Narrative review of current context of malaria and management strategies in Uganda (Part I)

Intervention portfolios analysis of Plasmodium vivax control in central China

BACKGROUND

The effects of a diverse spectrum of malaria interventions were evaluated through a deterministic Plasmodium vivax transmission model. This approach aimed to provide theoretical evidence of the performance of these interventions once implemented for achieving malaria elimination.

METHODS

An integrated intervention portfolio, including mass drug administration, insecticide treatment, and untreated bed nets, was analyzed through modeling. Additionally, data-driven calibration was implemented to infer coverages that effectively reproduced historical malaria patterns in China from 1971 to 1983.

RESULTS

MDA utilizing primaquine emerged as the most effective single intervention, achieving a 70% reduction in malaria incidence when implemented at full coverage. Furthermore, a strategic combination of MDA with primaquine, chloroquine, untreated bed nets, and seasonal insecticide treatments effectively eradicated malaria, attaining elimination at a coverage level of 70%. It was conclusively demonstrated that an integrated approach combining MDA and vector control measures is essential for the successful elimination of malaria.

CONCLUSION

High coverage of mass drug administration with primaquine and chloroquine before transmission was the key driver of the malaria decline in China from 1971 to 1983. The best-fit intervention coverage combinations derived from calibration are provided as a reference for malaria control in other countries.

Adding rapid diagnostic tests to community-based programmes for treating malaria

BACKGROUND

The World Health Organization (WHO) recommends parasitological testing of all suspected malaria cases using malaria rapid diagnostic tests (mRDTs) or microscopy prior to treatment. Some governments have extended this responsibility to community health workers (CHWs) to reduce malaria morbidity and mortality through prompt and appropriate treatment. This is an update of a Cochrane Review first published in 2013.

OBJECTIVES

To evaluate community-based management strategies for treating malaria or fever that incorporate both a definitive diagnosis with an mRDT and appropriate antimalarial treatment.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, five other databases, and three trials registers up to 14 September 2021.

SELECTION CRITERIA

We included individually randomized trials and cluster-randomized controlled trials (cRCTs), controlled before-after studies, and controlled interrupted time series studies in people living in malaria-endemic areas, comparing programmes that train CHWs and drug shop vendors to perform mRDTs and provide appropriate treatment versus similar programmes that do not use mRDTs, and versus routine health facility care.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. For each dichotomous outcome, we extracted the number of participants with the event and the total number of participants in each group, unless studies presented results at a population level only. Primary outcomes were all-cause mortality, hospitalizations, and number of people receiving an antimalarial within 24 hours. Secondary outcomes were malaria-specific mortality, severe malaria, outcomes related to antimalarial treatments, antibiotic prescribing to people with a negative microscopy or polymerase chain reaction (PCR) result, parasitaemia, anaemia, and all adverse events.

MAIN RESULTS

We included eight studies from several African countries, Afghanistan, and Myanmar. Staff included CHWs and drug shop vendors.  Community use of malaria rapid diagnostic tests compared to clinical diagnosis Compared to clinical diagnosis, mRDT diagnosis results in reduced prescribing of antimalarials to people who are found to be malaria parasite-negative by microscopy or PCR testing (71 fewer per 100 people, 95% confidence interval (CI) 79 to 51 fewer; risk ratio (RR) 0.17, 95% CI 0.07 to 0.40; 3 cRCTs, 7877 participants; moderate-certainty evidence). This reduction may be greater among CHWs compared to drug shop vendors. People diagnosed by mRDT are more likely to receive appropriate treatment; that is, an antimalarial if they are microscopy- or PCR-positive and no antimalarial if they are microscopy- or PCR-negative (RR 3.04, 95% CI 2.46 to 3.74, 3 cRCTs, 9332 participants; high-certainty evidence). Three studies found that a small percentage of people with a negative mRDT result (as read by the CHW or drug shop vendors at the time of treatment) were nevertheless given an antimalarial: 38/1368 (2.8%), 44/724 (6.1%) and 124/950 (13.1%). Conversely, in two studies, a few mRDT-positive people did not receive an antimalarial (0.5% and 0.3%), and one small cross-over study found that 6/57 (10.5%) people classified as non-malaria in the clinical diagnosis arm received an antimalarial. Use of mRDTs probably increases antibiotic use compared to clinical diagnosis (13 more per 100 people, 95% CI 3 to 29 more; RR 2.02, 95% CI 1.21 to 3.37; 2 cRCTs, 5179 participants; moderate-certainty evidence). We were unable to demonstrate any effect on mortality. Community use of malaria rapid diagnostic tests compared to health facility care Results were insufficient to reach any conclusion.

