ifinsecticide-treated bed nets (ITNs) are properly used.METHODS: A pair of cross-sectional surveys was carried out in the Lamarm districtof Sekong province, Laos, in March (dry season) and August (rainy season) in2008. Questionnaire-based interviews and blood examinations were conducted withfarmers and their household members from three randomly selected villages inMarch (127 households, 891 people) and August (128 households, 919 people).Logistic regression analysis, adjusted for potential confounding factors, wasused to assess the association between malaria infection status and frequency of overnight stays for the two weeks prior to the study in both the seasons.RESULTS: In March, 13.7% of participants reported staying overnight in a farming hut at least once in the previous two weeks. The percentage increased to 74.6% inAugust. Not only adults but also young children stayed overnight as often asadults. The use of an ITN the preceding night was common both in farming huts(66.3% in March, 95.2% in August), and in main residences (85.8% in March, 92.5% in August). Logistic regression analysis showed no statistical associationbetween malaria infection status and frequency of overnight stays in farming hutsin either study period. However, people sharing one family type net with fivepeople or more were significantly more likely to have malaria than those sharing a net with up to two people in the dry season.CONCLUSIONS: This study showed that staying overnight in farming huts was notassociated with an increased risk of malaria infection in the setting where ITNs were widely used in farming huts. It suggests that malaria infection duringovernight stays in farming huts might be preventable if ITNs are properly used inrural Laos.

PMCID: PMC3224235PMID: 21176242 [PubMed - indexed for MEDLINE]

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123. Malar J. 2010 Dec 6;9:353. doi: 10.1186/1475-2875-9-353.

Effects of transmission reduction by insecticide-treated bed nets (ITNs) onparasite genetics population structure: I. The genetic diversity of Plasmodiumfalciparum parasites by microsatellite markers in western Kenya.

Gatei W, Kariuki S, Hawley W, ter Kuile F, Terlouw D, Phillips-Howard P, NahlenB, Gimnig J, Lindblade K, Walker E, Hamel M, Crawford S, Williamson J, SlutskerL, Shi YP.

Malaria Branch, Division of Parasitic Diseases, Centers for Disease Control andPrevention, Atlanta, Georgia, USA.

BACKGROUND: Insecticide-treated bed nets (ITNs) reduce malaria transmission andare an important prevention tool. However, there are still information gaps onhow the reduction in malaria transmission by ITNs affects parasite geneticspopulation structure. This study examined the relationship between transmissionreduction from ITN use and the population genetic diversity of Plasmodiumfalciparum in an area of high ITN coverage in western Kenya.METHODS: Parasite genetic diversity was assessed by scoring eight single copyneutral multilocus microsatellite (MS) markers in samples collected from P.falciparum-infected children (< five years) before introduction of ITNs (1996,baseline, n = 69) and five years after intervention (2001, follow-up, n = 74).RESULTS: There were no significant changes in overall high mixed infections andunbiased expected heterozygosity between baseline (%MA = 94% and He = 0.75) andfollow up (%MA = 95% and He = 0.79) years. However, locus specific analysisdetected significant differences for some individual loci between the two timepoints. Pfg377 loci, a gametocyte-specific MS marker showed significant increase in mixed infections and He in the follow up survey (%MA = 53% and He = 0.57)compared to the baseline (%MA = 30% and He = 0.29). An opposite trend wasobserved in the erythrocyte binding protein (EBP) MS marker. There was moderategenetic differentiation at the Pfg377 and TAA60 loci (FST = 0.117 and 0.137respectively) between the baseline and post-ITN parasite populations. Further

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analysis revealed linkage disequilibrium (LD) of the microsatellites in thebaseline (14 significant pair-wise tests and ISA = 0.016) that was broken in the follow up parasite population (6 significant pairs and ISA = 0.0003). The locusspecific change in He, the moderate population differentiation and break in LDbetween the baseline and follow up years suggest an underlying change inpopulation sub-structure despite the stability in the overall genetic diversityand multiple infection levels.CONCLUSIONS: The results from this study suggest that although P. falciparumpopulation maintained an overall stability in genetic diversity after five years of high ITN coverage, there was significant locus specific change associated withgametocytes, marking these for further investigation.

PMCID: PMC3004940PMID: 21134282 [PubMed - indexed for MEDLINE]

124. Malar J. 2010 Nov 30;9:345. doi: 10.1186/1475-2875-9-345.

"Before we used to get sick all the time": perceptions of malaria and use oflong-lasting insecticide-treated bed nets (LLINs) in a rural Kenyan community.

Dye TD, Apondi R, Lugada ES, Kahn JG, Smith J, Othoro C.

Department of Public Health and Preventive Medicine, State University of New YorkUpstate Medical University, SUNY Upstate Medical University, Institute for Human Performance, Syracuse, New York 13210, USA. [email protected]

BACKGROUND: Malaria is a leading global cause of preventable morbidity andmortality, especially in sub-Saharan Africa, despite recent advances in treatmentand prevention technologies. Scale-up and wide distribution of long-lastinginsecticide-treated nets (LLINs) could rapidly decrease malarial disease inendemic areas, if used properly and continuously. Studies have shown thateffective use of LLINs depends, in part, upon understanding causal factorsassociated with malaria. This study examined malaria beliefs, attitudes, andpractices toward LLINs assessed during a large-scale integrated preventioncampaign (IPC) in rural Kenya.METHODS: Qualitative interviews were conducted with 34 IPC participants who

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received LLINs as part of a comprehensive prevention package of goods andservices. One month after distribution, interviewers asked these individualsabout their attitudes and beliefs regarding malaria, and about their use ofLLINs.RESULTS: Virtually all participants noted that mosquitoes were involved incausing malaria, though a substantial proportion of participants (47 percent)also mentioned an incorrect cause in addition to mosquitoes. For example,participants commonly noted that the weather (rain, cold) or consumption of badfood and water caused malaria. Regardless, most participants used the LLINs they were given and most mentioned positive benefits from their use, namely reductionsin malarial illness and in the costs associated with its diagnosis and treatment.CONCLUSIONS: Attitudes toward LLINs were positive in this rural community inWestern Kenya, and respondents noted benefits with LLIN use. With improvedunderstanding and clarification of the direct (mosquitoes) and indirect (e.g.,standing water) causes of malaria, it is likely that LLIN use can be sustained,offering effective household-level protection against malaria.

PMCID: PMC3225033PMID: 21118550 [PubMed - indexed for MEDLINE]

125. Malar J. 2010 Nov 18;9:330. doi: 10.1186/1475-2875-9-330.

How many mosquito nets are needed to achieve universal coverage? Recommendations for the quantification and allocation of long-lasting insecticidal nets for mass campaigns.

Kilian A, Boulay M, Koenker H, Lynch M.

Malaria Consortium, Development House, London EC2A 4LT, [email protected]

BACKGROUND: Long-lasting insecticidal nets are an effective tool for malariaprevention, and "universal coverage" with such nets is increasingly the goal ofnational malaria control programmes. However, national level campaigns in severalcountries have run out of nets in the course of distribution, indicating aproblem in the method used to estimate the quantity needed. PRESENTATION OF

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HYPOTHESIS: A major reason for the shortfall in estimation is the mismatchbetween the quantification factor used to plan procurement and the allocationalgorithm used at community level, in particular the effect of needing to add an additional net to households with an odd number of inhabitants. To solve thisproblem a revised quantification factor is suggested. TESTING HYPOTHESIS: Basedon data from a broad range of household surveys across Africa, the effect ofodd-numbered households on numbers of nets distributed is estimated via twofrequently used allocation methods. The impact of these algorithms on theproportion of households reaching a person to net ratio of 2:1, a frequently usedmarker of universal coverage is then calculated. IMPLICATIONS: In order to avoid stock-outs of nets during national coverage campaigns, it is recommended to use aquantification factor of 1.78 people per net, with an additional allocationfactor suggested to account for other common problems at the community levelresulting in a final recommended ratio of 1.60 people per net. It is alsorecommend that community level allocation procedures be aligned with procurement estimates to reduce shortages of nets during campaign distributions. Theseanalyses should enable programme managers to make evidence-based decisions andsupport a more efficient and effective use of LLIN distribution campaignresources.

PMCID: PMC2994892PMID: 21087460 [PubMed - indexed for MEDLINE]

126. PLoS One. 2010 Nov 10;5(11):e13129. doi: 10.1371/journal.pone.0013129.

Barriers to insecticide-treated mosquito net possession 2 years after a mass freedistribution campaign in Luangwa District, Zambia.

Larsen DA, Keating J, Miller J, Bennett A, Changufu C, Katebe C, Eisele TP.

Department of International Health and Development, Tulane University School ofPublic Health and Tropical Medicine, New Orleans, Louisiana, United States ofAmerica.

BACKGROUND AND METHODS: Roll Back Malaria set the goal of 100% of households in

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malaria endemic countries in Africa owning an insecticide-treated mosquito net(ITN) by 2010. Zambia has used mass free distribution campaigns and distribution through antenatal care (ANC) clinics to achieve high coverage.METHODOLOGY AND PRINCIPAL FINDINGS: We conducted a probability survey of 801households in 2008 to assess factors associated with households that lacked anITN after mass distribution. Community perceptions of barriers to ITN access werealso obtained from in-depth interviews with household heads that reported notowning an ITN. Nearly 74% of households in Luangwa district reported owning ≥1ITN. Logistic regression showed households without a child <5 years old duringthe ITN distribution campaigns were twice as likely to not have an ITN as thosewith a child <5 during distribution (Adjusted odds ratio (AOR)  = 2.43; 95%confidence interval (CI): 1.67-3.55). Households without a woman who attended an ANC in the past 2 years were more likely to be without ITNs compared tohouseholds with a woman who attended an ANC in the past 2 years (AOR  = 1.52; 95%CI: 1.04-2.21). In-depth interviews with heads of households without an ITNrevealed that old age was a perceived barrier to receiving an ITN duringdistribution, and that ITNs wore out before they could be replaced.CONCLUSIONS AND SIGNIFICANCE: Delivery of a large number of ITNs does nottranslate directly into 100% household coverage. Due to their design, current ITNdistribution strategies may miss households occupied by the elderly and thosewithout children or ANC access. ITN distribution strategies targeting theelderly, those with limited access to distribution points, and others most likelyto be missed are necessary if 100% ITN coverage of households is to be achieved.

PMCID: PMC2978084PMID: 21085711 [PubMed - indexed for MEDLINE]

127. Malar J. 2010 Nov 11;9:319. doi: 10.1186/1475-2875-9-319.

Trends in malaria morbidity among health care-seeking children under age five in Mopti and Sévaré, Mali between 1998 and 2006.

Rose-Wood A, Doumbia S, Traoré B, Castro MC.

Department of Global Health and Population, Harvard University, Boston,Massachusetts, USA. [email protected]

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BACKGROUND: In Mali, malaria is the leading cause of death and the primary cause of outpatient visits for children under five. The twin towns of Mopti and Sévaré have historically had high under-five mortality. This paper investigates thechanging malaria burden in children under five in these two towns for the years1998-2006, and the likely contribution of previous interventions aimed atreducing malaria.METHODS: A retrospective analysis of daily outpatient consultation records fromurban community health centres (CSCOMs) located in Mopti and Sévaré for the years1998-2006 was conducted. Risk factors for a diagnosis of presumptive malaria,using logistic regression and trends in presumptive malaria diagnostic rates,were assessed using multilevel analysis.RESULTS: Between 1998-2006, presumptive malaria accounted for 33.8% of allrecorded consultation diagnoses (10,123 out of 29,915). The monthly presumptivemalaria diagnostic rate for children under five decreased by 66% (average of 8diagnoses per month per 1,000 children in 1998 to 2.7 diagnoses per month in2006). The multi-level analysis related 37% of this decrease to the distribution of bed net treatment kits initiated in May of 2001. Children of the Fulani(Peuhl) ethnicity had significantly lower odds of a presumptive malaria diagnosiswhen compared to children of other ethnic groups.CONCLUSIONS: Presumptive malaria diagnostic rates have decreased between1998-2006 among health care-seeking children under five in Mopti and Sévaré. Abed net treatment kit intervention conducted in 2001 is likely to havecontributed to this decline. The results corroborate previous findings thatsuggest that the Fulani ethnicity is protective against malaria. The findings areuseful to encourage dialogue around the urban malaria situation in Mali,particularly in the context of achieving the target of reducing malaria morbidityin children younger than five by 50% by 2011 as compared to levels in 2000.

PMCID: PMC2993732PMID: 21067615 [PubMed - indexed for MEDLINE]

128. Malar J. 2010 Nov 1;9:309. doi: 10.1186/1475-2875-9-309.

Fairness and legitimacy of decisions during delivery of malaria services and ITN interventions in Zambia.

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Tuba M, Sandoy IF, Bloch P, Byskov J.

Center for International Health, University of Bergen, PO Box 7804, N-5020Bergen, Norway. [email protected]

BACKGROUND: Malaria is the leading cause of morbidity and the second leadingcause of mortality in Zambia. Perceptions of fairness and legitimacy of decisionsrelating to treatment of malaria cases within public health facilities anddistribution of ITNs were assessed in a district in Zambia. The study wasconducted within the framework of REsponse to ACcountable priority setting forTrust in health systems (REACT), a north-south collaborative action researchstudy, which evaluates the Accountability for Reasonableness (AFR) approach topriority setting in Zambia, Tanzania and Kenya.METHODS: This paper is based on baseline in-depth interviews (IDIs) conductedwith 38 decision-makers, who were involved in prioritization of malaria services and ITN distribution at district, facility and community levels in Zambia, oneFocus Group Discussion (FGD) with District Health Management Team managers andeight FGDs with outpatients' attendees. Perceptions and attitudes of providersand users and practices of providers were systematized according to the four AFR conditions relevance, publicity, appeals and leadership.RESULTS: Conflicting criteria for judging fairness were used by decision-makersand patients. Decision-makers argued that there was fairness in delivery ofmalaria treatment and distribution of ITNs based on alleged excessive supply offree malaria medicines, subsidized ITNs, and presence of a qualifiedhealth-provider in every facility. Patients argued that there was unfairness due to differences in waiting time, distances to health facilities, erratic supply ofITNs, no responsive appeal mechanisms, inadequate access to malaria medicines,ITNs and health providers, and uncaring providers. Decision-makers only perceivedgovernment bodies and donors/NGOs to be legitimate stakeholders to involve duringdelivery. Patients found government bodies, patients, indigenous healers, chiefs and politicians to be legitimate stakeholders during both planning and delivery.CONCLUSION: Poor status of the AFR conditions of relevance, publicity, appeals

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and leadership corresponds well to the differing perceptions of fairness andunfairness among outpatient attendees and decision-makers. This may have beenre-enforced by existing disagreements between the two groups regarding who thelegitimate stakeholders to involve during service delivery were. Conflictsidentified in this study could be resolved by promoting application of approachessuch as AFR during priority setting in the district.

PMCID: PMC2988042PMID: 21040552 [PubMed - indexed for MEDLINE]

129. Am J Trop Med Hyg. 2010 Nov;83(5):1014-9. doi: 10.4269/ajtmh.2010.09-0599.

Rapid scale-up of long-lasting insecticide-treated bed nets through integrationinto the national immunization program during child health week in Togo, 2004.

Wolkon A, Vanden Eng JL, Morgah K, Eliades MJ, Thwing J, Terlouw DJ, Takpa V,Dare A, Sodahlon YK, Doumanou Y, Hightower AW, Lama M, Thawani N, Slutsker L,Hawley WA.

National Center for Infectious Diseases, Division of Parasitic Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia 30341, USA. [email protected]

In December 2004, Togo was the first country to conduct a nationwide freeinsecticide-treated net (ITN) distribution as part of its National IntegratedChild Health Campaign. Community-based cross-sectional surveys were conducted oneand nine months post-campaign as part of a multidisciplinary evaluation of thenationwide distribution of ITNs to children 9-59 months of age to evaluate ITNownership, equity, and use. Our results demonstrated that at one monthpost-campaign, 93.1% of all eligible children received an ITN. Household ITNownership and equity increased significantly post-campaign. Nine monthspost-campaign, 78.6% of households with a child eligible to participate in thecampaign retained at least one campaign net. Use by eligible children was 43.5%at one month post-campaign (during the dry season) and 52.9% at nine monthspost-campaign (during the rainy season). Household ownership of at least one ITN

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increased from 8.0% pre-campaign to 62.5% one month post-campaign. Together,these findings demonstrate that in this setting, increased household ITNownership, equity, and retention can be achieved on a national scale through freeITN distribution during an integrated campaign.

PMCID: PMC2963961PMID: 21036829 [PubMed - indexed for MEDLINE]

130. Trans R Soc Trop Med Hyg. 2010 Dec;104(12):758-65. doi:10.1016/j.trstmh.2010.08.008. Epub 2010 Oct 16.

An experimental hut evaluation of PermaNet(®) 3.0, a deltamethrin-piperonylbutoxide combination net, against pyrethroid-resistant Anopheles gambiae andCulex quinquefasciatus mosquitoes in southern Benin.

N'Guessan R, Asidi A, Boko P, Odjo A, Akogbeto M, Pigeon O, Rowland M.

London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E7HT, UK. raphael.n'[email protected]

PermaNet 3.0 is a long-lasting combination net with deltamethrin present on thesides and a mixture of deltamethrin and piperonyl butoxide (PBO), an oxidasesynergist, on the top panel. An experimental hut trial comparing unwashed and 20 times washed PermaNet 3.0 and PermaNet 2.0, Olyset Net and a conventionaldeltamethrin-treated net washed three times was conducted in southern Benin.Anopheles gambiae and Culex quinquefasciatus from this area are highly resistant to pyrethroids through kdr and cytochrome P450 mechanisms. The unwashed PermaNet 3.0 killed slightly more A. gambiae (52%) than the unwashed PermaNet 2.0 (44%)(P=0.036), indicating only partial synergism of resistance. After washing therewas significant loss of activity to a similar level, with PermaNet 3.0 killing31%, PermaNet 2.0 killing 29% and the conventional net killing 26%. Blood-feedingrates were partially inhibited for unwashed PermaNet 3.0 and Olyset Net (27%inhibition). Personal protection against A. gambiae derived from PermaNet 3.0 wassimilar to that from PermaNet 2.0 before washing (50% vs. 47%), and after 20washes it decreased to 30%. Against C. quinquefasciatus, no treatment killed >24%entering the huts. The synergism from unwashed PermaNet 3.0 was lower than

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expected, probably due to an unidentified resistance mechanism unaffected by PBO.

Copyright © 2010 Royal Society of Tropical Medicine and Hygiene. All rightsreserved.

PMID: 20956008 [PubMed - indexed for MEDLINE]

131. Trans R Soc Trop Med Hyg. 2010 Dec;104(12):777-81. doi:10.1016/j.trstmh.2010.09.001. Epub 2010 Oct 16.

Towards eradication: three years after the tsunami of 2004, has malariatransmission been eliminated from the island of Simeulue?

Sudomo M, Arianti Y, Wahid I, Safruddin D, Pedersen EM, Charlwood JD.

Health Ecology Research and Development Centre, National Institute of HealthResearch and Development, Ministry of Health, Jl. Percetakan Negara 29, JakartaPusat, Jakarta 10560, Indonesia.

