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Verani JR, eno EN, Hunsperger EA, Munyua P, Osoro E, Marwanga D, Bigogo G, Amon D, Ochieng M, Etau P, Bandika V, Zimbulu V, Kiogora J, Burton JW, Okunga E, Samuels AM, Njenga K, Montgomery JM, Widdowson MA. Acute febrile illness in Kenya: Clinical characteristics and pathogens detected among patients hospitalized with fever, 2017-2019. PLoS One 2024; 19:e0305700. [PMID: 39088453 PMCID: PMC11293630 DOI: 10.1371/journal.pone.0305700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 06/04/2024] [Indexed: 08/03/2024] Open
Abstract
Acute febrile illness (AFI) is a common reason for healthcare seeking and hospitalization in Sub-Saharan Africa and is often presumed to be malaria. However, a broad range of pathogens cause fever, and more comprehensive data on AFI etiology can improve clinical management, prevent unnecessary prescriptions, and guide public health interventions. We conducted surveillance for AFI (temperature ≥38.0°C <14 days duration) among hospitalized patients of all ages at four sites in Kenya (Nairobi, Mombasa, Kakamega, and Kakuma). For cases of undifferentiated fever (UF), defined as AFI without diarrhea (≥3 loose stools in 24 hours) or lower respiratory tract symptoms (cough/difficulty breathing plus oxygen saturation <90% or [in children <5 years] chest indrawing), we tested venous blood with real-time PCR-based TaqMan array cards (TAC) for 17 viral, 8 bacterial, and 3 protozoal fever-causing pathogens. From June 2017 to March 2019, we enrolled 3,232 AFI cases; 2,529 (78.2%) were aged <5 years. Among 3,021 with outcome data, 131 (4.3%) cases died while in hospital, including 106/2,369 (4.5%) among those <5 years. Among 1,735 (53.7%) UF cases, blood was collected from 1,340 (77.2%) of which 1,314 (98.1%) were tested by TAC; 715 (54.4%) had no pathogens detected, including 147/196 (75.0%) of those aged <12 months. The most common pathogen detected was Plasmodium, as a single pathogen in 471 (35.8%) cases and in combination with other pathogens in 38 (2.9%). HIV was detected in 51 (3.8%) UF cases tested by TAC and was most common in adults (25/236 [10.6%] ages 18-49, 4/40 [10.0%] ages ≥50 years). Chikungunya virus was found in 30 (2.3%) UF cases, detected only in the Mombasa site. Malaria prevention and control efforts are critical for reducing the burden of AFI, and improved diagnostic testing is needed to provide better insight into non-malarial causes of fever. The high case fatality of AFI underscores the need to optimize diagnosis and appropriate management of AFI to the local epidemiology.
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Affiliation(s)
- Jennifer R. Verani
- Division of Global Health Protection, U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States of America
- Division of Global Health Protection, U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Eric Ng’ eno
- Washington State University Global Health, Nairobi, Kenya
| | - Elizabeth A. Hunsperger
- Division of Global Health Protection, U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States of America
- Division of Global Health Protection, U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Peninah Munyua
- Division of Global Health Protection, U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Eric Osoro
- Washington State University Global Health, Nairobi, Kenya
| | - Doris Marwanga
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Godfrey Bigogo
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Derrick Amon
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Melvin Ochieng
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Paul Etau
- Kenyatta National Hospital, Nairobi, Kenya
| | | | | | | | | | - Emmanuel Okunga
- Disease Surveillance and Response Unit, Ministry of Health, Nairobi, Kenya
| | - Aaron M. Samuels
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Kisumu, Kenya and Atlanta, Georgia, United States of America
| | - Kariuki Njenga
- Washington State University Global Health, Nairobi, Kenya
| | - Joel M. Montgomery
- Division of Global Health Protection, U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Marc-Alain Widdowson
- Division of Global Health Protection, U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States of America
- Division of Global Health Protection, U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
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2
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Koliopoulos P, Kayange N, Jensen C, Gröndahl B, Eichmann J, Daniel T, Huth F, Eckert T, Klamm N, Follmann M, Medina-Montaño GC, Hokororo A, Pretsch L, Klüber J, Schmidt C, Züchner A, Addo MM, Okamo B, Mshana SE, Gehring S. Challenges in Diagnosing and Treating Acutely Febrile Children with Suspected Malaria at Health Care Facilities in the Lake Mwanza Region of Tanzania. Am J Trop Med Hyg 2024; 110:202-208. [PMID: 38150741 PMCID: PMC10859794 DOI: 10.4269/ajtmh.23-0254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 09/20/2023] [Indexed: 12/29/2023] Open
Abstract
Acute febrile diseases transmitted by mosquitos are a diagnostic challenge for pediatricians working in sub-Saharan Africa. Misclassification due to the lack of rapid, reliable diagnostic tests leads to the overuse of antibiotics and antimalarials. Children presenting with acute fever and suspected of having malaria were examined at health care facilities in the Mwanza Region of Tanzania. The sensitivity and specificity of blood smear microscopy and malaria rapid diagnostic tests that targeted histidine-rich protein 2 and Plasmodium lactate dehydrogenase were compared with a multiplex reverse transcriptase-polymerase chain reaction (PCR)-ELISA. Six hundred ninety-eight children presented with acute fever and met the criteria for inclusion; 23% received antibiotics and 23% received antimalarials prior to admission. Subsequently, 20% were confirmed by PCR to have Plasmodium falciparum infection. Blood smear microscopy exhibited 33% sensitivity and 93% specificity. The malaria rapid test provided 87% sensitivity and 98% specificity in detecting acute malaria infections. Only 7% of malaria-negative children received antimalarials at Sengerema Designated District Hospital when treatment was guided by the results of rapid testing. In contrast, 75% of malaria-negative patients were treated with antimalarial drugs at health facilities that used blood smears as the standard diagnostic test. Misclassification and premedication of nonmalarial, febrile illnesses contribute to the emergence of antimalarial and antimicrobial resistance. The incorporation of malaria rapid diagnostic tests into the clinical routine translated into improved treatment and a significant reduction in antimalarial drug prescriptions.
