Factors affecting delay in seeking treatment among malaria patients along Thailand-Myanmar border in Tak Province, Thailand

Predictors of delayed health seeking for febrile children: multi-level analysis of cross-sectional study data from southern Ethiopia

Background

Febrile illnesses are commonly reported as a primary reason for seeking healthcare in sub-Saharan Africa. Timely diagnosis and getting prompt treatment within 24 h of fever onset is crucial to avert the risk of developing severe complications and death. Understanding factors contributing to delayed health seeking is important for public health interventions. Hence, this study aimed to assess individual- and contextual-level factors associated with the delay in seeking prompt treatment for children with fever.

Method

A community-based cross-sectional study was conducted from September 2022 to June 2023 in Gamo zone, southern Ethiopia. Three districts were chosen, and then, from each district, six clusters or kebeles were chosen by simple random sampling. A total of 820 caregivers were randomly selected. A two-level mixed-effects logistic regression model was employed to identify factors associated with the delay in seeking prompt treatment. The associations were measured by an adjusted odds ratio (AOR), and statistical significance was declared at a 5% level of significance.

Result

The prevalence of the delay in seeking prompt care was 47.8%. Factors contributing to the delay were caregivers who were aged 30 years and above [AOR 0.23, 95% confidence interval (CI): 0.10-0.52], caregivers who followed the Protestant religion (AOR 3.67, 95% CI: 2.08-6.48), caregivers unable to read and write (AOR 5.32, 95% CI: 6.80-11.70), merchant caregivers (AOR 6.63, 95% CI: 2.75-15.97), caregivers who were exposed to only one media source (AOR 9.3, 95% CI: 8.43-15.60), caregivers with the experience of child death (AOR 0.05, 95% CI: 0.01-0.22), and caregivers seeking permission from their partners to access healthcare (AOR 12.64, 95% CI: 6.98-22.89).

Conclusion and recommendations

There was a high level of delay in seeking healthcare. Targeted community education through mass media, healthcare facilities, and community-level awareness campaigns should be strengthened to improve early treatment seeking and lessen the consequences of delayed treatment seeking.

Demographic and socioeconomic obstacles to access to malaria services for Myanmar migrants in Thailand

BACKGROUND

Typically mobile and vulnerable, migrants face significant barriers to access to routine malaria prevention, diagnostics and treatment, which leads to unchecked malaria transmission, particularly in border regions with a high population displacement. This study aimed to investigate the demographic and socioeconomic obstacles to access to malaria services among Myanmar migrants residing in the Thailand-Myanmar border areas.

METHODS

A cross-sectional study was conducted in early 2024 across three districts near the Thailand-Myanmar border. Quantitative data were collected from Myanmar migrants using standardized questionnaires through structured surveys. Data analysis included descriptive statistics and simple and multiple logistic regression models.

RESULTS

Out of 300 participants, approximately a quarter (27.3%) reported adequate access to comprehensive malaria services, including prevention, diagnostics, treatment and malaria-related health information. In multiple logistic regression models, factors associated with inadequate access included Myanmar migrants aged over 60 years (aOR: 7.63, 95% CI 1.74-20.58), accompanied by one to three family members (aOR: 3.33, 95% CI 1.06-8.45), earning monthly incomes below 3000 THB (aOR: 5.13, 95% CI 1.38-19.09) and 3000 to 6000 THB (aOR: 3.64, 95% CI 1.06-12.51), belonging to the Karen ethnicity (aOR: 2.13, 95% CI 1.02-3.84), with poor perception toward malaria (aOR: 2.03, 95% CI 1.03-4.01) and with poor preventive and health-seeking practices (aOR: 5.83, 95% CI 2.71-9.55).

CONCLUSIONS

A significant proportion of Myanmar migrants encounter demographic and socioeconomic barriers to access to routine malaria services in Thailand. Tailored interventions are required to expand such access, including the recruitment of worksite health volunteers, strengthening the role of ethnic health organizations across the border and collaboration with private sector stakeholders (e.g. farm/company owners) to distribute preventive tools and ensure timely referral of suspected malaria cases to health facilities.

Delayed care-seeking in international migrant workers with imported malaria in China

BACKGROUND

Imported malaria cases continue to pose major challenges in China as well as in other countries that have achieved elimination. Early diagnosis and treatment of each imported malaria case is the key to successfully maintaining malaria elimination success. This study aimed to build an easy-to-use predictive nomogram to predict and intervene against delayed care-seeking among international migrant workers with imported malaria.

METHODS

A prediction model was built based on cases with imported malaria from 2012 to 2019, in Jiangsu Province, China. Routine surveillance information (e.g. sex, age, symptoms, origin country and length of stay abroad), data on the place of initial care-seeking and the gross domestic product (GDP) of the destination city were extracted. Multivariate logistic regression was performed to identify independent predictors and a nomogram was established to predict the risk of delayed care-seeking. The discrimination and calibration of the nomogram was performed using area under the curve and calibration plots. In addition, four machine learning models were used to make a comparison.

RESULTS

Of 2255 patients with imported malaria, 636 (28.2%) sought care within 24 h after symptom onset, and 577 (25.6%) sought care 3 days after symptom onset. Development of symptoms before entry into China, initial care-seeking from superior healthcare facilities and a higher GDP level of the destination city were significantly associated with delayed care-seeking among migrant workers with imported malaria. Based on these independent risk factors, an easy-to-use and intuitive nomogram was established. The calibration curves of the nomogram showed good consistency.

CONCLUSIONS

The tool provides public health practitioners with a method for the early detection of delayed care-seeking risk among international migrant workers with imported malaria, which may be of significance in improving post-travel healthcare for labour migrants, reducing the risk of severe malaria, preventing malaria reintroduction and sustaining achievements in malaria elimination.

Factors affecting delays in seeking treatment among malaria patients during the pre-certification phase in China

BACKGROUND

Delays in malaria treatment can not only lead to severe and even life-threatening complications, but also foster transmission, putting more people at risk of infection. This study aimed to investigate the factors influencing treatment delays among malaria patients and their health-seeking behaviour.

METHODS

The medical records of 494 patients diagnosed with malaria from 6 different malaria-endemic provinces in China were analysed. A bivariate and multivariable regression model was used to investigate the association between delays in seeking treatment and various factors. A Sankey diagram was used to visualize the trajectories of malaria patients seeking medical care. Total treatment delays were categorized as patient delays and doctor delays.

RESULTS

The incidence of total delays in seeking malaria treatment was 81.6%, of which 28.4% were delayed by patients alone and 34.8% by doctors alone. The median time from the onset of symptoms to the initial healthcare consultation was 1 day. The median time from the initial healthcare consultation to the conclusive diagnosis was 2 day. After being subjected to multiple logistic regression analysis, living in central China was less likely to experience patient delays (OR = 0.43, 95% CI 0.24-0.78). The factors significantly associated with the lower likelihood of doctor delays included: age between 30 to 49 (OR = 0.43, 95% CI 0.23-0.81), being single/divorce/separated (OR = 0.48, 95% CI 0.24-0.95), first visiting a county-level health institution (OR = 0.25, 95% CI 0.14-0.45), first visiting a prefectural health institution (OR = 0.06, 95% CI 0.03-0.12) and first visiting a provincial health institution (OR = 0.05, 95%CI 0.02-0.12). Conversely, individuals with mixed infections (OR = 2.04, 95% CI 1.02-4.08) and those experiencing periodic symptoms (OR = 1.71, 95% CI 1.00-2.92) might face increased doctor delays. Furthermore, higher financial burden and complications were found to be associated with patient delays. Doctor delays, in addition to incurring these two consequences, were associated with longer hospital stays.

CONCLUSION

There was a substantial delay in access to health care for malaria patients before China was certified malaria free. Region, marital status, periodic symptoms and the level of health institutions were factors contributing to delays in treatment-seeking among malaria patients.