The island of Simeulue was the first landfall of the tsunami of December 2004.The tsunami destroyed many villages on the island, leaving one third of thepopulation homeless. Malaria is endemic in Simeulue and an epidemic was reported to have occurred three months prior to the tsunami. Information concerningmalaria was, however, not easily available. The earthquakes related to thetsunami may have created extensive potential breeding sites of Anophelessundaicus, the probable vector, and increased vulnerability of the humanpopulation; a possibility of increased transmission made a further outbreakpossible. Consequently, subsequent to the tsunami, considerable amounts of aid,including anti-malarial measures such as insecticide treated mosquito-nets, were deployed on the island. A series of island-wide cross-sectional surveys wereconducted in 2005-2007 to determine whether these had had any effect on malariaprevalence. Larval sampling, and CDC light-trap and landing collections of hungrymosquitoes were also undertaken. The results indicate that despite the continuingpresence of potential vectors in some places the anti-malaria measures introducedfollowing the tsunami have controlled, and may be close to eliminating, malariafrom the island.

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Copyright © 2010 Royal Society of Tropical Medicine and Hygiene. Published byElsevier Ltd. All rights reserved.

PMID: 20952042 [PubMed - indexed for MEDLINE]

132. Malar J. 2010 Sep 29;9:264. doi: 10.1186/1475-2875-9-264.

Potential threat of malaria epidemics in a low transmission area, as exemplified by São Tomé and Príncipe.

Lee PW, Liu CT, do Rosario VE, de Sousa B, Rampao HS, Shaio MF.

The Anti-Malaria Team of Taiwan in São Tomé and Príncipe, Democratic Republic of São Tomé and Príncipe.

BACKGROUND: Plasmodium falciparum is the major cause of malaria infection in the island of São Tomé, in the Republic of São Tomé and Príncipe (STP), with anincidence of 40 - 50% before 2004. Since 2004, through the coordination of theMinistry of Health of STP and their Centro Nacional de Endemias (CNE), anintegrated malaria control programme has been intensively deployed on the island of São Tomé. Malaria morbidity and mortality decreased by 95% after three yearsof effective intervention. In the low transmission settings, however, malariaseasonal fluctuation can be a potential problem directly related to epidemics if ongoing control measures are interrupted. Studies on a number of associatedfactors with malaria epidemics and the measures taken to respond to outbreaks arepresented.METHODS: The integrated malaria control programme included indoor residualspraying (IRS), long-lasting insecticidal nets (LLINs), intermittent preventivetherapy for pregnant women, as well as early diagnosis and prompt treatment with artemisinin-based combination therapy (ACT). Regular implementation of anisland-wide IRS programme was carried out yearly in 2004-2007, and enhancedthroughout the island in 2009. Malaria incidence and prevalence were estimatedbased on passive case detection and mass screening, respectively. Slidepositivity rates were used for monitoring the beginning of a malaria epidemic or a seasonal peak.RESULTS: A steep decline of ca. 95% of malaria morbidity and mortality was

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observed between 2004 and 2008 with use of the combined control methods. Malaria incidence was 2.0%, 1.5%, and 3.0% for 2007, 2008, and 2009, respectively. InApril 2008, a cross-sectional country-wide surveillance showed malaria prevalenceof 3.5%, of which 95% cases were asymptomatic carriers. Only 50% of asymptomatic carriers were cured with ACT treatment, while 90% of the symptomatic patientswere cured by ACT treatment as confirmed with a follow up study. Malariamorbidity increased by three-fold during the first half of 2009 as compared tothe same period in 2008. Over this period of six months, severe malaria was also noted in all age groups and malaria mortality increased by two-fold in childrenless than five years old. After an emergency IRS was deployed, with increased useof LLINs, and an active search of asymptomatic carriers was followed and givencomplete ACT treatment, malaria incidence decreased to less than 1% in the secondhalf of 2009.CONCLUSION: At the initial stage of the integrated malaria control programme, IRScontributed to the visible effect on the rapid reduction of malaria morbidity andmortality, while this programme highlights an urgent demand for the improvementof other measures, particularly promotion of LLINs usage, with close monitoringof asymptomatic carriers and with ACT treatment in malaria transmission hotspots.In addition, both daily reports and a regular active surveillance to preventmalaria outbreaks should be established permanently, so that a fast response toepidemics can be effectively made when necessary.

PMCID: PMC2955676PMID: 20920216 [PubMed - indexed for MEDLINE]

133. Am J Trop Med Hyg. 2010 Oct;83(4):854-60. doi: 10.4269/ajtmh.2010.10-0331.

Predicting the unmet need for biologically targeted coverage ofinsecticide-treated nets in Kenya.

Noor AM, Alegana VA, Patil AP, Snow RW.

Malaria Public Health and Epidemiology Group, Centre for Geographic Medicine,Kenya Medical Research Institute/University of Oxford-Wellcome Trust ResearchProgramme, Kenyatta National Hospital Grounds, Nairobi, Kenya.

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[email protected]

In some countries the biological targeting of universal malaria prevention mayoffer optimal impact on disease and significant cost-savings compared withapproaches that presume universal risk. Spatially defined data on coverage oftreated nets from recent national household surveys in Kenya were used within aBayesian geostatistical framework to predict treated net coverage nationally.When combined with the distributions of malaria risk and population an estimated 8.1 million people were not protected with treated nets in 2010 in biologicallydefined priority areas. After adjusting for the proportion of nets in use thatwere not long lasting, an estimated 5.5 to 6.3 million long-lasting treated nets would be required to achieve universal coverage in 2010 in Kenya in at-risk areascompared with 16.4 to 18.1 million nets if not restricted to areas of greatestmalaria risk. In Kenya, this evidence-based approach could save the nationalprogram at least 55 million US dollars.

PMCID: PMC2946756PMID: 20889879 [PubMed - indexed for MEDLINE]

134. PLoS One. 2010 Sep 10;5(9). pii: e12660. doi: 10.1371/journal.pone.0012660.

Possession and usage of insecticidal bed nets among the people of Uganda: is BRACUganda Health Programme pursuing a pro-poor path?

Ahmed SM, Zerihun A.

Research and Evaluation Division, BRAC, Dhaka, Bangladesh. [email protected]

BACKGROUND: The use of insecticidal bed nets is found to be an effective publichealth tool for control of malaria, especially for under-five children andpregnant women. BRAC, an indigenous Bangladeshi non-governmental developmentorganization, started working in the East African state of Uganda in June 2006.As part of its efforts to improve the health and well-being of its participants, BRAC Uganda has been distributing long lasting insecticide-treated bed nets

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(LLIN) at a subsidized price through health volunteers since February 2008. This study was conducted in March-April 2009 to examine how equitable the programmehad been in consistence with BRAC Uganda's pro-poor policy.METHODOLOGY/PRINCIPAL FINDINGS: Information on possession of LLINs and relevantknowledge on its proper use and maintenance was collected from households either with an under-five child and/or a pregnant woman. The sample included threevillages from each of the 10 branch offices where BRAC Uganda's community-basedhealth programme was operating. Data were collected by trained enumeratorsthrough face-to-face interviews using a hand-held personal digital assistant(PDA). Findings reveal that the study population had superficial knowledge onmalaria and its transmission, including the use and maintenance of LLINs. Thehouseholds' rate of possession of bed nets (41-59%), and the proportion ofunder-five children (17-19%) and pregnant women (25-27%) who reported sleepingunder an LLIN were not encouraging. Inequity was observed in the number of LLINs possessed by the households, in the knowledge on its use and maintenance, andbetween the two programme areas.CONCLUSIONS/SIGNIFICANCE: The BRAC Uganda's LLINs distribution at a subsidizedprice appeared to be inadequate and inequitable, and BRAC's knowledgedissemination is insufficient for initiating preventive actions such as properuse of LLINs to interrupt malaria transmission. Findings contribute to theon-going debate on LLINs distribution in Africa and make a strong case for itsfree distribution.

PMCID: PMC2937018PMID: 20844749 [PubMed - indexed for MEDLINE]

135. Malar J. 2010 Sep 15;9:256. doi: 10.1186/1475-2875-9-256.

The potential role of the educational system in addressing the effect ofinadequate knowledge of mosquitoes on use of insecticide-treated nets in Ghana.

Kudom AA, Mensah BA.

Department of Entomology and Wildlife, School of Biological Sciences, University of Cape Coast, Ghana. [email protected]

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BACKGROUND: Since 2001, there has been a tremendous increase in number ofhouseholds protected by ITN and IRS in Ghana. However, there has not beenevidence of a reduction in malaria cases as expected and reported deaths haverather increased since 2007. As a result, this study was undertaken to get abetter understanding of perceptions of malaria, knowledge on mosquitoes and thevalue attached to ITNs among secondary and tertiary students in Cape Coast.METHODS: Structured questionnaires were administered randomly to gather data ondemographic characteristics of students, knowledge of mosquitoes and ITNs andattitude towards the use of ITN in seven public high schools and four tertiaryinstitutions in Cape Coast metropolis. In addition, curriculums of sciencecourses common to all students from junior high school to the university werecarefully examined.RESULTS: A total of 492 students took part in this study and more than 90% ofthem had high knowledge of malaria transmission and ITN, but little knowledge of mosquito life history. Only 1% in secondary and 2.1% in tertiary institutions hadseen or knew about all the development stages of mosquitoes. In high school andtertiary institutions, 24.2% and 10.8% of respondents, respectively, were able tomention other genera of mosquitoes, apart from Anopheles. Though 93.9% in senior high school and 86.7% in the tertiary institutions knew that ITNs are either usedto protect oneself from mosquito bites or to prevent malaria, 32.7% of therespondents in secondary and 21.9% in tertiary institutions who owned ITN did notuse them.CONCLUSIONS: The study reveals that respondents did not have adequate knowledgeon the biology and behaviour of mosquitoes. This appears to weaken theirknowledge of the link between the use of ITN and malaria control; the effect ofthis is that a significant number owned ITNs but did not use them. Theimplication is that if people will really accept and use ITN or other mosquitocontrol interventions, then just creating awareness of those interventions is notenough but people should also be educated on the life history of mosquitoes andon the mechanism of the control strategies. This can be effectively done through the formal education system.

PMCID: PMC2949741

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PMID: 20843345 [PubMed - indexed for MEDLINE]

136. PLoS Med. 2010 Aug 17;7(8):e1000328. doi: 10.1371/journal.pmed.1000328.

Rapid scaling up of insecticide-treated bed net coverage in Africa and itsrelationship with development assistance for health: a systematic synthesis ofsupply, distribution, and household survey data.

Flaxman AD, Fullman N, Otten MW Jr, Menon M, Cibulskis RE, Ng M, Murray CJ, LimSS.

Institute for Health Metrics and Evaluation, University of Washington, Seattle,Washington, United States of America.

BACKGROUND: Development assistance for health (DAH) targeted at malaria has risenexponentially over the last 10 years, with a large fraction of these resourcesdirected toward the distribution of insecticide-treated bed nets (ITNs).Identifying countries that have been successful in scaling up ITN coverage andunderstanding the role of DAH is critical for making progress in countries where coverage remains low. Sparse and inconsistent sources of data have preventedrobust estimates of the coverage of ITNs over time.METHODS AND PRINCIPAL FINDINGS: We combined data from manufacturer reports of ITNdeliveries to countries, National Malaria Control Program (NMCP) reports of ITNs distributed to health facilities and operational partners, and household surveydata using Bayesian inference on a deterministic compartmental model of ITNdistribution. For 44 countries in Africa, we calculated (1) ITN ownershipcoverage, defined as the proportion of households that own at least one ITN, and (2) ITN use in children under 5 coverage, defined as the proportion of childrenunder the age of 5 years who slept under an ITN. Using regression, we examinedthe relationship between cumulative DAH targeted at malaria between 2000 and 2008and the change in national-level ITN coverage over the same time period. In 1999,assuming that all ITNs are owned and used in populations at risk of malaria, meancoverage of ITN ownership and use in children under 5 among populations at riskof malaria were 2.2% and 1.5%, respectively, and were uniformly low across all 44

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countries. In 2003, coverage of ITN ownership and use in children under 5 was5.1% (95% uncertainty interval 4.6% to 5.7%) and 3.7% (2.9% to 4.9%); in 2006 it was 17.5% (16.4% to 18.8%) and 12.9% (10.8% to 15.4%); and by 2008 it was 32.8%(31.4% to 34.4%) and 26.6% (22.3% to 30.9%), respectively. In 2008, fourcountries had ITN ownership coverage of 80% or greater; six countries werebetween 60% and 80%; nine countries were between 40% and 60%; 12 countries werebetween 20% and 40%; and 13 countries had coverage below 20%. Excluding fouroutlier countries, each US$1 per capita in malaria DAH was associated with asignificant increase in ITN household coverage and ITN use in children under 5coverage of 5.3 percentage points (3.7 to 6.9) and 4.6 percentage points (2.5 to 6.7), respectively.CONCLUSIONS: Rapid increases in ITN coverage have occurred in some of the poorestcountries, but coverage remains low in large populations at risk. DAH targeted atmalaria can lead to improvements in ITN coverage; inadequate financing may be areason for lack of progress in some countries. Please see later in the articlefor the Editors' Summary.

PMCID: PMC2923089PMID: 20808957 [PubMed - indexed for MEDLINE]

137. East Afr J Public Health. 2009 Dec;6(3):317-25.

Social marketing and the fight against malaria in Africa: population servicesinternational (PSI) and insecticide treated nets (ITNS).

Omona J.

[email protected]

This textual analyses on Social marketing, Insecticide Treated Nets (ITNs) andPopulation Services International (PSI) were undertaken to achieve twoobjectives: (a) to contribute to the continuing debate and search for a betterstrategy for combating malaria in sub-Saharan Africa; and (b) to contribute totheory building on social marketing. The analyses revealed that Malaria hasreached an epidemic proportion and despite major inroads by PSI in combatingmalaria on the principles of social marketing, the strategies of pricing and

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segmentation of the clients are not appropriate for Sub-Saharan African countriesthat are mired in absolute poverty where majority of the rural communities eke a living on less than a dollar per day and the health sector does not receivepriority attention from policy makers and politicians. The descriptive statisticsand a one sample t test for the sampled countries suggest that sub-Saharancountries have not even met the hypothesized 5% investment of their GDP onhealth, compared to their counterparts, the developed countries, who are allabove this figure. The null hypothesis that there is no significant differentbetween the population and the sample means of both developed and a developingcountry in their investments in the health sector was also tested and rejected.Though the elements in some of the existent models and theories of socialmarketing such as Health Belief Model, Theory of Reasoned Action, SocialCognitive Theory and Trans-theoretical Models all attempt to advocate forelimination of constraints and barriers to effective access to a service orproduct, PSI is adamant to these and try to generalize these principles in allcontexts, including in Sub-Saharan Africa. The African scenario, where about 90% of Malaria related deaths cases in the world occur, demands more than what these theories present. Accordingly, it was concluded that however good intentionedsocial marketing is, in the case of ITNs in this region, it is counter productiveas the pricing de-motivates clients who usually have other pressing needs toaddress and segmentation limits coverage. Social marketing is thus more relevant to developed economies where absolute poverty no longer exist and people canafford to pay for health services. Malaria in sub-Saharan Africa needs a "carpet bombing" strategy. It was also concluded that for Sub-Saharan countries toeffectively address the MDG six on malaria, and implement the Abuja Summit andthe Roll Back Malaria partnership declarations, it requires a high degree ofpolitical commitment, amongst others, to enable the vulnerable communities haveaccess to free malaria treatment related drugs. Partners in the fight againstmalaria such as PSI should adopt a more eclectic intervention strategy, and becognizant of the fact that the strategy that works for Africa should be that

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which is based on strict equity and stimulates demand for ITNs. The paperconcludes by agreeing with Professors Curtis and Sachs that comprehensive malariacontrol in Africa is achievable by 2010, at the minimal cost if sound principles of public health and economics are observed. Millions of lives can be saved andAfrica will be given vital help in escaping from the viscous circle of povertyand diseases that continue to grip the continent. The target for all interventionefforts should be to eliminate the cost factor and ensure free distribution ofall malaria related treatment products.

PMID: 20803927 [PubMed - indexed for MEDLINE]

138. Med Trop (Mars). 2010 Jun;70(3):249-54.

[Operation to promote use of long-lasting insecticidal nets (LLIN) in FrenchGuiana in 2006: design, implementation and results].

[Article in French]

Mansotte F, Ravachol F, Carlisi R, Caudal J, Pinchon S, Maison D.

Direction de la Santé et du Développement Social de la Guyane, [email protected]

In 2006, the Regional Health Office (DSDS) in French Guiana undertook a majoroperation involving importation and distribution of long-lasting insecticidetreated nets (LLIN/ITN). In collaboration with the WHO, a Vietnamese manufacturerof LLINs suited to the requirements of French Guiana was sourced. With the helpof a dynamic local importer and dealer, a sales network was developed throughchemist shops located all over French Guiana. This network provided wide coveragesince these outlets can be found in all large communities. The selling priceranged from 15 to 23 euros depending on the model, i.e., hammock or bed size. In addition, LLINs were distributed within the framework of two special programs.First they are given to women giving birth in French Guiana and undergoingmedical surveillance as part of the Mother and Child Protection program by publichealthcare system. Second they are distributed in case of natural disaster orother events that could lead to an increased risk of vector-borne outbreaks.

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Thanks to this operation, a total of 13,882 LLINs were delivered in French Guianafrom July 2006 to December 2008. This milestone operation in the fight againstmalaria was made possible thanks to funding granted on a one-time basis after theoutbreak of dengue in 2005-2006. The structure of this operation and its survivalwill depend on the continued goodwill and determination of a small group of localpartners who created this successful distribution campaign with no specificguidance or program from the national authorities.

PMID: 20734592 [PubMed - indexed for MEDLINE]

139. Afr J Reprod Health. 2010 Mar;14(1):117-28.

Perceptions on the use of insecticide treated nets in parts of the Imo RiverBasin, Nigeria: implications for preventing malaria in pregnancy.

Chukwuocha UM, Dozie IN, Onwuliri CO, Ukaga CN, Nwoke BE, Nwankwo BO, Nwoke EA,Nwaokoro JC, Nwoga KS, Udujih OG, Iwuala CC, Ohaji ET, Morakinyo OM, Adindu BC.

Department of Public Health Technology, Federal University of Technology, Owerri,Imo state Nigeria. [email protected]

This study aimed at assessing perceptions on use of ITNs in parts of the ImoRiver Basin, Nigeria and its implications in preventing malaria in pregnancy.Data was collected using focus group discussions, key informant interviews andstructured questionnaires. Results showed high awareness on the benefits of ITNs.Factors affecting use of ITNs included its high cost, perceptions of chemicalsused to treat them as having dangerous effects on pregnancy, low utilization ofantenatal care, husband's lack of interest in malaria prevention and perceptions that adolescent girls are at low risk of getting malaria. The implications ofthese findings include demystifying the negative perceptions on the chemicalsused for net treatment and subsidizing the cost of ITNs to increase access. Thesefindings provide important lessons for malaria programmes that aim at increasing access to ITNs by pregnant women in developing countries.

PMID: 20695144 [PubMed - indexed for MEDLINE]

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140. Malar J. 2010 Aug 4;9:222. doi: 10.1186/1475-2875-9-222.

Ownership and usage of insecticide-treated bed nets after free distribution via avoucher system in two provinces of Mozambique.

Macedo de Oliveira A, Wolkon A, Krishnamurthy R, Erskine M, Crenshaw DP, Roberts J, Saúte F.

Malaria Branch, Division of Parasitic Diseases and Malaria, Center for GlobalHealth, US Centers for Disease Control and Prevention, Atlanta, USA.