AUTHORS' CONCLUSIONS

Use of mRDTs by CHWs and drug shop vendors compared to clinical diagnosis reduces prescribing of antimalarials to people without malaria. Deaths were uncommon in both groups. Antibiotic prescribing was higher in those with a negative mRDT than in those with a negative clinical diagnosis.

Challenges with accessing health care for young children presumed to have malaria in the rural district of Butaleja, Uganda: a qualitative study

Objective:

A qualitative study was conducted to gain insight into challenges reported by Butaleja households during a previous household survey. Specifically, this paper discusses heads of households’ and caregivers’ perceptions of challenges they face when seeking care for their very young children with fever presumed to be malaria.

Methods:

Eleven focus groups (FGs) were carried out with household members (five with heads of households and six with household caregivers) residing in five sub-counties located across the district. Purposive sampling was used to ensure the sample represented the religious diversity and geographical distance from the peri-urban center of the district. Each FG consisted of five to six participants. The FGs were conducted at a community centre by two pairs of researchers residing in the district and who were fluent in both English and the local dialect of Lunyole. The discussions were recorded, translated, and transcribed. Transcripts were reviewed and coded with the assistance of QDA Miner (version 4.0) qualitative data management software, and analyzed using thematic content analysis.

Results:

The FG discussions identified four major areas of challenges when managing acute febrile illness in their child under the age of five with presumed malaria (1) difficulties with getting to public health facilities due to long geographical distances and lack of affordable transportation; (2) poor service once at a public health facility, including denial of care, delay in treatment, and negative experiences with the staff; (3) difficulties with managing the child’s illness at home, including challenges with keeping home-stock medicines and administering medicines as prescribed; and (4) constrained to use private outlets despite their shortcomings.

Conclusions:

Future interventions may need to look beyond the public health system to improve case management of childhood malaria at the community level in rural districts such as Butaleja. Given the difficulties with accessing quality private health outlets, there is a need to partner with the private sector to explore feasible models of community-based health insurance programs and expand the role of informal private providers.

Understanding the context of delays in seeking appropriate care for children with symptoms of severe malaria in Uganda

Introduction

A large proportion of children with uncomplicated malaria receive appropriate treatment late, contributing to progression of illness to severe disease. We explored contexts of caregiver delays in seeking appropriate care for children with severe malaria.

Methods

This qualitative study was conducted at the Children’s Ward of Jinja Hospital, where children with severe malaria were hospitalized. A total of 22in-depth interviews were conducted with caregivers of children hospitalized with severe malaria. Issues explored were formulated based on the Partners for Applied Social Sciences (PASS) model, focusing on facilitators and barriersto caregivers’promptseeking and accessing ofappropriate care. The data were coded deductively using ATLAS.ti (version 7.5). Codes were then grouped into families based on emerging themes.

Results

Caregivers’ rating of initial symptoms as mild illness lead to delays in response. Use of home initiated interventions with presumably ineffective herbs or medicines was common, leading to further delay. When care was sought outside the home, drug shops were preferred over public health facilities for reasons of convenience. Drug shops often provided sub-optimal care, and thus contributed to delays in access to appropriate care. Public facilities were often a last resort when illness was perceived to be progressing to severe disease. Further delays occurred at health facilities due to inadequate referral systems.

