Correction to: Monitoring changes in malaria epidemiology and effectiveness of interventions in Ethiopia and Uganda: Beyond Garki Project baseline survey

Please be advised that one of the author names is incorrectly spelled in the published article: 'Irene Kyomuhagi' should be 'Irene Kyomuhangi'.

Insecticide resistance patterns in Uganda and the effect of indoor residual spraying with bendiocarb on kdr L1014S frequencies in Anopheles gambiae s.s

BACKGROUND

Resistance of malaria vectors to pyrethroid insecticides has been attributed to selection pressure from long-lasting insecticidal nets (LLINs), indoor residual spraying (IRS), and the use of chemicals in agriculture. The use of different classes of insecticides in combination or by rotation has been recommended for resistance management. The aim of this study was to understand the role of IRS with a carbamate insecticide in management of pyrethroid resistance.

METHODS

Anopheles mosquitoes were collected from multiple sites in nine districts of Uganda (up to five sites per district). Three districts had been sprayed with bendiocarb. Phenotypic resistance was determined using standard susceptibility tests. Molecular assays were used to determine the frequency of resistance mutations. The kdr L1014S homozygote frequency in Anopheles gambiae s.s. was used as the outcome measure to test the effects of various factors using a logistic regression model. Bendiocarb coverage, annual rainfall, altitude, mosquito collection method, LLIN use, LLINs distributed in the previous 5 years, household use of agricultural pesticides, and malaria prevalence in children 2-9 years old were entered as explanatory variables.

RESULTS

Tests with pyrethroid insecticides showed resistance and suspected resistance levels in all districts except Apac (a sprayed district). Bendiocarb resistance was not detected in sprayed sites, but was confirmed in one unsprayed site (Soroti). Anopheles gambiae s.s. collected from areas sprayed with bendiocarb had significantly less kdr homozygosity than those collected from unsprayed areas. Mosquitoes collected indoors as adults had significantly higher frequency of kdr homozygotes than mosquitoes collected as larvae, possibly indicating selective sampling of resistant adults, presumably due to exposure to insecticides inside houses that would disproportionately affect susceptible mosquitoes. The effect of LLIN use on kdr homozygosity was significantly modified by annual rainfall. In areas receiving high rainfall, LLIN use was associated with increased kdr homozygosity and this association weakened as rainfall decreased, indicating more frequency of exposure to pyrethroids in relatively wet areas with high vector density.

CONCLUSION

This study suggests that using a carbamate insecticide for IRS in areas with high levels of pyrethroid resistance may reduce kdr frequencies in An. gambiae s.s.

The use of formative research to inform the design of a seasonal malaria chemoprevention intervention in northern Nigeria

Background

Experience of seasonal malaria chemoprevention (SMC) is growing in the Sahel sub-region of Africa, though there remains insufficient evidence to recommend a standard deployment strategy. In 2012, a project was initiated in Katsina state, northern Nigeria, to design an appropriate and effective community-based delivery approach for SMC, in consultation with local stakeholders. Formative research (FR) was conducted locally to explore the potential feasibility and acceptability of SMC and to highlight information gaps and practical considerations to inform the intervention design.

Methods

The FR adopted qualitative methods; 36 in-depth interviews and 18 focus group discussions were conducted across 13 target groups active across the health system and within the community. Analysis followed the ‘framework’ approach. The process for incorporating the FR results into the project design was iterative which was initiated by a week-long ‘intervention design’ workshop with relevant stakeholders.

Results

The FR highlighted both supportive and hindering factors to be considered in the intervention design. Malaria control was identified as a community priority, the community health workers were a trusted resource and the local leadership exerted strong influence over household decisions. However, there were perceived challenges with quality of care at both community and health facility levels, referral linkage and supportive supervision were weak, literacy levels lower than anticipated and there was the potential for suspicion of ‘outside’ interventions. There was broad consensus across target groups that community-based SMC drug delivery would better enable a high coverage of beneficiaries and potentially garner wider community support. A mixed approach was recommended, including both community fixed-point and household-to-household SMC delivery. The FR findings were used to inform the overall distribution strategy, mechanisms for integration into the health system, capacity building and training approaches, supportive interventions to strengthen the health system, and the social mobilization strategy.