BACKGROUND: Insecticide-treated bed nets (ITNs) are an efficacious interventionfor malaria prevention. During a national immunization campaign in Mozambique,vouchers, which were to be redeemed at a later date for free ITNs, weredistributed in Manica and Sofala provinces. A survey to evaluate ITN ownershipand usage post-campaign was conducted.METHODS: Four districts in each province and four enumeration areas (EAs) in eachdistrict were selected using probability proportional to size. Within each EA, 32households (HHs) were selected using a simple random sample. Interviews to assessownership and usage were conducted in each of the selected HHs using personaldigital assistants.RESULTS: Valid interviews were completed for 947 (92.5%) (440 in Manica and 507in Sofala) of the 1,024 selected HHs. Among participating HHs, 65.0% in Manicaand 63.1% in Sofala reported that at least one child under five years of ageslept in the house the previous night. HH ownership of at least one bed net ofany kind was 20.6% (95% confidence interval [CI]: 7.9%-43.6%) and 35.6% (95% CI: 27.8%-44.3%) pre-campaign; and 55.1% (95% CI: 43.6%-66.1%) and 59.6 (95% CI:42.4%-74.7%) post-campaign in Manica and Sofala, respectively. Post-campaign HHownership of at least one ITN was 50.2% (95% CI: 41.8%-58.5%) for both provinces combined. In addition, 60.3% (95% CI: 50.6%-69.2%) of children under five yearsof age slept under an ITN the previous night.CONCLUSIONS: This ITN distribution increased bed net ownership and usage rates.Integration of ITN distribution with immunization campaigns presents anopportunity for reaching malaria control targets and should continue to be

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considered.

PMCID: PMC2925365PMID: 20684764 [PubMed - indexed for MEDLINE]

141. Malar J. 2010 Jul 22;9:211. doi: 10.1186/1475-2875-9-211.

Which family members use the best nets? An analysis of the condition of mosquito nets and their distribution within households in Tanzania.

Tsuang A, Lines J, Hanson K.

London School of Hygiene and Tropical Medicine, London, UK. [email protected]

BACKGROUND: Household ownership of insecticide-treated mosquito nets (ITNs) isincreasing, and coverage targets have been revised to address universal coverage with ITNs. However, many households do not have enough nets to cover everyone,and the nets available vary in physical condition and insecticide treatmentstatus. Since 2004, the Government of Tanzania has been implementing the TanzaniaNational Voucher Scheme (TNVS), which distributes vouchers for ITNs throughantenatal clinics to target pregnant women and their infants. This analysis aimedto determine the following: (1) coverage patterns of bed nets within householdsaccording to physical condition and treatment status; (2) who might be at risk ifmosquitoes were diverted from occupants of untreated nets to those not usingnets? (3) the degree to which those at highest risk of malaria use the mostprotective nets.METHODS: Data from the 2006 TNVS household survey were analysed to assesswithin-household distribution of net use. The associations between netcharacteristics and net user were also evaluated. Multivariate analysis wasapplied to the relationship between the number of holes per net and usercharacteristics while adjusting for confounders.RESULTS: In households with a net:person ratio better than 1:4 (one net for everyfour household members), more than 80% of the people in such households reported using a net the previous night. ITNs were most likely to be used by infants,

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young children (1-4 y), and women of childbearing age; they were least likely to be used by older women (>or=50 y), older children (5-14 y), and adult men. Thenets used by infants and women of childbearing age were in better-than-averagephysical condition; the nets used by older women and older children were inworse-than-average condition; while young children and adult men used nets inintermediate (average) condition. When adjusted for confounders, the nets used byyoung and older children had more holes than nets used by infants.CONCLUSIONS: Infants and other vulnerable groups were most likely to sleep under the most protective nets. Nevertheless, more communication efforts are needed to increase use of intact ITNs within households for children. Further research isnecessary to fully understand motivations influencing within-household netdistribution.

PMCID: PMC2918626PMID: 20663143 [PubMed - indexed for MEDLINE]

142. Health Policy Plan. 2011 Mar;26(2):133-41. doi: 10.1093/heapol/czq027. Epub 2010 Jul 21.

Household demand for insecticide-treated bednets in Tanzania and policy optionsfor increasing uptake.

Gingrich CD, Hanson KG, Marchant TJ, Mulligan JA, Mponda H.

Department of Business and Economics, Eastern Mennonite University, Harrisonburg,VA 22802, USA. [email protected]

There has been considerable controversy about the most appropriate means ofdelivering insecticide-treated nets (ITNs) to prevent malaria. Household demandfor ITNs is a key factor influencing the choice of delivery strategy, butevidence to date about price and income elasticities comes either from studies ofhypothetical willingness to pay or small-scale policy experiments. This studyestimates the price and income elasticities of demand for ITNs using nationallyrepresentative household survey data and actual consumer choices, in the context of a national scheme to provide vouchers for subsidized nets to pregnant women in

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Tanzania. Under this distribution system, the estimated price elasticity ofdemand for subsidized ITNs equals -0.12 and the income elasticity estimates rangefrom zero to 0.47, depending on household socio-economic status. The model alsoshows a substantial decline in short-term ITN purchases for women whose householdreceived a free ITN. These findings suggest that if the Tanzanian governmentcontinues to use a mixed public-private model to distribute ITNs, increasing the consumer subsidy alone will not dramatically improve ITN coverage. A concertedeffort is required including an increase in the subsidy amount, attention toincome growth for poor households, increases in women's and girls' educationlevels, and expansion of the retail ITN distribution network. Use of a catch-upcampaign to distribute free ITNs would increase coverage but raises questionsabout the effect of households' long-term purchase decisions for ITNs.

PMID: 20660208 [PubMed - indexed for MEDLINE]

143. Bull Soc Pathol Exot. 2010 Oct;103(4):223-9. doi: 10.1007/s13149-010-0068-6. Epub2010 Jul 20.

[A mosquito net for everyone in 2010].

[Article in French]

Pays JF.

CHU Necker-EM, Paris, France. [email protected]

At less than two hundred days of the 2010 deadline for the "Roll Back Malaria"initiative which committed itself to reduce by half, before that date, mortality due to malaria in the world and relying on the latest WHO reports pointing out,in Africa, major shortcomings concerning the accessibility to treatmentcombinations consisting of artemisinin and on the acknowledged fact that aninsufficient number of pregnant women receive an intermittent treatment, theauthor notes that a coverage, so-called universal, with the use of long actioninsecticide treated mosquito nets has become the Grail of the battle againstmalaria, with the perverse effects entailed, namely that of blinding realities orthrowing discredit on other types of possible interventions that are not

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consistent with an accounting logic. He also notes that the average figure ofestimated deaths due to malaria was at a quasi stagnation in 2008 and that thelives of 34,000 African children of less than 5 years of age saved between 2006and 2008 was achieved in the context of the reduction in infant mortalityresulting from a series of causes among which it is impossible to individualisemalaria with certainty. He finally points out that Eritrea, Rwanda, Zambia, SãoTome y Principe and the Tanzanian island of Zanzibar which quite regularly serve as showcases to RBM and UNICEF and which report spectacular progress in the fieldof prevention of malaria accompanied by a parallel reduction in its mortality,are, for different reasons, far from being representative of the totality ofAfrican countries and that they should be considered as exceptions rather thanexamples to be exploited without restraint. On the other hand, the authorconsiders that deluding the grand public into thinking that a few watchwords,slogans and simple, even simplistic, ideas would enable eradicating malaria giventhat large sums of money are made available, is not quite honest and may finally prove to be dangerous. He warns against the false hopes concerning the impact of coming discoveries on the antimalarial battle often conjured up to take overtoday's actions, by recalling that a century of scientific, technological andmedical progress has not positively translated into any decisive progress in the prevention or treatment of this disease, in spite of the issue of scientificpublications on the subject at every 20 minute interval since more than thirtyyears. Although the author willingly agrees that huge financial means areessential and for a long time to come, he however believes that they would notsuffice to enable, in countries with high rates of transmission, the elimination of a disease that is not solely linked to biological, ecological andentomological parameters, but that is also anchored to the economic, societal,social and cultural contexts that are quite often forgotten and on which it isdifficult, but essential, to act in order to obtain long lasting results. Herecalls, on this occasion, that man, as an individual in relationship with hissurroundings, should also be at the heart of the battle on the same footing as

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the anopheles and the plasmodium, even if this, at times, leads to clashesbetween medical logic and native social, traditional, popular, scholarly orreligious logics. He regrets, similarly and within the spirit of the Abujadeclaration, that the educational systems of African countries having a hightransmission rate do not play the role they had to assume in the battle againstmalaria and are not mobilised much better than they are, by including, forexample, in the primary and secondary curriculum of public and private schools,on the same footing as the learning of the alphabet or of the multiplicationtables, a compulsory adapted instruction in malaria, so that children not onlybecome victims but also "actors in the battle against malaria". The authorfinally underlines the absolute necessity to rapidly strengthen health carefacilities of the most affected countries, particularly in the rural area, andplead that this intensification becomes a true priority financed on its ownmerits. The Global Malaria Action Plan, that will take over from the RBM andwould have the advantage of masking the insufficient results obtained by thelatter, would have to face two huge challenges: an ancient but recurring one thatconcerns, in the context of a world economic crisis, the financing of the battle against malaria and the other one, new and associated with the development ofresistance by Plasmodium falciparum to artemisinin, a first- and last-lineantimalaria drug.

PMID: 20652477 [PubMed - indexed for MEDLINE]

144. BMC Health Serv Res. 2010 Jul 2;10 Suppl 1:S8. doi: 10.1186/1472-6963-10-S1-S8.

Methods for evaluating delivery systems for scaling-up malaria controlintervention.

Webster J, Chandramohan D, Hanson K.

Disease Control and Vector Biology Unit, London School of Hygiene and TropicalMedicine, Keppel Street, London WC1E 7HT, UK. [email protected]

BACKGROUND: Despite increased resources over the past few years the coverage of

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malaria control interventions is still inadequate to reach national andinternational targets and achieve the full potential of the interventions toimprove population health. One of the reasons for this inadequate coverage ofefficacious interventions is the limited understanding of the optimum deliverysystems of the interventions in different contexts. Although there have beendebates about how to deliver interventions, the methods for evaluating theeffectiveness of different delivery systems have rarely been discussed. Delivery of interventions is relatively complex and a thorough evaluation would need tolook holistically at multiple steps in the delivery process and at multiplefactors influencing the process. A better understanding of the strength of theevidence on delivery system effectiveness is needed in order to optimise deliveryof efficacious interventions.METHODS: A literature review was conducted of methods used to evaluate deliverysystems for insecticide treated nets, intermittent preventive treatment inpregnant women, and treatment for malaria in children.RESULTS: The methodology of delivery system evaluations varied. There wereinconsistencies between objectives and methods of the evaluations includinginappropriate outcome measures and unnecessary controls. There were few examples where the delivery processes were adequately described, or measured. We propose across sectional observational study design with attribution of the outcomes to a specific delivery system as an appropriate method for evaluating delivery systemsat scale.CONCLUSIONS: The proposed evaluation framework is adaptable to naturalexperiments at scale, and can be applied using data from routine surveys such as the Demographic and Health Surveys, modified by the addition of one to twoquestions for each intervention. This framework has the potential to enable widerapplication of rigorous evaluations and thereby improve the evidence base onwhich decisions about delivery systems for malaria control and other publichealth interventions are taken.

PMCID: PMC2895752PMID: 20594374 [PubMed - indexed for MEDLINE]

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145. Malar J. 2010 Jul 12;9:199. doi: 10.1186/1475-2875-9-199.

Impact of mass distribution of free long-lasting insecticidal nets on childhoodmalaria morbidity: the Togo National Integrated Child Health Campaign.

Terlouw DJ, Morgah K, Wolkon A, Dare A, Dorkenoo A, Eliades MJ, Vanden Eng J,Sodahlon YK, ter Kuile FO, Hawley WA.

Child and Reproductive Health, Liverpool School of Tropical Medicine, PembrokePlace, Liverpool, UK. [email protected]

BACKGROUND: An evaluation of the short-term impact on childhood malaria morbidityof mass distribution of free long-lasting insecticidal nets (LLINs) to householdswith children aged 9-59 months as part of the Togo National Integrated ChildHealth Campaign.METHODS: The prevalence of anaemia and malaria in children aged zero to 59 monthswas measured during two cross-sectional household cluster-sample surveysconducted during the peak malaria transmission, three months before (Sept 2004,n=2521) and nine months after the campaign (Sept 2005, n=2813) in three districtsrepresentative of Togo's three epidemiological malaria transmission regions:southern tropical coastal plains (Yoto), central fertile highlands (Ogou) andnorthern semi-arid savannah (Tone).RESULTS: In households with children<5 years of age, insecticide-treated net(ITN) ownership increased from <1% to >65% in all 3 districts. Reported ITN useby children during the previous night was 35.9%, 43.8% and 80.6% in Yoto, Ogouand Tone, respectively. Rainfall patterns were comparable in both years. Theoverall prevalence of moderate to severe anaemia (Hb<8.0 g/dL) was reduced by 28%(prevalence ratio [PR] 0.72, 95% CI 0.62-0.84) and mean haemoglobin was increasedby 0.35 g/dL (95% CI 0.25-0.45).The effect was predominantly seen in childrenaged 18-59 months and in the two southern districts: PR (95% CI) for moderate to severe anaemia and clinical malaria: Yoto 0.62 (0.44-0.88) and 0.49 (0.35-0.75); Ogou 0.54 (0.37-0.79) and 0.85 (0.57-1.27), respectively. Similar reductionsoccurred in children<18 months in Ogou, but not in Yoto. No effect was seen inthe semi-arid northern district despite a high malaria burden and ITN coverage.

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CONCLUSIONS: A marked reduction in childhood malaria associated morbidity wasobserved in the year following mass distribution of free LLINs in two of thethree districts in Togo. Sub-national level impact evaluations will contribute toa better understanding of the impact of expanding national malaria controlefforts.

PMCID: PMC2914062PMID: 20624305 [PubMed - indexed for MEDLINE]

146. Bull World Health Organ. 2010 Jul 1;88(7):509-18. doi: 10.2471/BLT.09.069203.Epub 2009 Dec 1.

Community-directed interventions for priority health problems in Africa: results of a multicountry study.

CDI Study Group.

Collaborators: Amazigo U, Diarra T, Wanji S, Enyong P, Tendongfor N, Njoumemi Z, Nana C, Moukam LV, Longang YT, Njie T, Datchoua F, Molioum I, Abia LK, Takougang I, Wabo JP, Darios TM, Henriette N, Ndeffo LN, Innocent F, Keuzeta JJ, Medard D, Tatah P, Amayunzu M, Oladepo O, Oshiname F, Ajuwon A, Jaiyeoba A, Alaba O,Olayinwola K, Otusanya S, Oyeyemi A, Titloye M, Adeniyi JD, Arulogun OS, SoyiboD, Lawanson OA, Adeniyi BA, Babalola CP, Elemile TT, Ndekwu OS, Oso JA, Andah L, Aiyede AI, Afolabi N, Kale OO, ElHassan E, Isyaku S, Sanda S, Enwezor FN, AdekeyeO, Agbo F, Ogungbemi MK, Lawong D, Folurunsho F, Ibrahim F, Gwom A, Akogun O,Badaki JA, Echeta DO, Adesina AO, Njobdi S, Manabete J, Shitta K, Ahmed U,Okeibunor J, Homeida M, Ndyomugyenyi R, Kabali AT, Kiberu B, Mugaba Z, SommerfeldJ, Remme JH, Brieger W, Zimicki S.

Special Programme for Research and Training in Tropical Diseases, World HealthOrganization, 20 avenue Appia, 1211 Geneva 27, Switzerland. [email protected]

OBJECTIVE: To determine the extent to which the community-directed approach used in onchocerciasis control in Africa could effectively and efficiently provideintegrated delivery of other health interventions.

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METHODS: A three-year experimental study was undertaken in 35 health districtsfrom 2005 to 2007 in seven research sites in Cameroon, Nigeria and Uganda. Fourtrial districts and one comparison district were randomly selected in each site. All districts had established ivermectin treatment programmes, and in the trialdistricts four other established interventions - vitamin A supplementation, useof insecticide-treated nets, home management of malaria and short-course,directly-observed treatment for tuberculosis patients - were progressivelyincorporated into a community-directed intervention (CDI) process. At the end of each of the three study years, we performed quantitative evaluations ofintervention coverage and provider costs, as well as qualitative assessments ofthe CDI process.FINDINGS: With the CDI strategy, significantly higher coverage was achieved than with other delivery approaches for all interventions except for short-course,directly-observed treatment. The coverage of malaria interventions more thandoubled. The district-level costs of delivering all five interventions were lowerin the CDI districts, but no cost difference was found at the first-line healthfacility level. Process evaluation showed that: (i) participatory processes were important; (ii) recurrent problems with the supply of intervention materials werea major constraint to implementation; (iii) the communities and communityimplementers were deeply committed to the CDI process; (iv) communityimplementers were more motivated by intangible incentives than by externalfinancial incentives.CONCLUSION: The CDI strategy, which builds upon the core principles of primaryhealth care, is an effective and efficient model for integrated delivery ofappropriate health interventions at the community level in Africa.

PMCID: PMC2897985PMID: 20616970 [PubMed - indexed for MEDLINE]

147. Am J Trop Med Hyg. 2010 Jul;83(1):115-21. doi: 10.4269/ajtmh.2010.09-0684.

Human antibody response to Anopheles gambiae saliva: an immuno-epidemiologicalbiomarker to evaluate the efficacy of insecticide-treated nets in malaria vector control.

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Drame PM, Poinsignon A, Besnard P, Le Mire J, Dos-Santos MA, Sow CS, Cornelie S, Foumane V, Toto JC, Sembene M, Boulanger D, Simondon F, Fortes F, Carnevale P,Remoue F.

Institut de Recherche pour le Développement (IRD), UR024 "Epidémiologie etPrévention" Unit, Dakar, Senegal. [email protected]

For the fight against malaria, the World Health Organization (WHO) has emphasizedthe need for indicators to evaluate the efficacy of vector-control strategies.This study investigates a potential immunological marker, based on human antibodyresponses to Anopheles saliva, as a new indicator to evaluate the efficacy ofinsecticide-treated nets (ITNs). Parasitological, entomological, andimmunological assessments were carried out in children and adults from amalaria-endemic region of Angola before and after the introduction of ITNs.Immunoglobulin G (IgG) levels to An. gambiae saliva were positively associatedwith the intensity of An. gambiae exposure and malaria infection. A significantdecrease in the anti-saliva IgG response was observed after the introduction ofITNs, and this was associated with a drop in parasite load. This study representsthe first stage in the development of a new indicator to evaluate the efficacy ofmalaria vector-control strategies, which could apply in other arthropodvector-borne diseases.

PMCID: PMC2912587PMID: 20595489 [PubMed - indexed for MEDLINE]

148. Malar J. 2010 Jun 28;9:187. doi: 10.1186/1475-2875-9-187.

Impact of promoting longer-lasting insecticide treatment of bed nets upon malariatransmission in a rural Tanzanian setting with pre-existing high coverage ofuntreated nets.

Russell TL, Lwetoijera DW, Maliti D, Chipwaza B, Kihonda J, Charlwood JD, SmithTA, Lengeler C, Mwanyangala MA, Nathan R, Knols BG, Takken W, Killeen GF.