Choice of health providers and health-seeking behaviour among forest goer population in Myanmar: findings from a cross-sectional household survey

BACKGROUND

In Myanmar, malaria still poses a significant burden for vulnerable populations particularly forest goers even though impressive progress has been made over the past decade. Limited evidence existed related to forest goers' health-seeking behaviour and factors that drive decision making for providers' choice to support national malaria programmes towards elimination. In response to that, this research is conducted to identify who they preferred and what are the factors associated with providers' choice in malaria febrile illness and Rapid Diagnostic Testing (RDT).

METHODS

A cross-sectional study applying quantitative household survey was completed with 479 forest goer households in 20 malaria endemic townships across Myanmar. The household data was collected with the types of providers that they consulted for recent and previous febrile episodes. To identify the factors associated with providers' choices, univariate and multivariate multinomial logistic regressions were done using Stata version 14.1. Statistical significance was set as p = 0.05.

RESULTS

A total of 307 individuals experienced fever within one month and 72.3% sought care from providers. Also, a total of 509 forest goers reported that they had a previous febrile episode and 62.6% received care from a provider. Furthermore, 56.2% said that they had RDT testing during these previous febrile illnesses. They consulted public facilities and public health staff, private facilities, private and semi-private providers, community health volunteers or workers in their residing village and those located outside their villages but majority preferred those within their villages. On multivariate analyses, second richest quintile (public, RRR = 12.9) (semi-private, RRR = 17.9), (outside, RRR = 8.4) and access to 4 and above nearby providers (public, RRR = 30.3) (semi-private, RRR = 1.5) (outside, RRR = 0.5) were found to be significantly associated with provider choice for recent fever episode. Similar findings were also found for previous febrile illness and RDT testing among forest goers.

CONCLUSIONS

It was highlighted in this study that in forest goer households, they preferred nearby providers and the decision to choose providers seemed to be influenced by their access to number of nearby providers and socio-economic status when they sought care from a provider regardless of fever occurrence location. It was important that the national programmes considere involving these nearby providers in elimination efforts.

Seroepidemiological surveillance, community perceptions and associated risk factors of malaria exposure among forest-goers in Northeastern Thailand

Malaria remains a major public health challenge in Thailand. Continuous assessment and understanding of the behavior and perceptions related to malaria exposure in the high-risk group are necessary to achieve the elimination goal. This study aimed to investigate the parasite prevalence, seroprevalence rate, knowledge, attitudes, and practices (KAP), and malaria risk factors in rural communities living close to a forested area in the northeastern part of Thailand. A community-based cross-sectional survey was conducted in three forest-goer communities (i.e., Ban Khok, Ban Koh, and Dong Yang) located in Khamcha-i district, Mukdahan Province, Thailand, from July to August 2019. Demographic, socioeconomic information and KAP data were collected using a structured questionnaire. Parasite prevalence was determined by microscopy. Seroprevalence was determined via ELISA using two Plasmodium falciparum (PfAMA-1 and PfMSP-1₁₉) and two Plasmodium vivax (PvAMA-1 and PvMSP-1₁₉) antigens. Age-adjusted antibody responses were analyzed using a reversible catalytic model to calculate seroconversion rate (SCR). Malaria parasite was not detected in any of the 345 participants. The overall malaria seroprevalence was 72.2% for PfAMA-1, 18.8% for PfMSP-1₁₉, 32.5% for PvAMA-1, and 4.4% for PvMSP-1₁₉. The proportion of seroprevalence for P. falciparum and P. vivax antigens was significantly highest in Ban Koh (35.1%, P < 0.001) and Don Yang (18.8%, P < 0.001), respectively. For all parasite antigens except PvMSP-1₁₉, the proportion of seropositive individuals significantly increased with age (P < 0.001). Based on the SCRs, there was a higher level of P. falciparum transmission than P. vivax. Regarding KAP, almost all respondents showed adequate knowledge and awareness about malaria. Nevertheless, significant effort is needed to improve positive attitudes and practices concerning malaria prevention measures. Multivariate regression analyses showed that living in Ban Koh was associated with both P. falciparum (adjusted odds ratio [aOR] 12.87, P < 0.001) and P. vivax (aOR 9.78, P < 0.001) seropositivities. We also found significant associations between age and seropositivity against P. falciparum and P. vivax antigens. The data suggest that seroepidemiological surveillance using AMA-1 and MSP-1₁₉ antigens may provide further evidence to reconstruct malaria exposure history. The absence of weak evidence of recent malaria transmission in Mukdahan Province is promising in the context of the disease elimination program.

Care-seeking delay of imported malaria to China: implications for improving post-travel healthcare for migrant workers

BACKGROUND

Imported malaria cases continue to pose major challenges in China as well as in other countries having achieved elimination. Our study aims to identify the factors influencing the timing of care-seeking after symptom onset among migrant workers with imported malaria, in order to develop innovative interventions to improve access and provision of post-travel healthcare for returning migrants.

METHODS

We analysed the timing and types of healthcare service utilization after symptom onset among patients with imported malaria between 2012 and 2019 in Jiangsu Province, China. Moreover, decision tree models were used to explore the factors influencing the care-seeking timing after symptom onset among patients with imported malaria.

RESULTS

A total of 2255 cases of imported malaria were identified from 1 June 2012 through 31 December 2019. Patients with malaria imported into China were mainly male migrant labourers returning from sub-Saharan Africa (96.8%). A substantial number of patients with imported malaria sought healthcare >3 days after symptom onset, which clearly represented delayed healthcare-seeking behaviour. According to the decision tree analysis, initial healthcare seeking from healthcare facilities at higher administrative levels, infection with Plasmodium vivax and absence of malaria infection history were significantly associated with delayed healthcare seeking in patients with imported malaria.

CONCLUSION

The delay in seeking of medical care among migrant workers with imported malaria should be considered and addressed by specific interventions. In addition to increasing awareness about these issues among health care professionals, improved access to healthcare facilities at higher administrative levels as well as improved diagnostic capacity of healthcare facilities at lower administrative levels should be developed. Moreover, education programs targeting populations at risk of malaria importation and delayed healthcare seeking should be improved to facilitate early healthcare seeking and service use.

A comparison of malaria prevention behaviours, care-seeking practices and barriers between malaria at-risk worksite migrant workers and villagers in Northern Shan State, Myanmar-a mixed method study

Background

Migrant populations are at an increased risk of exposure to malaria due to their nature of work and seasonal migration. This study aimed to compare malaria prevention behaviours and care-seeking practices among worksite migrant workers and villagers in the malaria-at-risk areas of Eastern Myanmar close to the China border.

Methods

A mixed method study was conducted in March 2019. The malaria-at-risk worksites in the four targeted townships, and villages located the nearest to these worksites were approached. Key stakeholders, such as worksite managers and village leaders, were interviewed.

Results

A total of 23 worksites, which employed 880 migrants and 447 locals, and 20 villages, which were homes for 621 migrants and 9731 locals, were successfully interviewed. Regarding malaria prevention behaviours, sleeping under a bed net was common among both worksites (74%) and villages (85%). In contrast, insecticide-treated nets/long-lasting insecticidal nets (ITN/LLIN) usage was much lower in the worksites than in the villages (39% vs 80%). Regarding care-seeking practices for febrile illness, self-medication was a popular choice for both worksite workers and villagers owing to the easy availability of western medicine. Moreover, local-belief-driven traditional practices were more common among villagers. For occasions in which fever was not relieved, both would seek health care from rural health centres, private clinics, or public hospitals. As for barriers, villagers mostly cited language barriers, which often lead to misunderstanding between health providers and them. In contrast, most of the worksites cited logistics issues as they were in remote areas with devastated road conditions and the routes to formal health facilities were not secure due to frequent armed conflicts.

Conclusion

This study demonstrated that site-workers and villagers had different malaria prevention behaviours and care-seeking practices even though they resided in the same geographic area. Hence, it is important to recognize such differences for more effective intervention approaches.