Conclusions

Formative research played a valuable role in exploring local socio-cultural contexts and health system realities. Both opportunities and challenges for the introduction of SMC delivery were highlighted, which were appropriately considered in the design of the project.

Exposure to deltamethrin affects development of Plasmodium falciparum inside wild pyrethroid resistant Anopheles gambiae s.s. mosquitoes in Uganda

Background

Pyrethroid resistance in African vector mosquitoes is a threat to malaria control. Resistant mosquitoes can survive insecticide doses that would normally be lethal. We studied effects of such doses on Plasmodium falciparum development inside kdr-resistant Anopheles gambiae s.s. in Uganda.

Methods

We collected An. gambiae s.s. homozygous for kdr-L1014S mutation, fed them on blood samples from 42 P. falciparum-infected local patients, then exposed them either to nets treated with sub-lethal doses of deltamethrin or to untreated nets. After seven days, we dissected 692 mosquitoes and examined their midguts for oocysts. Prevalence (proportion infected) and intensity of infection (number of oocysts per infected mosquito) were recorded for each group.

Results

Both prevalence and intensity of infection were significantly reduced in deltamethrin-exposed mosquitoes, compared to those exposed to untreated nets. With low doses (2.5–5.0 mg/m²), prevalence was reduced by 59 % (95 % CI = 22 %-78 %) and intensity by 41 % (95 % CI = 25 %-54 %). With high doses (10–16.7 mg/m²), prevalence was reduced by 80 % (95 % CI = 67 %-88 %) and intensity by 34 % (95 % CI = 20 %-46 %).

Conclusions

We showed that, with locally-sampled parasites and mosquitoes, doses of pyrethroids that are sub-lethal for resistant mosquitoes can interfere with parasite development inside mosquitoes. This mechanism could enable pyrethroid-treated nets to prevent malaria transmission despite increasing vector resistance.

Interventions to improve motivation and retention of community health workers delivering integrated community case management (iCCM): stakeholder perceptions and priorities

Despite resurgence in the use of community health workers (CHWs) in the delivery of community case management of childhood illnesses, a paucity of evidence for effective strategies to address key constraints of worker motivation and retention endures. This work reports the results of semi-structured interviews with 15 international stakeholders, selected because of their experiences in CHW program implementation, to elicit their views on strategies that could increase CHW motivation and retention. Data were collected to identify potential interventions that could be tested through a randomized control trial. Suggested interventions were organized into thematic areas; cross-cutting approaches, recruitment, training, supervision, incentives, community involvement and ownership, information and data management, and mHealth. The priority interventions of stakeholders correspond to key areas of the work motivation and CHW literature. Combined, they potentially provide useful insight for programmers engaging in further enquiry into the most locally relevant, acceptable, and evidence-based interventions.

Novel Cross-Border Approaches to Optimise Identification of Asymptomatic and Artemisinin-Resistant Plasmodium Infection in Mobile Populations Crossing Cambodian Borders

Background

Human population movement across country borders presents a real challenge for malaria control and elimination efforts in Cambodia and its neighbouring countries. To quantify Plasmodium infection among the border-crossing population, including asymptomatic and artemisinin resistant (AR) parasites, three official border crossing points, one from each of Cambodia's borders with Thailand, Laos and Vietnam, were selected for sampling.

Methods and Findings

A total of 3206 participants (of 4110 approached) were recruited as they crossed the border, tested for malaria and interviewed. By real-time polymerase chain reaction (RT-PCR), 5.4% of all screened individuals were found to harbour Plasmodium parasites. The proportion was highest at the Laos border (11.5%). Overall there were 97 P. vivax (55.7%), 55 P. falciparum (31.6%), two P. malariae (1.1%) and 20 mixed infections (11.5%). Of identified infections, only 20% were febrile at the time of screening. Of the 24 P. falciparum samples where a further PCR was possible to assess AR, 15 (62.5%) had mutations in the K13 propeller domain gene, all from participants at the Laos border point. Malaria rapid diagnostic test (RDT) pLDH/HRP-2 identified a positivity rate of 3.2% overall and sensitivity compared to RT-PCR was very low (43.1%). Main individual risk factors for infection included sex, fever, being a forest-goer, poor knowledge of malaria prevention methods and previous malaria infection. Occupation, day of the week and time of crossing (morning vs. afternoon) also appeared to play an important role in predicting positive cases.