Biomedical and Environmental Thematic Group, Ifakara Health Institute, P.O. Box53, Ifakara, Tanzania. [email protected]

BACKGROUND: The communities of Namawala and Idete villages in southern Tanzania

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experienced extremely high malaria transmission in the 1990s. By 2001-03,following high usage rates (75% of all age groups) of untreated bed nets, a4.2-fold reduction in malaria transmission intensity was achieved. Since 2006, a national-scale programme has promoted the use of longer-lasting insecticidetreatment kits (consisting of an insecticide plus binder) co-packaged with allbed nets manufactured in the country.METHODS: The entomological inoculation rate (EIR) was estimated through monthlysurveys in 72 houses randomly selected in each of the two villages. Mosquitoeswere caught using CDC light traps placed beside occupied bed nets between Januaryand December 2008 (n = 1,648 trap nights). Sub-samples of mosquitoes were takenfrom each trap to determine parity status, sporozoite infection and Anophelesgambiae complex sibling species identity.RESULTS: Compared with a historical mean EIR of approximately 1400 infectiousbites/person/year (ib/p/y) in 1990-94; the 2008 estimate of 81 ib/p/y represents an 18-fold reduction for an unprotected person without a net. The combined impactof longer-lasting insecticide treatments as well as high bed net coverage wasassociated with a 4.6-fold reduction in EIR, on top of the impact from the use ofuntreated nets alone. The scale-up of bed nets and subsequent insecticidaltreatment has reduced the density of the anthropophagic, endophagic primaryvector species, Anopheles gambiae sensu stricto, by 79%. In contrast, thereduction in density of the zoophagic, exophagic sibling species Anophelesarabiensis was only 38%.CONCLUSION: Insecticide treatment of nets reduced the intensity of malariatransmission in addition to that achieved by the untreated nets alone. Impactswere most pronounced against the highly anthropophagic, endophagic primaryvector, leading to a shift in the sibling species composition of the A. gambiaecomplex.

PMCID: PMC2902500PMID: 20579399 [PubMed - indexed for MEDLINE]

149. Malar J. 2010 Jun 24;9:183. doi: 10.1186/1475-2875-9-183.

Bed net ownership in Kenya: the impact of 3.4 million free bed nets.

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Hightower A, Kiptui R, Manya A, Wolkon A, Vanden Eng JL, Hamel M, Noor A, Sharif SK, Buluma R, Vulule J, Laserson K, Slutsker L, Akhwale W.

Division of Parasitic Diseases and Malaria, Centers for Disease Control, Centerfor Global Health, Mailstop F22, 4770 Buford Highway, Atlanta, GA 30341, [email protected]

BACKGROUND: In July and September 2006, 3.4 million long-lastinginsecticide-treated bed nets (LLINs) were distributed free in a campaigntargeting children 0-59 months old (CU5s) in the 46 districts with malaria inKenya. A survey was conducted one month after the distribution to evaluate whoreceived campaign LLINs, who owned insecticide-treated bed nets and other bednets received through other channels, and how these nets were being used. Thefeasibility of a distribution strategy aimed at a high-risk target group to meet bed net ownership and usage targets is evaluated.METHODS: A stratified, two-stage cluster survey sampled districts and enumerationareas with probability proportional to size. Handheld computers (PDAs) withattached global positioning systems (GPS) were used to develop the samplingframe, guide interviewers back to chosen households, and collect survey data.RESULTS: In targeted areas, 67.5% (95% CI: 64.6, 70.3%) of all households withCU5s received campaign LLINs. Including previously owned nets, 74.4% (95% CI:71.8, 77.0%) of all households with CU5s had an ITN. Over half of CU5s (51.7%,95% CI: 48.8, 54.7%) slept under an ITN during the previous evening. Nearly fortypercent (39.1%) of all households received a campaign net, elevating overallhousehold ownership of ITNs to 50.7% (95% CI: 48.4, 52.9%).CONCLUSIONS: The campaign was successful in reaching the target population,families with CU5s, the risk group most vulnerable to malaria. Targeteddistribution strategies will help Kenya approach indicator targets, but will needto be combined with other strategies to achieve desired population coveragelevels.

PMCID: PMC2912322PMID: 20576145 [PubMed - indexed for MEDLINE]

150. Malar J. 2010 Jun 23;9:177. doi: 10.1186/1475-2875-9-177.

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Effect of trimethoprim-sulphamethoxazole on the risk of malaria in HIV-infectedUgandan children living in an area of widespread antifolate resistance.

Gasasira AF, Kamya MR, Ochong EO, Vora N, Achan J, Charlebois E, Ruel T, Kateera F, Meya DN, Havlir D, Rosenthal PJ, Dorsey G.

School of Medicine, Makerere University Kampala, Uganda. [email protected]

BACKGROUND: Daily trimethoprim-sulfamethoxazole (TS) protects against malaria,but efficacy may be diminished as anti-folate resistance increases. This studyassessed the incidence of falciparum malaria and the prevalence ofresistance-conferring Plasmodium falciparum mutations in HIV-infected childrenreceiving daily TS and HIV-uninfected children not taking TS.MATERIALS AND METHODS: Subjects were 292 HIV-infected and 517 uninfected childrenfrom two cohort studies in Kampala, Uganda observed from August 2006 to December 2008. Daily TS was given to HIV-infected, but not HIV-uninfected children and allparticipants were provided an insecticide-treated bed net. Standardized protocolswere used to measure the incidence of malaria and identify markers of antifolate resistance.RESULTS: Sixty-five episodes of falciparum malaria occurred in HIV-infected and491 episodes in uninfected children during the observation period. TS wasassociated with a protective efficacy of 80% (0.10 vs. 0.45 episodes per personyear, p < 0.001), and efficacy did not vary over three consecutive 9.5 monthperiods (81%, 74%, 80% respectively, p = 0.506). The prevalences of dhfr 51I,108N, and 59R and dhps 437G and 540E mutations were each over 90% among parasitesinfecting both HIV-infected and uninfected children. Prevalence of the dhfr 164L mutation, which is associated with high-level resistance, was significantlyhigher in parasites from HIV-infected compared to uninfected children (8% vs. 1%,p = 0.001). Sequencing of the dhfr and dhps genes identified only one additional polymorphism, dhps 581G, in 2 of 30 samples from HIV-infected and 0 of 54 samplesfrom uninfected children.CONCLUSION: Despite high prevalence of known anti-folate resistance-mediatingmutations, TS prophylaxis was highly effective against malaria, but wasassociated with presence of dhfr 164L mutation.

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PMCID: PMC2903607PMID: 20573194 [PubMed - indexed for MEDLINE]

151. Malar J. 2010 Jun 18;9:173. doi: 10.1186/1475-2875-9-173.

System effectiveness of a targeted free mass distribution of long lastinginsecticidal nets in Zanzibar, Tanzania.

Beer N, Ali AS, de Savigny D, Al-Mafazy AW, Ramsan M, Abass AK, Omari RS,Björkman A, Källander K.

Division of Global Health IHCAR, Department of Public Health Sciences, KarolinskaInstitutet, 171 77 Stockholm, Sweden. [email protected]

BACKGROUND: Insecticide-treated nets (ITN) and long-lasting insecticidal treated nets (LLIN) are important means of malaria prevention. Although there isconsensus regarding their importance, there is uncertainty as to which deliverystrategies are optimal for dispensing these life saving interventions. A targetedmass distribution of free LLINs to children under five and pregnant women wasimplemented in Zanzibar between August 2005 and January 2006. The outcomes ofthis distribution among children under five were evaluated, four to nine monthsafter implementation.METHODS: Two cross-sectional surveys were conducted in May 2006 in two districts of Zanzibar: Micheweni (MI) on Pemba Island and North A (NA) on Unguja Island.Household interviews were conducted with 509 caretakers of under-five children,who were surveyed for socio-economic status, the net distribution process,perceptions and use of bed nets. Each step in the distribution process wasassessed in all children one to five years of age for unconditional andconditional proportion of success. System effectiveness (the accumulatedproportion of success) and equity effectiveness were calculated, and predictorsfor LLIN use were identified.RESULTS: The overall proportion of children under five sleeping under any type oftreated net was 83.7% (318/380) in MI and 91.8% (357/389) in NA. The LLIN usagewas 56.8% (216/380) in MI and 86.9% (338/389) in NA. Overall system effectivenesswas 49% in MI and 87% in NA, and equity was found in the distribution scale-up inNA. In both districts, the predicting factor of a child sleeping under an LLINwas caretakers thinking that LLINs are better than conventional nets (OR = 2.8, p

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= 0.005 in MI and 2.5, p = 0.041 in NA), in addition to receiving an LLIN (OR =4.9, p < 0.001 in MI and in OR = 30.1, p = 0.001 in NA).CONCLUSIONS: Targeted free mass distribution of LLINs can result in high andequitable bed net coverage among children under five. However, in order tosustain high effective coverage, there is need for complimentary distributionstrategies between mass distribution campaigns. Considering the community'spreferences prior to a mass distribution and addressing the communities concerns through information, education and communication, may improve the LLIN usage.

PMCID: PMC2911471PMID: 20565860 [PubMed - indexed for MEDLINE]

152. Malar J. 2010 Jun 10;9:156. doi: 10.1186/1475-2875-9-156.

Progress and challenges to control malaria in a remote area of Chittagong hilltracts, Bangladesh.

Haque U, Hashizume M, Sunahara T, Hossain S, Ahmed SM, Haque R, Yamamoto T, GlassGE.

International Center for Diarrhoeal Disease Research Bangladesh, Mohakhali, Dhaka1212, Bangladesh. [email protected]

BACKGROUND: Malaria is endemic in 13 eastern districts where the overallinfection prevalence is 3.97%. In 2006, Bangladesh received US$ 36.9 million fromthe Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) to support thenational malaria control programme of Bangladesh.OBJECTIVES: The objective of this study was to i) clarify factors associated withtreatment seeking behaviours of malaria ii) distribution of LLIN, and iii)re-treatment of ITN in remote area of a CHT district of Bangladesh two yearsafter implementation of national control programme.METHODS: All households of Rajasthali sub-district of Rangamati district(households about 5,322, population about 24,097), all BRAC health workers (n =15), health facilities and drug vendors' locations were mapped. Distances fromhouseholds to health facilities, BRAC health workers and drug vendors werecalculated. Logistic regression analysis was performed to assess the associationsbetween the choice of the treatment and the distance to various treatment

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sources, education, occupation and ethnicity. SaTScan was used to detectclustering of treatment-seeking approaches.FINDINGS: LLIN distribution and the re-treatment of ITN exceeded target goals.The most common treatment facility for malaria-associated fever was malariacontrol programme led by BRAC and government (66.6%) followed by the drug vendor (48.8%).CONCLUSION: Closeness to health facilities run by the malaria control programmeand drug vendors were significantly associated with the choice of treatment. Ahigh proportion of people preferred drug vendors without having a properdiagnosis. Drug vendors are highly patronized and thus there is a need to improvetheir services for public health good. Otherwise it may cause incompletetreatment, misuse of anti-malarial drugs that will contribute to the risk of drugresistance and jeopardize the present malaria control efforts in Bangladesh.

PMCID: PMC2910016PMID: 20537127 [PubMed - indexed for MEDLINE]

153. East Afr Med J. 2009 Jul;86(7):314-22.

Use of insecticide treated bed nets among pregnant women in Kilifi District,Kenya.

Njoroge FK, Kimani VN, Ongore D, Akwale WS.

Department of Community Health, College of Health Sciences, University ofNairobi, P.O. Box 19676-0202 Nairobi, Kenya.

BACKGROUND: Malaria is one of the most serious public health problems in Kenya.Pregnant women are among the groups with the highest risk of malaria. Use ofinsecticide treated bed nets (ITNs) is a cost-effective method of controllingmalaria. Despite this, there is low utilisation of ITNs among pregnant women inKilifi district which is an endemic malaria zone.OBJECTIVE: To determine knowledge, attitude and practice on the use of ITNs inthe prevention of malaria among pregnant women in Kilifi district.DESIGN: A descriptive cross-sectional study.SETTING: The district hospital and the five health centres in Kilifi districtSUBJECTS: Two hundred and twenty pregnant women attending antenatal clinics (ANC)between October and December 2007.RESULTS: Knowledge on malaria illness and ITNs was high with majority of pregnant

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women having adequate level of knowledge (86.9%). There was significantassociation between level of education and adequate knowledge (P-value = 0.010). Good attitude on ITNs use was low. There was no association between good attitudeand any of the socio-demographic variables. The majority of pregnant womenattending ANC owned ITNs (75.4%). ITNs usage was high (70.5%). There wassignificant association between religion and good practice (p-value = 0.050).Although adequate level of knowledge on malaria and protective role of ITNs washigh, there was no association between knowledge with practice and attitude.CONCLUSION: Before any malaria preventive intervention is implemented in an area,different socio-cultural factors must be considered when behaviouralinterventions for malaria control are designed and implemented. Targeted healtheducation should be disseminated to the community to remove stigma andmisconceptions associated with ITNs. Community concerns and fears should beaddressed.

PMID: 20499780 [PubMed - indexed for MEDLINE]

154. East Afr Med J. 2009 Jul;86(7):308-13.

Use of insecticide treated nets among caregivers of children under five years in Makueni District, Kenya.

Malusha JM, Mwanzo I, Yitambe A, Mbugi JP.

Ministry of Public Health and Sanitation, P.O. Box 172-01100, Kajiado, Kenya.

BACKGROUND: Insecticide treated nets (ITNs) have been identified as a keystrategy in addressing malaria problem among young children and pregnant women.Their utilisation among under fives, however, have been found to be low in someareas.OBJECTIVE: To identify factors affecting net utilisation (sleeping underinsecticide treated net) among caregivers of under fives in Makueni District inKenya.DESIGN: A cross-sectional, descriptive study.SETTING: Eight sub-locations in Wote division Makueni district.SUBJECTS: Four hundred caregivers of children aged five years and below.RESULTS: The results indicated that 88.5% of caregivers were aware of ITNs. Theproportion of households with children below five years that owned mosquito netwere found to be 46.2%, and only 32.0% had at least a treated net. Slightly more

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than half of treated nets were used by under fives (52.2%) compared to 47.8% usedby children over five years including adults. The main reason cited by majorityof caregivers as a hindrance to net utilisation was lack of treated nets inhouseholds (72.3%). Utilisation of ITNs by under five children was found to bepositively associated with knowledge of ITNs (p = 0.024), marital status (p =0.018) and occupation (p = 0.043).CONCLUSION: Utilisation of ITNs by under fives was low despite high level ofawareness among caregivers. Factors such as awareness of ITNs, marital status andoccupation significantly affected ITNs utilisation. Although the government with support from other stakeholders has recently embarked on large scale distributionof nets in high risky districts, more interventions from various stakeholders areneeded to increase availability and accessibility of subsidised permanentlytreated nets, including interventions to address non-compliance to properutilisation of nets. There is also need for intensive education emphasising ontheir proper and consistent use. Scaling up proper use of ITNs along with otherinitiatives can contribute significantly in reducing malaria.

PMID: 20499779 [PubMed - indexed for MEDLINE]

155. Niger J Clin Pract. 2010 Jun;13(2):144-8.

ITN utilization among pregnant women attending ANC in Etsako West Lga, Edo State,Nigeria.

Wagbatsoma VA, Aigbe EE.

Department of Community Health, School of Medicine, College of Medical Sciences, University of Benin, Benin City, Nigeria.

OBJECTIVE: To determine the factors affecting utilization of ITN by pregnantwomen in Etsako West LGA, Edo State.METHODOLOGY: A descriptive cross-sectional study design was employed. Using asystematic sampling method, a total of 385 respondents were selected from all ANCfacilities in the LGA following a verbally obtained consent. Tool for datacollection was a semi-structured, researcher administered questionnaire.RESULT: The respondents' knowledge of cause of malaria was good, as 269 (69%) had

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good knowledge but only 9 (2.3%) knew its effects on the foetus. Meanwhile,ownership of ITN and its use were very low, 36 (9.3%) and 31 (8.0) respectively. The main factor affecting the use of the commodity in the LGA was unavailability of ITNs. Other factors included belief of the women on the effectiveness of thecommodity, level of education, marital status and family sizes ofrespondents.CONCLUSION: Use of Insecticide treated bed net has been hampered byunavailability of the commodity. It is therefore recommended that efforts should be made to make the commodity available to reduce morbidity and mortality amongthis vulnerable group.

PMID: 20499745 [PubMed - indexed for MEDLINE]

156. Malar J. 2010 May 18;9:133. doi: 10.1186/1475-2875-9-133.

Assessing bed net use and non-use after long-lasting insecticidal netdistribution: a simple framework to guide programmatic strategies.

Vanden Eng JL, Thwing J, Wolkon A, Kulkarni MA, Manya A, Erskine M, Hightower A, Slutsker L.

Centers for Disease Control and Prevention, Center for Global Health, Division ofParasitic Diseases and Malaria, 4770 Buford Hwy MS F-22, Atlanta, GA 30341, USA. [email protected]

BACKGROUND: Insecticide-treated nets (ITNs) are becoming increasingly availableto vulnerable populations at risk for malaria. Their appropriate and consistentuse is essential to preventing malaria, but ITN use often lags behind ITNownership. In order to increase ITN use, it is necessary to devise strategiesthat accurately identify, differentiate, and target the reasons and types ofnon-use.METHODS: A simple method based on the end-user as the denominator was employed toclassify each individual into one of four ITN use categories: 1) living inhouseholds not owning an ITN; 2) living in households owning, but not hanging an ITN; 3) living in households owning and hanging an ITN, but who are not sleeping under one; and 4) sleeping under an ITN. This framework was applied to surveydata designed to evaluate long-lasting insecticidal nets (LLINs) distributions

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following integrated campaigns in five countries: Togo, Sierra Leone, Madagascar,Kenya and Niger.RESULTS: The percentage of children <5 years of age sleeping under an ITN ranged from 51.5% in Kenya to 81.1% in Madagascar. Among the three categories ofnon-use, children living in households without an ITN make up largest group(range: 9.4%-30.0%), despite the efforts of the integrated child healthcampaigns. The percentage of children who live in households that own but do not hang an ITN ranged from 5.1% to 16.1%. The percentage of children living inhouseholds where an ITN was suspended, but who were not sleeping under it ranged from 4.3% to 16.4%. Use by all household members in Sierra Leone (39.9%) andMadagascar (60.4%) indicate that integrated campaigns reach beyond their desired target populations.CONCLUSIONS: The framework outlined in this paper provides a helpful tool toexamine the deficiencies in ITN use. Monitoring and evaluation strategiesdesigned to assess ITN ownership and use can easily incorporate this approachusing existing data collection instruments that measure the standard indicators.

PMCID: PMC2890673PMID: 20482776 [PubMed - indexed for MEDLINE]

157. Acta Trop. 2010 Oct;116(1):24-30. doi: 10.1016/j.actatropica.2010.05.002. Epub2010 May 11.

Wash-resistance and field evaluation of alphacypermethrin treated long-lastinginsecticidal net (Interceptor) against malaria vectors Anopheles culicifacies andAnopheles fluviatilis in a tribal area of Orissa, India.

Sharma SK, Upadhyay AK, Haque MA, Tyagi PK, Raghavendra K, Dash AP.