Conclusion

Communities living in endemic areas need to be sensitized about the significance of fever, even if mild, as an indicator of malaria. Additionally, amidst ongoing efforts at bringing antimalarial treatment services closer to communities, the value of drug shops as providers ofrationalantimalarialtreatment needs to be reviewed.

An Evaluation of Active Case Detection in Malaria Control Program in Kiyuni Parish of Kyankwanzi District, Uganda

Malaria remains one of the leading health burdens in the developing world, especially in several sub-Saharan Africa countries; and Uganda has some of the highest recorded measures of malaria transmission intensity in the world. It is evident that the prevalence of malaria infection, the incidence of disease, and mortality from severe malaria remain very high in Uganda. Although the recent stable political and economic situation in the last few decades in Uganda supported for a fairly good appreciation of malaria control, the declines in infection, morbidity, and mortality are not sufficient to interrupt transmission and this country is among the top 4 countries with cases of malaria, especially among children under 5 years of age. In fact, Uganda, which is endemic in over 95% of the country, is a representative of challenges facing malaria control in Africa. In this study, we evaluated an active case detection program in 6 randomly selected villages, Uganda. This program covered a potential target population of 5,017 individuals. Our team screened 12,257 samples of malaria by active case detection, every 4 months, from February 2015 to January 2017 in the 6 villages (a total of 6 times). This study assessed the perceptions and practices on malaria control in Kiyuni Parish of Kyankwanzi district, Uganda. Our study presents that the incidence of malaria is sustained high despite efforts to scale-up and improve the use of LLINs and access to ACDs, based on the average incidence confirmed by RDTs.

Understanding Unlicensed Drug Vendor Practices Related to Childhood Malaria in One Rural District of Uganda: An Exploratory Study

This study investigated unlicensed drug outlets' practices for the management of malaria in the rural district of Butaleja, Uganda. A qualitative design using semistructured interviews was used. Interviews were recorded, translated, transcribed, and analyzed using thematic analysis. A total of 75 vendors, representing 85% of the outlets in the study area, were interviewed. Most of the vendors were associated with a drug shop type of outfit. About three-quarters reported having completed some level of postsecondary education, but just one-tenth of the vendors had qualifications that made them eligible to apply for a license to operate a drug shop. While most outlets stocked at least one type of antimalarial, only about one-quarter stocked an artemisinin-based combination therapy (ACT), one-quarter expressed a preference for ACTs, and less than one-tenth attested to firmly adhering to the national malaria treatment guidelines on dispensing ACTs as the first-line option. In contrast, nine out of 10 vendors stocked quinine and well over a third stocked antimalarials no longer recommended, such as chloroquine and sulphadoxine-pyrimethamine. Given the ongoing gap between the national malaria policy and unlicensed drug outlet practices, this study calls for greater engagement of unlicensed vendors to improve the management of childhood malaria.

Detection of Plasmodium Species by High-Resolution Melt Analysis of DNA from Blood Smears Acquired in Southwestern Uganda

Microscopic diagnosis of malaria using Giemsa-stained blood smears is the standard of care in resource-limited settings. These smears represent a potential source of DNA for PCR testing to confirm Plasmodium infections or for epidemiological studies of archived samples. Therefore, we assessed the use of DNA extracts from stained blood smears for the detection of Plasmodium species using real-time PCR. We extracted DNA from archived blood smears and corresponding red blood cell pellets collected from asymptomatic children in southwestern Uganda in 2010. We then performed real-time PCR followed by high-resolution melting (HRM) to identify Plasmodium species, and we compared our results to those of microscopy. We analyzed a total of 367 blood smears and corresponding red blood cell pellets, including 185 smears (50.4%) that were positive by microscopy. Compared to microscopy, PCR-HRM analysis of smear DNA had a sensitivity of 93.0% (95% confidence interval [CI], 88.2 to 96.2%) and a specificity of 96.7% (95% CI, 93.0 to 98.8%), and PCR-HRM analysis of pellet DNA had a sensitivity of 100.0% (95% CI, 98.0 to 100.0%) and a specificity of 94.0% (95% CI, 89.4 to 96.9%). Identification of positive PCR-HRM results to the species level revealed Plasmodium falciparum (92.0%), Plasmodium ovale (5.6%), and Plasmodium malariae (2.4%). PCR-HRM analysis of DNA extracts from Giemsa-stained thick blood smears or corresponding blood pellets had high sensitivity and specificity for malaria diagnosis, compared to microscopy. Therefore, blood smears can provide an adequate source of DNA for confirmation of Plasmodium species infections and can be used for retrospective genetic studies.

