An urban-to-rural continuum of malaria risk: new analytic approaches characterize patterns in Malawi

Urban malaria and its determinants in Eastern Ethiopia: the role of Anopheles stephensi and urbanization

BACKGROUND

Malaria prevention and control strategies have been hampered by urbanization and the spread of Anopheles stephensi. The spread of this vector into Africa further complicates the already complex malaria situation, that could put about 126 million Africans at risk of infection. Hence, this study aimed to assess the determinants of urban malaria, focusing on the role of urbanization and the distribution of An. stephensi in Eastern Ethiopia.

METHODS

A matched case control study was conducted among febrile urban residents of Dire Dawa (malaria positive as cases and negative as a control). A capillary blood sample was collected for parasite identification using microscopic examination and an interviewer administered questionnaire was used to collect additional data. Centers for Disease Control and Prevention miniature light traps (CDC-LT) and Prokopack aspirator were used to collect adult mosquito vectors from the selected cases and control houses to identify the mosquito vector species. Then, the data were exported to STATA for analysis. Conditional logistic regression was done to identify determinants, and principal component Analysis (PCA) was done for some independent variables.

RESULTS

This study enrolled 132 cases and 264 controls from urban setting only. Of the 132 cases, 90 cases were positive for Plasmodium falciparum, 34 were positive for Plasmodium vivax and 8 had mixed infections. All cases and controls were similar with regard to their respective age and sex. Travel history (AOR: 13.1, 95% CI 2.8-61.4), presence of eves and holes on walls (AOR: 2.84, 95% CI 1.5-5.5), history of malaria diagnosis (AOR: 2.4, 95% CI 1.1-5.3), owning any livestock (AOR: 7.5, 95% CI 2.4-22.8), presence of stagnant water in the area (AOR: 3.2, 95% CI 1.7-6.1), sleeping under bed net the previous night (AOR: 0.21, 95% CI 0.1-0.6) and knowledge on malaria and its prevention (AOR: 2.2, 95% CI 1.2-4.1) were determinants of urban malaria infection. About 34 adult Anopheles mosquitoes were collected and identified from those selected cases and control houses and 27 of them were identified as An. stephensi.

CONCLUSION

Among the cases, the dominant species were P. falciparum. This study identified travel history, house condition, past infection, livestock ownership, stagnant water, bed net use, and malaria knowledge as determinants of infection. This study also found the dominance of the presence of An. stephensi among the collected mosquito vectors. This suggests that the spread of An. stephensi may be impacting malaria infection in the study area. Hence, strengthening urban-targeted malaria interventions should be enhanced to prevent and control further urban malaria infection and spread.

"Dengue fever is not just urban or rural: Reframing its spatial categorization."

Infectious diseases exploit niches that are often spatially defined as urban and/or rural. Yet spatial research on infectious diseases often fails to define "urban" and "rural" and how these contexts might influence their epidemiology. We use dengue fever, thought to be mostly an urban disease with rural foci, as a device to explore local definitions of urban and rural spaces and the impact of these spaces on dengue risk in the provinfine urban and rural locales. Interviews conducted from 2019 to 2021 with 71 residents and 23 health personce of Esmeraldas, Ecuador. Ecuador, like many countries, only uses population size and administrative function to denel found that they identified the availability of basic services, extent of their control over their environment, and presence of underbrush and weeds (known in Ecuador as monte and maleza and conceptualized in this paper as natural disorder) as important links to their conceptions of space and dengue risk. This broader conceptualization of space articulated by local residents and professionals reflects a more sophisticated approach to characterizing dengue risk than using categories of urban and rural employed by the national census and government. Rather than this dichotomous category of space, dengue fever can be better framed for health interventions in terms of specific environmental features and assemblages of high-risk spaces. An understanding of how community members perceive risk enhances our ability to collaborate with them to develop optimal mitigation strategies.