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Affiliation(s)
- Philip Koliopoulos
- Center of Pediatric and Adolescent Medicine, University Medical Center, Mainz, Germany
| | - Neema Kayange
- Department of Pediatric and Adolescent Medicine, Bugando Medical Centre, Mwanza, Tanzania
| | - Christian Jensen
- Center of Pediatric and Adolescent Medicine, University Medical Center, Mainz, Germany
| | - Britta Gröndahl
- Center of Pediatric and Adolescent Medicine, University Medical Center, Mainz, Germany
| | - Jana Eichmann
- Department of Pediatric and Adolescent Medicine, St. Joseph Hospital, Berlin, Germany
| | - Tim Daniel
- Center of Pediatric and Adolescent Medicine, University Medical Center, Mainz, Germany
| | - Florian Huth
- Department of Visceral and Thoracic Surgery, Klinikum Worms, Worms, Germany
| | - Till Eckert
- Department of Internal Medicine, GeoMed Kreisklinik, Gerolzhofen, Germany
| | - Nele Klamm
- Center of Gynecology and Obstetrics, Augusta-Kranken-Anstalt, Bochum, Germany
| | - Marlene Follmann
- Department of Internal Medicine, Gesundheits- und Pflegezentrum, Rüsselsheim, Germany
| | | | - Adolfine Hokororo
- Department of Pediatric and Adolescent Medicine, Bugando Medical Centre, Mwanza, Tanzania
| | - Leah Pretsch
- Center of Pediatric and Adolescent Medicine, University Medical Center, Mainz, Germany
| | - Julia Klüber
- Department of Infection and Immunity, Luxembourg Institute of Health, Esch-sur-Alzette, Luxembourg
| | - Christian Schmidt
- Department of Pediatric and Adolescent Medicine, St. Vinzenz-Hospital, Dinslaken, Germany
| | - Antke Züchner
- CCBRT Maternity and Newborn Hospital, Dar es Salaam, Tanzania
| | - Marylyn M. Addo
- Institute for Infection Research and Vaccine Development, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Bernard Okamo
- Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | | | - Stephan Gehring
- Center of Pediatric and Adolescent Medicine, University Medical Center, Mainz, Germany
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3
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Evans MV, Ihantamalala FA, Randriamihaja M, Aina AT, Bonds MH, Finnegan KE, Rakotonanahary RJL, Raza-Fanomezanjanahary M, Razafinjato B, Raobela O, Raholiarimanana SH, Randrianavalona TH, Garchitorena A. Applying a zero-corrected, gravity model estimator reduces bias due to heterogeneity in healthcare utilization in community-scale, passive surveillance datasets of endemic diseases. Sci Rep 2023; 13:21288. [PMID: 38042891 PMCID: PMC10693580 DOI: 10.1038/s41598-023-48390-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 11/26/2023] [Indexed: 12/04/2023] Open
Abstract
Data on population health are vital to evidence-based decision making but are rarely adequately localized or updated in continuous time. They also suffer from low ascertainment rates, particularly in rural areas where barriers to healthcare can cause infrequent touch points with the health system. Here, we demonstrate a novel statistical method to estimate the incidence of endemic diseases at the community level from passive surveillance data collected at primary health centers. The zero-corrected, gravity-model (ZERO-G) estimator explicitly models sampling intensity as a function of health facility characteristics and statistically accounts for extremely low rates of ascertainment. The result is a standardized, real-time estimate of disease incidence at a spatial resolution nearly ten times finer than typically reported by facility-based passive surveillance systems. We assessed the robustness of this method by applying it to a case study of field-collected malaria incidence rates from a rural health district in southeastern Madagascar. The ZERO-G estimator decreased geographic and financial bias in the dataset by over 90% and doubled the agreement rate between spatial patterns in malaria incidence and incidence estimates derived from prevalence surveys. The ZERO-G estimator is a promising method for adjusting passive surveillance data of common, endemic diseases, increasing the availability of continuously updated, high quality surveillance datasets at the community scale.
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Affiliation(s)
- Michelle V Evans
- MIVEGEC, Univ. Montpellier, CNRS, IRD, Montpellier, France.
- NGO Pivot, Ranomafana, Ifanadiana, Madagascar.
- Department of Global Health and Social Medicine, Blavatnik Institute at Harvard Medical School, Boston, MA, USA.
| | - Felana A Ihantamalala
- NGO Pivot, Ranomafana, Ifanadiana, Madagascar
- Department of Global Health and Social Medicine, Blavatnik Institute at Harvard Medical School, Boston, MA, USA
| | - Mauricianot Randriamihaja
- MIVEGEC, Univ. Montpellier, CNRS, IRD, Montpellier, France
- NGO Pivot, Ranomafana, Ifanadiana, Madagascar
| | | | - Matthew H Bonds
- NGO Pivot, Ranomafana, Ifanadiana, Madagascar
- Department of Global Health and Social Medicine, Blavatnik Institute at Harvard Medical School, Boston, MA, USA
| | - Karen E Finnegan
- NGO Pivot, Ranomafana, Ifanadiana, Madagascar
- Department of Global Health and Social Medicine, Blavatnik Institute at Harvard Medical School, Boston, MA, USA
| | - Rado J L Rakotonanahary
- NGO Pivot, Ranomafana, Ifanadiana, Madagascar
- Department of Global Health and Social Medicine, Blavatnik Institute at Harvard Medical School, Boston, MA, USA
| | | | | | - Oméga Raobela
- National Malaria Program, Ministry of Health, Antananarivo, Madagascar
| | | | | | - Andres Garchitorena
- MIVEGEC, Univ. Montpellier, CNRS, IRD, Montpellier, France
- NGO Pivot, Ranomafana, Ifanadiana, Madagascar
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4
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Olliaro P, Nkeramahame J, Salami O, Moore CE, Horgan P, Baiden R, Kukula V, Adjei A, Kapisi J, Hopkins H, Kaawa-Mafigiri D, Ekusai-Sebatta D, Rutebemberwa E, Kitutu FE, Tinto H, Kiemde F, Compaoré A, Valia D, Dittrich S. Advancing Access to Diagnostic Tools Essential for Universal Health Coverage and Antimicrobial Resistance Prevention: An Overview of Trials in Sub-Saharan Africa. Clin Infect Dis 2023; 77:S125-S133. [PMID: 37490744 PMCID: PMC10368407 DOI: 10.1093/cid/ciad326] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Indexed: 07/27/2023] Open
Abstract
We introduce the Antimicrobial Resistance Diagnostic Use Accelerator program, and the articles in this Supplement, which cover the program in 3 sub-Saharan Africa countries.
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Affiliation(s)
- Piero Olliaro
- International Severe Acute Respiratory and Emerging Infection Consortium, Pandemic Sciences Institute, University of Oxford, Oxford, United Kingdom
- FIND, Geneva, Switzerland
| | | | | | - Catrin E Moore
- Nuffield Department of Medicine, Big Data Institute, University of Oxford, Oxford, United Kingdom
- Centre for Neonatal and Paediatric Infection, Institute for Infection and Immunity, St George's University of London, London, United Kingdom
| | - Philip Horgan
- FIND, Geneva, Switzerland
- Nuffield Department of Medicine, Big Data Institute, University of Oxford, Oxford, United Kingdom
- Evidence & Impact Oxford, Oxford, United Kingdom
| | | | - Vida Kukula
- Dodowa Health Research Centre, Dodowa, Ghana
| | | | - James Kapisi
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Heidi Hopkins
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | | | - Elizeus Rutebemberwa
- Department of Health Policy and Planning, Makerere University School of Public Health, Kampala, Uganda
| | - Freddy Eric Kitutu
- Department of Pharmacy, Makerere University School of Health Sciences, Kampala, Uganda
| | - Halidou Tinto
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de La Santé, Nanoro, Burkina Faso
| | - François Kiemde
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de La Santé, Nanoro, Burkina Faso
| | - Adélaïde Compaoré
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de La Santé, Nanoro, Burkina Faso
| | - Daniel Valia
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de La Santé, Nanoro, Burkina Faso
| | - Sabine Dittrich
- FIND, Geneva, Switzerland
- Center for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Deggendorf Institute of Technology, European Campus Rottal Inn, Pfarrkirchen, Germany
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5
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Forero-Peña DA, Carrión-Nessi FS, Lopez-Perez M, Sandoval-de Mora M, Amaya ID, Gamardo ÁF, Chavero M, Figuera L, Marcano MV, Camejo-Ávila NA, Hidalgo M, Arenas CJ, Arévalo-Herrera M, Herrera S. Seroprevalence of viral and bacterial pathogens among malaria patients in an endemic area of southern Venezuela. Infect Dis Poverty 2023; 12:33. [PMID: 37038195 PMCID: PMC10084699 DOI: 10.1186/s40249-023-01089-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 03/27/2023] [Indexed: 04/12/2023] Open
Abstract
BACKGROUND Malaria remains a leading public health problem worldwide. Co-infections with other pathogens complicate its diagnosis and may modify the disease's clinical course and management. Similarities in malaria clinical presentation with other infections and overlapping endemicity result in underdiagnosis of co-infections and increased mortality. Thus, the aim of this study was to determine the seroprevalence of viral and bacterial pathogens among diagnosed malaria patients in malaria-endemic areas in Venezuela. METHODS A cross-sectional study was conducted on malaria patients attending three reference medical centres in Ciudad Bolivar, Venezuela. Clinical evaluation and laboratory tests for dengue virus (DENV), chikungunya virus (CHIKV), viral hepatitis [hepatitis A virus (HAV), hepatitis B virus (HBV), and hepatitis C virus (HCV)], and leptospirosis (LEP) were performed by enzyme-linked immunosorbent assays. Previous exposure to these pathogens was defined by the presence of specific immunoglobulin (Ig) G, and co-infection or recent exposure (CoRE) was determined by the presence of specific IgM alone or IgM + IgG. Data analysis considered descriptive statistics. Parameter distribution was statistically evaluated using Kolmogorov-Smirnov test and the necessary comparison tests. Odds ratio (OR) for complications was determined according to CoRE presence with a 95% confidence interval (CI). RESULTS A total of 161 malaria patients were studied, 66% infected with Plasmodium vivax, 27% with P. falciparum, and 7.5% harboured P. vivax/P. falciparum mixed infection. Previous exposure to DENV (60%) and CHIKV (25%) was frequent. CoRE was confirmed in 55 of the 161 malaria patients (34%) and were more frequent in P. falciparum (49%) than in P. vivax (29%) and mixed malaria patients (25%) (OR = 2.43, 95% CI: 1.39-4.25, P = 0.018). The most frequent CoRE was DENV (15%), followed by HAV (12%), HBV (6.2%), CHIKV (5.5%), and LEP (3.7%); HCV CoRE was absent. Complicated malaria was significantly more frequent in patients with CoRE (56%) than those without CoRE (36%; OR = 2.31, 95% CI: 1.18-4.92, P = 0.013). CONCLUSIONS We found high CoRE prevalence in malaria patients as determined by serology in the study region; cases were associated with a worse clinical outcome. Further prospective studies with samples from different infection sites and the use of molecular tools are needed to determine the clinical significance of these findings.