Private sector role, readiness and performance for malaria case management in Uganda, 2015

Background

Several interventions have been put in place to promote access to quality malaria case management services in Uganda’s private sector, where most people seek treatment. This paper describes evidence using a mixed-method approach to examine the role, readiness and performance of private providers at a national level in Uganda. These data will be useful to inform strategies and policies for improving malaria case management in the private sector.

Methods

The ACTwatch national anti-malarial outlet survey was conducted concurrently with a fever case management study. The ACTwatch nationally representative anti-malarial outlet survey was conducted in Uganda between May 18th 2015 and July 2nd 2015. A representative sample of sub-counties was selected in 14 urban and 13 rural clusters with probability proportional to size and a census approach was used to identify outlets. Outlets eligible for the survey met at least one of three criteria: (1) one or more anti-malarials were in stock on the day of the survey; (2) one or more anti-malarials were in stock in the 3 months preceding the survey; and/or (3) malaria blood testing (microscopy or RDT) was available. The fever case management study included observations of provider-patient interactions and patient exit interviews. Data were collected between May 20th and August 3rd, 2015. The fever case management study was implemented in the private sector. Potential outlets were identified during the main outlet survey and included in this sub-sample if they had both artemisinin-based combination therapy (ACT) [artemether–lumefantrine (AL)], in stock on the day of survey as well as diagnostic testing available.

Results

A total of 9438 outlets were screened for eligibility in the ACTwatch outlet survey and 4328 outlets were found to be stocking anti-malarials and were interviewed. A total of 9330 patients were screened for the fever case management study and 1273 had a complete patient observation and exit interview. Results from the outlet survey illustrate that the majority of anti-malarials were distributed through the private sector (54.3%), with 31.4% of all anti-malarials distributed through drug stores and 14.4% through private for-profit health facilities. Availability of different anti-malarials and diagnostic testing in the private sector was: ACT (80.7%), quality-assured (QA) ACT (72.0%), sulfadoxine–pyrimethamine (SP) (47.1%), quinine (73.2%) and any malaria blood testing (32.9%). Adult QAACT ($1.62) was three times more expensive than SP ($0.48). The results from the fever case management study found 44.4% of respondents received a malaria test, and among those who tested positive for malaria, 60.0% received an ACT, 48.5% received QAACT; 14.4% a non-artemisinin therapy; 14.9% artemether injection, and 42.5% received an antibiotic.

Conclusion

The private sector plays an important role in malaria case management in Uganda. While several private sector initiatives have improved availability of QAACT, there are gaps in malaria diagnosis and distribution of non-artemisinin monotherapies persists. Further private sector strategies, including those focusing on drug stores, are needed to increase coverage of parasitological testing and removal of non-artemisinin therapies from the marketplace.

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-017-1824-x) contains supplementary material, which is available to authorized users.

Anti-malarial landscape in Myanmar: results from a nationally representative survey among community health workers and the private sector outlets in 2015/2016

Background

In 2015/2016, an ACTwatch outlet survey was implemented to assess the anti-malarial and malaria testing landscape in Myanmar across four domains (Eastern, Central, Coastal, Western regions). Indicators provide an important benchmark to guide Myanmar’s new National Strategic Plan to eliminate malaria by 2030.