Post-war status of water supply, sanitation, hygiene and related reported diseases in Tigray, Ethiopia: A community-based cross-sectional study

Water, sanitation and hygiene (WASH) associated diseases remain a global public health issue and linked with Sustainable Development Goal 6. In November 2020, a war broke out in Tigray, Ethiopia, resulting in a negative health consequence. The post war status of WASH and its associated diseases are not documented. The aim of this study was to assess the status of drinking water, sanitation and hygiene practices and the prevalence of WASH-associated diseases in Tigray, Ethiopia following the war. A community-based cross-sectional study was conducted in 24 randomly selected accessible districts of Tigray, Ethiopia. A standardized questionnaire was used to collect data from households in the study. Data was collected from 2338 households. Descriptive statistics and binary logistic regression were used to analyze the data. The average age of respondents was 28.7 years (SD = 6.2). The majority of respondents 2030 (86.8%) were married and 1698 (72.6%) were rural residents. Nearly one third of the respondents were uneducated and around 40% have either radio or TV as means of communication. More than half (55.2%) of the respondents had a family size of over 5. A quarter (25%, 95% CI: 23.3, 26.8) of study participants had access to a basic water supply. Less than a tenth (7.7%, 95% CI: 6.6, 8.8) of households had access to basic sanitation. Basic hand washing was available in 2% of households. Malaria, diarrhoea, skin infection and eye infection were the common reported disease in the community. Marital status, family size, place of residence and liquid waste management were the most important predictors of reported diseases. Access to basic water, sanitation and hygiene services was low, and the prevalence of malaria, diarrhoea and skin infections was higher. There were differences in WASH services and reported diseases according to zone and place of residence (urban-rural). Post war, improved access to basic water, sanitation and hygiene services is recommended to prevent WASH-associated diseases in Tigray, Ethiopia. Furthermore, the prevention oriented policy of the country needs better implementation to reduce preventable diseases and ensure better health status in the community.

Drivers of autochthonous malaria cases over time: could the Central European present the African future?

BACKGROUND

Results of spatial and temporal comparison of malaria hotspots and coldspots could improve the health measures of malaria control and eradication strategies. The study aimed to reveal the spatially and temporally independent correlations between the potentially most effective background variables and the number of autochthonous malaria cases.

METHODS

Relationships between malaria cases and background variables were studied in 2 km × 2 km sized quadrates (10 Central European and 10 African). In addition to the current habitat structure of the African sites, annual precipitation, and annual mean temperature, data of the above parameters detected in the nineteenth and twentieth centuries and currently in the Central European sites were included in the analyses (n = 40). Mann-Whitney tests, Principal Component Analysis, and Generalized Linear Models were used for the examinations.

RESULTS

In addition to the apparent significant positive correlation of malaria cases with annual rainfall and mean temperature, several correlations were found for habitat parameters. The cover of marshlands in the 19th-century habitat structure of Central European quadrates was considerably the same as in the recent African ones. The extent of rural residential areas was significantly smaller in the 19th-century habitat structure of Central European quadrats than in present-day African ones. According to the revealed correlations, the surface cover of rural residential areas is the main driver of the number of autochthonous malaria cases that we can directly impact.

CONCLUSIONS

The study confirmed with historical comparison that not only the annual rainfall and mean temperature, the cover of marshlands and other habitats with breeding sites, but also the elements of the rural human environment play a significant role in the high number of autochthonous malaria cases, probably through the concentration and enhancing sites for vector mosquitoes. The latter confirms that a rapid urbanization process could reduce malaria cases in the most infected areas of Africa. Until the latter happens, extensive biological control of Anopheles larvae and chemical control (both outdoor and indoor) of their imagoes, further mosquito nets, repellents, and carbon dioxide traps will need to be applied more widely in the most heavily infested areas.