Conclusions

This study offers a novel approach to identify asymptomatic infections and monitor AR parasite flow among mobile and migrant populations crossing the borders. Similar screening activities are recommended to identify other hot borders and characterise potential hot spots of AR. Targeted “customised” interventions and surveillance activities should be implemented in these sites to accelerate elimination efforts in the region.

Monitoring changes in malaria epidemiology and effectiveness of interventions in Ethiopia and Uganda: Beyond Garki Project baseline survey

Background

Scale-up of malaria interventions seems to have contributed to a decline in the disease but other factors may also have had some role. Understanding changes in transmission and determinant factors will help to adapt control strategies accordingly.

Methods

Four sites in Ethiopia and Uganda were set up to monitor epidemiological changes and effectiveness of interventions over time. Here, results of a survey during the peak transmission season of 2012 are reported, which will be used as baseline for subsequent surveys and may support adaptation of control strategies. Data on malariometric and entomological variables, socio-economic status (SES) and control coverage were collected.

Results

Malaria prevalence varied from 1.4 % in Guba (Ethiopia) to 9.9 % in Butemba (Uganda). The most dominant species was Plasmodium vivax in Ethiopia and Plasmodium falciparum in Uganda. The majority of human-vector contact occurred indoors in Uganda, ranging from 83 % (Anopheles funestus sensu lato) to 93 % (Anopheles gambiae s.l.), which is an important factor for the effectiveness of insecticide-treated nets (ITNs) or indoor residual spraying (IRS). High kdr-L1014S (resistance genotype) frequency was observed in A. gambiae sensu stricto in Uganda. Too few mosquitoes were collected in Ethiopia, so it was not possible to assess vector habits and insecticide resistance levels. ITN ownership did not vary by SES and 56–98 % and 68–78 % of households owned at least one ITN in Ethiopia and Uganda, respectively. In Uganda, 7 % of nets were purchased by households, but the nets were untreated. In three of the four sites, 69–76 % of people with access to ITNs used them. IRS coverage ranged from 84 to 96 % in the three sprayed sites. Half of febrile children in Uganda and three-quarters in Ethiopia for whom treatment was sought received diagnostic tests. High levels of child undernutrition were detected in both countries carrying important implications on child development. In Uganda, 7–8 % of pregnant women took the recommended minimum three doses of intermittent preventive treatment.

Conclusion

Malaria epidemiology seems to be changing compared to earlier published data, and it is essential to have more data to understand how much of the changes are attributable to interventions and other factors. Regular monitoring will help to better interpret changes, identify determinants, modify strategies and improve targeting to address transmission heterogeneity.

Mobile health (mHealth) approaches and lessons for increased performance and retention of community health workers in low- and middle-income countries: a review

Background

Mobile health (mHealth) describes the use of portable electronic devices with software applications to provide health services and manage patient information. With approximately 5 billion mobile phone users globally, opportunities for mobile technologies to play a formal role in health services, particularly in low- and middle-income countries, are increasingly being recognized. mHealth can also support the performance of health care workers by the dissemination of clinical updates, learning materials, and reminders, particularly in underserved rural locations in low- and middle-income countries where community health workers deliver integrated community case management to children sick with diarrhea, pneumonia, and malaria.

Objective

Our aim was to conduct a thematic review of how mHealth projects have approached the intersection of cellular technology and public health in low- and middle-income countries and identify the promising practices and experiences learned, as well as novel and innovative approaches of how mHealth can support community health workers.

Methods

In this review, 6 themes of mHealth initiatives were examined using information from peer-reviewed journals, websites, and key reports. Primary mHealth technologies reviewed included mobile phones, personal digital assistants (PDAs) and smartphones, patient monitoring devices, and mobile telemedicine devices. We examined how these tools could be used for education and awareness, data access, and for strengthening health information systems. We also considered how mHealth may support patient monitoring, clinical decision making, and tracking of drugs and supplies. Lessons from mHealth trials and studies were summarized, focusing on low- and middle-income countries and community health workers.

Results

The review revealed that there are very few formal outcome evaluations of mHealth in low-income countries. Although there is vast documentation of project process evaluations, there are few studies demonstrating an impact on clinical outcomes. There is also a lack of mHealth applications and services operating at scale in low- and middle-income countries. The most commonly documented use of mHealth was 1-way text-message and phone reminders to encourage follow-up appointments, healthy behaviors, and data gathering. Innovative mHealth applications for community health workers include the use of mobile phones as job aides, clinical decision support tools, and for data submission and instant feedback on performance.