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Affiliation(s)
- David A Forero-Peña
- Biomedical Research and Therapeutic Vaccines Institute, Ciudad Bolivar, Venezuela.
- Internal Medicine Department, "Ruiz y Páez" University Hospital Complex, Ciudad Bolivar, Venezuela.
| | - Fhabián S Carrión-Nessi
- Biomedical Research and Therapeutic Vaccines Institute, Ciudad Bolivar, Venezuela
- "Dr. Francisco Battistini Casalta" Health Sciences School, University of Oriente - Bolivar Nucleus, Ciudad Bolivar, Venezuela
| | - Mary Lopez-Perez
- Department of Immunology and Microbiology, Faculty of Health and Medical Sciences, Centre for Medical Parasitology, University of Copenhagen, Copenhagen, Denmark
| | - Marisol Sandoval-de Mora
- Internal Medicine Department, "Ruiz y Páez" University Hospital Complex, Ciudad Bolivar, Venezuela
| | - Iván D Amaya
- "Dr. Francisco Battistini Casalta" Health Sciences School, University of Oriente - Bolivar Nucleus, Ciudad Bolivar, Venezuela
| | - Ángel F Gamardo
- Biomedical Research and Therapeutic Vaccines Institute, Ciudad Bolivar, Venezuela
| | - Melynar Chavero
- Biomedical Research and Therapeutic Vaccines Institute, Ciudad Bolivar, Venezuela
| | - Luisamy Figuera
- Biomedical Research and Therapeutic Vaccines Institute, Ciudad Bolivar, Venezuela
| | - María V Marcano
- Biomedical Research and Therapeutic Vaccines Institute, Ciudad Bolivar, Venezuela
| | - Natasha A Camejo-Ávila
- Biomedical Research and Therapeutic Vaccines Institute, Ciudad Bolivar, Venezuela
- "Dr. Francisco Battistini Casalta" Health Sciences School, University of Oriente - Bolivar Nucleus, Ciudad Bolivar, Venezuela
| | - Mariana Hidalgo
- Immunoparasitology Laboratory, Microbiology and Cell Biology Centre, Venezuelan Institute for Scientific Research, Miranda, Venezuela
| | - Cariagne J Arenas
- Biomedical Research and Therapeutic Vaccines Institute, Ciudad Bolivar, Venezuela
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Chao DL, Oron AP, Chabot-Couture G, Sopekan A, Nnebe-Agumadu U, Bates I, Piel FB, Nnodu O. Contribution of malaria and sickle cell disease to anaemia among children aged 6-59 months in Nigeria: a cross-sectional study using data from the 2018 Demographic and Health Survey. BMJ Open 2022; 12:e063369. [PMID: 36385021 PMCID: PMC9670918 DOI: 10.1136/bmjopen-2022-063369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To estimate the fraction of anaemia attributable to malaria and sickle cell disease (SCD) among children aged 6-59 months in Nigeria. DESIGN Cross-sectional analysis of data from Nigeria's 2018 Demographic and Health Survey (DHS). SETTING Nigeria. PARTICIPANTS 11 536 children aged 6-59 months from randomly selected households were eligible for participation, of whom 11 142 had complete and valid biomarker data required for this analysis. Maternal education data were available from 10 305 of these children. PRIMARY OUTCOME MEASURE Haemoglobin concentration. RESULTS We found that 70.6% (95% CI: 62.7% to 78.5%) of severe anaemia was attributable to malaria compared with 12.4% (95% CI: 11.1% to 13.7%) of mild-to-severe and 29.6% (95% CI: 29.6% to 31.8%) of moderate-to-severe anaemia and that SCD contributed 0.6% (95% CI: 0.4% to 0.9%), 1.3% (95% CI: 1.0% to 1.7%) and 10.6% (95% CI: 6.7% to 14.9%) mild-to-severe, moderate-to-severe and severe anaemia, respectively. Sickle trait was protective against anaemia and was associated with higher haemoglobin concentration compared with children with normal haemoglobin (HbAA) among malaria-positive but not malaria-negative children. CONCLUSIONS This approach used offers a new tool to estimate the contribution of malaria to anaemia in many settings using widely available DHS data. The fraction of anaemia among young children in Nigeria attributable to malaria and SCD is higher at more severe levels of anaemia. Prevention of malaria and SCD and timely treatment of affected individuals would reduce cases of severe anaemia.
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Affiliation(s)
- Dennis L Chao
- Institute for Disease Modeling, Bill & Melinda Gates Foundation, Seattle, Washington, USA
| | - Assaf P Oron
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
| | | | - Alayo Sopekan
- Department of Public Health, Federal Ministry of Health, Abuja, Nigeria
| | - Uche Nnebe-Agumadu
- Department of Paediatrics, University of Abuja College of Health Sciences, Abuja, Nigeria
| | - Imelda Bates
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Frédéric B Piel
- Department of Epidemiology and Biostatistics, Imperial College London, London, UK
| | - Obiageli Nnodu
- Centre of Excellence for Sickle Cell Disease Research & Training (CESRTA), University of Abuja, Abuja, Nigeria
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7
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Namuganga JF, Nankabirwa JI, Maiteki-Ssebuguzi C, Gonahasa S, Opigo J, Staedke SG, Rutazaana D, Ebong C, Dorsey G, Tomko SS, Kizza T, Mawejje HD, Arinaitwe E, Rosenthal PJ, Kamya MR. East Africa International Center of Excellence for Malaria Research: Impact on Malaria Policy in Uganda. Am J Trop Med Hyg 2022; 107:33-39. [PMID: 36228904 PMCID: PMC9662221 DOI: 10.4269/ajtmh.21-1305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 05/16/2022] [Indexed: 12/24/2022] Open
Abstract
Malaria is the leading cause of disease burden in sub-Saharan Africa. In 2010, the East Africa International Center of Excellence for Malaria Research, also known as the Program for Resistance, Immunology, Surveillance, and Modeling of Malaria (PRISM), was established to provide a comprehensive approach to malaria surveillance in Uganda. We instituted cohort studies and a robust malaria and entomological surveillance network at selected public health facilities that have provided a platform for monitoring trends in malaria morbidity and mortality, tracking the impact of malaria control interventions (indoor residual spraying of insecticide [IRS], use of long-lasting insecticidal nets [LLINs], and case management with artemisinin-based combination therapies [ACTs]), as well as monitoring of antimalarial drug and insecticide resistance. PRISM studies have informed Uganda's malaria treatment policies, guided selection of LLINs for national distribution campaigns, and revealed widespread pyrethroid resistance, which led to changes in insecticides delivered through IRS. Our continuous engagement and interaction with policy makers at the Ugandan Ministry of Health have enabled PRISM to share evidence, best practices, and lessons learned with key malaria stakeholders, participate in malaria control program reviews, and contribute to malaria policy and national guidelines. Here, we present an overview of interactions between PRISM team members and Ugandan policy makers to demonstrate how PRISM's research has influenced malaria policy and control in Uganda.