Methods

This was a cross-sectional survey, which employed stratified cluster-random sampling across four regions in Myanmar. A census of community health workers (CHWs) and private outlets with potential to distribute malaria testing and/or treatment was conducted. An audit was completed for all anti-malarials, malaria rapid diagnostic tests.

Results

A total of 28,664 outlets were approached and 4416 met the screening criteria. The anti-malarial market composition comprised CHWs (41.5%), general retailers (27.9%), itinerant drug vendors (11.8%), pharmacies (10.9%), and private for-profit facilities (7.9%). Availability of different anti-malarials and diagnostic testing among anti-malarial-stocking CHWs was as follows: artemisinin-based combination therapy (ACT) (81.3%), chloroquine (67.0%), confirmatory malaria test (77.7%). Less than half of the anti-malarial-stocking private sector had first-line treatment in stock: ACT (41.7%) chloroquine (41.8%), and malaria diagnostic testing was rare (15.4%). Oral artemisinin monotherapy (AMT) was available in 27.7% of private sector outlets (Western, 54.1%; Central, 31.4%; Eastern; 25.0%, Coastal; 15.4%). The private-sector anti-malarial market share comprised ACT (44.0%), chloroquine (26.6%), and oral AMT (19.6%). Among CHW the market share was ACT (71.6%), chloroquine (22.3%); oral AMT (3.8%). More than half of CHWs could correctly state the national first-line treatment for uncomplicated falciparum and vivax malaria (59.2 and 56.9%, respectively) compared to the private sector (15.8 and 13.2%, respectively). Indicators on support and engagement were as follows for CHWs: reportedly received training on malaria diagnosis (60.7%) or national malaria treatment guidelines (59.6%), received a supervisory or regulatory visit within 12 months (39.1%), kept records on number of patients tested or treated for malaria (77.3%). These indicators were less than 20% across the private sector.

Conclusion

CHWs have a strong foundation for achieving malaria goals and their scale-up is merited, however gaps in malaria commodities and supplies must be addressed. Intensified private sector strategies are urgently needed and must be scaled up to improve access and coverage of first-line treatments and malaria diagnosis, and remove oral AMT from the market place. Future policies and interventions on malaria control and elimination in Myanmar should take these findings into consideration across all phases of implementation.

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-017-1761-8) contains supplementary material, which is available to authorized users.

Optimal control of a malaria model with asymptomatic class and superinfection

In this paper, we introduce a malaria model with an asymptomatic class in human population and exposed classes in both human and vector populations. The model assumes that asymptomatic individuals can get re-infected and move to the symptomatic class. In the case of an incomplete treatment, symptomatic individuals move to the asymptomatic class. If successfully treated, the symptomatic individuals recover and move to the susceptible class. The basic reproduction number, R₀, is computed using the next generation approach. The system has a disease-free equilibrium (DFE) which is locally asymptomatically stable when R₀<1, and may have up to four endemic equilibria. The model exhibits backward bifurcation generated by two mechanisms; standard incidence and superinfection. If the model does not allow for superinfection or deaths due to the disease, then DFE is globally stable which suggests that backward bifurcation is no longer possible. Simulations suggest that total prevalence of malaria is the highest if all individuals show symptoms upon infection, but then undergoes an incomplete treatment and the lowest when all the individuals first move to the symptomatic class then treated successfully. Total prevalence is average if more individuals upon infection move to the asymptomatic class. We study optimal control strategies applied to bed-net use and treatment as main tools for reducing the total number of symptomatic and asymptomatic individuals. Simulations suggest that the optimal control strategies are very dynamic. Although they always lead to decrease in the symptomatic infectious individuals, they may lead to increase in the number of asymptomatic infectious individuals. This last scenario occurs if a large portion of newly infected individuals move to the symptomatic class but many of them do not complete treatment or if they all complete treatment but the superinfection rate of asymptomatic individuals is average.