Forest malaria and prospects for anti-malarial chemoprophylaxis among forest goers: findings from a qualitative study in Thailand

BACKGROUND

Across the Greater Mekong Subregion, malaria remains a dangerous infectious disease, particularly for people who visit forested areas where residual transmission continues. Because vector control measures offer incomplete protection to forest goers, chemoprophylaxis has been suggested as a potential supplementary measure for malaria prevention and control. To implement prophylaxis effectively, additional information is needed to understand forest goers' activities and their willingness to use malaria prevention measures, including prophylaxis, and how it could be delivered in communities. Drawing on in-depth interviews with forest goers and stakeholders, this article examines the potential acceptability and implementation challenges of malaria prophylaxis for forest goers in northeast Thailand.

METHODS

In-depth interviews were conducted with forest goers (n = 11) and stakeholders (n = 16) including healthcare workers, community leaders, and policymakers. Interviews were audio-recorded, transcribed and coded using NVivo, employing an inductive and deductive approach, for thematic analysis.

RESULTS

Forest goers were well aware of their (elevated) malaria risk and reported seeking care for malaria from local health care providers. Forest goers and community members have a close relationship with the forest but are not a homogenous group: their place and time-at-risk varied according to their activities and length of stay in the forest. Among stakeholders, the choice and cost of anti-malarial prophylactic regimen-its efficacy, length and complexity, number of tablets, potential side effects, and long-term impact on users-were key considerations for its feasibility. They also expressed concern about adherence to the preventive therapy and potential difficulty treating malaria patients with the same regimen. Prophylaxis was considered a low priority in areas with perceived accessible health system and approaching malaria elimination.

CONCLUSIONS

In the context of multi-drug resistance, there are several considerations for implementing malaria prophylaxis: the need to target forest goers who are at-risk with a clear period of exposure, to ensure continued use of vector control measures and adherence to prophylactic anti-malarials, and to adopt an evidence-based approach to determine an appropriate regimen. Beyond addressing current intervention challenges and managing malaria incidence in low-transmission setting, it is crucial to keep malaria services available and accessible at the village level especially in areas home to highly mobile populations.

Malaria treatment-seeking behaviour and its associated factors: A cross-sectional study in rural East Nusa Tenggara Province, Indonesia

INTRODUCTION

The World Health Organization recommends seeking medical treatment within 24 hours after transmission of malaria to reduce the risk of severe complications and its onwards spread. However, in some parts of Indonesia, including East Nusa Tenggara Province (ENTP), this adherence is not achieved for a range of reasons including delays in visiting health centres. This study aims to determine factors related to the poor understanding of appropriate malaria treatment-seeking behaviour (AMTSB) of rural adults in ENTP. AMTSB was defined as seeking treatment at professional health facilities within 24 hours of the onset of malaria symptoms.

METHODS

A cross-sectional study was conducted in the East Sumba, Belu, and East Manggarai district of ENTP between October and December 2019. A multi-stage cluster sampling procedure was applied to enrol 1503 participants aged between 18 and 89 years of age. Data were collected through face-to-face interviews. Multivariable logistic regression analyses were used to assess significant factors associated with the poor understanding of AMTSB.

RESULTS

Eighty-six percent of participants were found to be familiar with the term malaria. However, poor understanding level of AMTSB in rural adults of ENTP achieved 60.4% with a 95% confidence interval (CI): 56.9-63.8. Poor understanding of AMTSB was significantly higher for adults with no education (adjusted odds ratio (AOR) 3.42, 95% CI: 1.81, 6.48) compared to those with a diploma or above education level; having low SES (AOR: 1.87, 95% CI: 1.19, 2.96) compared to those having high SES; residing at least three kilometres (km) away from the nearest health facilities (AOR: 1.73, 95% CI: 1.2, 2.5) compared to those living within one km from the nearest health service; and working as farmer (AOR: 1.63, 95% CI: 1.01-2.63) compared to those working at government or non-government sector. Whilst, other factors such as ethnicity and family size were not associated with the poor understanding of AMTSB.

CONCLUSION

The proportion of rural adults having a poor understanding of AMTSB was high leading to ineffective implementation of artemisinin-based combination therapies as the method to treat malaria in ENTP. Improving awareness of AMTSB for rural adults having low level education, low SES, working as a farmer, and living at least three km from the nearest health facilities is critical to support the efficacy of malaria treatment in ENTP. This method will support the Indonesian government's objective to achieve malaria elimination by 2030.

Risk factors for the accuracy of the initial diagnosis of malaria cases in China: a decision-tree modelling approach

Background

Early accurate diagnosis and risk assessment for malaria are crucial for improving patients’ terminal prognosis and preventing them from progressing to a severe or critical stage. This study aims to describe the accuracy of the initial diagnosis of malaria cases with different characteristics and the factors that affect the accuracy in the context of the agenda for a world free of malaria.

Methods

A retrospective study was conducted on 494 patients admitted to hospitals with a diagnosis of malaria from January 2014 through December 2016. Descriptive statistics were calculated, and decision tree analysis was performed to predict the probability of patients who may be misdiagnosed.

Results

Of the 494 patients included in this study, the proportions of patients seeking care in county-level, prefecture-level and provincial-level hospitals were 27.5% (n = 136), 26.3% (n = 130) and 8.3% (n = 41), respectively; the proportions of patients seeking care in clinic, township health centre and Centres for Disease Control and Prevention were 25.9% (n = 128), 4.1% (n = 20), and 7.9% (n = 39), respectively. Nearly 60% of malaria patients were misdiagnosed on their first visit, and 18.8% had complications. The median time from onset to the first visit was 2 days (IQR: 0-3 days), and the median time from the first visit to diagnosis was 3 days (IQR: 0–4 days). The decision tree classification of malaria patients being misdiagnosed consisted of six categorical variables: healthcare facilities for the initial diagnosis, time interval between onset and initial diagnosis, region, residence type, insurance status, and age.

Conclusions

Insufficient diagnostic capacity of healthcare facilities with lower administrative levels for the first visit was the most important risk factor in misdiagnosing patients. To reduce diagnostic errors, clinicians, government decision-makers and communities should consider strengthening the primary care facilities, the time interval between onset and initial diagnosis, residence type, and health insurance status.

Forest malaria and prospects for anti-malarial chemoprophylaxis among forest goers: findings from a qualitative study in Lao PDR

Background

Despite significant decline in malarial incidence and mortality in countries across the Greater Mekong Subregion, the disease remains a public health challenge in the region; transmission continues mainly among people who visit forests in remote areas, often along international borders, where access to primary healthcare is limited. In the absence of effective vector-control measures and limited exposure periods, malaria chemoprophylaxis has been proposed as a strategy to protect forest goers. As a rarely used approach for indigenous populations, questions remain about its feasibility and acceptability. Drawing on in-depth interviews with forest goers and stakeholders, this article examines opportunities and challenges for implementation of anti-malarial chemoprophylaxis for forest goers in Lao PDR.

Methods

In-depth interviews were conducted with 16 forest goers and 15 stakeholders in Savannakhet province, Lao PDR. Interview topics included experience of malaria prevention and health services, and perceptions of prophylaxis as a potential component of malaria elimination strategy. The interviews were transcribed and coded using inductive and deductive approaches for qualitative thematic analysis.

Results

In ethnically and geographically diverse villages, awareness of malaria risk prompts forest goers to protect themselves, albeit sub-optimally using available preventive measures. Stakeholders highlighted challenges for targeting at-risk populations and approaches to address forest malaria in southern Lao PDR. Among policymakers, choice and cost of anti-malarials, particularly their efficacy and source of funding, were key considerations for the feasibility of malaria prophylaxis. Acceptability of prophylaxis among forest goers was also influenced by the complexity of the regimen, including the number of tablets and timing of doses. Implementation of prophylaxis may be affected by a lack of transportation and communication barriers in remote communities.

Conclusion

Adding prophylaxis to existing malaria control activities requires strengthening the capacity of local health workers in Lao PDR. Ideally, this would be part of an integrated approach that includes strategies to address the other febrile illnesses that forest goers describe as priority health concerns. The prophylactic regimen also requires careful consideration in terms of effectiveness and simplicity of dosing.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-021-04027-z.