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Affiliation(s)
- Jane F. Namuganga
- Infectious Diseases Research Collaboration, Kampala, Uganda;,Address correspondence to Jane F. Namuganga, Plot 2C Nakasero Hill, P.O. Box 7475 Kampala, Uganda. E-mail:
| | - Joaniter I. Nankabirwa
- Infectious Diseases Research Collaboration, Kampala, Uganda;,Makerere University College of Health Sciences, Kampala, Uganda
| | | | | | - Jimmy Opigo
- National Malaria Control Division, Ministry of Health, Kampala, Uganda
| | - Sarah G. Staedke
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Damian Rutazaana
- National Malaria Control Division, Ministry of Health, Kampala, Uganda
| | - Chris Ebong
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Grant Dorsey
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Sheena S. Tomko
- Department of Biology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Timothy Kizza
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | | | - Philip J. Rosenthal
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Moses R. Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda;,Makerere University College of Health Sciences, Kampala, Uganda
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8
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Ahorlu CS, Ndong IC, Okyere D, Mensah BA, Chu CE, Enos JY, Abuaku B. The Effect of Mass Testing, Treatment and Tracking on the Prevalence of Febrile Illness in Children under 15 in Ghana. Pathogens 2022; 11:pathogens11101118. [PMID: 36297175 PMCID: PMC9609179 DOI: 10.3390/pathogens11101118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/16/2022] [Accepted: 09/24/2022] [Indexed: 11/18/2022] Open
Abstract
Background: Malaria remains a serious threat to children under 15 years of age in sub-Sahara Africa. Mass testing, treatment and tracking (MTTT) of malaria has been reported to reduce parasite load significantly. However, the impact of MTTT on the prevalence of febrile illnesses in children under 15 is not yet clear. This study explores the impact of MTTT complemented by prompt home-based management of malaria on febrile illnesses and their treatment in children under 15 years old. Methods: A cohort of 460 children under 15 years were recruited from the Pakro subdistrict in Ghana during a community-wide implementation of a quarterly MTTT intervention. The MTTT implementation involved testing all household members for malaria using RDTs, and positive cases were treated with Artemisinin-based combination therapy (ACT). Febrile illnesses among this cohort in the two weeks prior to the prevalence survey at baseline and endline were recorded to constitute date for analysis. Results: The prevalence of febrile illnesses, such chills, convulsion, fever, diarrhoea, headache, vomit, cough/rashes or stomachache, etc., were recorded). Asymptomatic parasitaemia prevalence at baseline was 53.3%, which dropped to 44.1% at evaluation. An overall decrease in the parasitaemia prevalence of 33.0% (OR = 0.67, CI = 0.50, 0.89) was observed at evaluation compared to baseline after adjusting for age, ITN use and temperature. A 67% decrease in severe anaemia cases (Hb < 7) was observed at evaluation. Conclusion: Our findings suggest that implementing MTTT complemented by home-based timely management of malaria does not only reduce febrile illnesses and for that matter malaria prevalence, but could also reduce severe anaemia in children under 15 years old.
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Affiliation(s)
- Collins Stephen Ahorlu
- Department of Epidemiology, Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, Legon, Accra P.O. Box LG 581, Ghana
- Correspondence:
| | - Ignatius Cheng Ndong
- Department of Epidemiology, Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, Legon, Accra P.O. Box LG 581, Ghana
- Department of Biochemistry, Faculty of Science, Catholic University of Cameroon, Bamenda P.O. Box 572, Cameroon
| | - Daniel Okyere
- Department of Epidemiology, Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, Legon, Accra P.O. Box LG 581, Ghana
| | - Benedicta A. Mensah
- Department of Epidemiology, Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, Legon, Accra P.O. Box LG 581, Ghana
| | - Chuo Ennestine Chu
- Department of Epidemiology, Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, Legon, Accra P.O. Box LG 581, Ghana
- Department of Biochemistry, Faculty of Science, Catholic University of Cameroon, Bamenda P.O. Box 572, Cameroon
| | - Juliana Y. Enos
- Department of Epidemiology, Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, Legon, Accra P.O. Box LG 581, Ghana
| | - Benjamin Abuaku
- Department of Epidemiology, Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, Legon, Accra P.O. Box LG 581, Ghana
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9
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Montiel Ishino FA, Rowan C, Talham C, Villalobos K, Poudel D, Rajbhandari-Thapa J, Ambikile JS, Williams F. Household profiles of neglected tropical disease symptoms among children: A latent class analysis of built-environment features of Tanzanian households using the Demographic and Health Survey. J Glob Health 2022; 12:04067. [PMID: 36057837 PMCID: PMC9441010 DOI: 10.7189/jogh.12.04067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background While malaria and neglected tropical disease (NTD) morbidity and mortality rates among children <5 years old have decreased through public health efforts in the United Republic of Tanzania, associations between household environments and disease outcomes are relatively unknown. Methods We conducted latent class analysis (LCA) on 2015-2016 Tanzania Demographic Health Survey data from mothers with children <5 years old (N = 10 233) to identify NTD household risk profiles. The outcome of child NTD was assessed by mothers’ reports of recent diarrhoea, cough, treatment for enteric parasites, and fever symptoms. Household-built environment indicators included urban/rural designation, electricity access, water source, cooking fuel, flooring, wall, and roofing materials. External environmental covariates were considered to further differentiate profiles. Results Five profiles were identified in the sample: rural finished walls households (40.2%) with the lowest NTD risk; rural rudimentary households (20.9%) with intermediate-low NTD risk; finished material households (22.5%) with intermediate NTD risk; urban households (14.4%) with intermediate-high NTD risk and high likelihood of enteric parasites; rural finished roof/walls households (2.1%) with the highest overall NTD risk. Conclusions This study is among the first to use LCA to examine household environment characteristics to assess child NTD risk in Tanzania. This paper serves as a framework for community-level rapid NTD risk assessment for targeted health promotion interventions.