Conclusions

With partnerships forming between governments, technologists, non-governmental organizations, academia, and industry, there is great potential to improve health services delivery by using mHealth in low- and middle-income countries. As with many other health improvement projects, a key challenge is moving mHealth approaches from pilot projects to national scalable programs while properly engaging health workers and communities in the process. By harnessing the increasing presence of mobile phones among diverse populations, there is promising evidence to suggest that mHealth can be used to deliver increased and enhanced health care services to individuals and communities, while helping to strengthen health systems.

Vector control in some countries of Southeast Asia: comparing the vectors and the strategies

The use of information on malaria vector behaviour in vector control is discussed in relation to the area of Southeast Asia comprising Cambodia, Laos, Myanmar, Thailand and Vietnam. The major vectors in the region are Anopheles dirus, An. minimus, An. maculatus and An. sundaicus, of which An. dirus is the most important. Options for vector control and the biological features of mosquitoes, which would make them amenable to control by these measures, are listed. The methods with the greatest potential for controlling each of the four vector species are described. Experiences of vector control by residual spraying, insecticide-treated nets and larva control and of personal protection against the four vectors are outlined, and it is noted that choice of control strategy is often determined by epidemiological, economic and political considerations, whilst entomological observations may help to explain failures of control and to indicate alternative strategies. Future research needs include basic entomological field studies using the most appropriate indicators to detect changes related to rapidly changing environmental conditions, such as loss of forest and climate change. Further studies of the efficacy of insecticide-treated mosquito nets, with greater attention to study design, are needed before it can be assumed that they will work in Southeast Asia. At the same time, research to improve sustainable utilization of nets is important, bearing in mind that nets are not the only means to control malaria and should not drain resources from supervision and training, which improve access to diagnosis and treatment of malaria and other diseases. Research is needed to make decisions on whether vector control is appropriate in different environments, and, if so, how to carry it out in different health systems. Researchers need to play a greater role in making operational research (entomological, epidemiological, social, economic and health systems research) of good quality an integral component of implementation programmes.

The Anopheles punctulatus group of mosquitoes in the Solomon Islands and Vanuatu surveyed by allozyme electrophoresis

Four species within the Anopheles punctulatus group of mosquitoes (Diptera: Culicidae) were identified by allozyme analysis of samples collected from thirty-three localities in Guadalcanal, Makira, Malaita, Temotu and Western Provinces in the Solomon Islands and six localities on Efate, Espiritu Santo, Maewo and Malekula Islands in Vanuatu. Three of these species are members of the An.farauti complex. A key is given to identify five species of the An.punctulatus group known to occur in the Solomon Islands using their isoenzyme characteristics. An.farauti No. 1 was widespread in coastal areas of the Solomon Islands and was the only species detected in Vanuatu, including Efate Island (where Faureville is the type locality of An.farauti Laveran sensu stricto). An.farauti No. 2 and An.punctulatus were common in the Solomon Islands in more inland areas. An.farauti No. 7, reported here for the first time, was found as larvae in freshwater at six localities on north Guadalcanal. Three other members of the An.punctulatus group which have been reported previously from the Solomon Islands: An.koliensis, An.renellensis and an electrophoretic variant of An.farauti sensu lato, were not found in our samples. Previously recognized vectors of malaria and bancroftian filariasis in the Solomon Islands are An.farauti No. 1 (i.e. An.farauti s.s.), An.koliensis and An.punctulatus s.s. Adult females of An.farauti No. 2 and An.farauti No. 7 were not attracted to human bait in areas where their larvae occurred, indicating that these two species are not anthropophilic and therefore unlikely to transmit human pathogens.

Malaria in Cambodia

There are around half a million cases of malaria with 5-10,000 deaths per year in Cambodia. Incidence rates vary in different parts of the country. Malaria control is hampered by multiple drug resistance of Plasmodium falciparum, inaccessibility to the major vector, poor security in most malarious areas, and lack of resources. The control strategy emphasises improvement of clinical management and provision of prompt and accurate diagnosis in order to reduce morbidity and to prevent mortality. In addition health information and drug distribution systems are being improved. The use of pyrethroid-treated mosquito nets and health education are being promoted. Particular attention is given to returning refugees as they settle into the country.