Urbanization and malaria have a contextual relationship in endemic areas: A temporal and spatial study in Ghana

In West Africa, malaria is one of the leading causes of disease-induced deaths. Existing studies indicate that as urbanization increases, there is corresponding decrease in malaria prevalence. However, in malaria-endemic areas, the prevalence in some rural areas is sometimes lower than in some peri-urban and urban areas. Therefore, the relationship between the degree of urbanization, the impact of living in urban areas, and the prevalence of malaria remains unclear. This study explores this association in Ghana, using epidemiological data at the district level (2015-2018) and data on health, hygiene, and education. We applied a multilevel model and time series decomposition to understand the epidemiological pattern of malaria in Ghana. Then we classified the districts of Ghana into rural, peri-urban, and urban areas using administratively defined urbanization, total built areas, and built intensity. We converted the prevalence time series into cross-sectional data for each district by extracting features from the data. To predict the determinant most impacting according to the degree of urbanization, we used a cluster-specific random forest. We find that prevalence is impacted by seasonality, but the trend of the seasonal signature is not noticeable in urban and peri-urban areas. While urban districts have a slightly lower prevalence, there are still pockets with higher rates within these regions. These areas of high prevalence are linked to proximity to water bodies and waterways, but the rise in these same variables is not associated with the increase of prevalence in peri-urban areas. The increase in nightlight reflectance in rural areas is associated with an increased prevalence. We conclude that urbanization is not the main factor driving the decline in malaria. However, the data indicate that understanding and managing malaria prevalence in urbanization will necessitate a focus on these contextual factors. Finally, we design an interactive tool, 'malDecision' that allows data-supported decision-making.

Distribution and dynamics of Anopheles gambiae s.l. larval habitats in three Senegalese cities with high urban malaria incidence

Urban malaria has become a challenge for most African countries due to urbanization, with increasing population sizes, overcrowding, and movement into cities from rural localities. The rapid expansion of cities with inappropriate water drainage systems, abundance of water storage habitats, coupled with recurrent flooding represents a concern for water-associated vector borne diseases, including malaria. This situation could threaten progress made towards malaria elimination in sub-Saharan countries, including Senegal, where urban malaria has presented as a threat to national elimination gains. To assess drivers of urban malaria in Senegal, a 5-month study was carried out from August to December 2019 in three major urban areas and hotspots for malaria incidence (Diourbel, Touba, and Kaolack) including the rainy season (August-October) and partly dry season (November-December). The aim was to characterize malaria vector larval habitats, vector dynamics across both seasons, and to identify the primary eco- environmental entomological factors contributing to observed urban malaria transmission. A total of 145 Anopheles larval habitats were found, mapped, and monitored monthly. This included 32 in Diourbel, 83 in Touba, and 30 in Kaolack. The number of larval habitats fluctuated seasonally, with a decrease during the dry season. In Diourbel, 22 of the 32 monitored larval habitats (68.75%) were dried out by December and considered temporary, while the remaining 10 (31.25%) were classified as permanent. In the city of Touba 28 (33.73%) were temporary habitats, and of those 57%, 71% and 100% dried up respectively by October, November, and December. However, 55 (66.27%) habitats were permanent water storage basins which persisted throughout the study. In Kaolack, 12 (40%) permanent and 18 (60%) temporary Anopheles larval habitats were found and monitored during the study. Three malaria vectors (An. arabiensis, An. pharoensis and An. funestus s.l.) were found across the surveyed larval habitats, and An. arabiensis was found in all three cities and was the only species found in the city of Diourbel, while An. arabiensis, An. pharoensis, and An. funestus s.l. were detected in the cities of Touba and Kaolack. The spatiotemporal observations of immature malaria vectors in Senegal provide evidence of permanent productive malaria vector larval habitats year-round in three major urban centers in Senegal, which may be driving high urban malaria incidence. This study aimed to assess the presence and type of anopheline larvae habitats in urban areas. The preliminary data will better inform subsequent detailed additional studies and seasonally appropriate, cost-effective, and sustainable larval source management (LSM) strategies by the National Malaria Control Programme (NMCP).

Exploring the role of spending on malaria incidence in Uganda using the auto-regressive distributed lag approach

BACKGROUND

Malaria has remained a persistent global health problem. Despite multiple government and donor initiatives to eradicate malaria and its detrimental effects on Uganda's health outcomes, the incidence of malaria is worrying as it appears higher than the average of 219 cases per 1000 for sub-Saharan Africa for the period 2017-2018. This study investigated the effect of public and private healthcare spending on the incidence of malaria in Uganda.