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Affiliation(s)
- Francisco A Montiel Ishino
- Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
| | - Claire Rowan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Charlotte Talham
- Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
| | - Kevin Villalobos
- Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
| | - Dikshit Poudel
- Department of Agricultural and Applied Economics, College of Agricultural and Environmental Science, University of Georgia, Athens, Georgia, USA
| | - Janani Rajbhandari-Thapa
- Department of Health Policy and Management, College of Public Health, University of Georgia, Athens, Georgia, USA
| | - Joel Seme Ambikile
- Department of Community Health Nursing, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Faustine Williams
- Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
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10
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Marquart L, Webb L, O'Rourke P, Gatton ML, Hsiang MS, Kalnoky M, Jang IK, Ntuku H, Mumbengegwi DR, Domingo GJ, McCarthy JS, Britton S. The in-vivo dynamics of Plasmodium falciparum HRP2: implications for the use of rapid diagnostic tests in malaria elimination. Malar J 2022; 21:233. [PMID: 35922803 PMCID: PMC9351188 DOI: 10.1186/s12936-022-04245-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 07/13/2022] [Indexed: 11/24/2022] Open
Abstract
Background Rapid diagnostic tests (RDTs) that rely on the detection of Plasmodium falciparum histidine-rich protein 2 (PfHRP2) have become key tools for diagnosing P. falciparum infection. The utility of RDTs can be limited by PfHRP2 persistence, however it can be a potential benefit in low transmission settings where detection of persistent PfHRP2 using newer ultra-sensitive PfHRP2 based RDTs can serve as a surveillance tool to identify recent exposure. Better understanding of the dynamics of PfHRP2 over the course of a malaria infection can inform optimal use of RDTs. Methods A previously published mathematical model was refined to mimic the production and decay of PfHRP2 during a malaria infection. Data from 15 individuals from volunteer infection studies were used to update the original model and estimate key model parameters. The refined model was applied to a cohort of patients from Namibia who received treatment for clinical malaria infection for whom longitudinal PfHRP2 concentrations were measured. Results The refinement of the PfHRP2 dynamic model indicated that in malaria naïve hosts, P. falciparum parasites of the 3D7 strain produce 33.6 × 10−15 g (95% CI 25.0–42.1 × 10−15 g) of PfHRP2 in vivo per parasite replication cycle, with an elimination half-life of 1.67 days (95% CI 1.11–3.40 days). The refined model included these updated parameters and incorporated individualized body fluid volume calculations, which improved predictive accuracy when compared to the original model. The performance of the model in predicting clearance of PfHRP2 post treatment in clinical samples from six adults with P. falciparum infection in Namibia improved when using a longer elimination half-life of 4.5 days, with 14% to 67% of observations for each individual within the predicted range. Conclusions The updated mathematical model can predict the growth and clearance of PfHRP2 during the production and decay of a mono-infection with P. falciparum, increasing the understanding of PfHRP2 antigen dynamics. This model can guide the optimal use of PfHRP2-based RDTs for reliable diagnosis of P. falciparum infection and re-infection in endemic settings, but also for malaria surveillance and elimination programmes in low transmission areas. Supplementary Information The online version contains supplementary material available at 10.1186/s12936-022-04245-z.
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Affiliation(s)
- Louise Marquart
- QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia. .,University of Queensland, Brisbane, QLD, Australia.
| | - Lachlan Webb
- QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Peter O'Rourke
- QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | | | - Michelle S Hsiang
- Department of Pediatrics, University of Texas, Southwestern, Dallas, TX, USA.,Malaria Elimination Initiative, Institute for Global Health Services, University of California, San Francisco, CA, USA.,Department of Pediatrics, University of California, San Francisco, CA, USA
| | | | | | - Henry Ntuku
- Malaria Elimination Initiative, Institute for Global Health Services, University of California, San Francisco, CA, USA
| | | | | | - James S McCarthy
- QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia.,University of Queensland, Brisbane, QLD, Australia
| | - Sumudu Britton
- QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia.,University of Queensland, Brisbane, QLD, Australia
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11
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Rugarabamu S, Mwanyika GO, Rumisha SF, Sindato C, Lim HY, Misinzo G, Mboera LEG. Seroprevalence and associated risk factors of selected zoonotic viral hemorrhagic fevers in Tanzania. Int J Infect Dis 2021; 109:174-181. [PMID: 34242761 DOI: 10.1016/j.ijid.2021.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 07/01/2021] [Accepted: 07/03/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To determine the seroprevalence of selected zoonotic viral hemorrhagic fevers (VHFs) and their associated risk factors in Tanzania. METHODS Blood samples were collected from consenting outpatients and community members in eight districts selected from five ecological zones of Tanzania. Serum was harvested and tested for the presence of immunoglobulin G (IgG) and M (IgM) antibodies against Crimean-Congo hemorrhagic fever (CCHF), Ebola virus disease (EVD), Marburg virus disease (MVD), Rift Valley fever (RVF), and yellow fever (YF). RESULTS The presence of IgM and IgG antibodies against CCHF, EVD, MVD, RVF, and YF was detected in 64 of 500 samples (12.8%). The prevalences of IgM and IgG antibodies to CCHF, EVD, MVD, RFV, and YF were 2.0%, 3.4%, 1.2%, 4.8%, and 1.4%, respectively. Contact with wild animals (OR = 1.2, CI = 1.3-1.6) and keeping goats (OR = 1.3, CI = 1.5-1.9) were significantly associated with RVF, while contact with bats (OR = 1.2, CI = 1.1-1.5) was associated with MVD. CONCLUSION The findings of this study provide evidence of exposure to CCHF, EVD, MVD, RVF, and YF in Tanzania. Since most of these VHFs occurred without apparent clinical forms of the disease, these findings call for the need to strengthen the surveillance system and management of febrile illnesses in Tanzania.
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Affiliation(s)
- Sima Rugarabamu
- SACIDS Foundation for One Health, Sokoine University of Agriculture, Morogoro, Tanzania; Department of Veterinary Microbiology, Parasitology and Biotechnology, Sokoine University of Agriculture, Morogoro, Tanzania; Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
| | - Gaspary O Mwanyika
- SACIDS Foundation for One Health, Sokoine University of Agriculture, Morogoro, Tanzania; Department of Veterinary Microbiology, Parasitology and Biotechnology, Sokoine University of Agriculture, Morogoro, Tanzania; Mbeya University of Science and Technology, Mbeya, Tanzania.
| | - Susan F Rumisha
- National Institute for Medical Research, Headquarters, Dar es Salaam, Tanzania; Malaria Atlas Project, Geospatial Health and Development, Telethon Kids Institute, Perth, Western Australia.
| | - Calvin Sindato
- SACIDS Foundation for One Health, Sokoine University of Agriculture, Morogoro, Tanzania; National Institute for Medical Research, Tabora Research Centre, Tabora, Tanzania.
| | - Hee-Young Lim
- Korea Disease Control and Prevention Agency, National Institute of Health, Osong, Chungchungbukdo, Republic of Korea.
| | - Gerald Misinzo
- SACIDS Foundation for One Health, Sokoine University of Agriculture, Morogoro, Tanzania; Department of Veterinary Microbiology, Parasitology and Biotechnology, Sokoine University of Agriculture, Morogoro, Tanzania.
| | - Leonard E G Mboera
- SACIDS Foundation for One Health, Sokoine University of Agriculture, Morogoro, Tanzania.
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12
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Peterson I, Kapito-Tembo A, Bauleni A, Nyirenda O, Pensulo P, Still W, Valim C, Cohee L, Taylor T, Mathanga DP, Laufer MK. Overdiagnosis of Malaria Illness in an Endemic Setting: A Facility-Based Surveillance Study in Malawi. Am J Trop Med Hyg 2021; 104:2123-2130. [PMID: 33939628 PMCID: PMC8176516 DOI: 10.4269/ajtmh.20-1209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 03/03/2021] [Indexed: 11/07/2022] Open
Abstract
In endemic settings where asymptomatic malaria infections are common, malaria infection can complicate fever diagnosis. Factors influencing fever misdiagnosis, including accuracy of malaria rapid diagnostic tests (mRDTs) and the malaria-attributable fraction of fevers (MAF), require further investigation. We conducted facility-based surveillance in Malawi, from January 2012 through December 2013 in settings of high perennial (Chikhwawa), high seasonal (Thoylo), and moderate seasonal (Ndirande) malaria transmission. Consecutive patients presenting to outpatient departments were screened; those with suspected malaria illness were tested by mRDT or routine thick-smear microscopy. Test positivity rates (TPRs), positive predictive value (PPVs) of mRDTs, and MAFs were calculated by site, age, and season. Of 41,471 patients, 10,052 (24.2%) tested positive for malaria. The TPR was significantly greater in Chikhwawa (29.9%; 95% CI, 28.6-30.0) compared with Thyolo (13.2%; 95% CI, 12.5-13.7) and Ndirande (13.1%; 95% CI, 12.2-14.4). The overall PPV was 77.8% (95% CI, 76.8-78.7); it was lowest among infants (69.9%; 95% CI, 65.5-74.2) and highest among school-age children (81.9%; 95% CI, 80.3-83.4). Malaria infection accounted for about 50% of fevers in children younger than 5 years old with microscopy-confirmed Plasmodium falciparum infection, and less than 20% of such fevers in school-age children. Outpatient settings in Malawi had a high burden of malaria illness, but also possible overdiagnosis of malaria illness. Interventions to reduce malaria transmission and rapid testing for other common febrile illness may improve diagnostic clarity among outpatients in malaria endemic settings.