Low prevalence of laboratory-confirmed malaria in clinically diagnosed adult women from the Wakiso district of Uganda

Background

The malaria burden in sub-Saharan Africa (SSA) has fallen substantially. Nevertheless, malaria remains a serious health concern, and Uganda ranks third in SSA in total malaria burden. Epidemiological studies of adult malaria in Uganda are scarce and little is known about rates of malaria in non-pregnant adult women. This pilot study assessed malaria prevalence among adult women from Wakiso district, historically a highly malaria endemic region.

Methods

Adult women using public health services were screened for malaria, HIV and pregnancy. A physician-selected subset of women presenting to the Outpatient Department of Entebbe General Hospital (EGH) with current fever (axillary temperature ≥37.5 °C) or self-reporting fever during the previous 24 h, and a positive thick smear for malaria in the EGH laboratory were enrolled (n = 86). Women who self-identified as pregnant or HIV-positive were excluded from screening. Malaria infection was then assessed using HRP2/pLDH rapid diagnostic tests (RDTs) in all participants. Repeat microscopy and PCR were performed at a research laboratory for a subset of participants. In addition, 104 women without a history of fever were assessed for asymptomatic parasitaemia using RDT, and a subset of these women screened for parasitaemia using microscopy (40 women) and PCR (40 women).

Results

Of 86 women diagnosed with malaria by EGH, only two (2.3%) had malaria confirmed using RDT, subsequently identified as a Plasmodium falciparum infection by research microscopy and PCR. Subset analysis of hospital diagnosed RDT-negative participants detected one sub-microscopic infection with Plasmodium ovale. Compared to RDT, sensitivity, specificity and PPV of hospital microscopy were 100% (CI 19.8–100), 0% (CI 0–5.32) and 2.33% (CI 0.403–8.94) respectively. Compared to PCR, sensitivity, specificity and PPV of hospital microscopy were 100% (CI 31.0–100), 0% (CI 0–34.5) and 23.1% (CI 6.16–54.0), respectively. No malaria was detected among asymptomatic women using RDT, research microscopy or PCR.

Conclusions

Malaria prevalence among adult women appears to be low in Wakiso, but is masked by high rates of malaria overdiagnosis. More accurate malaria testing is urgently needed in public hospitals in this region to identify true causes of febrile illness and reduce unnecessary provision of anti-malarial therapy.

Assets and challenges facing caregivers when managing malaria in young children in rural Uganda

Background

Despite efforts to improve malaria management for children, a substantial gap remains between policy and practice in Uganda. The aim of this study was to create quantitative profiles of assets and challenges facing caregivers in Butaleja District when managing malaria in children aged 5 years and under. The objectives were: (1) to estimate caregivers’ assets and challenges during an acute episode; and, (2) to ascertain which caregiver attributes influenced receipt of an appropriate anti-malarial the most.

Methods

Data from a 2011 cross-sectional, household survey and ten psychometrically justified scales were used to estimate caregivers’ assets and challenges. The scales scores were simple counts across a series of items, for example, the number of times a caregiver answered a knowledge item correctly or the number of times a caregiver relied on a credible source for information. Since high scores on six of the scales reflected attributes that eased the burden of caregiving, these were labelled ‘caregiver assets’. Similarly, high scores on four of the measures signalled that a caregiver was having trouble managing the malaria episode, thereby reflecting deficits, and these were labelled ‘caregiver challenges’. ANOVAs were used to compare scale scores between caregivers of children who received an appropriate anti-malarial versus those who did not.

Results

On the six asset scales, caregivers averaged highest on knowledge (65 %), followed by correct episode management (48 %), use of trustworthy information sources (40 %), ability to initiate or redirect their child’s treatment (37 %), and lowest on possible encounters with health professionals to assist in treatment decisions (33 %). Similarly, the average caregiver reported problems with 74 % of the issues they might encounter in accessing advice, and 56 % of the problems in obtaining the best anti-malarial. Caregivers whose children received an appropriate anti-malarial demonstrated greater assets and fewer challenges than those whose child did not, with important regional differences existing. Overall, no one region performed particularly well across all ten scales.