Epidemiology of malaria in displaced Khmers on the Thai-Kampuchean border

Malaria epidemiology from 1983 to 1985 in displaced Khmers living in camps on the Thai-Kampuchean border was studied for planning and evaluation of control measures. The annual parasite incidence per 1000 people fell from 359 in 1983 and 350 in 1984 to 116 in 1985. Incidence varied by camp according to the suitability of the habitat for the vectors. Camps with high incidence had a higher ratio of Plasmodium falciparum to P. vivax, a higher mortality rate, especially in young children and sometimes pregnant women, but a lower case fatality rate than camps with low incidence. Transmission occurred year round, but peaked in the rainy season in 1983 and 1984. In 1985 there was a steady decline in incidence, largely owing to evacuation of many camps away from forested areas. Mortality rates per 100,000 people were 62, 77 and 28 and case fatality rates 0.41, 0.31 and 0.42% in 1983, 1984 and 1985 respectively. The case fatality rate for cerebral malaria was 21 to 26%. Epidemiological information has been more useful for planning than for evaluating control measures.

Murine typhus among Khmers living at an evacuation site on the Thai-Kampuchean border

An outbreak of febrile disease involving 170 Khmer adults at an evacuation site in Thailand occurred during the dry season of 1986, only 8 months after the camp was constructed. The illnesses were characterized by persistent fever, retro-orbital headache, myalgias, and clinical response to tetracycline within 2-3 days. The symptoms, effectiveness of tetracycline, and presence of a large rat population raised the suspicion of murine typhus. Fourteen (74%) of 19 patients had elevated or rising antibody titers against Rickettsia typhi, confirming the clinical diagnosis. Rats were caught, and they and their fleas were identified. In agreement with the known Thai host and vector, 80 (93%) of 86 rats were Rattus exulans, and all of 32 fleas were Xenopsylla cheopis. This first reported outbreak of murine typhus in Thailand is notable for its occurrence in a new human settlement only 8 months after construction.

Treatment of falciparum malaria with quinne and tetracycline or combined mefloquine/sulfadoxine/pyrimethamine on the Thai-Kampuchean border

Three different regimens were compared for treatment of falciparum malaria in displaced Kampucheans living in encampments on the Thai-Kampuchean border in 1983: single dose 750 mg mefloquine, 1.5 g sulfadoxine, 75 mg pyrimethamine (MSP); 600 mg quinine 8-hourly for 3 days and 500 mg tetracycline 8-hourly for 7 days (Q3T7); or 600 mg quinine 8-hourly for 7 days and 500 mg tetracycline 8-hourly for 7 days (Q7T7). Radical cure rates were 98% (40/41) for MSP, 76% (32/42) for Q3T7 and 92% (33/36) for Q7T7. The criterion for treatment failure was reappearance of parasites by 35 days after commencement of treatment or no parasite clearance. Treatment failures comprised one case of reduction but no clearance of parasites (RII resistance) for MSP, 10 recrudescences (RI) for Q3T7 and 3 recrudescences (RI) for Q7T7. The radical cure rate for Q3T7 was significantly lower than that for MSP (P less than 0.01), whilst Q7T7 significantly from the other groups. Parasite clearance time was shorter (2.4 days) with MSP than with Q3T7 (3.5 days) and Q7T7 (3.3 days). There was little difference in side effects between the regimens, and tolerance was good. The MSP and Q7T7 regimens are both effective for treatment, but the single dose of MSP is much easier to manage than 7 days of quinine and tetracycline.

Occurrence of rickettsia-like symbionts among species of the Aedes scutellaris group (Diptera:Culicidae)

Rickettsia-like organisms were seen by electron microscopy in the oocytes and nurse cells of Aedes hebrideus and A. scutellaris scutellaris and in the oocytes of A. pseudoscutellaris, a Samoan stock of A. polynesiensis and in three Fijian stocks of A. polynesiensis. None were found in the ovaries of A. alcasidi, A. s. katherinensis, A. cooki nor in a second stock of Samoan A. polynesiensis. It is suggested that the distribution of rickettsia-like symbionts among species of the A. scutellaris group conflicts in some cases with the hypothesis that these organisms are responsible for cytoplasmic incompatibility in the group.