METHODS

Employing time series data spanning over 20 years from the first quarter of 2000 to the last quarter of 2019, the study builds a model based on the Grossman framework for analysing demand for health. The estimation technique used was the ARDL approach that takes into account reverse causality and incidental relationships. Prior to the adoption of the technique, a bounds test was performed to determine whether the variables contained in the model have a long-term relationship. Several diagnostic tests for serial correlation, functional normality, and heteroskedastic specification error were carried out to verify the ARDL model's goodness of fit. Additionally, the cumulative sum of recursive (CUSUM) and cumulative sum of squares of recursive residuals (CUSUMSQ) were used to test model stability.

RESULTS

The results indicate that in the long run, an increase in public spending of one percent significantly reduces malaria incidence by 0.196 at the 10 percent level of significance. On the other hand, there is no significant evidence of private health expenditure's effect on malaria incidence. However, in the short run, public spending reduces malaria incidence by a smaller magnitude of 0.158 percent relative to the long-run. Still, private expenditure is found to exhibit no significant effect. Additional findings point to the importance of GDP per capita and urban population growth in reducing malaria incidence, whereas female unemployment, income inequality, as well as female-headed household. In the short run, however, the female-headed households and urban population growth are found to significantly reduce malaria incidence while an improvement in regulatory quality decreases malaria incidence by 0.129 percent.

CONCLUSIONS

There is need for further government interventions to reduce malaria incidence in the country via budget allocation, as well as the strengthening of programmes to raise household income to support private health spending, in addition to the development of strategies to promote well-planned and organized urban centres.

Factors influencing fever care-seeking for children under five years of age in The Gambia: a secondary analysis of 2019-20 DHS data

BACKGROUND

Malaria contributes to excess child mortality in The Gambia. Children under five are at risk of severe malaria and death if not treated promptly and appropriately. It is crucial that a child with fever receive appropriate care from a trained provider. The aim was to identify influences on child fever care-seeking in The Gambia to inform malaria control strategies.

METHODS

This cross-sectional analysis of The Gambia 2019-20 Demographic and Health Survey used logistic regression analysis to identify associations between source of care for a child with fever (public or private healthcare provider, other, or no treatment) and mother, child, and household characteristics.

RESULTS

Only 52.0% of mothers sought care from a trained healthcare provider for a child with fever-45.1% from a public facility and 7.0% from the private sector. 35.2% of mothers did not seek treatment. Mothers in urban households were 2.67 times as likely (aOR, 95% CI 1.504-4.736) as mothers in rural households to seek care from an informal source (e.g., pharmacy) versus not seeking treatment, and 0.29 times as likely (aOR, 95% CI 0.165-0.515) as mothers in rural households to seek care from a public provider versus informal source. Mothers in wealthier households were 2.30 times as likely (aOR, 95% CI 1.274-4.164) as mothers in poorer households to seek care from an informal source versus no treatment and half as likely as mothers in poorer households to seek care from a public provider versus informal source (aOR 0.53, 95% CI 0.291-0.959).

CONCLUSIONS

Maintaining The Gambia's malaria control achievements will require the active engagement and oversight of private pharmacies along with continued integrated community case management to reach mothers who do not seek care for a child with fever, and remove challenges to seeking appropriate care from trained providers. Whether influenced by convenience, costs, perceived urgency, or other factors, given the likelihood of urban mothers and mothers in wealthier households to seek care from private pharmacies, it will be necessary to incorporate private pharmacies into malaria control strategies while building public sector capacity and workforce, and initiating more effective attitude and behavioural change among mothers and households.