National Institute of Malaria Research, Field Station, Sector-5, Rourkela 769002, Orissa, India. [email protected]

A field trial was conducted on the efficacy of Interceptor nets-a long-lastinginsecticidal net (LLN) factory treated with alphacypermethrin 0.667% (w/w)corresponding to 200mg/m(2), against malaria vectors Anopheles culicifacies andAnopheles fluviatilis in one of the highly endemic areas of Orissa. The studyarea comprised 19 villages which were randomized into three clusters and

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designated as Interceptor net cluster, untreated net cluster, and no net cluster.Baseline studies showed that both the vector species An. culicifacies and An.fluviatilis were 100% susceptible to alphacypermethrin. Results ofwash-resistance and bio-efficacy of Interceptor nets showed 100% mortality in An.culicifacies and An. fluviatilis even after 20 washings. Bioassays on theInterceptor nets while in use in the field conditions showed a knockdown effecton 70-90% mosquitoes during different months of intervention after 3 min ofexposure and 100% mortality was recorded after 24h of recovery period. The medianknockdown time for these species ranged between 4.10-5.25 min and 4.00-5.00 minrespectively during intervention period. In Interceptor net study area, there wasa significant reduction of 88.9, 96.3 and 90.6% in the entry rate of An.culicifacies, An. fluviatilis and other anopheline species respectively with anover all reduction of 87.5% in total mosquitoes. The overall feeding success rateof mosquitoes in the trial villages was only 12.8% in comparison to 35.0 and78.8% in villages with untreated nets and no nets respectively. A significantreduction was also recorded in parity rate and human blood index of vectorspecies in Interceptor net area. The results of the study showed that Interceptornets are effective against the malaria vectors and may be used as a suitableintervention strategy in high-risk areas.

Copyright 2010 Elsevier B.V. All rights reserved.

PMID: 20465990 [PubMed - indexed for MEDLINE]

158. Malar J. 2010 May 10;9:121. doi: 10.1186/1475-2875-9-121.

Effect of training on the use of long-lasting insecticide-treated bed nets on theburden of malaria among vulnerable groups, south-west Ethiopia: baseline results of a cluster randomized trial.

Deribew A, Alemseged F, Birhanu Z, Sena L, Tegegn A, Zeynudin A, Dejene T,Sudhakar M, Abdo N, Tessema F.

Department of Epidemiology, Jimma University, Jimma, [email protected]

BACKGROUND: In Ethiopia, the utilization of long-lasting insecticide-treated bed

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nets (LLITN) is hampered by behavioural factors such as low awareness andnegative attitude of the community. The aim of this study was to present thedesign and baseline results of a cluster randomized trial on the effect oftraining of household heads on the use of LLITN.METHODS: This baseline survey was undertaken from February to March, 2009 as partof a randomized cluster trial. A total of 11 intervention and 11 control Gots(villages) were included in the Gilgel Gibe Field Research Centre, south-westEthiopia. House to house visit was done in 4135 households to collect informationabout the use of LLITN and socio-demographic variables. For the diagnosis ofmalaria and anaemia, blood samples were collected from 2410 under-five childrenand 242 pregnant women.RESULTS: One fourth of the households in the intervention and control Gots hadfunctional LLITN. Only 30% of the observed LLITN in the intervention and 28% inthe control Gots were hanged properly. Adults were more likely to utilize LLITNthan under-five children in the control and intervention Gots. The prevalence of malaria in under-five children in the intervention and control Gots was 10.5% and8.3% respectively. The intervention and control Gots had no significantdifference concerning the prevalence of malaria in under-five children, [OR =1.28, (95%CI: 0.97, 1.69)]. Eight (6.1%) pregnant women in the intervention andeight (7.2%) in the control Gots were positive for malaria (P = 0.9). Children inthe intervention Gots were less likely to have anaemia than children in thecontrol Gots, [OR = 0.75, (95%CI: 0.62, 0.85)].CONCLUSION: The availability and utilization of LLITN was low in the study area. The prevalence of malaria and anaemia was high. Intervention strategies ofmalaria should focus on high risk population and vulnerable groups.

PMCID: PMC2891814PMID: 20459742 [PubMed - indexed for MEDLINE]

159. BMC Infect Dis. 2010 Apr 30;10:109. doi: 10.1186/1471-2334-10-109.

Lives saved by Global Fund-supported HIV/AIDS, tuberculosis and malaria programs:estimation approach and results between 2003 and end-2007.

Komatsu R, Korenromp EL, Low-Beer D, Watt C, Dye C, Steketee RW, Nahlen BL,

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Lyerla R, Garcia-Calleja JM, Cutler J, Schwartländer B.

The Global Fund to Fight AIDS, Tuberculosis and Malaria, Chemin Blandonnet 8,1214 Vernier, Geneva, Switzerland. [email protected]

BACKGROUND: Since 2003, the Global Fund has supported the scale-up of HIV/AIDS,tuberculosis and malaria control in low- and middle-income countries. This paper presents and discusses a methodology for estimating the lives saved throughselected service deliveries reported to the Global Fund.METHODS: Global Fund-supported programs reported, by end-2007, 1.4 millionHIV-infected persons on antiretroviral treatment (ARV), 3.3 million newsmear-positive tuberculosis cases detected in DOTS (directly observed TBtreatment, short course) programs, and 46 million insecticide-treated mosquitonets (ITNs) delivered. We estimated the corresponding lives saved usingadaptations of existing epidemiological estimation models.RESULTS: By end-2007, an estimated 681,000 lives (95% uncertainty range619,000-774,000) were saved and 1,097,000 (993,000-1,249,000) life-years gainedby ARV. DOTS treatment would have saved 1.63 million lives (1.09-2.17 million)when compared against no treatment, or 408,000 lives (265,000-551,000) whencompared against non-DOTS treatment. ITN distributions in countries with stableendemic falciparum malaria were estimated to have achieved protection frommalaria for 26 million of child-years at risk cumulatively, resulting in 130,000 (27,000-232,000) under-5 deaths prevented.CONCLUSIONS: These results illustrate the scale of mortality effects thatsupported programs may have achieved in recent years, despite margins ofuncertainty and covering only selected intervention components. Evidence-basedevaluation of disease impact of the programs supported by the Global Fund withinternational and in-country partners must be strengthened using population-leveldata on intervention coverage and demographic outcomes, information on quality ofservices, and trends in disease burdens recorded in national health informationsystems.

PMCID: PMC2876166PMID: 20433714 [PubMed - indexed for MEDLINE]

160. Malar J. 2010 Apr 27;9:113. doi: 10.1186/1475-2875-9-113.

Field efficacy of a new mosaic long-lasting mosquito net (PermaNet 3.0) against

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pyrethroid-resistant malaria vectors: a multi centre study in Western and CentralAfrica.

Corbel V, Chabi J, Dabiré RK, Etang J, Nwane P, Pigeon O, Akogbeto M, Hougard JM.

Institut de Recherche pour le Développement, UR016, Caractérisation et Contrôledes Populations de Vecteurs, 01 BP 4414 RP Cotonou, République du Bé[email protected]

BACKGROUND: Due to the spread of pyrethroid-resistance in malaria vectors inAfrica, new strategies and tools are urgently needed to better control malariatransmission. The aim of this study was to evaluate the performances of a newmosaic long-lasting insecticidal net (LLIN), i.e. PermaNet 3.0, against wildpyrethroid-resistant Anopheles gambiae s.l. in West and Central Africa.METHODS: A multi centre experimental hut trial was conducted in Malanville(Benin), Vallée du Kou (Burkina Faso) and Pitoa (Cameroon) to investigate theexophily, blood feeding inhibition and mortality induced by PermaNet 3.0 (i.e. a mosaic net containing piperonyl butoxide and deltamethrin on the roof)comparatively to the WHO recommended PermaNet 2.0 (unwashed and washed 20-times) and a conventionally deltamethrin-treated net (CTN).RESULTS: The personal protection and insecticidal activity of PermaNet 3.0 andPermaNet 2.0 were excellent (>80%) in the "pyrethroid-tolerant" area ofMalanville. In the pyrethroid-resistance areas of Pitoa (metabolic resistance)and Vallée du Kou (presence of the L1014F kdr mutation), PermaNet 3.0 showedequal or better performances than PermaNet 2.0. It should be noted however thatthe deltamethrin content on PermaNet 3.0 was up to twice higher than that ofPermaNet 2.0. Significant reduction of efficacy of both LLIN was noted after 20washes although PermaNet 3.0 still fulfilled the WHO requirement for LLIN.CONCLUSION: The use of combination nets for malaria control offers promisingprospects. However, further investigations are needed to demonstrate the benefitsof using PermaNet 3.0 for the control of pyrethroid resistant mosquitopopulations in Africa.

PMCID: PMC2877060PMID: 20423479 [PubMed - indexed for MEDLINE]

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161. Indian J Pediatr. 2010 Apr;77(4):425-30. doi: 10.1007/s12098-010-0051-z. Epub2010 Mar 19.

Insecticide treated nets, antimalarials and child survival in India.

Lal S, Lahariya C, Saxena VK.

National Centre for Disease Control (National Institute of CommunicableDiseases), Sham Nath Marg, Delhi, India.

Malaria has been a complex public health problem affecting mainly the poor andthe rural communities in India. Insecticide treated nets (ITN) and antimalarials are the two proven interventions for prevention and control of malaria. ITN hasbeen amply demonstrated to be an effective intervention to protect children from malaria, and in preventing deaths due to falciparum malaria. Antimalarials are a therapeutic intervention for management of malaria, and prevention ofcomplications due to Plasmodium falciparum infection. However, implementation of these interventions is fraught with problems of complex and multidimensionalnature at the periphery. These can be addressed by optimizing the use of the 2interventions, the insecticide treated nets and antimalarials, for area specific application and country specific needs, determined by the eco-epidemiologicaldiversity of malaria in India. This article reviews the significant role of ITNin reducing child mortality, and the judicious use of antimalarials in themanagement of malaria patient, and the problems associated with the use of these interventions in protecting children against malaria in India.

PMID: 20422322 [PubMed - indexed for MEDLINE]

162. Malar J. 2010 Apr 21;9:107. doi: 10.1186/1475-2875-9-107.

Comparison of anaemia and parasitaemia as indicators of malaria control inhousehold and EPI-health facility surveys in Malawi.

Mathanga DP, Campbell CH Jr, Vanden Eng J, Wolkon A, Bronzan RN, Malenga GJ, Ali D, Desai M.

Malaria Alert Centre, College of Medicine, University of Malawi, P/Bag 360,

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Blantyre 3, Malawi. [email protected]

BACKGROUND: The World Health Organization has recommended that anaemia be used asan additional indicator to monitor malaria burden at the community level asmalaria interventions are nationally scaled up. To date, there are no publishedevaluations of this recommendation.METHODS: To evaluate this recommendation, a comparison of anaemia andparasitaemia among 6-30 month old children was made during two repeatedcross-sectional household (HH) and health facility (HF) surveys in six districts across Malawi at baseline (2005) and in a follow-up survey (2008) after a scaleup of malaria control interventions.RESULTS: HH net ownership did not increase between the years (50.5% vs. 49.8%),but insecticide treated net (ITN) ownership increased modestly from 41.5% (95%CI: 37.2%-45.8%) in 2005 to 45.3% (95% CI: 42.6%-48.0%) in 2008. ITN use bychildren 6-30 months old, who were living in HH with at least one net, increased from 73.6% (95% CI:68.2%-79.1%) to 80.0% (95% CI:75.9%-84.1%) over the three-yearperiod. This modest increase in ITN use was associated with a decrease inmoderate to severe anaemia (Hb <8 g/dl) from 18.4% (95% CI:14.9%-21.8%) in 2005to 15.4% (13.2%-17.7%) in 2008, while parasitaemia, measured as positive-slidemicroscopy, decreased from 18.9% (95% CI:14.7%-23.2%) to 16.9% (95%CI:13.8%-20.0%), a relative reduction of 16% and 11%, respectively. In HFsurveys, anaemia prevalence decreased from 18.3% (95% CI: 14.9%-21.7%) to 15.4%(95% CI: 12.7%-18.2%), while parasitaemia decreased from 30.6% (95% CI:25.7%-35.5%) to 13.2% (95% CI: 10.6%-15.8%), a relative reduction of 15% and 57%,respectively.CONCLUSION: Increasing access to effective malaria prevention was associated witha reduced burden of malaria in young Malawian children. Anaemia measured at theHF level at time of routine vaccination may be a good surrogate indicator for itsmeasurement at the HH level in evaluating national malaria control programmes.

PMCID: PMC2864286PMID: 20409342 [PubMed - indexed for MEDLINE]

163. Malar J. 2010 Apr 20;9:102. doi: 10.1186/1475-2875-9-102.

Costs and effects of two public sector delivery channels for long-lastinginsecticidal nets in Uganda.

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Kolaczinski JH, Kolaczinski K, Kyabayinze D, Strachan D, Temperley M,Wijayanandana N, Kilian A.

Malaria Consortium - Africa Regional Office, PO Box 8045, Plot 2, Sturrock Road, Kampala, Uganda. [email protected]

BACKGROUND: In Uganda, long-lasting insecticidal nets (LLIN) have beenpredominantly delivered through two public sector channels: targeted campaigns orroutine antenatal care (ANC) services. Their combination in a mixed-modelstrategy is being advocated to quickly increase LLIN coverage and maintain itover time, but there is little evidence on the efficiency of each system. Thisstudy evaluated the two delivery channels regarding LLIN retention and use, andestimated the associated costs, to contribute towards the evidence-base on LLINdelivery channels in Uganda.METHODS: Household surveys were conducted 5-7 months after LLIN distribution,combining questionnaires with visual verification of LLIN presence. Focus groups and interviews were conducted to further investigate determinants of LLINretention and use. Campaign distribution was evaluated in Jinja and Adjumaniwhile ANC distribution was evaluated only in the latter district. Costs werecalculated from the provider perspective through retrospective analysis ofexpenditure data, and effects were estimated as cost per LLIN delivered and cost per treated-net-year (TNY). These effects were calculated for the total number ofLLINs delivered and for those retained and used.RESULTS: After 5-7 months, over 90% of LLINs were still owned by recipients, and between 74% (Jinja) and 99% (ANC Adjumani) were being used. Costing resultsshowed that delivery was cheapest for the campaign in Jinja and highest for theANC channel, with economic delivery cost per net retained and used of USD 1.10and USD 2.31, respectively. Financial delivery costs for the two channels weresimilar in the same location, USD 1.04 for campaign or USD 1.07 for ANC delivery in Adjumani, but differed between locations (USD 0.67 for campaign delivery inJinja). Economic cost for ANC distribution were considerably higher (USD 2.27)compared to campaign costs (USD 1.23) in Adjumani.CONCLUSIONS: Targeted campaigns and routine ANC services can both achieve highLLIN retention and use among the target population. The comparatively higher

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economic cost of delivery through ANC facilities was at least partially due tothe relatively short time this system had been in existence. Further studiescomparing the cost of well-established ANC delivery with LLIN campaigns and otherdelivery channels are thus encouraged.

PMCID: PMC2868859PMID: 20406448 [PubMed - indexed for MEDLINE]

164. Cochrane Database Syst Rev. 2010 Apr 14;(4):CD006657. doi:10.1002/14651858.CD006657.pub2.

Indoor residual spraying for preventing malaria.

Pluess B, Tanser FC, Lengeler C, Sharp BL.

Public Health and Epidemiology, Swiss Tropical and Public Health Institute,Basel, Switzerland, 4002.

BACKGROUND: Primary malaria prevention on a large scale depends on two vectorcontrol interventions: indoor residual spraying (IRS) and insecticide-treatedmosquito nets (ITNs). Historically, IRS has reduced malaria transmission in many settings in the world, but the health effects of IRS have never been properlyquantified. This is important, and will help compare IRS with other vectorcontrol interventions.OBJECTIVES: To quantify the impact of IRS alone, and to compare the relativeimpacts of IRS and ITNs, on key malariological parameters.SEARCH STRATEGY: We searched the Cochrane Infectious Diseases Group SpecializedRegister (September 2009), CENTRAL (The Cochrane Library 2009, Issue 3), MEDLINE (1966 to September 2009), EMBASE (1974 to September 2009), LILACS (1982 toSeptember 2009), mRCT (September 2009), reference lists, and conferenceabstracts. We also contacted researchers in the field, organizations, andmanufacturers of insecticides (June 2007).SELECTION CRITERIA: Cluster randomized controlled trials (RCTs), controlledbefore-and-after studies (CBA) and interrupted time series (ITS) of IRS compared to no IRS or ITNs. Studies examining the impact of IRS on special groups notrepresentative of the general population, or using insecticides and dosages notrecommended by the World Health Organization (WHO) were excluded.DATA COLLECTION AND ANALYSIS: Two authors independently reviewed trials for

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inclusion. Two authors extracted data, assessed risk of bias and analysed thedata. Where possible, we adjusted confidence intervals (CIs) for clustering.Studies were grouped into those comparing IRS with no IRS, and IRS compared with ITNs, and then stratified by malaria endemicity.MAIN RESULTS: IRS versus no IRSStable malaria (entomological inoculation rate(EIR) > 1): In one RCT in Tanzania IRS reduced re-infection with malariaparasites detected by active surveillance in children following treatment;protective efficacy (PE) 54%. In the same setting, malaria case incidenceassessed by passive surveillance was marginally reduced in children aged one tofive years; PE 14%, but not in children older than five years (PE -2%). In theIRS group, malaria prevalence was slightly lower but this was not significant (PE6%), but mean haemoglobin was higher (mean difference 0.85 g/dL).In one CBA trialin Nigeria, IRS showed protection against malaria prevalence during the wetseason (PE 26%; 95% CI 20 to 32%) but not in the dry season (PE 6%; 95% CI -4 to 15%). In one ITS in Mozambique, the prevalence was reduced substantially over aperiod of 7 years (from 60 to 65% prevalence to 4 to 8% prevalence; the weighted PE before-after was 74% (95% CI 72 to 76%).Unstable malaria (EIR < 1): In twoRCTs, IRS reduced the incidence rate of all malaria infections;PE 31% in India,and 88% (95% CI 69 to 96%) in Pakistan. By malaria species, IRS also reduced the incidence of P. falciparum (PE 93%, 95% CI 61 to 98% in Pakistan) and P. vivax(PE 79%, 95% CI 45 to 90% in Pakistan); There were similar impacts on malariaprevalence for any infection: PE 76% in Pakistan; PE 28% in India. When lookingseparately by parasite species, for P. falciparum there was a PE of 92% inPakistan and 34% in India; for P. vivax there was a PE of 68% in Pakistan and no impact demonstrated in India (PE of -2%).IRS versus Insecticide Treated Nets(ITNs)Stable malaria (EIR > 1): Only one RCT was done in an area of stabletransmission (in Tanzania). When comparing parasitological re-infection by activesurveillance after treatment in short-term cohorts, ITNs appeared better, but it was likely not to be significant as the unadjusted CIs approached 1 (risk ratioIRS:ITN = 1.22). When the incidence of malaria episodes was measured by passive

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case detection, no difference was found in children aged one to five years (risk ratio = 0.88, direction in favour of IRS). No difference was found for malariaprevalence or haemoglobin.Unstable malaria (EIR < 1): Two studies; for incidence and prevalence, the malaria rates were higher in the IRS group compared to theITN group in one study. Malaria incidence was higher in the IRS arm in India(risk ratio IRS:ITN = 1.48) and in South Africa (risk ratio 1.34 but the cluster unadjusted CIs included 1). For malaria prevalence, ITNs appeared to give better protection against any infection compared to IRS in India (risk ratio IRS:ITN =1.70) and also for both P. falciparum (risk ratio IRS:ITN = 1.78) and P. vivax(risk ratio IRS:ITN = 1.37).AUTHORS' CONCLUSIONS: Historical and programme documentation has clearlyestablished the impact of IRS. However, the number of high-quality trials are toofew to quantify the size of effect in different transmission settings. Theevidence from randomized comparisons of IRS versus no IRS confirms that IRSreduces malaria incidence in unstable malaria settings, but randomized trial datafrom stable malaria settings is very limited. Some limited data suggest that ITN give better protection than IRS in unstable areas, but more trials are needed to compare the effects of ITNs with IRS, as well as to quantify their combinedeffects.