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Affiliation(s)
- Ingrid Peterson
- Center for Vaccine Development and Global Health, University of Maryland Baltimore, Baltimore, Maryland
- Blantyre Malaria Project, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Atupele Kapito-Tembo
- Malaria Alert Center, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Andrew Bauleni
- Malaria Alert Center, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Osward Nyirenda
- Blantyre Malaria Project, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Paul Pensulo
- Blantyre Malaria Project, College of Medicine, University of Malawi, Blantyre, Malawi
| | - William Still
- Center for Vaccine Development and Global Health, University of Maryland Baltimore, Baltimore, Maryland
| | - Clarissa Valim
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts
| | - Lauren Cohee
- Center for Vaccine Development and Global Health, University of Maryland Baltimore, Baltimore, Maryland
| | - Terrie Taylor
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan
| | - Don P. Mathanga
- Malaria Alert Center, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Miriam K. Laufer
- Center for Vaccine Development and Global Health, University of Maryland Baltimore, Baltimore, Maryland
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13
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Molla E, Behaksra SW, Tadesse FG, Dugassa S, Gadisa E, Mamo H. Past eight-year malaria data in Gedeo zone, southern Ethiopia: trend, reporting-quality, spatiotemporal distribution, and association with socio-demographic and meteorological variables. BMC Infect Dis 2021; 21:91. [PMID: 33478414 PMCID: PMC7817977 DOI: 10.1186/s12879-021-05783-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 01/11/2021] [Indexed: 12/02/2022] Open
Abstract
Background Informed decision making is underlined by all tiers in the health system. Poor data record system coupled with under- (over)-reporting of malaria cases affects the country’s malaria elimination activities. Thus, malaria data at health facilities and health offices are important particularly to monitor and evaluate the elimination progresses. This study was intended to assess overall reported malaria cases, reporting quality, spatiotemporal trends and factors associated in Gedeo zone, South Ethiopia. Methods Past 8 years retrospective data stored in 17 health centers and 5 district health offices in Gedeo Zone, South Ethiopia were extracted. Malaria cases data at each health center with sociodemographic information, between January 2012 and December 2019, were included. Meteorological data were obtained from the national meteorology agency of Ethiopia. The data were analyzed using Stata 13. Results A total of 485,414 suspected cases were examined for malaria during the previous 8 years at health centers. Of these suspects, 57,228 (11.79%) were confirmed malaria cases with an overall decline during the 8-year period. We noted that 3758 suspected cases and 467 confirmed malaria cases were not captured at the health offices. Based on the health centers records, the proportions of Plasmodium falciparum (49.74%) and P. vivax (47.59%) infection were nearly equivalent (p = 0.795). The former was higher at low altitudes while the latter was higher at higher altitudes. The over 15 years of age group accounted for 11.47% of confirmed malaria cases (p < 0.001). There was high spatiotemporal variation: the highest case record was during Belg (12.52%) and in Dilla town (18,150, 13.17%, p < 0.001) which is located at low altitude. Monthly rainfall and minimum temperature exhibited strong associations with confirmed malaria cases. Conclusion A notable overall decline in malaria cases was observed during the eight-year period. Both P. falciparum and P. vivax were found at equivalent endemicity level; hence control measures should continue targeting both species. The noticed under reporting, the high malaria burden in urban settings, low altitudes and Belg season need spatiotemporal consideration by the elimination program. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-05783-8.
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Affiliation(s)
- Eshetu Molla
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia. .,Department of Medical Laboratory Sciences, Dilla University, Dilla, Ethiopia. .,Department of Microbial, Cellular and Molecular Biology, Addis Ababa University, Addis Ababa, Ethiopia.
| | | | - Fitsum G Tadesse
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia.,Institute of Biotechnology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Sisay Dugassa
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Hassen Mamo
- Department of Microbial, Cellular and Molecular Biology, Addis Ababa University, Addis Ababa, Ethiopia
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14
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Reichert EN, Hume JCC, Sagara I, Healy SA, Assadou MH, Guindo MA, Barney R, Rashid A, Yang IK, Golden A, Domingo GJ, Duffy PE, Slater HC. Ultra-sensitive RDT performance and antigen dynamics in a high-transmission Plasmodium falciparum setting in Mali. Malar J 2020; 19:323. [PMID: 32883286 PMCID: PMC7469912 DOI: 10.1186/s12936-020-03389-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 08/25/2020] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The recent expansion of tools designed to accurately quantify malaria parasite-produced antigens has enabled us to evaluate the performance of rapid diagnostic tests (RDTs) as a function of the antigens they detect-typically histidine rich protein 2 (HRP2) or lactate dehydrogenase (LDH). METHODS For this analysis, whole blood specimens from a longitudinal study in Bancoumana, Mali were used to evaluate the performance of the ultra-sensitive HRP2-based Alere™ Malaria Ag P.f RDT (uRDT). The samples were collected as part of a transmission-blocking vaccine trial in a high transmission region for Plasmodium falciparum malaria. Furthermore, antigen dynamics after successful anti-malarial drug treatment were evaluated in these samples using the Q-Plex Human Malaria Array (4-Plex) to quantify antigen concentrations. RESULTS The uRDT had a 50% probability of a positive result at 207 pg/mL HRP2 [95% credible interval (CrI) 160-268]. Individuals with symptomatic infection remained positive by uRDT for a median of 33 days [95% confidence interval (CI) 28-47] post anti-malarial drug treatment. Biphasic exponential decay models accurately captured the population level post-treatment dynamics of both HRP2 and Plasmodium LDH (pLDH), with the latter decaying more rapidly. Motivated by these differences in rates of decay, a novel algorithm that used HRP2:pLDH ratios to predict if an individual had active versus recently cleared P. falciparum infection was developed. The algorithm had 77.5% accuracy in correctly classifying antigen-positive individuals as those with and without active infection. CONCLUSIONS These results characterize the performance of the ultra-sensitive RDT and demonstrate the potential for emerging antigen-quantifying technologies in the field of malaria diagnostics to be helpful tools in distinguishing between active versus recently cleared malaria infections.