Conclusions

Findings from this study suggest that the low use of artemisinin-based combination therapy (ACT) in Butaleja for children 5 years and under may result from caregivers’ high perceived barrier to accessing ACT and low perceived benefits from ACT.

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-016-1521-1) contains supplementary material, which is available to authorized users.

Caregivers' treatment-seeking behaviors and predictors of whether a child received an appropriate antimalarial treatment: a household survey in rural Uganda

Background

This study responds to a rural community’s concern that, despite national initiatives, malaria management in young children falls short of national guidelines in their district. This study aimed to: (1) describe caregivers’ treatment-seeking behaviors in the rural district of Butaleja, (2) estimate the percentage of children who received an appropriate antimalarial, and (3) determine factors that maximized the likelihood of receiving an appropriate antimalarial. Appropriate antimalarial in this study is defined as having received only the Uganda’s age-specific first-line malaria treatment for uncomplicated and severe malaria during the course of the febrile illness.

Methods

A household survey design was used in 2011 to interview 424 caregivers with a child aged five and under who had fever within the two weeks preceding the survey. The survey evaluated factors that included: knowledge about malaria and its treatment, management practices, decision-making, and access to artemisinin combination therapy (ACT) and information sources. Bivariate analysis, followed by logistic regression, was used to determine predictors of the likelihood of receiving an appropriate antimalarial.

Results

Home management was the most common first action, with most children requiring a subsequent action to manage their fever. Overall, 20.9 % of children received a blood test, 68.4 % received an antimalarial, and 41.0 % received an ACT. But closer inspection showed that only 31.6 % received an appropriate antimalarial. These results confirm that ACT usage and receipt of an appropriate antimalarial in Butaleja remain well below the 2010/2015 target of 85 %. While nine survey items differentiated significantly whether a child had or had not received an appropriate antimalarial, our logistic regression model identified four items as independent predictors of likelihood that a child would receive an appropriate antimalarial: obtaining antimalarials from regulated outlets (OR = 14.99); keeping ACT in the home for future use (OR = 6.36); reporting they would select ACT given the choice (OR = 2.31); and child’s age older than four months (OR = 5.67).

Conclusions

Few children in Butaleja received malaria treatment in accordance with national guidelines. This study highlighted the importance of engaging the full spectrum of stakeholders in the management of malaria in young children - including licensed and unlicensed providers, caregivers, and family members.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-1815-5) contains supplementary material, which is available to authorized users.

More than one rabbit out of the hat: Radiation, transgenic and symbiont-based approaches for sustainable management of mosquito and tsetse fly populations

Mosquitoes (Diptera: Culicidae) and tsetse flies (Diptera: Glossinidae) are bloodsucking vectors of human and animal pathogens. Mosquito-borne diseases (malaria, filariasis, dengue, zika, and chikungunya) cause severe mortality and morbidity annually, and tsetse fly-borne diseases (African trypanosomes causing sleeping sickness in humans and nagana in livestock) cost Sub-Saharan Africa an estimated US$ 4750 million annually. Current reliance on insecticides for vector control is unsustainable: due to increasing insecticide resistance and growing concerns about health and environmental impacts of chemical control there is a growing need for novel, effective and safe biologically-based methods that are more sustainable. The integration of the sterile insect technique has proven successful to manage crop pests and disease vectors, particularly tsetse flies, and is likely to prove effective against mosquito vectors, particularly once sex-separation methods are improved. Transgenic and symbiont-based approaches are in development, and more advanced in (particularly Aedes) mosquitoes than in tsetse flies; however, issues around stability, sustainability and biosecurity have to be addressed, especially when considering population replacement approaches. Regulatory issues and those relating to intellectual property and economic cost of application must also be overcome. Standardised methods to assess insect quality are required to compare and predict efficacy of the different approaches. Different combinations of these three approaches could be integrated to maximise their benefits, and all have the potential to be used in tsetse and mosquito area-wide integrated pest management programmes.