PMID: 20393950 [PubMed - indexed for MEDLINE]

165. Am J Trop Med Hyg. 2010 Apr;82(4):525-8. doi: 10.4269/ajtmh.2010.09-0188.

Syndromic diagnosis of malaria in rural Sierra Leone and proposed additions tothe national integrated management of childhood illness guidelines for fever.

Nnedu ON, Rimel B, Terry C, Jalloh-Vos H, Baryon B, Bausch DG.

Tulane University Health Sciences Center, New Orleans, Louisiana, [email protected]

Many countries in Africa, including Sierra Leone, have adopted artemisinin-based combination therapy as first-line therapy for treatment of patients with malaria.

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Because laboratory testing is often unavailable in rural areas, the cost-benefit and viability of this approach may depend on accurately diagnosing malaria byusing clinical criteria. We assessed the accuracy of syndromic diagnosis formalaria in three peripheral health units in rural Sierra Leone and determinedfactors that were associated with an accurate malaria diagnosis. Of 175 children diagnosed with malaria on syndromic grounds, 143 (82%) were confirmed by theParacheck-Pf test. In a multivariate analysis, splenomegaly (P = 0.04) was theonly clinical sign significantly associated with laboratory-confirmed malaria,and sleeping under a bed net was protective (P = 0.05). Our findings show thatclinical malaria is diagnosed relatively accurately in rural Sierra Leone.Incorporating bed net use and splenomegaly into the national IntegratedManagement of Childhood Illness guidelines for evaluation of fever may furtherenhance diagnostic accuracy for malaria.

PMCID: PMC2844576PMID: 20348493 [PubMed - indexed for MEDLINE]

166. Malar J. 2010 Mar 24;9:84. doi: 10.1186/1475-2875-9-84.

Evaluation of Interceptor long-lasting insecticidal nets in eight communities in Liberia.

Banek K, Kilian A, Allan R.

Uganda Malaria Surveillance Project, PO Box 7475, Kampala, [email protected]

BACKGROUND: By 2008, the WHO Pesticide Evaluation Scheme (WHOPES) recommendedfive long-lasting insecticidal nets (LLINs) for the prevention of malaria:Olyset((R)), PermaNet 2.0((R)), Netprotect((R)), Duranet((R)) andInterceptor((R)). Field information is available for both Olyset(R) andPermaNet((R)), with limited data on the newer LLINs. To address this gap, a fieldevaluation was carried out to determine the acceptability and durability ofInterceptor((R)) LLINs.METHODS: A one-year prospective field study was conducted in eight rural returneevillages in Liberia. Households were randomized to receive Interceptor((R)) LLINsor conventionally treated nets (CTNs). Primary outcomes were levels of residual

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alpha-cypermethrin measured by HPLC and participant utilization/acceptability of the ITNs.RESULTS: A total of 398 nets were analysed for residual alpha-cypermethrin. Themedian baseline concentrations of insecticide were 175.5 mg/m2 for theInterceptor((R)) LLIN and 21.8 mg/m2 for the CTN. Chemical residue loss after aone year follow-up period was 22% and 93% respectively. Retention and utilizationof nets remained high (94%) after one year, irrespective of type, whileparasitaemia prevalence decreased from 29.7% at baseline to 13.6% during thefollow up survey (p = < 0.001). Interview and survey data show perceivedeffectiveness of ITNs was just as important as other physical attributes ininfluencing net utilization.CONCLUSION: Interceptor((R)) LLINs are effective and desirable in ruralcommunities in Liberia. Consideration for end user preferences should beincorporated into product development of all LLINs in the future, in order toachieve optimum retention and utilization.

PMCID: PMC2858215PMID: 20334677 [PubMed - indexed for MEDLINE]

167. Am J Trop Med Hyg. 2010 Mar;82(3):420-5. doi: 10.4269/ajtmh.2010.09-0597.

Contribution of integrated campaign distribution of long-lasting insecticidalnets to coverage of target groups and total populations in malaria-endemic areas in Madagascar.

Kulkarni MA, Vanden Eng J, Desrochers RE, Cotte AH, Goodson JL, Johnston A,Wolkon A, Erskine M, Berti P, Rakotoarisoa A, Ranaivo L, Peat J.

HealthBridge, Ottawa, Ontario, Canada. [email protected]

In October 2007, Madagascar conducted a nationwide integrated campaign to delivermeasles vaccination, mebendazole, and vitamin A to children six months to fiveyears of age. In 59 of the 111 districts, long-lasting insecticidal nets (LLINs) were delivered to children less than five years of age in combination with theother interventions. A community-based, cross-sectional survey assessed LLINownership and use six months post-campaign during the rainy season. LLINownership was analyzed by wealth quintile to assess equity. In the 59 districts, 76.8% of households possessed at least one LLIN from any source and 56.4% of

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households possessed a campaign net. Equity of campaign net ownership wasevident. Post-campaign, the LLIN use target of > or = 80% by children less thanfive years of age and a high level of LLIN use (69%) by pregnant women wereattained. Targeted LLIN distribution further contributed to total populationcoverage (60%) through use of campaign nets by all age groups.

PMCID: PMC2829903PMID: 20207867 [PubMed - indexed for MEDLINE]

168. Am J Trop Med Hyg. 2010 Mar;82(3):415-9. doi: 10.4269/ajtmh.2010.09-0579.

Insecticide-treated nets can reduce malaria transmission by mosquitoes which feedoutdoors.

Govella NJ, Okumu FO, Killeen GF.

Ifakara Health Institute, Dar es Salaam, Tanzania. [email protected]

Insecticide treated nets (ITNs) represent a powerful means for controllingmalaria in Africa because the mosquito vectors feed primarily indoors at night.The proportion of human exposure that occurs indoors, when people are asleep and can conveniently use ITNs, is therefore very high. Recent evidence suggestsbehavioral changes by malaria mosquito populations to avoid contact with ITNs by feeding outdoors in the early evening. We adapt an established mathematical modelof mosquito behavior and malaria transmission to illustrate how ITNs can achieve communal suppression of malaria transmission exposure, even where mosquito evade them and personal protection is modest. We also review recent reports fromTanzania to show that conventional mosquito behavior measures can underestimatethe potential of ITNs because they ignore the importance of human movements.

PMCID: PMC2829902PMID: 20207866 [PubMed - indexed for MEDLINE]

169. Acta Trop. 2010 Jul-Aug;115(1-2):131-6. doi: 10.1016/j.actatropica.2010.02.014.Epub 2010 Mar 3.

Anopheline fauna and malaria transmission in four ecologically distinct zones in

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Cameroon.

Atangana J, Bigoga JD, Patchoké S, Ndjemaï MN, Tabue RN, Nem TE, Fondjo E.

National Malaria Control Programme, Ministry of Public Health, Cameroon, P.O.Box: 14386, Yaounde, Cameroon.

Knowledge of baseline malaria transmission intensity in a given environment isimportant to guide malaria control interventions. In Cameroon, recent informationon malaria transmission intensity is insufficient. Therefore, an entomologicalstudy was conducted in four ecologically different sites throughout the countryto assess the seasonal patterns in malaria transmission intensity. Anophelesarabiensis was the main vector in six of the nine study sites, while An. gambiae sensu stricto was the most important vector in the other three sites. Cleardifferences in entomological inoculation rates (EIR) were observed between thestudy sites, ranging from 0.1 infective bites per person per night in thesahelian zone of the country to 5.5 infective bites per person per night in theforest zone. Based on the observed behaviour of the vectors, insecticide-treated bed nets will be highly effective in controlling malaria. However, in the hightransmission areas, additional measures will be needed to reduce the malariaburden to acceptable levels.

2010 Elsevier B.V. All rights reserved.

PMID: 20206111 [PubMed - indexed for MEDLINE]

170. Malar J. 2010 Feb 24;9:58. doi: 10.1186/1475-2875-9-58.

Malaria indicator survey 2007, Ethiopia: coverage and use of major malariaprevention and control interventions.

Jima D, Getachew A, Bilak H, Steketee RW, Emerson PM, Graves PM, Gebre T,Reithinger R, Hwang J; Ethiopia Malaria Indicator Survey Working Group.

Collaborators: Amena M, Bergeron L, Bilak H, Chirwa B, Demeke F, Dinkessa W,Ejigsemahu Y, Emerson PM, Endeshaw T, Etana K, Fente G, Filler S, Frolov A, GausiK, Gebre T, Gebreyesus TA, Getachew A, Getachew A, Graves PM, Haile-Giorgis Z,

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Hailemariam A, Hwang J, Jima D, Kebede H, Lilay A, Lungu C, Medhin A, Mekasha A, Miller J, Mosher AW, Muhamed H, Mulatu S, Nefdt R, Ngondi J, Olana D, Reithinger R, Richards FO Jr, Seid A, Shargie EB, Steketee R, Tadesse Z, Teferri T,Tekalegne A, Tenaw E, Tilahun A, Wolkon A, Yigezu B, Yohannes G.

Diseases Prevention and Control Department, Federal Ministry of Health, AddisAbaba, Ethiopia.

BACKGROUND: In 2005, a nationwide survey estimated that 6.5% of households inEthiopia owned an insecticide-treated net (ITN), 17% of households had beensprayed with insecticide, and 4% of children under five years of age with a feverwere taking an anti-malarial drug. Similar to other sub-Saharan African countriesscaling-up malaria interventions, the Government of Ethiopia set an ambitiousnational goal in 2005 to (i) provide 100% ITN coverage in malarious areas, with amean of two ITNs per household; (ii) to scale-up indoor residual spraying ofhouseholds with insecticide (IRS) to cover 30% of households targeted for IRS;and (iii) scale-up the provision of case management with rapid diagnostic tests(RDTs) and artemisinin-based combination therapy (ACT), particularly at theperipheral level.METHODS: A nationally representative malaria indicator survey (MIS) was conductedin Ethiopia between September and December 2007 to determine parasite and anaemiaprevalence in the population at risk and to assess coverage, use and access toscaled-up malaria prevention and control interventions. The survey used atwo-stage random cluster sample of 7,621 households in 319 census enumerationareas. A total of 32,380 people participated in the survey. Data was collectedusing standardized Roll Back Malaria Monitoring and Evaluation Reference GroupMIS household and women's questionnaires, which were adapted to the localcontext.RESULTS: Data presented is for households in malarious areas, which according to the Ethiopian Federal Ministry of Health are defined as being located <2,000 maltitude. Of 5,083 surveyed households, 3,282 (65.6%) owned at least one ITN. In ITN-owning households, 53.2% of all persons had slept under an ITN the priornight, including 1,564/2,496 (60.1%) children <5 years of age, 1,891/3,009

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(60.9%) of women 15 - 49 years of age, and 166/266 (65.7%) of pregnant women.Overall, 906 (20.0%) households reported to have had IRS in the past 12 months.Of 747 children with reported fever in the two weeks preceding the survey, 131(16.3%) sought medical attention within 24 hours. Of those with fever, 86 (11.9%)took an anti-malarial drug and 41 (4.7%) took it within 24 hours of fever onset. Among 7,167 surveyed individuals of all ages, parasitaemia as estimated bymicroscopy was 1.0% (95% CI 0.5 - 1.5), with 0.7% and 0.3% due to Plasmodiumfalciparum and Plasmodium vivax, respectively. Moderate-severe anaemia(haemoglobin <8 g/dl) was observed in 239/3,366 (6.6%, 95% CI 4.9-8.3) children<5 years of age.CONCLUSIONS: Since mid-2005, the Ethiopian National Malaria Control Programme hasconsiderably scaled-up its malaria prevention and control interventions,demonstrating the impact of strong political will and a committed partnership.The MIS showed, however, that besides sustaining and expanding malariaintervention coverage, efforts will have to be made to increase interventionaccess and use. With ongoing efforts to sustain and expand malaria interventioncoverage, to increase intervention access and use, and with strong involvement ofthe community, Ethiopia expects to achieve its targets in terms of coverage anduptake of interventions in the coming years and move towards eliminating malaria.

PMCID: PMC2841196PMID: 20178654 [PubMed - indexed for MEDLINE]

171. Trans R Soc Trop Med Hyg. 2010 Jun;104(6):423-8. doi:10.1016/j.trstmh.2010.01.001. Epub 2010 Feb 11.

Increased financial accessibility and targeted education messages could increase ownership and use of mosquito nets in Purulia District, West Bengal, India.

Biswas AK, Hutin YJ, Ramakrishnan R, Patra B, Gupte MD.

West Bengal Directorate of Public Health, Kolkata, West Bengal, India; Master of Applied Epidemiology (MAE)-Field Epidemiology Training Programme (FETP), NationalInstitute of Epidemiology (NIE), Chennai, Tamil Nadu, India.

Insecticide-treated mosquito nets are effective in reducing malaria transmission

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and mortality, yet they are underused for prevention. In this study, 561households in 33 clusters were surveyed to estimate the coverage of net ownershipand the frequency of use according to selected characteristics. Of the 540participating household heads, 247 (46%) owned mosquito nets. Of 1681 individualsin households with mosquito nets, 1359 (81%) used the nets. A household monthlyincome > or =2000 Indian rupees (US$45) was strongly associated with mosquito netownership (prevalence ratio=12, 95% CI 7.8-82). Factors independently associated with net use in multivariate analysis included age < 35 years (P<0.001), sleepinginside (P<0.001), use of repellent (P=0.03) as well as knowledge that mosquitoes cause malaria (P=0.002) and that malaria is severe in children (P<0.001). Whilst household income is the strongest determinant of mosquito net ownership, selectedknowledge elements are associated with net use. It is necessary to improvefinancial accessibility to nets and to communicate that malaria is a diseasetransmitted by mosquitoes that could be fatal in children.

2010 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd.All rights reserved.

PMID: 20153006 [PubMed - indexed for MEDLINE]

172. Trop Med Int Health. 2010 Apr;15(4):480-8. doi: 10.1111/j.1365-3156.2010.02478.x.Epub 2010 Feb 9.

Long-lasting insecticide-treated net usage in eastern Sierra Leone - the success of free distribution.

Gerstl S, Dunkley S, Mukhtar A, Maes P, De Smet M, Baker S, Maikere J.

Médecins Sans Frontières-United Kingdom, London, UK. [email protected]<[email protected]>

OBJECTIVE: Médecins Sans Frontières (MSF) runs a malaria control project in Boand Pujehun districts (population 158 000) that includes the mass distribution,routine delivery and demonstration of correct use of free, long-lastinginsecticide-treated nets (LLINs). In 2006/2007, around 65 000 LLINs weredistributed. The aim of this follow-up study was to measure LLIN usage andownership in the project area.METHODS: Heads of 900 randomly selected households in 30 clusters were

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interviewed, using a standardized questionnaire, about household use of LLINs.The condition of any LLIN was physically assessed.RESULTS: Of the 900 households reported, 83.4% owning at least one LLIN. Of the16.6% without an LLIN, 91.9% had not participated in the MSF mass distribution.In 94.1% of the households reporting LLINs, the nets were observed hangingcorrectly over the beds. Of the 1135 hanging LLINs, 75.2% had no holes or 10 orfewer finger-size holes. The most common source of LLINs was MSF (75.2%). Of the 4997 household members, 67.2% reported sleeping under an LLIN the night beforethe study, including 76.8% of children under 5 years and 73.0% of pregnant women.CONCLUSION: Our results show that MSF achieved good usage with freely distributedLLINs. It is one of the few areas where results almost achieve the new targetsset in 2005 by Roll Back Malaria to have at least 80% of pregnant women andchildren under 5 years using LLINs by 2010.

PMID: 20149163 [PubMed - indexed for MEDLINE]

173. PLoS One. 2010 Feb 4;5(2):e9047. doi: 10.1371/journal.pone.0009047.

Differential patterns of infection and disease with P. falciparum and P. vivax inyoung Papua New Guinean children.

Lin E, Kiniboro B, Gray L, Dobbie S, Robinson L, Laumaea A, Schöpflin S, StanisicD, Betuela I, Blood-Zikursh M, Siba P, Felger I, Schofield L, Zimmerman P,Mueller I.

PNG Institute of Medical Research, Madang, Papua New Guinea.

BACKGROUND: Where P. vivax and P. falciparum occur in the same population, thepeak burden of P. vivax infection and illness is often concentrated in youngerage groups. Experiences from malaria therapy patients indicate that immunity isacquired faster to P. vivax than to P. falciparum challenge. There is howeverlittle prospective data on the comparative risk of infection and disease fromboth species in young children living in co-endemic areas.METHODOLOGY/PRINCIPAL FINDINGS: A cohort of 264 Papua New Guinean children aged1-3 years (at enrolment) were actively followed-up for Plasmodium infection and

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febrile illness for 16 months. Infection status was determined by lightmicroscopy and PCR every 8 weeks and at each febrile episode. A generalisedestimating equation (GEE) approach was used to analyse both prevalence ofinfection and incidence of clinical episodes. A more pronounced rise inprevalence of P. falciparum compared to P. vivax infection was evident withincreasing age. Although the overall incidence of clinical episodes wascomparable (P. falciparum: 2.56, P. vivax 2.46 episodes / child / yr), P.falciparum and P. vivax infectious episodes showed strong but opposing agetrends: P. falciparum incidence increased until the age of 30 months with little change thereafter, but incidence of P. vivax decreased significantly with agethroughout the entire age range. For P. falciparum, both prevalence and incidenceof P. falciparum showed marked seasonality, whereas only P. vivax incidence butnot prevalence decreased in the dry season.CONCLUSIONS/SIGNIFICANCE: Under high, perennial exposure, children in PNG beginacquiring significant clinical immunity, characterized by an increasing abilityto control parasite densities below the pyrogenic threshold to P. vivax, but not to P. falciparum, in the 2(nd) and 3(rd) year of life. The ability to relapsefrom long-lasting liver-stages restricts the seasonal variation in prevalence of P. vivax infections.

PMCID: PMC2816213PMID: 20140220 [PubMed - indexed for MEDLINE]

174. Int J Epidemiol. 2010 Feb;39(1):72-9. doi: 10.1093/ije/dyp363.

An assessment of Lot Quality Assurance Sampling to evaluate malaria outcomeindicators: extending malaria indicator surveys.

Biedron C, Pagano M, Hedt BL, Kilian A, Ratcliffe A, Mabunda S, Valadez JJ.

Department of Global Health and Population, Harvard School of Public Health,Boston, MA, USA.