Plasmodium Parasitaemia and Urine Alterations among Pregnant Women Attending Antenatal Care in Aba Metropolis, Abia State, Nigeria

Malaria presents a huge threat to pregnant women, their foetus, and children below five years. This study is aimed at assessing malaria prevalence, associated clinical symptoms, and urine abnormalities among pregnant women in Aba metropolis, Abia State, Nigeria. A cross-sectional study involving 450 pregnant women purposively selected from nine health care centres was conducted. Data were analysed using SPSS version 26. The overall malaria prevalence rate was 68.4% (n = 308). Age group of 21-25 years had the highest prevalence rate of 20.4% (n = 92) while the least was recorded among the age group of 41-45 years (17 (3.8%)). Pregnant women in their first trimester had the greatest prevalence rate of 28.6% (n = 129), and the least prevalence was recorded among those in their third trimester (7 (15.6%)). The primigravidae were mostly infected at the rate of 27.7% (n = 125) whereas the multigravidae recorded the least prevalence of 85 (18.9%). Participants with secondary education were the most susceptible at the rate of 38.6% (n = 174). The infected participants exhibited significantly higher frequencies of reported fever (p > 0.001, OR 12.881, 95% CI 3.977-41.725) and headaches (p < 0.001, OR 4.688, 95% CI 1.819-12.083). However, cold, cough, body pains, poor appetite, and catarrh showed no significant association with malaria infection at p > 0.05. Participants using long-lasting insecticidal nets (LLINs) showed significantly lower prevalence rate of malaria infection (p < 0.001, OR 2.485, 95% CI 1.619-3.814). Malaria-infected participants showed statistically significant frequencies of proteinuria (p < 0.001, OR 274.14, 95% CI 16.91-4444.0), bilirubinuria (p < 0.001, OR 49.29, 95% CI 11.01-186.34), and urobilinogenuria (p < 0.001, OR 65.16, 95% CI 4.00-1062.40) than those not infected. Ascorbic acid, nitrate, and ketone showed no significant associations with malaria infection at p > 0.005. Infected participants had statistically significant amber and clear urine colour whereas there was no statistically significant difference between the pH levels of urine of the malaria-infected and malaria-noninfected pregnant women.

Prevalence of Endemic Respiratory Viruses During the COVID-19 Pandemic in Urban and Rural Malawi

Background

We investigated endemic respiratory virus circulation patterns in Malawi, where no lockdown was imposed, during the COVID-19 pandemic.

Methods

Within a prospective household cohort in urban and rural Malawi, adult participants provided upper respiratory tract (URT) samples at 4 time points between February 2021 and April 2022. Polymerase chain reaction (PCR) was performed for SARS-CoV-2, influenza, and other endemic respiratory viruses.

Results

1626 URT samples from 945 participants in 542 households were included. Overall, 7.6% (n = 123) samples were PCR- positive for >1 respiratory virus; SARS-CoV-2 (4.4%) and rhinovirus (2.0%) were most common. No influenza A virus was detected. Influenza B and respiratory syncytial virus (RSV) were rare. Higher virus positivity were detected in the rural setting and at earlier time points. Coinfections were infrequent.

Conclusions

Endemic respiratory viruses circulated in the community in Malawi during the pandemic, though influenza and RSV were rarely detected. Distinct differences in virus positivity and demographics were observed between urban and rural cohorts.

Urbanicity and child health in 26 sub-Saharan African countries: Settlement type and its association with mortality and morbidity

Urbanization and changing settlement patterns have affected health environments in African countries. A profound understanding of the intricate association between urbanicity and health is imperative for formulating effective interventions. This study aims to classify settlement types based on urbanicity and assess their effects on child health in 26 African countries, utilizing data from the Demographic and Health Survey and the Global Human Settlements Layer. The advanced settlement classification incorporates a multidimensional urbanicity scale and globally standardized urban extents, along with identifying urban slums. This approach derives six distinct settlement types: urban center, urban cluster, deprived urban settlement, rural town, rural cluster, and rural village. A multilevel logistic regression model examines the relationship between settlement types and health outcomes, encompassing mortality, fever, anemia, diarrhea, and cough in children under five. The analysis reveals that children living in rural villages and deprived urban settlements face a high burden of adverse health conditions. However, the size and direction of urbanicity's effects vary depending on the specific outcome. These findings highlight the significance of tailored interventions acknowledging health environments within each settlement to promote health equity.