Barriers to seeking health care among returning travellers with malaria: A systematic review

OBJECTIVE

To identify barriers to seeking health care among returning travellers with malaria with the aim of developing targeted interventions that improve early health care-seeking behaviour, diagnosis and treatment.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a systematic review of published medical literature, selecting studies that investigated and reported barriers to seeking health care among returning travellers and migrants with malaria. In total, 633 articles were screened, of which four studies met the inclusion criteria after a full-text review.

RESULTS

The four studies reported barriers to seeking healthcare among returning travellers in China, the United States, Thailand and the Dominican Republic. Three studies had an observational design. The identified barriers were summarised based on the appraisal delay, illness delay and utilisation delay stages. During appraisal delays, low awareness of malaria was the most significant factor. Once the patient assessed that he or she was ill, belonging to a specific minority ethnicity, being infected with P. vivax and receiving a low level of social support were predictors of delayed health care-seeking. Finally, the most significant factor associated with utilisation delays was the monetary cost.

CONCLUSION

The health care-seeking behaviour of returning travellers with malaria should be further investigated and improved. Addressing the identified barriers and gaps in health care-seeking behaviour among returning travellers with malaria, particularly among groups at high risk of travel-associated infections, is important to prevent severe disease and deaths as well as secondary transmission and epidemics.

Social Support between Diabetes Patients and Non-Diabetes Persons in Yangon, Myanmar: A Study Applying ENRICHD Social Support Instrument

Diabetes patients, due to the chorionic nature of the disease, need complex and long-term care for control and prevention of complications. The patients themselves find it difficult to adopt appropriate disease management after diagnosis and they need social support from family, friends, and their environment, especially in lower- and middle-income countries where medical service is limited, and they need self-care of disease and lifestyle modification. In Myanmar, however, the study for social support among diabetes patients is still limited. Therefore, we conducted a case-control study to investigate the social support among diabetes patients and the association between socioeconomic factors in Yangon, which has the highest prevalence of diabetes in Myanmar. Social support between diabetes patients who came to diabetes special clinics and non-diabetes community control was assessed by applying transculturally translated ENRICHD Social Support Instrument (ESSI). Among the diabetes patients’ group, more than 70% had high perceived social support, specifically higher level of informational and emotional social support. Robust multiple regression models revealed significant positive associations between total social support and independent variables: p value < 0.001 for monthly household income and being married, and p value < 0.05 for household number and frequency of having meals together with family. These findings suggest that perceived social support among patients with diabetes may be mainly affected by the patients’ family conditions, such as household income and living with a spouse, in Myanmar culture.

A comparative study on knowledge and practice against malaria among Accredited Social Health Activists (ASHAs) of low and high endemic regions of Tripura, Northeast India

Introduction:

This study was conducted to compare and evaluate the knowledge as well as the practice of community health volunteers, Accredited social health activists (ASHAs) in low and high malaria-endemic regions of Tripura, Northeast India.

Materials and Methods:

In this descriptive cross-sectional study, all ASHAs working in the randomly selected two blocks of each low and high malaria-endemic areas were included in the study. While ASHAs with less than 1-year experience were excluded from the study. The ASHAs were interviewed and information was gathered on knowledge and practice against malaria management. Chi-square test was used to identify differences in responses among the ASHAs.

Results:

Significant differences in knowledge of mixed malarial infection (P < 0.001) and early symptoms of malaria (P = 0.005) were observed when responses of high malaria-endemic ASHAs (HMEA) were compared to low endemic ASHAs (LMEA). With respect to malaria testing skills, 83.16% HMEA affirmed that they could perform Rapid diagnostic (RD) kit tests as opposed to 57.24% LMEA, (P < 0.001). Disturbingly only two HMEA could correctly describe the duration for Pf and Pv treatment.

Conclusion:

The study identifies major lacunae in the balance of knowledge and practices of ASHAs in both study areas of Tripura. Therefore,for a successful projected malaria elimination program, community-level ASHA volunteers need to have accurate malaria knowledge and management approaches irrespective of the endemicity. This study will help to understand the operational constraints and plan educational training for ASHA volunteers in malaria-endemic regions.

Determination of cut-off and correlates of delay in treatment-seeking of febrile illness: a retrospective analysis

Background

Early diagnosis and treatment of malaria symptoms reduces the risk of severe complication and malaria transmission. However, delay in malaria diagnosis and treatment is a major public health problem in India. The primary aim of the study was to determine cut-off for the delay in seeking treatment of fever, and the secondary aim was to identify the factors associated with delay in malaria-endemic areas of Assam, Northeast India.

Methods

The present study analysed data from two prior cross-sectional surveys (community- and hospital-based) that was conducted to study the health-seeking behaviour of people residing in high malaria-endemic areas of Assam, Northeast India. The hospital-based survey data were used to determine optimal cut-off for the delay in reporting, and further, used to identify the factors associated with delay using community-based data.

Results

Mean age of fever cases was similar in both community- and hospital-based surveys (23.1 years vs 24.2 years, p = 0.229). Delay in reporting fever was significantly higher among hospital inpatients compared to community-based fever cases (3.6 ± 2.1 vs 4.0 ± 2.6 days; p = 0.006). Delay of > 2 days showed higher predictive ability (sensitivity: 96.4%, and ROC area: 67.5%) compared to other cut-off values (> 3, > 4, and > 5 days). Multivariable logistic regression analysis revealed that the adjusted odds ratio (aOR) of delay was significantly higher for people living in rural areas (1.52, 95%CI: 1.11–2.09), distance (> 5 km) to health facility (1.93, 95%CI: 1.44–2.61), engaged in agriculture work (2.58, 95%CI: 1.97–3.37), and interaction effect of adult male aged 20–40 years (1.71, 95%CI: 1.06–2.75).

Conclusion

The delay (> 2 days) in seeking treatment was likely to be twice among those who live in rural areas and travel > 5 km to assess health care facility. The findings of the study are useful in designing effective intervention programmes for early treatment of febrile illness to control malaria.

Malaria hot spot along the foothills of Rakhine state, Myanmar: geospatial distribution of malaria cases in townships targeted for malaria elimination

Background

Myanmar has targeted elimination of malaria by 2030. In three targeted townships of Rakhine state of Myanmar, a project is being piloted to eliminate malaria by 2025. The comprehensive case investigation (CCI) and geotagging of cases by health workers is a core activity under the project. However, the CCI data is not analyzed for obtaining information on geospatial distribution of cases and timeliness of diagnosis. In this regard, we aimed to depict geospatial distribution and assess the proportion with delayed diagnosis among diagnosed malaria cases residing in three targeted townships during April 2018 to March 2019.

Methods

This was a cross sectional analysis of CCI data routinely collected by national malaria control programme. The geocode (latitude and longitude) of the address was analysed using Quantum Geographic Information System software to deduce spot maps and hotspots of cases. The EpiData analysis software was used to summarize the proportion with delay in diagnosis (diagnosed ≥24 hours after the fever onset).

Results

Of the 171 malaria cases diagnosed during study period, the CCI was conducted in 157 (92%) cases. Of them, 127 (81%) cases reported delay in diagnosis, 138 (88%) cases were indigenous who got infection within the township and 13 (8%) were imported from outside the township. Malaria hotspots were found along the foothills with increase in cases during the rainy season. The indigenous cases were concentrated over the foothills in the northern and southern borders of Toungup township.

Conclusion

In the targeted townships for malaria elimination, the high proportion of the cases was indigenous and clustered at the foothill areas during rainy season. The programme should strengthen case surveillance and healthcare services in the areas with aggregation of cases to eliminate the malaria in the township. As high majority of patients have delayed diagnosis, the reasons for delay has to be explored and corrective measures needs to be taken.