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Affiliation(s)
| | - Jen C C Hume
- Laboratory of Malaria Immunology and Vaccinology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - Issaka Sagara
- Malaria Research and Training Center, Mali-National Institute of Allergy and Infectious Diseases International Center for Excellence in Research, University of Science, Techniques and Technologies of Bamako, Bamako, Mali
| | - Sara A Healy
- Laboratory of Malaria Immunology and Vaccinology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - Mahamadoun H Assadou
- Malaria Research and Training Center, Mali-National Institute of Allergy and Infectious Diseases International Center for Excellence in Research, University of Science, Techniques and Technologies of Bamako, Bamako, Mali
| | - Merepen A Guindo
- Malaria Research and Training Center, Mali-National Institute of Allergy and Infectious Diseases International Center for Excellence in Research, University of Science, Techniques and Technologies of Bamako, Bamako, Mali
| | | | | | | | | | | | - Patrick E Duffy
- Laboratory of Malaria Immunology and Vaccinology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
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15
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Sherrard-Smith E, Hogan AB, Hamlet A, Watson OJ, Whittaker C, Winskill P, Ali F, Mohammad AB, Uhomoibhi P, Maikore I, Ogbulafor N, Nikau J, Kont MD, Challenger JD, Verity R, Lambert B, Cairns M, Rao B, Baguelin M, Whittles LK, Lees JA, Bhatia S, Knock ES, Okell L, Slater HC, Ghani AC, Walker PGT, Okoko OO, Churcher TS. The potential public health consequences of COVID-19 on malaria in Africa. Nat Med 2020; 26:1411-1416. [PMID: 32770167 DOI: 10.1038/s41591-020-1025-y] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 07/23/2020] [Indexed: 01/08/2023]
Abstract
The burden of malaria is heavily concentrated in sub-Saharan Africa (SSA) where cases and deaths associated with COVID-19 are rising1. In response, countries are implementing societal measures aimed at curtailing transmission of SARS-CoV-22,3. Despite these measures, the COVID-19 epidemic could still result in millions of deaths as local health facilities become overwhelmed4. Advances in malaria control this century have been largely due to distribution of long-lasting insecticidal nets (LLINs)5, with many SSA countries having planned campaigns for 2020. In the present study, we use COVID-19 and malaria transmission models to estimate the impact of disruption of malaria prevention activities and other core health services under four different COVID-19 epidemic scenarios. If activities are halted, the malaria burden in 2020 could be more than double that of 2019. In Nigeria alone, reducing case management for 6 months and delaying LLIN campaigns could result in 81,000 (44,000-119,000) additional deaths. Mitigating these negative impacts is achievable, and LLIN distributions in particular should be prioritized alongside access to antimalarial treatments to prevent substantial malaria epidemics.
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Affiliation(s)
- Ellie Sherrard-Smith
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK
| | - Alexandra B Hogan
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK
| | - Arran Hamlet
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK
| | - Oliver J Watson
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK
| | - Charlie Whittaker
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK
| | - Peter Winskill
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK
| | - Fatima Ali
- National Malaria Elimination Programme, Abuja, Nigeria
| | | | | | | | | | - Jamilu Nikau
- National Malaria Elimination Programme, Abuja, Nigeria
| | - Mara D Kont
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK
| | - Joseph D Challenger
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK
| | - Robert Verity
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK
| | - Ben Lambert
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK
| | - Matthew Cairns
- Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Bhargavi Rao
- Manson Unit, Médecins Sans Frontières (Operational Centre Amsterdam), London, UK
| | - Marc Baguelin
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK.,Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Lilith K Whittles
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK
| | - John A Lees
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK
| | - Sangeeta Bhatia
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK
| | - Edward S Knock
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK
| | - Lucy Okell
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK
| | - Hannah C Slater
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK.,PATH, Seattle, WA, USA
| | - Azra C Ghani
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK
| | - Patrick G T Walker
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK
| | | | - Thomas S Churcher
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK.
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16
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Mbohou Nchetnkou C, Nyabeyeu Nyabeyeu H, Kojom Foko LP, Lehman LG. Comparison of the fluorescence microscopy Cyscope® with light microscopy for malaria diagnosis in a small and active surveillance in Cameroon. Trop Med Health 2020; 48:61. [PMID: 32742185 PMCID: PMC7385968 DOI: 10.1186/s41182-020-00234-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 05/28/2020] [Indexed: 12/27/2022] Open
Abstract
Background Malaria has a negative impact on the activities of companies in endemic countries especially in Cameroon. In this regard, an increasingly growing number of companies have started to include management of malarious patients in their health policies. In the present study, we will evaluate the diagnostic performances of a fluorescence microscopy (FM), Cyscope® microscope, in the detection of malaria parasites. Methods A cross-sectional study was conducted among employees of two companies of the town of Douala on 21 and 22 March 2017. Sociodemographic information of employees was collected using a questionnaire form. Blood samples of ~ 10 μL were collected by venipuncture for the diagnosis of malaria using FM and light microscopy (LM). Performances of FM with respect to sensitivity (Se), specificity (Sp), positive and negative predictive values (PPV and NPV), positive and negative likelihood rates (PLR and NLR), accuracy, reliability, and Kappa index were calculated using LM as gold standard. Results In total, 442 employees, aged 37.8 ± 9.7 years old on average, were included in the study. Prevalence of malaria using FM and LM was 39.2% and 17%, respectively (p < 0.01). Plasmodium falciparum and P. vivax were the two species involved in malaria infection cases. In terms of developmental stages, 68%, 45.3%, and 1.3% of employees carried gametocytes, trophozoites, and schizonts, respectively. Findings on diagnostic performances of FM were as follows: Se = 84%, Sp = 69.95%, PPV = 63.58%, NPV = 95.5%, accuracy = 89.36%, and reliability = 53.95%. Sensitivity of Cyscope® microscope increased as a function of parasitemia with values ranging from 76.92% at parasitemia between 1 and 500 parasites/μL to 91.11% at parasitemia between 501 and 5000 parasites/μL. The geometric mean parasite density was1850 parasites per μL of blood (range 1600-40,000), and most of employees (60.8%) had moderate parasitemia. The performances of FM were similar between febrile and afebrile patients. Conclusions This study showed good performances of Cyscope® microscope and outlines that this diagnostic tool could be used in management of malaria at workplace.
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Affiliation(s)
- Christian Mbohou Nchetnkou
- Department of Animal Organisms, Faculty of Science, The University of Douala, P.O. Box 24157, Douala, Cameroon
| | - Hervé Nyabeyeu Nyabeyeu
- Department of Animal Organisms, Faculty of Science, The University of Douala, P.O. Box 24157, Douala, Cameroon
| | - Loick P Kojom Foko
- Department of Animal Organisms, Faculty of Science, The University of Douala, P.O. Box 24157, Douala, Cameroon
| | - Leopold G Lehman
- Department of Animal Organisms, Faculty of Science, The University of Douala, P.O. Box 24157, Douala, Cameroon.,Department of Biological Sciences, Faculty of Medicine and Pharmaceutical Sciences, The University of Douala, P.O. Box 24157, Douala, Cameroon
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17
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Falciparum Malaria in Febrile Patients at Sentinel Sites for Influenza Surveillance in the Central African Republic from 2015 to 2018. Interdiscip Perspect Infect Dis 2020; 2020:3938541. [PMID: 32802053 PMCID: PMC7403902 DOI: 10.1155/2020/3938541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 05/09/2020] [Accepted: 07/01/2020] [Indexed: 12/03/2022] Open
Abstract
Malaria is a major public health issue in the Central African Republic (CAR) despite massive scale-up of malaria interventions. However, no information is available on the incidence of malaria in febrile illness cases or on the distribution of malaria infection according to demographic characteristics, which are important indicators and valuable epidemiological surveillance tools. This study therefore aimed to characterize malaria in the network of sentinel sites set up for influenza surveillance. A retrospective analysis was conducted to explore the data from these sentinel sites from 2015 to 2018. The Paracheck-Pf® rapid diagnosis test kit was used to screen for malaria in febrile illness cases. A total of 3609 malaria cases were identified in 5397 febrile patients, giving an incidence rate of 66.8%. The age group of 1–4 years was the most affected by malaria (76.0%). Moreover, prevalence varied across different sentinel sites, with the Bossembele Health Center, located in a rural area, showing an incidence of 96%, the Saint Joseph Health Center in a semiurban area of Bangui showing an incidence of 75%, and the Bangui Pediatric Complex in an urban site with an incidence of only 44.6%. Malaria transmission was holoendemic over the four-year study period, and malaria incidence decreased from 2016 to 2018. The incidence of malaria coinfection with influenza was 6.8%. This study demonstrated clear microspatial heterogeneity of malaria. Malaria was consistently the most frequent cause of febrile illness. Including sites in different climate zones in the CAR will allow for a more representative study.