BACKGROUND: Large investments and increased global prioritization of malariaprevention and treatment have resulted in greater emphasis on programmemonitoring and evaluation (M&E) in many countries. Many countries currently uselarge multistage cluster sample surveys to monitor malaria outcome indicators on

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a regional and national level. However, these surveys often mask local-levelvariability important to programme management. Lot Quality Assurance Sampling(LQAS) has played a valuable role for local-level programme M&E. If incorporated into these larger surveys, it would provide a comprehensive M&E plan at little,if any, extra cost.METHODS: The Mozambique Ministry of Health conducted a Malaria Indicator Survey(MIS) in June and July 2007. We applied LQAS classification rules to the 345sampled enumeration areas to demonstrate identifying high- and low-performingareas with respect to two malaria program indicators-'household possession of anybednet' and 'household possession of any insecticide-treated bednet (ITN)'.RESULTS: As shown by the MIS, no province in Mozambique achieved the 70% coveragetarget for household possession of bednets or ITNs. By applying LQASclassification rules to the data, we identify 266 of the 345 enumeration areas ashaving bednet coverage severely below the 70% target. An additional 73 wereidentified with low ITN coverage.CONCLUSIONS: This article demonstrates the feasibility of integrating LQAS intomultistage cluster sampling surveys and using these results to support acomprehensive national, regional and local programme M&E system. Furthermore, in the recommendations we outlined how to integrate the Large Country-LQAS designinto macro-surveys while still obtaining results available through currentsampling practices.

PMCID: PMC2912491PMID: 20139435 [PubMed - indexed for MEDLINE]

175. Acta Trop. 2010 Jun;114(3):177-83. doi: 10.1016/j.actatropica.2010.01.012. Epub2010 Feb 2.

A community-directed strategy for sustainable malaria elimination on islands:short-term MDA integrated with ITNs and robust surveillance.

Kaneko A.

Karolinska Institutet, Island Malaria Group, Scheeles labo B2, Stockholm, [email protected]

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In the Asia Pacific sites with low and unstable transmission, elimination should be feasible with existing tools. On Aneityum island, Vanuatu, both Plasmodiumfalciparum and Plasmodium vivax malaria were eliminated in 1991 afterimplementation of a combined intervention package, including mass drugadministration (MDA) and insecticide-treated bed nets (ITNs), with high degree ofcommunity involvement. Subsequently, community-based surveillance and vectorcontrol measures have kept. By reviewing the experiences of the Aneityum project,I intended to examine the roles of community in malaria elimination. To besuccessful, the program should transfer major intervention components from theexternal donor-directed initiative to the community-directed approach. Scaling upof community involvement from simple participation to social participation, wherecommunities involve in health planning functions is necessary from malariacontrol to malaria elimination.

Copyright (c) 2010 Elsevier B.V. All rights reserved.

PMID: 20132788 [PubMed - indexed for MEDLINE]

176. CMAJ. 2010 Feb 9;182(2):152-6. doi: 10.1503/cmaj.090268. Epub 2010 Jan 11.

Assessment of a national voucher scheme to deliver insecticide-treated mosquitonets to pregnant women.

Marchant T, Schellenberg D, Nathan R, Armstrong-Schellenberg J, Mponda H, JonesC, Sedekia Y, Bruce J, Hanson K.

London School of Hygiene and Tropical Medicine, London, [email protected]

BACKGROUND: The benefits of a health-related intervention may be compromised bythe challenges of delivering the intervention on a large scale. We analyzed theprocess involved in the Tanzania National Voucher Scheme, a system for deliveringinsecticide-treated mosquito nets to pregnant women. We aimed to identifypotential ways to equitably improve overall coverage of the intervention.METHODS: We defined five steps in the process. We collected data from amultistage cluster survey of nationally representative households conducted in2007 across 21 districts in Tanzania. Using these data, we multiplied the rate of

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success of each step cumulatively to estimate the overall success of the system.RESULTS: The rate of coverage for use of insecticide-treated nets among pregnant women was 23% (95% confidence interval [CI] 19%-27%). We observed largedifferences in coverage by socio-economic status, from 7% (95% CI 4%-13%) amongparticipants in the poorest households to 48% (95% CI 38%-59%) among those in therichest households. The rate of success of each step in the process was high(60%-98%). However, the cumulative rate of success for the process as a whole waslow (30%). The largest and most inequitable reduction in coverage occurred in thestep involving treatment of nets with insecticide.INTERPRETATION: The cumulative effect of modest attrition at several steps in theprocess substantially diminished the overall rate of coverage for all women, but most markedly among the poorest participants. Analysis of the process suggeststhat delivery of nets treated with long-lasting insecticide rather than untreatednets packaged with an insecticide-treatment kit could result in an improvement incoverage of 22 percentage points, from 30% to 52%.

PMCID: PMC2817322PMID: 20064944 [PubMed - indexed for MEDLINE]

177. Malar J. 2010 Jan 6;9:7. doi: 10.1186/1475-2875-9-7.

Malaria control under the Taliban regime: insecticide-treated net purchasing,coverage, and usage among men and women in eastern Afghanistan.

Howard N, Shafi A, Jones C, Rowland M.

London School of Hygiene and Tropical Medicine, London, [email protected]

BACKGROUND: Scaling up insecticide-treated mosquito net (ITN) coverage is a keymalaria control strategy even in conflict-affected countries 12. Socio-economicfactors influence access to ITNs whether subsidized or provided free to users.This study examines reported ITN purchasing, coverage, and usage in easternAfghanistan and explores women's access to health information during the Taliban regime (1996-2001). This strengthens the knowledge base on household-level healthchoices in complex-emergency settings.

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METHODS: Fifteen focus group discussions (FGDs) and thirty in-depth interviewswere conducted with men and women from ITN-owning and non-owning households. FGDsincluded rank ordering, pile sorting and focused discussion of malaria knowledge and ITN purchasing. Interviews explored general health issues, prevention andtreatment practices, and women's malaria knowledge and concerns. Seven keyinformant interviews with health-related workers and a concurrent survey of 200ITN-owning and 214 non-owning households were used to clarify or quantifyfindings.RESULTS: Malaria knowledge was similar among men and women and ITN owners andnon-owners. Women reported obtaining health information through a variety ofsources including clinic staff, their husbands who had easier access toinformation, and particularly female peers. Most participants considered ITNsvery desirable, though not usually household necessities. ITN owners reportedmore household assets than non-owners. Male ITN owners and non-owners ranked rugsand ITNs as most desired, while women ranked personal assets such as jewelleryhighest. While men were primarily responsible for household decision-making andpurchasing, older women exerted considerable influence. Widow-led and landlesshouseholds reported most difficulties purchasing ITNs. Most participants wantedto buy ITNs only if they could cover all household members. When not possible,preferential usage was given to women and children.CONCLUSIONS: Despite restricted access to health facilities and formal education,Afghan women were surprisingly knowledgeable about the causes of malaria and the value of ITNs in prevention. Inequities in ITN usage were noted between ratherthan within households, with some unable to afford even one ITN and others notwanting ITNs unless all household members could be protected. Malaria knowledgethus appears a lesser barrier to ITN purchasing and coverage in easternAfghanistan than are pricing and distribution strategies.

PMCID: PMC2817706PMID: 20053281 [PubMed - indexed for MEDLINE]

178. PLoS One. 2009 Dec 23;4(12):e8321. doi: 10.1371/journal.pone.0008321.

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Interactions between age and ITN use determine the risk of febrile malaria inchildren.

Bejon P, Ogada E, Peshu N, Marsh K.

Kenyan Medical Research Institute (KEMRI), Centre for Geographic MedicineResearch (Coast), Kilifi, Kenya. [email protected]

Erratum in PLoS One. 2011;6(2). doi:10.1371/annotation/73a096b6-934c-4bc7-b0b1-de1f11231350.

BACKGROUND: Control measures which reduce individual exposure to malaria areexpected to reduce disease, but also to eventually reduce immunity. Reassuringly,long term data following community wide ITN distribution show sustained benefits at a population level. However, the more common practice in Sub-Saharan Africa isto target ITN distribution on young children. There are few data on the long termoutcomes of this practice.METHODOLOGY/PRINCIPAL FINDINGS: Episodes of febrile malaria were identified byactive surveillance in 383 children over 18 months of follow up. In order tocompare the short and long term outcomes of ITN use, we examined interactionsbetween ITN use and age (12-42 months of age versus 42-80 months) in determining the risk of febrile malaria. ITN use and older age protected against the first oronly episode of malaria (Hazard Ratio [HR] = 0.33, 95%CI 0.17-0.65 and HR = 0.30,95%CI 0.17-0.51, respectively). The interaction term between ITN use and olderage was HR = 2.91, 95%CI 1.02-8.3, p = 0.045, indicating that ITNs did notprotect older children. When multiple episodes were included in analysis, ITN useand older age were again protective against malaria episodes (Incident Rate Ratio[IRR] = 0.43 95%CI 0.27-0.7) and IRR = 0.23, 95%CI 0.13-0.42, respectively) andthe interaction term indicated that ITNs did not protect older children (IRR =2.71, 95%CI 1.3-5.7, p = 0.008).CONCLUSIONS/SIGNIFICANCE: These data on age interactions with ITN use suggestthat larger scale studies on the long term individual outcomes should beundertaken if the policy of targeted ITN use for vulnerable groups is tocontinue.

PMCID: PMC2792723PMID: 20037643 [PubMed - indexed for MEDLINE]

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179. PLoS One. 2009 Dec 22;4(12):e8409. doi: 10.1371/journal.pone.0008409.

Is the scale up of malaria intervention coverage also achieving equity?

Steketee RW, Eisele TP.

Malaria Control and Evaluation Partnership in Africa (MACEPA)-PATH,Ferney-Voltaire, France. [email protected]

BACKGROUND AND METHODS: Malaria in Africa is most severe in young children andpregnant women, particularly in rural and poor households. In many countries,malaria intervention coverage rates have increased as a result of scale up; butthis may mask limited coverage in these highest-risk populations. Reports werereviewed from nationally representative surveys in African malaria-endemiccountries from 2006 through 2008 to understand how reported intervention coveragerates reflect access by the most at-risk populations.RESULTS: Reports were available from 27 Demographic and Health Surveys (DHSs),Multiple Indicator Cluster Surveys (MICSs), and Malaria Indicator Surveys (MISs) during this interval with data on household intervention coverage by urban orrural setting, wealth quintile, and sex. Household ownership ofinsecticide-treated mosquito nets (ITNs) varied from 5% to greater than 60%, and was equitable by urban/rural and wealth quintile status among 13 (52%) of 25countries. Malaria treatment rates for febrile children under five years of agevaried from less than 10% to greater than 70%, and while equitable coverage wasachieved in 8 (30%) of 27 countries, rates were generally higher in urban andrichest quintile households. Use of intermittent preventive treatment in pregnantwomen varied from 2% to more than 60%, and again tended to be higher in urban andrichest quintile households. Across all countries, there were no significantmale/female inequalities seen for children sleeping under ITNs or receivingantimalarial treatment for febrile illness. Parasitemia and anemia rates fromeight national surveys showed predominance in poor and rural populations.CONCLUSIONS/SIGNIFICANCE: Recent efforts to scale up malaria interventioncoverage have achieved equity in some countries (especially with ITNs), butdelivery methods in other countries are not addressing the most at-risk

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populations. As countries seek universal malaria intervention coverage, theirdelivery systems must reach the rural and poor populations; this is not a smalltask, but it has been achieved in some countries.

PMCID: PMC2791860PMID: 20027289 [PubMed - indexed for MEDLINE]

180. Malar J. 2009 Dec 16;8:298. doi: 10.1186/1475-2875-8-298.

A cluster randomized controlled cross-over bed net acceptability and preferencetrial in Solomon Islands: community participation in shaping policy for malariaelimination.

Atkinson JA, Bobogare A, Vallely A, Boaz L, Kelly G, Basifiri W, Forsyth S, BakerP, Appleyard B, Toaliu H, Williams G.

Pacific Malaria Initiative Support Centre, Australian Centre for Internationaland Tropical Health, School of Population Health, University of Queensland,Brisbane, Australia. [email protected]

BACKGROUND: A key component of the malaria elimination strategy in SolomonIslands (SI) is widespread coverage of long-lasting insecticidal nets (LLINs).The success of this strategy is dependent on LLIN acceptability and compliance.There has been unresolved debate among policy makers and donors as to which type of LLIN would be most appropriate for large-scale distribution in SI, andanecdotal reports of a lack of acceptability of certain brands of LLINs. Acluster randomized controlled crossover bed net acceptability and preferencetrial was therefore carried out from July to September, 2008 to inform policy andto facilitate community engagement and participation in the selection of the mostappropriate LLIN for use in SI.METHOD: A three-stage sampling method was used to randomly select the studypopulation from Malaita Province, SI. Three brands of LLINs were assessed in thisstudy: Olyset, PermaNet and DuraNet. Bed net acceptability and preference wereevaluated through surveys at three defined time points after short andlonger-term trial of each LLIN.RESULTS: The acceptability of PermaNet after short-term use (96.5%) wassignificantly greater than Olyset (67.3%, p < 0.001) and DuraNet (69.8%, p <

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0.001). The acceptability of DuraNet and Olyset after short-term use was notsignificantly different at the 5% level. LLINs that were perceived not to preventmosquito bites were significantly less acceptable than LLINs that were perceived to prevent mosquito bites (OR 0.15; 95%CI 0.03 to 0.6). LLINs that allow apleasant night's sleep (OR 6.3; 95%CI:3.3-12.3) and have a soft texture (OR 5.7; 95%CI:1.9-20.5) were considered more acceptable than those that did not. Olyset'sacceptability decreased over time and this was due to net wrinkling/shrinkageafter washing resulting in reduced efficiency in preventing mosquito bites. Theincrease in DuraNet acceptability was a result of a reduction in minor adverseevents following longer-term use.CONCLUSION: This research was conducted to inform LLIN procurement as part of thenational malaria control and elimination programme in SI. The success of malaria elimination in the Pacific and elsewhere relies on provision of acceptableinterventions, consideration of local-level realities and engagement ofcommunities in strategy development.TRIAL REGISTRATIONS: Clinical trials ACTRN12608000322336.

PMCID: PMC2803192PMID: 20015402 [PubMed - indexed for MEDLINE]

181. Malar J. 2009 Dec 9;8:283. doi: 10.1186/1475-2875-8-283.

The effects of zooprophylaxis and other mosquito control measures against malariain Nouna, Burkina Faso.

Yamamoto SS, Louis VR, Sié A, Sauerborn R.

Institute of Public Health, University of Heidelberg, Im Neuenheimer Feld 324,69120 Heidelberg, Germany. [email protected]

BACKGROUND: In the absence of large scale, organized vector control programmes,individual protective measures against mosquitoes are essential for reducing the transmission of diseases like malaria. Knowledge of the types and effectivenessof mosquito control methods used by households can aid in the development andpromotion of preventive measures.

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METHODS: A matched, population-based case control study was carried out in thesemi-urban region of Nouna, Burkina Faso. Surveys and mosquito captures wereconducted for each participating household. Data were analysed using conditional logistic regression and Pearson's product-moment correlations.RESULTS: In Nouna, Burkina Faso, the main types of reported mosquito controlmeasures used included sleeping under bed nets (insecticide-treated anduntreated) and burning mosquito coils. Most of the study households kept animals within the compound or house at night. Insecticide house sprays, donkeys, rabbitsand pigs were significantly associated with a reduced risk of malaria only inunivariate analyses.CONCLUSION: Given the conflicting results of the effects of zooprophylaxis fromprevious studies, other community-based preventive measures, such as bed nets,coils and insecticide house-spraying, may be of more benefit.

PMCID: PMC2799429PMID: 20003189 [PubMed - indexed for MEDLINE]

182. East Afr J Public Health. 2009 Aug;6(2):205-10.

Knowledge, attitudes and practices of local inhabitants about insecticide treatednets (ITNs) for malaria control in an endemic area of Ethiopia.

Kaliyaperumal K, Yesuf D.

Jimma University, School of Environmental Health Sciences, Jimma, [email protected]

OBJECTIVE: The present study was conducted to assess the knowledge, attitudes andpractices of local residents about insecticide treated nets (ITNs) for malariacontrol in an endemic area of Ethiopia.METHODS: A descriptive cross-survey was conducted from July 2008 to September2008. A structured questionnaire collecting sociodemographic, ITNs andmalaria-related KAP information was administered to the representatives ofhouseholds.SETTINGS: Azendabo town, Ethiopia.RESULTS: 84% of the inhabitants had awareness about malaria transmission;mosquito bites were identified correctly as the cause of malaria. 85.2%respondents indicated that mosquitoes bite at night. ITNs awareness level ofinhabitants was 92.4%; however, just 57.8% of them own ITNs. 96.2% and 91.5% of

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the inhabitants indicated the foremost reasons for nonpossession of ITNs were dueto unaffordability and nonavailability. Inhabitants average monthly incomesignificantly associated with the ITNs ownership at p<0.05 and, howevereducational status of the respondents and ITNs ownership was not significant(p=0.1).CONCLUSION: Indeed, respondents had adequate knowledge regarding ITNs and malariarelated information. However, inhabitants had poor attitude and practice towards the ITNs utilization due to lack of availability and affordability. Therefore,besides health education campaign, distribution and promotion of ITNs to entirerural residents at free of charge may possibly bring constructive outcome in the near future.

PMID: 20000031 [PubMed - indexed for MEDLINE]

183. J Infect Dis. 2010 Jan 1;201(1):123-31. doi: 10.1086/648595.

The effect of intermittent preventive treatment during pregnancy on malarialantibodies depends on HIV status and is not associated with poor deliveryoutcomes.

Serra-Casas E, Menéndez C, Bardají A, Quintó L, Dobaño C, Sigauque B, Jiménez A, Mandomando I, Chauhan VS, Chitnis CE, Alonso PL, Mayor A.

Barcelona Centre for International Health Research, Hospital Clínic/Institutd'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona,Barcelona, Spain.

BACKGROUND: Intermittent preventive treatment during pregnancy (IPTp) withsulfadoxine-pyrimethamine (SP) is recommended for malaria prevention insub-Saharan Africa. However, studies reporting the effect of IPTp onmalaria-specific immunity are scarce and are based on findings in humanimmunodeficiency virus (HIV)-negative primigravidae.METHODS: Plasma samples obtained from 302 pregnant women (177 who were HIVnegative, 88 who were HIV positive, and 37 who were of unknown HIV status)participating in a placebo-controlled trial of IPTp with SP (IPTp-SP) wereanalyzed for the presence of antibodies against merozoite antigens, whole asexualparasites, and variant surface antigens from chondroitin sulfate A-binding and

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nonbinding lines. Antibody levels were compared between intervention groups, and their association with morbidity outcomes was assessed.RESULTS: HIV-positive mothers receiving SP had lower levels of peripheralantibodies against apical membrane antigen-1 and variant surface antigens, aswell as lower levels of cord antibodies against erythrocyte-binding antigen-175and parasite lysate, than did HIV-positive placebo recipients. No differencebetween intervention groups was observed among HIV-negative mothers. Highantibody levels were associated with maternal infection and an increased risk of a first malaria episode in infants. Antibody responses were not consistentlyassociated with reduced maternal anemia, prematurity, or low birth weight.CONCLUSIONS: The IPTp-associated reduction in antibodies in HIV-infected women,but not in HIV-uninfected women, may reflect a higher efficacy of theintervention in preventing malaria among HIV-positive mothers. This reduction didnot translate into an enhanced risk of malaria-associated morbidity in mothersand infants. Trial registration. Clinicaltrials.gov identifier NCT00209781.

PMID: 19954383 [PubMed - indexed for MEDLINE]

184. Malar J. 2009 Nov 16;8:256. doi: 10.1186/1475-2875-8-256.

Predicting the impact of insecticide-treated bed nets on malaria transmission:the devil is in the detail.

Gu W, Novak RJ.