Plasma mEV levels in Ghanain malaria patients with low parasitaemia are higher than those of healthy controls, raising the potential for parasite markers in mEVs as diagnostic targets

This study sought to measure medium-sized extracellular vesicles (mEVs) in plasma, when patients have low Plasmodium falciparum early in infection. We aimed to define the relationship between plasma mEVs and: (i) parasitaemia, (ii) period from onset of malaria symptoms until seeking medical care (patient delay, PD), (iii) age and (iv) gender. In this cross-sectional study, n = 434 patients were analysed and Nanosight Tracking Analysis (NTA) used to quantify mEVs (vesicles of 150–500 nm diameter, isolated at 15,000 × g, β-tubulin-positive and staining for annexin V, but weak or negative for CD81). Overall plasma mEV levels (1.69 × 10¹⁰ mEVs mL⁻¹) were 2.3-fold higher than for uninfected controls (0.51 × 10¹⁰ mEVs mL⁻¹). Divided into four age groups, we found a bimodal distribution with 2.5- and 2.1-fold higher mEVs in infected children (<11 years old [yo]) (median:2.11 × 10¹⁰ mEVs mL⁻¹) and the elderly (>45 yo) (median:1.92 × 10¹⁰ mEVs mL⁻¹), respectively, compared to uninfected controls; parasite density varied similarly with age groups. There was a positive association between mEVs and parasite density (r = 0.587, p < 0.0001) and mEVs were strongly associated with PD (r = 0.919, p < 0.0001), but gender had no effect on plasma mEV levels (p = 0.667). Parasite density was also exponentially related to patient delay. Gender (p = 0.667) had no effect on plasma mEV levels. During periods of low parasitaemia (PD = 72h), mEVs were 0.93-fold greater than in uninfected controls. As 75% (49/65) of patients had low parasitaemia levels (20–500 parasites µL⁻¹), close to the detection limits of microscopy of Giemsa-stained thick blood films (5–150 parasites µL⁻¹), mEV quantification by NTA could potentially have early diagnostic value, and raises the potential of Pf markers in mEVs as early diagnostic targets.

Health education through mass media announcements by loudspeakers about malaria care: prevention and practice among people living in a malaria endemic area of northern Myanmar

Background

Interventions to raise community awareness about malaria prevention and treatment have used various approaches with little evidence on their efficacy. This study aimed to determine the effectiveness of loudspeaker announcements regarding malaria care and prevention practices among people living in the malaria endemic villages of Banmauk Township, Sagaing Region, Myanmar.

Methods

Four villages among the most malaria-burdened areas were randomly selected: two villages were assigned as the intervention group, and two as the control. Prior to the peak transmission season of malaria in June 2018, a baseline questionnaire was administered to 270 participants from randomly selected households in the control and intervention villages. The loudspeaker announcements broadcasted health messages on malaria care and prevention practices regularly at 7:00 pm every other day. The same questionnaire was administered at 6-month post intervention to both groups. Descriptive statistics, Chi-square, and the t-test were utilized to assess differences between and within groups.

Results

Participants across the control and intervention groups showed similar socio-economic characteristics; the baseline knowledge, attitude and practice mean scores were not significantly different between the groups. Six months after the intervention, improvements in scores were observed at p-value < 0.001 in both groups, however; the increase was greater among the intervention group. The declining trend of malaria was also noticed during the study period. In addition, more than 75% of people expressed positive opinions of the intervention.

Conclusions

The loudspeaker intervention was found to be feasible and effective, as shown by the significant improvement in scores related to prevention and care-seeking practices for malaria as well as reduced malaria morbidity. Expanding the intervention to a larger population in this endemic region and evaluating its long-term effectiveness are essential in addition to replicating this in other low-resource malaria endemic regions.

Determinants of malaria treatment delay in northwestern zone of Tigray region, Northern Ethiopia, 2018

BACKGROUND

Globally malaria affects 212 million people and causes 438,000 deaths each year. Ensuring early and timely treatment of malaria is important for preventing and controlling of life-threatening complications and further transmission. Even though malaria treatment is widely available in Ethiopia, 47-84% of patients present after 24 h of onset of first symptoms. This study assessed the determinants of delay for malaria treatment in Tigray, Ethiopia.

METHODS

A health facility-based case-control study design in northwestern zone of Tigray was conducted from September 2018 to January 2019. All the study participants enrolled were confirmed malaria patients (by microscopy or rapid diagnostic test) and who sought treatment. Cases were defined as malaria patients who sought treatment after 24 h of the onset of the first symptom and control were those who sought treatment within 24 h onset of symptom. A structured questionnaire was used to collect data on the determinants of malaria treatment delay. Data were entered into EpiInfo 7.0 and exported to SPSS 20.0 for analysis. Binary logistic regression was computed to identify predictors of delay for malaria treatment.

RESULTS

In total 161 cases and 161 controls were identified. Being residents of Tahtay Adyabo district (AOR = 2.84, 95% CI 1.29-6.27), having no formal education (AOR = 2.39, 95% CI 1.09-5.22), the decisions to seek health care being taken by the patient (AOR = 2.38 95% CI 1.09-5.2), the decisions to seek health care being taken by their fathers (AOR = 2.52, 95% CI 1.13-5.62), and having good knowledge about malaria symptoms (AOR = 2.02, 95% CI 1.21-3.39) were found determinants of delay for malaria treatment.

CONCLUSION

In this study, delays in obtaining treatment for malaria were associated with having no formal education, knowing about the signs and symptoms of malaria, living in Tahtay Adyabo district, and decision-making on seeking malaria treatment. The results suggests having treatment commenced at sites closer to the community and strengthened awareness-raising activity about the importance of early seeking for all with malaria-like symptoms, especially for household heads would contribute to improved treatment and reduced complications from malaria.

Assessment of community knowledge, practice, and determinants of malaria case households in the rural area of Raya Azebo district, Northern Ethiopia, 2017

Background

In Ethiopia malaria is one of the leading causes of outpatient visits and admission. Still, it remains a major cause of morbidity and mortality in the study area. Therefore, this study was aimed to assess the knowledge, practice, and determinant of malaria case households in rural areas of Raya Azebo district, Northern Ethiopia.

Method

A community-based cross-sectional survey was conducted in the selected villages of Raya Azebo district from January to June 2017. A multi-stage random sampling method was employed to select a total of 422 study households. Data was collected using a semi-structured questionnaire. The household head was interviewed face to face. Logistic regression analysis was used to determine the determinant of malaria cases households.

Result

A total of 412 (97.6) of the respondents had ever heard about malaria. About 63% of households recognized the causes of malaria to be a mosquito bite. Around 173 (41%) of the study households had been treated for malaria within a year of data collection. This study also revealed that the presence of mosquito breeding sites near to home, bed bug infestation, outdoor sleep due to bed bugs and household with poor bed net practicing were significantly associated with malaria case households.

Conclusion

Although the overall knowledge on malaria transmission, symptoms, and the preventive measure was relatively good, the rate of household insecticide-treated net coverage and utilization were reported low in the area. Therefore, the distribution of adequate bed net with community-based education is a key intervention to promote household insecticide-treated net utilization. In addition, an effective bed bug management strategy is necessary to overcome the outdoor sleeping habit of the community in the area.

Predictors of Health-Seeking Behavior for Fever Cases among Caregivers of Under-Five Children in Malaria-Endemic Area of Imo State, Nigeria

Fever is one of the most common symptoms of pediatric illnesses; it is an important early symptom of malaria. Fever had served as the entry point for presumptive treatment of malaria among children in Nigerian. Appropriate HSB is important when seeking treatment for fever among under-five children; this will help for better prognosis because treatment will be initiated early. This study attempted to identify caregiver’s HSB for under-five children with fever. A cross-sectional study was conducted in Imo-State, Nigeria. Appropriate HSB was operationally defined as seeking treatment from health facility within 24 h of fever. Data were obtained using pretested self-administered questionnaire. Data were analyzed using SPSS version 22. Simple and multiple logistic regression were used to determine predictors of appropriate HSB. A total of 559 eligible respondents were recruited; 103 (18.6%) caregivers had appropriate HSB. The predictors of HSB are being male child (aOR = 2.760; 95% CI:1.536–4.958), the age of child younger than 27 months (aOR = 2.804; 95% CI:1.485–5.295), employed caregivers (aOR = 1.882; 95% CI:1.014–3.493), number of household members (aOR = 2.504; 95% CI:1.464–4.283), and caregivers who decided to seek treatment at early stage (aOR = 7.060; 95% CI:1.616–30.852). Only 18.6% caregivers practiced appropriate HSB for fever cases among under-five children. It is essential to educate caregivers and emphasise on early treatment of fever and appropriate use of health facilities for fever. The findings will be used to improve intervention at the community level and will be compared with follow-up data to evaluate their effectiveness.