Urban malaria vector bionomics and human sleeping behavior in three cities in Senegal

BACKGROUND

Malaria is endemic in Senegal, with seasonal transmission, and the entire population is at risk. In recent years, high malaria incidence has been reported in urban and peri-urban areas of Senegal. An urban landscape analysis was conducted in three cities to identify the malaria transmission indicators and human behavior that may be driving the increasing malaria incidence occurring in urban environments. Specifically, mosquito vector bionomics and human sleeping behaviors including outdoor sleeping habits were assessed to guide the optimal deployment of targeted vector control interventions.

METHODS

Longitudinal entomological monitoring using human landing catches and pyrethrum spray catches was conducted from May to December 2019 in Diourbel, Kaolack, and Touba, the most populous cities in Senegal after the capital Dakar. Additionally, a household survey was conducted in randomly selected houses and residential Koranic schools in the same cities to assess house structures, sleeping spaces, sleeping behavior, and population knowledge about malaria and vector control measures.

RESULTS

Of the 8240 Anopheles mosquitoes collected from all the surveyed sites, 99.4% (8,191) were An. gambiae s.l., and predominantly An. arabiensis (99%). A higher number of An. gambiae s.l. were collected in Kaolack (77.7%, n = 6496) than in Diourbel and Touba. The overall mean human biting rate was 14.2 bites per person per night (b/p/n) and was higher outdoors (15.9 b/p/n) than indoors (12.5 b/p/n). The overall mean entomological inoculation rates ranged from 3.7 infectious bites per person per year (ib/p/y) in Diourbel to 40.2 ib/p/y in Kaolack. Low anthropophilic rates were recorded at all sites (average 35.7%). Of the 1202 households surveyed, about 24.3% of household members slept outdoors, except during the short rainy season between July and October, despite understanding how malaria is transmitted and the vector control measures used to prevent it.

CONCLUSION

Anopheles arabiensis was the primary malaria vector in the three surveyed cities. The species showed an outdoor biting tendency, which represents a risk for the large proportion of the population sleeping outdoors. As all current vector control measures implemented in the country target endophilic vectors, these data highlight potential gaps in population protection and call for complementary tools and approaches targeting outdoor biting malaria vectors.

Digitally managed larviciding as a cost-effective intervention for urban malaria: operational lessons from a pilot in São Tomé and Príncipe guided by the Zzapp system

BACKGROUND

Once a mainstay of malaria elimination operations, larval source management (LSM)-namely, the treatment of mosquito breeding habitats-has been marginalized in Africa in favour of long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS). However, the development of new technologies, and mosquitoes' growing resistance to insecticides used in LLINs and IRS raise renewed interest in LSM.

METHODS

A digitally managed larviciding (DML) operation in three of the seven districts of São Tomé and Príncipe (STP) was launched by the Ministry of Health (MOH) and ZzappMalaria LTD. The operation was guided by the Zzapp system, consisting of a designated GPS-based mobile application and an online dashboard, which facilitates the detection, sampling and treatment of mosquito breeding sites. During the operation, quality assurance (QA) procedures and field management methods were developed and implemented.

RESULTS

12,788 water bodies were located and treated a total of 128,864 times. The reduction impact on mosquito population and on malaria incidence was 74.90% and 52.5%, respectively. The overall cost per person protected (PPP) was US$ 0.86. The cost varied between areas: US$ 0.44 PPP in the urban area, and US$ 1.41 PPP in the rural area. The main cost drivers were labour, transportation and larvicide material.

CONCLUSION

DML can yield highly cost-effective results, especially in urban areas. Digital tools facilitate standardization of operations, implementation of QA procedures and monitoring of fieldworkers' performance. Digitally generated spatial data also have the potential to assist integrated vector management (IVM) operations. A randomized controlled trial (RCT) with a larger sample is needed to further substantiate findings.