Division of Infectious Diseases, University of Alabama, Birmingham, Alabama35294, USA. [email protected]

BACKGROUND: Insecticide-treated bed nets (ITNs), including long-lastinginsecticidal nets (LLINs), play a primary role in global campaigns to roll backmalaria in tropical Africa. Effectiveness of treated nets depends on directimpacts on individual mosquitoes including killing and excite-repellency, whichvary considerably among vector species due to variations in host-seekingbehaviours. While monitoring and evaluation programmes of ITNs have focuses onmorbidity and all-cause mortality in humans, local entomological context receiveslittle attention. Without knowing the dynamics of local vector species and their

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responses to treated nets, it is difficult to predict clinical outcomes when ITN applications are scaled up across African continent. Sound model frameworksincorporating intricate interactions between mosquitoes and treated nets areneeded to develop the predictive capacity for scale-up applications of ITNs.METHODS: An established agent-based model was extended to incorporate the direct outcomes, e.g. killing and avoidance, of individual mosquitoes exposing to ITNsin a hypothetical village setting with 50 houses and 90 aquatic habitats.Individual mosquitoes were tracked throughout the life cycle across thelandscape. Four levels of coverage, i.e. 40, 60, 80 and 100%, were applied at thehousehold level with treated houses having only one bed net. By using Latinhypercube sampling scheme, parameters governing killing, diverting and personalprotection of net users were evaluated for their relative roles in containingmosquito populations, entomological inoculation rates (EIRs) and malariaincidence.RESULTS: There were substantial gaps in coverage between households andindividual persons, and 100% household coverage resulted in circa 50% coverage ofthe population. The results show that applications of ITNs could give rise tovarying impacts on population-level metrics depending on values of parametersgoverning interactions of mosquitoes and treated nets at the individual level.The most significant factor in determining effectiveness was killing capabilityof treated nets. Strong excito-repellent effect of impregnated nets might lead tohigher risk exposure to non-bed net users.CONCLUSION: With variabilities of vector mosquitoes in host-seeking behavioursand the responses to treated nets, it is anticipated that scale-up applicationsof INTs might produce varying degrees of success dependent on local entomologicaland epidemiological contexts. This study highlights that increased ITN coverageled to significant reduction in risk exposure and malaria incidence only whentreated nets yielded high killing effects. It is necessary to test efficacy oftreated nets on local dominant vector mosquitoes, at least in laboratory, formonitoring and evaluation of ITN programmes.

PMCID: PMC2780451PMID: 19917119 [PubMed - indexed for MEDLINE]

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185. Malar J. 2009 Nov 11;8:252. doi: 10.1186/1475-2875-8-252.

Spatial risk profiling of Plasmodium falciparum parasitaemia in a high endemicityarea in Côte d'Ivoire.

Raso G, Silué KD, Vounatsou P, Singer BH, Yapi A, Tanner M, Utzinger J, N'GoranEK.

Département Environnement et Santé, Centre Suisse de Recherches Scientifiques,Abidjan, Côte d'Ivoire. [email protected]

BACKGROUND: The objective of this study was to identify demographic,environmental and socioeconomic risk factors and spatial patterns of Plasmodiumfalciparum parasitaemia in a high endemicity area of Africa, and to specify howthis information can facilitate improved malaria control at the district level.METHODS: A questionnaire was administered to about 4,000 schoolchildren in 55schools in western Côte d'Ivoire to determine children's socioeconomic status andtheir habit of sleeping under bed nets. Environmental data were obtained fromsatellite images, digitized ground maps and a second questionnaire addressed toschool directors. Finger prick blood samples were collected and P. falciparumparasitaemia determined under a microscope using standardized, quality-controlledmethods. Bayesian variogram models were utilized for spatial risk modelling andmapping of P. falciparum parasitaemia at non-sampled locations, assumingstationary and non-stationary underlying spatial dependence.RESULTS: Two-thirds of the schoolchildren were infected with P. falciparum andthe mean parasitaemia among infected children was 959 parasites/microl of blood. Age, socioeconomic status, not sleeping under a bed net, coverage rate with bednets and environmental factors (e.g., normalized difference vegetation index,rainfall, land surface temperature and living in close proximity to standingwater) were significantly associated with the risk of P. falciparum parasitaemia.After accounting for spatial correlation, age, bed net coverage, rainfall during the main malaria transmission season and distance to rivers remained significant covariates.CONCLUSION: It is argued that a massive increase in bed net coverage,

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particularly in villages in close proximity to rivers, in concert with othercontrol measures, is necessary to bring malaria endemicity down to intermediateor low levels.

PMCID: PMC2783037PMID: 19906295 [PubMed - indexed for MEDLINE]

186. J Epidemiol Community Health. 2011 Jan;65(1):78-82. doi:10.1136/jech.2008.085449. Epub 2009 Nov 5.

Timing of delivery of malaria preventive interventions in pregnancy: results fromthe Tanzania national voucher programme.

Marchant T, Hanson K, Nathan R, Mponda H, Bruce J, Jones C, Sedekia Y, Mshinda H,Schellenberg J.

London School of Hygiene and Tropical Medicine, London, [email protected]

BACKGROUND: Across sub-Saharan Africa, pregnant women attend routine healthservices around the 20th week of gestation.OBJECTIVE: To investigate, with a view to maximising effectiveness of malariacontrol tools delivered via routine services, coverage of an antenatal clinicinsecticide-treated net (ITN) voucher scheme in Tanzania by gestational age.METHODS: Household and antenatal clinic survey data from 21 districts in Tanzaniawere collected and analysed annually 2005-2007. Optimal voucher protection wasdefined as giving women access to vouchers for 24 weeks of pregnancy (weeks 16and 40 gestation). The relationship between gestational age and use of ITNsthroughout pregnancy was explored.RESULTS: Coverage of the ITN voucher was high (84% in 2007), but only 61% ofoptimal voucher protection was achieved. It was reduced by a combination of late attendance at clinic and staff not distributing vouchers at first visit. Anincreasing trend by gestational age in ITN use was observed each survey year,rising in 2007 from 23% of first-trimester women to 30% of women post partum(χ(2)=5.9, p=0.01).CONCLUSION: Uptake of malaria interventions is not evenly distributed throughout pregnancy. Including gestational age in pregnancy coverage indicators can enhance

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understanding of the public health potential available from pregnancyinterventions.

PMID: 19897468 [PubMed - indexed for MEDLINE]

187. Malar J. 2009 Oct 29;8:248. doi: 10.1186/1475-2875-8-248.

Impact of insecticide-treated nets on wild pyrethroid resistant Anophelesepiroticus population from southern Vietnam tested in experimental huts.

Van Bortel W, Chinh VD, Berkvens D, Speybroeck N, Trung HD, Coosemans M.

Institute of Tropical Medicine, Dept Parasitology, Nationalestraat 155, B-2000Antwerpen, Belgium. [email protected]

BACKGROUND: In this study, the efficacy of insecticide-treated nets was evaluatedin terms of deterrence, blood-feeding inhibition, induced exophily and mortality on a wild resistant population of Anopheles epiroticus in southern Vietnam, inorder to gain insight into the operational consequences of the insecticideresistance observed in this malaria vector in the Mekong delta.METHOD: An experimental station, based on the model of West Africa and adapted tothe behaviour of the target species, was built in southern Vietnam. The studydesign was adapted from the WHO phase 2 guidelines. The study arms included aconventionally treated polyester net (CTN) with deltamethrin washed just beforeexhaustion, the WHO recommended long-lasting insecticidal net (LLIN) PermaNet 2.0unwashed and 20 times washed and PermaNet 3.0, designed for the control ofpyrethroid resistant vectors, unwashed and 20 times washed.RESULTS: The nets still provided personal protection against the resistant An.epiroticus population. The personal protection ranged from 67% for deltamethrinCTN to 85% for unwashed PermaNet 3.0. Insecticide resistance in the An.epiroticus mosquitoes did not seem to alter the deterrent effect of pyrethroids. A significant higher mortality was still observed among the treatment armsdespite the fact that the An. epiroticus population is resistant against thetested insecticides.CONCLUSION: This study shows that CTN and LLINs still protect individuals againsta pyrethroid resistant malaria vector from the Mekong region, where insecticideresistance is caused by a metabolic mechanism. In the light of a possible

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elimination of malaria from the Mekong region these insights in operationalconsequences of the insecticide resistance on control tools is of upmostimportance.

PMCID: PMC2781025PMID: 19874581 [PubMed - indexed for MEDLINE]

188. Vector Borne Zoonotic Dis. 2010 May;10(4):403-10. doi: 10.1089/vbz.2008.0191.

Wash-resistance and field efficacy of Olyset net, a permethrin-incorporatedlong-lasting insecticidal netting, against Anopheles minimus-transmitted malaria in Assam, Northeastern India.

Dev V, Raghavendra K, Barman K, Phookan S, Dash AP.

National Institute of Malaria Research (Field Station), Chachal, Guwahati, [email protected]

INTRODUCTION: The long-lasting insecticidal nets are ready-to-use, pretreatednets, which do not require retreatment for 4-5 years. Olyset nets that are madeof high-density polyethylene monofilament yarn with 2% w/w permethrinincorporated (corresponding to 1 g/m(2)) are type-2 in which insecticide isincorporated into the polymers and are wash resistant. In these, insecticidemigrates to the surface of the netting fiber to be bioavailable againstmosquitoes and other insect pests. STUDY SITE AND OBJECTIVES: The present studywas a village scale, field-based trial that was conducted in Plasmodiumfalciparum predominant area of Assam to assess feasibility, acceptability, andsustainability of this intervention against vector populations and diseasetransmission. We here report the research findings of Olyset net as anintervention against Anopheles minimus-transmitted malaria in foothill area ofAssam for the first year of observations beginning July 2005 till June 2006.RESULTS: An. minimus, the mosquito vector species, was observed to be fullysusceptible to permethrin. Follow-up investigations revealed that An. minimusmosquitoes had virtually disappeared in Olyset net villages, which wascorroborated by data on human bait mosquito-landing catches. There was aconsistent decline in the malarial incidence in Olyset net intervention villages,and the overall impact on the malarial transmission was significant compared to

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untreated net and no-net control villages for the corresponding study period. Thebioavailability of insecticide on Olyset netting fiber was consistent (100% kill effect) up to 10 months of monitoring, and was observed to be wash resistant evenafter the 20th wash at fortnightly intervals.CONCLUSIONS: The Olyset nets were safe to use, wash resistant, and assessed to beoperationally feasible, community-based intervention for sustainable managementof disease vectors against malaria. Community compliance and acceptance was high,and users reported decreased nuisance due to biting mosquitoes.

PMID: 19874188 [PubMed - indexed for MEDLINE]

189. Ann Afr Med. 2009 Apr-Jun;8(2):85-9. doi: 10.4103/1596-3519.56234.

Insecticide-treated nets usage and malaria episodes among boarding students inZaria, northern Nigeria.

Aliyu AA, Alti-Mu'azu M.

Department of Community Medicine, A.B.U., Zaria, Nigeria. [email protected]

BACKGROUND: Despite malaria being the largest public health problem in AfricaSouth of Sahara with over one million associated deaths each year, there has beenlittle progress in its prevention/control during the past decades. Therefore,this study was conducted to determine the knowledge, attitude, use ofinsecticide-treated nets (ITNs), and the prevalence of malaria episodes amongboarding secondary school pupils in Zaria, Nigeria.METHODS: A multi-stage sampling technique was used to sample five (5) secondaryschools within Zaria, from which six classes (JSS 1 - 3 and SS 1- 3) ofrespondents were then randomly selected. Structured, closed-endedself-administered questionnaires were used to collect information on demographic characteristics, knowledge, attitude, and use of ITNs, reasons for non-use andmalaria episodes in last 12 months.RESULTS: A total of 150 students from the five (5) boarding secondary schoolswere interviewed, majority were in the age group 15-17 (53.3%) with a mean (x) SDof 16.8 0.8 years. Males were 60% and females 40% of respondents. Majority of therespondents (87.3%) knew about and had actually seen an ITN; only 43.3% were

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current users. Most of the current users of ITN noticed a significant reductionin malaria episodes in the last 12 months. This was statistically significant(P=0.004). Cost and availability were reasons sited by non-ITN users.CONCLUSION: There is urgent need on the part of all the three tiers of Governmentfor public health awareness campaigns through information, education andcommunication (IEC) to create positive ITN culture and usage. It is alsosuggested that ITN usage among boarding school pupils should be incorporated intoschool health service.

PMID: 19805937 [PubMed - indexed for MEDLINE]

190. BMC Public Health. 2009 Oct 1;9:369. doi: 10.1186/1471-2458-9-369.

The use of insecticide treated nets by age: implications for universal coveragein Africa.

Noor AM, Kirui VC, Brooker SJ, Snow RW.

Malaria Public Health and Epidemiology Group, Centre for Geographic Medicine,KEMRI-University of Oxford-Wellcome Trust Collaborative Programme, KenyattaNational Hospital Grounds, Nairobi, Kenya. [email protected]

BACKGROUND: The scaling of malaria control to achieve universal coverage requiresa better understanding of the population sub-groups that are least protected and provide barriers to interrupted transmission. Here we examine the age pattern of use of insecticide treated nets (ITNs) in Africa in relation to biologicalvulnerabilities and the implications for future prospects for universal coverage.METHODS: Recent national household survey data for 18 malaria endemic countriesin Africa were assembled to identify information on use of ITNs by age and sex.Age-structured medium variant projected population estimates for the mid-pointyear of the earliest and most recent national surveys were derived to compute thepopulation by age protected by ITNs.RESULTS: All surveys were undertaken between 2005 and 2009, either as demographichealth surveys (n = 12) or malaria indicator surveys (n = 6). Countries werecategorized into three ITN use groups: <10%; 10 to <20%; and > or =20% and

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projected population estimates for the mid-point year of 2007 were computed. Ingeneral, the pattern of overall ITNs use with age was similar by country andacross the three country groups with ITNs use initially high among children <5years of age, sharply declining among the population aged 5-19 years, beforerising again across the ages 20-44 years and finally decreasing gradually inolder ages. For all groups of countries, the highest proportion of the populationnot protected by ITNs (38% - 42%) was among those aged 5-19 years.CONCLUSION: In malaria-endemic Africa, school-aged children are the leastprotected with ITNs but represent the greatest reservoir of infections. Withincreasing school enrollment rates, school-delivery of ITNs should be considered as an approach to reach universal ITNs coverage and improve the likelihood ofimpacting upon parasite transmission.

PMCID: PMC2761895PMID: 19796380 [PubMed - indexed for MEDLINE]

191. Trends Parasitol. 2009 Nov;25(11):511-6. doi: 10.1016/j.pt.2009.08.002. Epub 2009Sep 9.

Predicting changing malaria risk after expanded insecticide-treated net coverage in Africa.

Smith DL, Hay SI, Noor AM, Snow RW.

Department of Biology and Emerging Pathogens Institute, University of Florida,P.O. Box 100009, Gainesville, Florida 32610, USA. [email protected]

The Roll Back Malaria (RBM) partnership has established goals for protectingvulnerable populations with locally appropriate vector control. In many places,these goals will be achieved by the mass distribution of insecticide treatedbednets (ITNs). Mathematical models can forecast an ITN-driven realignment ofmalaria endemicity, defined by the Plasmodium falciparum parasite rate (PfPR) in children, to predict PfPR endpoints and appropriate program timelines for thischange in Africa. The relative ease of measuring PfPR and its widespread use makeit particularly suitable for monitoring and evaluation. This theory provides a

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method for context-dependent evaluation of ITN programs and a basis for settingrational ITN coverage targets over the next decade.

PMCID: PMC2768685PMID: 19744887 [PubMed - indexed for MEDLINE]

192. J Pak Med Assoc. 2009 Jun;59(6):354-8.

Awareness and use of insecticide treated nets among women attending ante-natalclinic in a northern state of Nigeria.

Musa OI, Salaudeen GA, Jimoh RO.

Dept of Epidemiology & Community Health, College of Health Sciences, Universityof Ilorin, Ilorin, Nigeria.

OBJECTIVE: To determine the awareness, accessibility and use of ITN by pregnantwomen attending ante-natal clinic (ANC) at the Primary Health Care (PHC) levelconsidering the Government commitment of ensuring that at least 60% of pregnantwomen benefit from ITN by year 2010.METHODS: This descriptive cross sectional study was carried out in all 78 PHCcentres in the state. Four hundred and fifty-five (455) pregnant women thatconsented to the study where interviewed during their ANC sessions usingsemi-structured questionnaires. Data entry and analysis was done on a microcomputer; frequency tables and cross tabulations of important variables weredone; and Chi-square test was used for the test of significance.RESULTS: About one-third 164 (36%) of the respondents were aware of ITN inmalaria prevention, but less than a third 124 (27%) had ever used it and only 88 (19%) were currently using it, while 104 (23%) of the total respondents had amember of their household using ITN. Some of the difficulties encountered orexperienced by respondents currently using ITN were scarcity of new nets,difficulty in getting chemicals for re-treatment of nets, non availability ofquality ITN for sale. Three hundred and thirty-one (73%) respondents have neverused ITN before because of lack of awareness 136 (41%), price of ITN is toocostly 26 (8%) and non-availability of ITN for purchase 67 (20%). Respondents'age, educational level, parity and source of information or awareness on ITN have

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no significant influence on ITN use (P > 0.05); however, the frequency of malariaattack among respondents using ITN was lower than those not using it and this wassignificant (P > 0.0043).CONCLUSION: Awareness and utilization of ITN among pregnant women and theirhousehold members is still low despite Government policy of free ITN forvulnerable groups and subsidized nets for other people. There is need to focus oncreating demand for ITNs through all available health information channelsincluding social marketing.

PMID: 19534367 [PubMed - indexed for MEDLINE]

193. Trans R Soc Trop Med Hyg. 2009 Nov;103(11):1098-104. doi:10.1016/j.trstmh.2009.03.003. Epub 2009 Apr 5.

Preliminary examination of integrated vector management in a tropical rainforest area of Cameroon.

Matthews GA, Dobson HM, Nkot PB, Wiles TL, Birchmore M.

The Yaoundé Initiative Foundation, c/o IPARC, Imperial College London, SilwoodPark, Ascot SL5 7PY, UK. [email protected]

In the tropical rainforest area of Cameroon, people are affected by blackflies(Simulium spp.) and mosquitoes (Anopheles spp). Use of insecticide-treated bednets (ITNs) has been promoted to protect vulnerable groups from mosquito bites,whereas historically indoor residual spraying (IRS) was the primary intervention.In a malaria-endemic area, a pilot study examined different mosquito controlinterventions applied to entire villages to assess their impact on vectors,malaria incidence and the quality of life of the communities. The Sanaga Rivernear these villages was treated with insecticide to kill blackfly larvae. Amedical survey of the six villages had shown that 20% of the population suffered from malaria, while 50% were infected with onchocerciasis and 5% with Loa loa.IRS+ITN using ICON CS (lambda-cyhalothrin capsule suspension formulation) orimproved screening of houses combined with outdoor misting reduced the numbers ofmosquitoes collected from exit traps compared to the other treatments. More

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sporozoites were detected in mosquitoes sampled in exit traps in the untreatedvillage than in the treated villages. Malaria incidence several months aftertreatments was not significantly different from pre-treatment levels. Blackflyadult populations were reduced for several weeks following larvicide application but recovered when treatment was halted.

PMID: 19345969 [PubMed - indexed for MEDLINE]