'Health Promoting School' Model in Prevention of Vector-Borne Diseases in Odisha: A Pilot Intervention

We tested 'Health-Promoting School model' for vector-borne diseases (VBDs) through behavioural changes among students in India for better control of the diseases in the community. A total of 1098 students from eight co-ed schools (four controls and four interventions) of Odisha participated in the study. Intervention was 12 h of class room teaching and activities on mosquito dynamics, source identification, prevention and management of VBDs. Control schools were provided with the leaflets and posters covering the objectives. Impact was assessed through change in knowledge and practice through pre- and post-test. Total mean transformed score in pre-intervention survey in both the groups was nearly 33, which increased to 38.6 and 53.9 in control and intervention group, respectively. In intervention group the mean days of absenteeism due to VBDs was reduced nearly by four times. The model can be used as effective health-promoting measures for vector control.

Spatiotemporal epidemiology, environmental correlates, and demography of malaria in Tak Province, Thailand (2012-2015)

Background

Tak Province, at the Thai–Myanmar border, is one of three high malaria incidence areas in Thailand. This study aimed to describe and identify possible factors driving the spatiotemporal trends of disease incidence from 2012 to 2015.

Methods

Climate variables and forest cover were correlated with malaria incidence using Pearson’s r. Statistically significant clusters of high (hot spots) and low (cold spots) annual parasite incidence per 1000 population (API) were identified using Getis-Ord Gi* statistic.

Results

The total number of confirmed cases declined by 76% from 2012 to 2015 (Plasmodium falciparum by 81%, Plasmodium vivax by 73%). Incidence was highly seasonal with two main annual peaks. Most cases were male (62.75%), ≥ 15 years (56.07%), and of Myanmar (56.64%) or Thai (39.25%) nationality. Median temperature (1- and 2-month lags), average temperature (1- and 2-month lags) and average relative humidity (2- and 3-month lags) correlated positively with monthly total, P. falciparum and P. vivax API. Total rainfall in the same month correlated with API for total cases and P. vivax but not P. falciparum. At sub-district level, percentage forest cover had a low positive correlation with P. falciparum, P. vivax, and total API in most years. There was a decrease in API in most sub-districts for both P. falciparum and P. vivax. Sub-districts with the highest API were in the Tha Song Yang and Umphang Districts along the Thai–Myanmar border. Annual hot spots were mostly in the extreme north and south of the province.

Conclusions

There has been a large decline in reported clinical malaria from 2012 to 2015 in Tak Province. API was correlated with monthly climate and annual forest cover but these did not account for the trends over time. Ongoing elimination interventions on one or both sides of the border are more likely to have been the cause but it was not possible to assess this due to a lack of suitable data. Two main hot spot areas were identified that could be targeted for intensified elimination activities.

Electronic supplementary material

The online version of this article (10.1186/s12936-019-2871-2) contains supplementary material, which is available to authorized users.

Transmission risk beyond the village: entomological and human factors contributing to residual malaria transmission in an area approaching malaria elimination on the Thailand-Myanmar border

Background

A mixed methods study was conducted to look at the magnitude of residual malaria transmission (RMT) and factors contributing to low (< 1% prevalence), but sustained transmission in rural communities on the Thai–Myanmar border.

Methods

A cross-sectional behaviour and net survey, observational surveys and entomological collections in both villages and forested farm huts frequented by community members for subsistence farming practices were conducted.

Results

Community members frequently stayed overnight at subsistence farm huts or in the forest. Entomological collections showed higher biting rates of primary vectors in forested farm hut sites and in a more forested village setting compared to a village with clustered housing and better infrastructure. Despite high levels of outdoor biting, biting exposure occurred predominantly indoors, particularly for non-users of long-lasting insecticidal nets (LLINs). Risk of biting exposure was exacerbated by sub-optimal coverage of LLINs, particularly in subsistence farm huts and in the forest. Furthermore, early waking hours when people had left the safety of their nets coincided with peaks in biting in later morning hours.

Conclusions

Entomological and epidemiological findings suggest drivers and modulators of sustained infection prevalence in the area to be: higher mosquito abundance in forested areas where LLINs were used less frequently or could not be used; late sleeping and waking times coinciding with peak biting hours; feeding preferences of Anopheles taking them away from contact with LLIN and indoor residual spraying (IRS), e.g. exophagy and zoophagy; non-use of LLIN and use of damaged/torn LLIN; high population movement across the border and into forested areas thereby increasing risk of exposure, decreasing use of protection and limiting access to healthcare; and, Plasmodium vivax predominance resulting in relapse(s) of previous infection. The findings highlight gaps in current intervention coverage beyond the village setting.

Electronic supplementary material

The online version of this article (10.1186/s12936-019-2852-5) contains supplementary material, which is available to authorized users.

Multilevel Analysis of Factors Associated with Treatment-Seeking Behaviors among Caregivers with Febrile Children in Malawi

Early diagnosis and treatment of childhood fever, an important sign of potentially serious infections such as malaria, is essential for controlling disease progression, and ultimately, preventing deaths. This study examined individual- and community-level factors associated with treatment-seeking behaviors and promptness in these behaviors among caregivers of febrile under-five children in Malawi. The 2015-2016 Malawi Demographic Health Survey was used to analyze a nationally representative sample of 4,133 under-five children who had fever within 2 weeks before the survey. A multilevel logistic regression model was used to examine the association between individual- and community-level factors and treatment-seeking behaviors. Approximately 67.3% of the caregivers reported seeking treatment for their febrile child, whereas only 46.3% reported promptly seeking treatment. Children from communities with moderate and high percentages of educated caregivers were more likely to be taken for treatment (adjusted odds ratio [aOR] = 1.26, 95% CI = 1.01-1.58 and aOR = 1.31, 95% CI = 1.02-1.70, respectively) than those from communities with a low percentage of educated caregivers. Children from communities with moderate and high percentages of caregivers complaining about the distance to a health facility were less likely to be taken for treatment (aOR = 0.74, 95% CI = 0.58-0.96 and aOR = 0.67, 95% CI = 0.51-0.88, respectively). At the individual level, having a cough in the last 2 weeks, region, religion, and having better health behaviors in other health dimensions were associated with fever treatment-seeking behaviors among Malawian caregivers. Programs aimed at improving treatment-seeking behaviors should consider these factors and the regional variations observed in this study.

Estimating malaria disease burden in the Asia-Pacific

Background: The Asia-Pacific aims to eliminate malaria by 2030. Many of the 22 endemic countries have earlier targets. To track progress towards elimination and predict timelines and funding required it is essential to have an accurate picture of the true burden of malaria over time. Estimating this is a major challenge with most countries having incomplete data on numbers of cases and wide variation between health system access and performance. Regular estimates are published by the World Health Organization (WHO), but these are not split by species, can have a wide range of uncertainty, change over time and are not available for every year. Methods: For the Asia Pacific Leaders Malaria Alliance, the burden of malaria for the 22 malaria-endemic countries in the Asia-Pacific from 2000 to 2015 was estimated by combining data submitted by countries to WHO with a systematic review to estimate the proportion of cases recorded. Due to a lack of suitable data, it was only possible to apply this method to 2013-2015. A simplified method was then derived to estimate the annual burden of falciparum and vivax malaria as inputs to a mathematical model to predict the cost of elimination, which is described elsewhere. Results: The total number of estimated cases was around double the number of confirmed cases reported in the Asia Pacific with a broad range of uncertainty around these estimates due primarily to sparsity of data with which to estimate proportions of cases reported. The ranges of estimated burdens were mostly like those published for countries by WHO, with some exceptions. Conclusions: The accuracy and precision of malaria burden estimates could be greatly improved by having more regular large surveys on access to healthcare in malaria-endemic areas and making subnational data on malaria incidence and reporting completeness publicly available.