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18
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Plucinski MM, Candrinho B, Dimene M, Smith T, Thwing J, Colborn J, Rogier E, Zulliger R. Estimation of Malaria-Attributable Fever in Malaria Test-Positive Febrile Outpatients in Three Provinces of Mozambique, 2018. Am J Trop Med Hyg 2020; 102:151-155. [PMID: 31701868 DOI: 10.4269/ajtmh.19-0537] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Like most malaria-endemic countries, Mozambique relies on tabulation of confirmed malaria test-positive febrile patients to track incidence of malaria. However, this approach is potentially biased by incidental malaria parasitemia in patients with fever of another etiology. We compared pan-Plasmodium aldolase and lactate dehydrogenase and Plasmodium falciparum histidine-rich protein 2 (PfHRP2) antigen concentrations measured using a laboratory bead-based assay of samples collected from 1,712 febrile and afebrile patients of all ages in Maputo, Zambézia, and Cabo Delgado provinces. We used a Bayesian latent class model to estimate the proportion of malaria-attributable fevers in malaria test-positive febrile patients. Depending on the antigen, estimated rates of malaria-attributable fever in malaria test-positive febrile patients were 100% in Maputo, 33-58% in Zambézia, and 63-74% in Cabo Delgado. Our findings indicate that most malaria test-positive febrile patients in the three provinces of Mozambique had a fever that was likely caused by the concurrent malaria infection. Counting malaria test-positive febrile patients for estimation of malaria incidence appears to be appropriate in this setting.
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Affiliation(s)
- Mateusz M Plucinski
- United States President's Malaria Initiative, Centers for Disease Control and Prevention, Atlanta, Georgia.,Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Baltazar Candrinho
- National Malaria Control Program, Ministry of Health, Maputo, Mozambique
| | - Mercia Dimene
- National Malaria Control Program, Ministry of Health, Maputo, Mozambique
| | - Tom Smith
- University of Basel, Basel, Switzerland.,Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Julie Thwing
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - James Colborn
- Clinton Health Access Initiative, Maputo, Mozambique
| | - Eric Rogier
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Rose Zulliger
- United States President's Malaria Initiative, Centers for Disease Control and Prevention, Maputo, Mozambique.,Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
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19
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Chandna A, White LJ, Pongvongsa T, Mayxay M, Newton PN, Day NPJ, Lubell Y. Accounting for aetiology: can regional surveillance data alongside host biomarker-guided antibiotic therapy improve treatment of febrile illness in remote settings? Wellcome Open Res 2019; 4:1. [PMID: 31245630 PMCID: PMC6589932 DOI: 10.12688/wellcomeopenres.14976.2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2019] [Indexed: 11/20/2022] Open
Abstract
Background: Across Southeast Asia, declining malaria incidence poses a challenge for healthcare providers, in how best to manage the vast majority of patients with febrile illnesses who have a negative malaria test. In rural regions, where the majority of the population reside, empirical treatment guidelines derived from central urban hospitals are often of limited relevance. In these settings, health workers with limited training deliver care, often without any laboratory diagnostic support. In this paper, we model the impact of point-of-care C-reactive protein testing to inform the decision to prescribe antibiotics and regional surveillance data to inform antibiotic selection, and then simulate the subsequent impact on mortality from febrile illnesses, rooted in the real-world context of rural Savannakhet province, southern Laos. Methods: Our model simulates 100 scenarios with varying quarterly incidence of six key pathogens known to be prevalent in rural Laos. In the simulations, community health workers either prescribe antibiotics in-line with current practice as documented in health facilities in rural Laos, or with the aid of the two interventions. We provide cost-effectiveness estimates for each strategy alone and then for an integrated approach using both interventions. Results: We find that each strategy is predicted to be highly cost-effective, and that the combined approach is predicted to result in the biggest reduction in mortality (averting a predicted 510 deaths per year in rural Savannakhet, a 28% reduction compared to standard practice) and is highly cost-effective, with an incremental cost-effectiveness ratio of just $66 per disability-adjusted life year averted. Conclusions: Substantial seasonal variation in the predicted optimal empirical antibiotic treatment for febrile illness highlights the benefits of up-to-date information on regional causes of fever. In this modelling analysis, an integrated system incorporating point-of-care host biomarker testing and regional surveillance data appears highly cost-effective, and may warrant piloting in a real-life setting.
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Affiliation(s)
- Arjun Chandna
- Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Department for Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Lisa J. White
- Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Tiengkham Pongvongsa
- Savannakhet Provincial Health Department, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Savannakhet Province, Lao People's Democratic Republic
| | - Mayfong Mayxay
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Savannakhet Provincial Health Department, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Savannakhet Province, Lao People's Democratic Republic
- Institute of Research and Education Development, University of Health Sciences, Vientiane, Lao People's Democratic Republic
| | - Paul N. Newton
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Savannakhet Provincial Health Department, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Savannakhet Province, Lao People's Democratic Republic
| | - Nicholas P. J. Day
- Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Yoel Lubell
- Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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20
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Chandna A, White LJ, Pongvongsa T, Mayxay M, Newton PN, Day NPJ, Lubell Y. Accounting for aetiology: can regional surveillance data alongside host biomarker-guided antibiotic therapy improve treatment of febrile illness in remote settings? Wellcome Open Res 2019; 4:1. [PMID: 31245630 PMCID: PMC6589932 DOI: 10.12688/wellcomeopenres.14976.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2018] [Indexed: 10/14/2023] Open
Abstract
Background: Across Southeast Asia, declining malaria incidence poses a challenge for healthcare providers, in how best to manage the vast majority of patients with febrile illnesses who have a negative malaria test. In rural regions, where the majority of the population reside, empirical treatment guidelines derived from central urban hospitals are often of limited relevance. In these settings, relatively untrained health workers deliver care, often without any laboratory diagnostic support. In this paper, our aim was to model the impact on mortality from febrile illness of using point-of-care C-reactive protein testing to inform the decision to prescribe antibiotics and regional surveillance data to inform antibiotic selection, rooted in the real-world context of rural Savannakhet province, southern Laos. Methods: Our model simulates 100 scenarios with varying quarterly incidence of six key pathogens known to be prevalent in rural Laos. In the simulations, community health workers either prescribe antibiotics in-line with current practice as documented in health facilities in rural Laos, or with the aid of the two interventions. We provide cost-effectiveness estimates for each strategy alone and then for an integrated approach using both interventions. Results: We find that each strategy alone is predicted to be highly cost-effective, and that the combined approach is predicted to result in the biggest reduction in mortality (averting a predicted 510 deaths per year in rural Savannakhet, a 28% reduction compared to standard practice) and is highly cost-effective, with an incremental cost-effectiveness ratio of just $66 per disability-adjusted life year averted. Conclusions: Substantial seasonal variation in the predicted optimal empirical antibiotic treatment for febrile illness highlights the benefits of up-to-date information on regional causes of fever. In this modelling analysis, an integrated system incorporating point-of-care host biomarker testing and regional surveillance data appears highly cost-effective, and may warrant piloting in a real-life setting.
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Affiliation(s)
- Arjun Chandna
- Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Department for Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Lisa J. White
- Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Tiengkham Pongvongsa
- Savannakhet Provincial Health Department, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Savannakhet Province, Lao People's Democratic Republic
| | - Mayfong Mayxay
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Savannakhet Provincial Health Department, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Savannakhet Province, Lao People's Democratic Republic
- Institute of Research and Education Development, University of Health Sciences, Vientiane, Lao People's Democratic Republic
| | - Paul N. Newton
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Savannakhet Provincial Health Department, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Savannakhet Province, Lao People's Democratic Republic
| | - Nicholas P. J. Day
- Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Yoel Lubell
- Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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