Optimizing Routine Malaria Surveillance Data in Urban Environments: A Case Study in Maputo City, Mozambique

In urban settings in malaria-endemic countries, malaria incidence is not well characterized and assumed to be typically very low and consisting largely of imported infections. In such contexts, surveillance systems should adapt to ensure that data are of sufficient spatial and temporal resolution to inform appropriate programmatic interventions. The aim of this research was to 1) assess spatial and temporal trends in reported malaria cases in Maputo City, Mozambique, using an expanded case notification form and 2) to determine how malaria surveillance can be optimized to characterize the local epidemiological context, which can then be used to inform targeted entomological investigations and guide implementation of localized malaria responses. This study took place in all six health facilities of KaMavota District in Maputo City, Mozambique. A questionnaire was administered to all confirmed cases from November 2019 to August 2021. Households of cases were retrospectively geolocated using local landmarks as reference. Overall, 2,380 malaria cases were reported, with the majority being uncomplicated (97.7%) and a median age of 21 years; 70.8% of cases had reported traveling outside the city in the past month with nine reporting traveling internationally. Maps of the 1,314 malaria cases that were geolocated showed distinct spatial patterns. The expanded case notification form enables a more granular overview of the malaria epidemiology in Maputo City; the geolocation data clearly show the areas where endemic transmission is likely, thus informing where resources should be prioritized. As urbanization is rapidly increasing in malaria endemic areas, identifying systems and key variables to collect ensures an operational way to characterize urban malaria through optimization of routine data to inform decision-making.

Routine Healthcare Facility- and Antenatal Care-Based Malaria Surveillance: Challenges and Opportunities

Most monitoring and evaluation tools for measuring malaria burden, intervention coverage, and impact of interventions use periodic nationally representative cross-sectional household surveys. These provide advantages in terms of selecting a large, unbiased, population-based sample; however, they are infrequently conducted, are resource-intensive, and do not provide longitudinal data with sufficient granularity. Given the heterogeneity of malaria transmission within most endemic countries, systems with the capacity to provide more granular and frequent data would be more actionable by national malaria control programs and local implementing partners. There is increasing interest in using routine health facility data, usually from outpatient department visits, for monitoring malaria burden. Data from pregnant women attending antenatal care (ANC) could minimize bias related to fever care-seeking among outpatient department visits and provide more granular parasite prevalence data. Most pregnant women attend ANC at least once and are thus highly representative of the overall pregnant population. A growing body of evidence suggests that malaria parasitemia in pregnant women is correlated with parasitemia in children aged < 5 years in moderate to high transmission areas, allowing for monitoring parasitemia in real time. Additional data are needed to assess whether pregnant women are sufficiently representative of the overall population to yield valid malaria prevalence and intervention coverage estimates. Although use of routinely collected ANC data faces many of the same challenges experienced by other routinely collected health facility data, the opportunity to improve parasite prevalence monitoring and the associated health benefits to mothers and infants of early detection of parasitemia make these efforts valuable.

Automated measurement of malaria parasitaemia among asymptomatic blood donors in Malawi using the Sysmex XN-31 analyser: could such data be used to complement national malaria surveillance in real time?

BACKGROUND

The recent worldwide increase in malaria cases highlights the need for renewed efforts to eliminate malaria. The World Health Organization advocates that malaria surveillance becomes a core intervention. Current methods to estimate the malaria burden rely on clinical malaria case reports and surveys of asymptomatic parasite infection mainly from children  < 5 years. In this study the hypothesis was that screening blood donors for malaria parasites would provide real-time information on the asymptomatic reservoir of parasites in the adult population and mirror other surveillance data.

METHODS

This study was conducted in Malawi, a high malaria burden country, at the Malawi Blood Transfusion Service, which collects blood units at donation sites countrywide. A secondary analysis was conducted on data obtained from a prior Sysmex XN-31 analyser malaria diagnostic evaluation study utilizing residual donor blood samples. XN-31 malaria results, donor age, sex, geographical location, and collection date, were analysed using standard statistical methods.

RESULTS

The malaria parasite prevalence in blood donors was 11.6% (614/5281 samples) increasing seasonally from December (8.6%) to April (18.3%). The median age was 21 years and 45.9% of donors were from urban areas, which showed a lower prevalence compared to non-urban regions. The Central administrative region had the highest and the Northern region the lowest malaria parasite prevalence. The donors were predominantly male (80.2%), 13.1% of whom had malaria parasites, which was significantly higher (p < 0.0001) than for female donors (7.4%). Multivariable logistic regression analysis showed that age, location, and collection month were significant predictors of malaria positivity in males, whereas in females only location was significant. There was no gender difference in parasite density nor gametocyte carriage.