Malaria prevalence, knowledge, perception, preventive and treatment behavior among military in Champasak and Attapeu provinces, Lao PDR: a mixed methods study

Background

Malaria is a major health problem in Lao People's Democratic Republic (Lao PDR) with high transmission in remote and forest areas, particularly in the South. The military is at risk of malaria infection especially those deployed in forest areas. This study determined the prevalence of malaria infection and assessed knowledge, perception, and preventive and treatment behavior regarding malaria among military personnel in two southern provinces in Lao PDR.

Methods

Quantitative and qualitative approaches were undertaken in Champasak and Attapeu provinces in 2017. From 313 military personnel, quantitative data were collected through questionnaire-based interviews and blood samples used for parasite detection by polymerase chain reaction (PCR). Qualitative data were collected through 7 focus group discussions and 17 in-depth interviews among 49 military personnel. Fisher's exact test and Mann-Whitney U test were used to assess the association between malaria infection and participant characteristics. Content analysis for qualitative data was performed to explore perception and treatment behaviors regarding malaria.

Results

The prevalence of malaria infection was 11.2% (Plasmodium falciparum: 1.3%, Plasmodium vivax: 9.3% and mixed infections: 0.6%). Many participants understood that malaria is transmitted through mosquito bites, although they did not necessarily know the name of vector mosquitoes (Anopheles). Surprisingly, more than a half also believed that malaria is transmitted through drinking stream water. One-third of the participants used long-lasting insecticidal nets. Due to limited supply, participants were often unable to use mosquito repellent and coils when necessary. Because participants were unable to receive timely diagnosis and appropriate treatment for malaria in their camps, they commonly practiced self-treatment using antibiotics, painkillers, and/or traditional medicines. They only go to a healthcare facility through their supervisor if their conditions worsen.

Conclusions

The prevalence of symptomatic and asymptomatic malaria was conspicuous among military in forest areas. Many participants believed that malaria is transmitted not only by mosquito bites but also from drinking stream water. Preventive equipment was often insufficient. Self-treatment was practiced before referring to healthcare facility. To further prevent military from contracting malaria, the National Malaria Control Program and military body should provide adequate and suitable health education, protective equipment, and on-site malaria case management.

A comparative study of epidemiological investigations of malaria outbreaks and related deaths in two districts of Jharkhand during the same prewinter season using shoe-leather epidemiology

Background:

Following news of deaths in two districts of Jharkhand (West Singhbum and Garhwa) in November 2016, epidemiological investigations were contemplated to investigate any current outbreak of falciparum malaria and deaths attributed to it.

Methodology:

The epidemiological investigations, verbal autopsy of suspected deaths attributed to malaria and keys interviews were conducted in the 2^nd and 4^th week of November 2016 in Khuntpani and Dhurki block of West Singhbum and Garhwa districts, respectively, following a strict protocol.

Results:

The affected villages were Argundi and Korba-Pahariya and their adjacent tolas in Khuntpani and Dhurki block. Undoubtedly, there was the continuous transmission of falciparum malaria in both the regions in October and November 2016. The total cases (according to case definitions) were 1002, of them, 338 and 12 patients were positive for Plasmodium falciparum positive (Pf +ve) and Plasmodium vivax positive (Pv +ve), respectively, in the affected areas of Khuntpani block. In Dhurki block, out of the total of 631 patients fulfilling the case definition, 65 patients were PF +ve and 23 Pv +ve. Comparing to the last year, there is remarkably high number of falciparum cases. Verbal autopsy of deceased individuals showed that malaria might be one of the strongly probable diagnoses, but not conclusively.

Conclusion:

According to epidemiological investigation, verbal autopsy and key interviews conducted, it may be concluded that there is a definite outbreak of falciparum malaria in the area and environment is congenial for malaria and other tropical diseases.

Plasmodium Infections in Anopheles Mosquitoes in Ubon Ratchathani Province, Northeastern Thailand During a Malaria Outbreak

An unprecedented malaria outbreak occurred in Ubon Ratchathani Province, northeastern Thailand, in 2014. The province showed the highest number of malaria cases of all Thai provinces. Five entomological surveys were conducted at 8 sentinel sites from September 2013 to September 2015 to address the role of different Anopheles species in malaria transmission. Mosquito collections were conducted using human landing catches and cow bait. A total of 10,369 Anopheles mosquitoes were collected and 2,240 were morphologically identified as potential malaria vectors, including An. dirus (n = 78), An. minimus (n = 18), An. sawadwongporni (n = 4), An. barbirostris s.l. (n = 819), An. philippinensis (n = 612), An. nivipes (n = 676), An. annularis (n = 42), An. aconitus (n = 7), and An. rampae (n = 142). Real-time polymerase chain reaction was used to screen for the presence of Plasmodium spp. in salivary glands. The proportion of primary vectors of surveyed villages was very low (<1%), and no Plasmodium-infected specimens were detected among in the 2,240 Anopheles mosquitoes tested. The absence of positive Plasmodium samples during malaria outbreaks suggests that malaria transmission most likely occurred outside the villages, particularly in the deep-forested hilly areas that provided suitable habitats for competent malaria vectors. These results emphasize the need to develop vector control related to village community activities to reduce malaria transmission along Thailand border areas.

W. Gunasekera WMKT, Premaratne R, Ringwald P, Fernando D. Response of imported malaria patients to antimalarial medicines in Sri Lanka following malaria elimination

After eliminating local malaria transmission and being certified as a malaria-free country, Sri Lanka is facing the challenge of imported malaria. At the same time, the country has the unique opportunity to be a case study for other countries in a similar situation by approaching this issue systematically, guided by evidence. This study demonstrates the importance of developing a mechanism to detect imported malaria and adopting an evidence-based approach to study the resistance of imported malaria to anti-malarial medicines. This is a prospective study of patients diagnosed with imported malaria in Sri Lanka and treated according to the national treatment guidelines, over 24 months (2015/2016). The clinical features, time to diagnosis, origin of the infection, infecting species, parasite density and the treatment given were recorded. All patients were followed up for 28 days, and in the case of Plasmodium vivax and P. ovale infections, the follow up period was extended to 12 months to establish treatment failures and relapses. Fifty nine uncomplicated and 15 severe imported malaria cases were reported in Sri Lanka during the study period. Most of these infections originated in either Sub-Saharan Africa or South and Southeast Asia. Having a P. vivax infection and low parasitic counts were significantly associated with relative diagnostic delay. One of the 14 uncomplicated P. falciparum patients and two of the 12 severe P. falciparum malaria patients who were followed up till day 28 had a late clinical failure. The others responded adequately to treatment both clinically and parasitologically. There was no treatment failure reported amongst any other species. This study, which is the first to assess the therapeutic response of imported malaria in Sri Lanka after elimination, demonstrates that the current antimalarial treatment policies and strategies in Sri Lanka have been effective against infections acquired overseas up until the end of year 2016.

Comparison of the diagnostic performance of microscopic examination with nested polymerase chain reaction for optimum malaria diagnosis in Upper Myanmar

BACKGROUND

Accurate diagnosis of Plasmodium infection is crucial for prompt malaria treatment and surveillance. Microscopic examination has been widely applied as the gold standard for malaria diagnosis in most part of malaria endemic areas, but its diagnostic value has been questioned, particularly in submicroscopic malaria. In this study, the diagnostic performance of microscopic examination and nested polymerase chain reaction (PCR) was evaluated to establish optimal malaria diagnosis method in Myanmar.

METHODS

A total of 1125 blood samples collected from residents in the villages and towns located in Naung Cho, Pyin Oo Lwin, Tha Beik Kyin townships and Mandalay of Upper Myanmar were screened by microscopic examination and species-specific nested PCR method.

RESULTS

Among the 1125 blood samples, 261 samples were confirmed to be infected with malaria by microscopic examination. Evaluation of the 1125 samples by species-specific nested PCR analysis revealed that the agreement between microscopic examination and nested PCR was 87.3% (261/299). Nested PCR successfully detected 38 Plasmodium falciparum or Plasmodium vivax infections, which were missed in microscopic examination. Microscopic examinations also either misdiagnosed the infected Plasmodium species, or did not detect mixed infections with different Plasmodium species in 31 cases.

CONCLUSIONS

The nested PCR method is more reliable than conventional microscopic examination for the diagnosis of malaria infections, and this is particularly true in cases of mixed infections and submicroscopic infections. Given the observed higher sensitivity and specificity of nested PCR, the molecular method holds enormous promise in malaria diagnosis and species differentiation, and can be applied as an effective monitoring tool for malaria surveillance, control and elimination in Myanmar.

Microgeographically diverse Plasmodium vivax populations at the Thai-Myanmar border

Malaria transmission along international borders of the Greater Mekong Subregion is a big challenge for regional malaria elimination. At the Thai-Myanmar border, Plasmodium falciparum cases have dropped dramatically; however, increasing P. vivax prevalence and the emerging reports on hidden malaria burden due to asymptomatic infections demand attention. We conducted cross-sectional surveys to detect asymptomatic malaria infections in a small village located at Thai-Myanmar border and genotyped P. vivax infections in order to understand the level of genetic diversity on such a microgeographic scale. PCR/RFLP and DNA sequencing identified high levels of genetic polymorphisms at both Pvmsp3α and Pvmsp3β loci among P. vivax infections. Combining the PCR/RFLP patterns of Pvmsp3α and Pvmsp3β, a total of 10 genotypes were observed among 17 samples, while concatenated DNA sequences of Pvmsp3α and 3β generated 14 haplotypes with haplotype diversity of 0.97. These markedly diverse parasites on a microgeographic scale suggest the circulation of a considerably large parasite population at the international border.

Malaria control along China-Myanmar Border during 2007-2013: an integrated impact evaluation

BACKGROUND

Implementing effective interventions remain a lot of difficulties along all border regions. The emergence of artemisinin resistance of Plasmodium falciparum strains in the Greater Mekong Subregion is a matter of great concern. China has effectively controlled cross-border transmission of malaria and artemisinin resistance of P. falciparum along the China-Myanmar border.

METHODS

A combined quantitative and qualitative study was used to collect data, and then an integrated impact evaluation was conducted to malaria control along the China-Myanmar border during 2007-2013.

RESULTS

The parasite prevalence rate (PPR) in the five special regions of Myanmar was decreased from 13.6 % in March 2008 to 1.5 % in November 2013. Compared with the baseline (PPR in March 2008), the risk ratio was only 0.11 [95 % confidence interval (CI), 0.09-0. 14) in November 2013, which is equal to an 89 % reduction in the malaria burden. Annual parasite incidence (API) across 19 Chinese border counties was reduced from 19.6 per 10 000 person-years in 2006 to 0.9 per 10 000 person-years in 2013. Compared with the baseline (API in 2006), the API rate ratio was only 0.05(95 % CI, 0.04-0.05) in 2013, which equates to a reduction of the malaria burden by 95.0 %. Meanwhile, the health service system was strengthened and health inequity of marginalized populations reduced along the international border.

CONCLUSION

The effective collaboration between China, Myanmar and the international non-governmental organization promptly carried out the core interventions through simplified processes. The integrated approaches dramatically decreased malaria burden of Chinese-Myanmar border.

The role of early detection and treatment in malaria elimination

Falciparum malaria persists in hard-to-reach areas or demographic groups that are missed by conventional healthcare systems but could be reached by trained community members in a malaria post (MP). The main focus of a MP is to provide uninterrupted and rapid access to rapid diagnostic tests (RDTs) and artemisinin-based combination therapy (ACT) too all inhabitants of a village. RDTs allow trained community members to perform malaria diagnosis accurately and prescribe appropriate treatment, reducing as much as possible any delay between the onset of fever and treatment. Early treatment with ACT and with a low-dose of primaquine prevents further transmission from human to mosquito. A functioning MP represents an essential component of any malaria elimination strategy. Implementing large-scale, high-coverage, community-based early diagnosis and treatment through MPs requires few technological innovations but relies on a very well structured organization able to train, supervise and supply MPs, to monitor activity and to perform strict malaria surveillance.

Determinants of delay in malaria care-seeking behaviour for children 15 years and under in Bata district, Equatorial Guinea

Background

Malaria remains a major cause of morbidity and mortality in children under 5 years of age in Equatorial Guinea. Early appropriate treatment can reduce progression of the illness to severe stages, thus reducing of mortality, morbidity and onward transmission. The factors that contribute to malaria treatment delay have not been studied previously in Equatorial Guinea. The objective of this study was to assess the determinants of delay in seeking malaria treatment for children in the Bata district, in mainland Equatorial Guinea.

Methodology

A cross-sectional study was conducted in Bata district, in 2013, which involved 428 houses in 18 rural villages and 26 urban neighbourhoods. Household caregivers were identified in each house and asked about their knowledge of malaria and about the management of the last reported malaria episode in a child 15 years and younger under their care. Bivariate and multivariate statistical analyses were conducted to determine the relevance of socio-economic, geographical and behavioural factors on delays in care-seeking behaviour.

Results

Nearly half of the children sought treatment at least 24 h after the onset of the symptoms. The median delay in seeking care was 2.8 days. Children from households with the highest socio-economic status were less likely to be delayed in seeking care than those from households with the lowest socio-economic status (OR 0.37, 95 % CI 0.19–0.72). Children that first received treatment at home, mainly paracetamol, were more than twice more likely to be delayed for seeking care, than children who did not first receive treatment at home (OR 2.36, 95 % CI 1.45–3.83). Children living in a distance >3 km from the nearest health facility were almost two times more likely to be delayed in seeking care than those living closer to a facility but with non significant association once adjusted for other variables (OR 1.75, 95 % CI 0.88–3.47).

Conclusion

To decrease malaria morbidity and mortality in Bata district, efforts should be addressed to reduce household delays in seeking care. It is necessary to provide free access to effective malaria diagnosis and treatment, to reinforce malaria management at community level through community health workers and drug sellers and to increase awareness on the severity of malaria, the importance of early diagnosis and appropriate treatment.

Durations and Delays in Care Seeking, Diagnosis and Treatment Initiation in Uncomplicated Pulmonary Tuberculosis Patients in Mumbai, India

Background

Timely diagnosis and treatment initiation are critical to reduce the chain of transmission of Tuberculosis (TB) in places like Mumbai, where almost 60% of the inhabitants reside in overcrowded slums. This study documents the pathway from the onset of symptoms suggestive of TB to initiation of TB treatment and examines factors responsible for delay among uncomplicated pulmonary TB patients in Mumbai.

Methods

A population-based retrospective survey was conducted in the slums of 15 high TB burden administrative wards to identify 153 self-reported TB patients. Subsequently in-depth interviews of 76 consenting patients that fit the inclusion criteria were undertaken using an open-ended interview schedule. Mean total, first care seeking, diagnosis and treatment initiation duration and delays were computed for new and retreatment patients. Patients showing defined delays were divided into outliers and non-outliers for all three delays using the median values.

Results

The mean duration for the total pathway was 65 days with 29% of patients being outliers. Importantly the mean duration of first care seeking was similar in new (24 days) and retreatment patients (25 days). Diagnostic duration contributed to 55% of the total pathway largely in new patients. Treatment initiation was noted to be the least among the three durations with mean duration in retreatment patients twice that of new patients. Significantly more female patients experienced diagnostic delay. Major shift of patients from the private to public sector and non-allopaths to allopaths was observed, particularly for treatment initiation.

Conclusion

Achieving positive behavioural changes in providers (especially non-allopaths) and patients needs to be considered in TB control strategies. Specific attention is required in counselling of TB patients so that timely care seeking is effected at the time of relapse. Prioritizing improvement of environmental health in vulnerable locations and provision of point of care diagnostics would be singularly effective in curbing pathway delays.