CONCLUSIONS

This study demonstrates the powerful utility of screening blood donors for malaria parasites using the XN-31, which not only improves the safety of blood transfusion, but provides valuable complementary surveillance data for malaria control, especially targeting males, who are generally excluded from periodic household surveys. Blood donations are sourced countrywide, year-round, and thus provide dynamic, real-time information on the malaria burden. Furthermore, the XN-31 identifies the asymptomatic human reservoir of infectious gametocytes, which must be targeted to eliminate malaria.

Prevention and control of COVID-19 by primary health care facilities in China: a field-survey-based qualitative study in three typical cities

Background

During the coronavirus disease 2019 (COVID-19) containment, primary health care (PHC) facilities inChina played an important role in providing both healthcare and public care services to community populations. The tasks of COVID-19 containment facilitated by PHC facilities were different among different regions and during different periods of COVID-19 pandemic. We sought to investigate the gaps on task participation, explore existing problems and provide corresponding solutions.

Methods

Semi-structured face-to-face interviews with COVID-19 prevention and control management teams of PHC facilities were conducted. Purposive stratified sampling was used and 32 team members of 22 PHC facilities were selected from Wuhan (as high-risk city), Shanghai (as medium-risk city) and Zunyi (as low-risk city). Framework analysis was employed to analyze the transcribed recordings.

Results

The main tasks of PHC facilities during the early period of the pandemic included assisting in contact tracing and epidemiological investigation, screening of populations at high-risk at travel centers/internals, house-by-house, or pre-examination/triage within PHC facilities; at-home/ centralized quarantine management; the work of fever sentinel clinics.

Further analyses revealed the existing problems and suggestions for improvement or resolutions. Regular medical supply reserves were recommended because of the medical supply shortage during the pre-outbreak period. Temporarily converted quarantine wards and centralized quarantine centers could be used to deal with pressures on patients’ treatment and management of the febrile patients. Only after strict evaluation of nucleic acid testing (NAT) results and housing conditions, decision on quarantine at-home or centralized quarantine centers could be made. Settings of fever sentinel clinics at PHC facilities allowed fever patients with no COVID-19 infection risks for treatment without being transferred to fever clinics of the designed secondary hospitals. Psychological intervention was sometimes in need and really helped in addressing individuals’ mental pressures.

Conclusions

During the COVID-19 containment, PHC facilities in China were responsible for different tasks and several problems were encountered in the working process. Accordingly, specific and feasible suggestions were put forward for different problems. Our findings are highly beneficial for healthcare teams and governments in handling similar situations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07770-4.

Rural-Urban Differences: Using Finer Geographic Classifications to Reevaluate Distance and Choice of Health Services in Malawi

There is no universal understanding of what defines urban or rural areas nor criteria for differentiating within these. When assessing access to health services, traditional urban-rural dichotomies may mask substantial variation. We use geospatial methods to link household data from the 2015-2016 Malawi Demographic Health Survey to health facility data from the Malawi Service Provision Assessment and apply a new proposed four-category classification of geographic area (urban major metropolitan area, urban township, rural, and remote) to evaluate households' distance to, and choice of, primary, secondary, and tertiary health care in Malawi. Applying this new four-category definition, approximately 3.8 million rural- and urban-defined individuals would be reclassified into new groups, nearly a quarter of Malawi's 2015 population. There were substantial differences in distance to the nearest facility using this new categorization: remote households are (on average) an additional 5 km away from secondary and tertiary care services versus rural households. Health service choice differs also, particularly in urban areas, a distinction that is lost when using a simple binary classification: those living in major metropolitan households have a choice of five facilities offering comprehensive primary care services within a 10-km zone, whereas urban township households have no choice, with only one such facility within 10 km. Future research should explore how such expanded classifications can be standardized and used to strengthen public health and demographic research.