The Global Technical Strategy 2016-2030 of the World Health Organization (WHO) has the ambitious goal of malaria being eliminated from at least 35 countries by 2030. However, in areas with ...once-stable malaria transmission, the reservoir of human infection may be intermittently symptomatic or fully silent yet still lead to transmission, posing a serious challenge to elimination. Mass drug administration (MDA), defined as the provision of a therapeutic dose of an effective anti-malarial drug to the entire target population, irrespective of infection status or symptoms, is one strategy to combat the silent human reservoir of infection. MDA is currently recommended by the WHO as a potential strategy for the elimination of Plasmodium falciparum malaria in areas approaching interruption of transmission, given the prerequisites of good access to case management, effective vector control and surveillance, and limited potential for reintroduction. Recent community randomized controlled trials of MDA with dihydroartemisinin-piperaquine, implemented as part of a comprehensive package of interventions, have shown this strategy to be safe and effective in significantly lowering the malaria burden in pre-elimination settings. Here it is argued that effectively implemented MDA should be kept in the elimination toolbox as a potential strategy for P. falciparum elimination in a variety of settings, including islands, appropriate low transmission settings, and in epidemics and complex emergencies. Effectively implemented MDA using an ACT has been shown to be safe, unrelated to the emergence of drug resistance, and may play an important role in sufficiently lowering the malaria burden to allow malaria transmission foci to be more easily identified, and to allow elimination programmes to more feasibly implement case-based surveillance and follow-up activities. To be most impactful and guard against drug resistance, MDA should use an ACT, achieve high programmatic coverage and adherence, be implemented when transmission is lowest in areas of limited risk of immediate parasite reintroduction, and must always be implemented only once good access to case management, high coverage of effective vector control, and strong surveillance have been achieved. If these considerations are taken into account, MDA should prove to be a valuable tool for the malaria elimination toolbox.
Previous studies of anemia epidemiology have been geographically limited with little detail about severity or etiology. Using publicly available data, we estimated mild, moderate, and severe anemia ...from 1990 to 2010 for 187 countries, both sexes, and 20 age groups. We then performed cause-specific attribution to 17 conditions using data from the Global Burden of Diseases, Injuries and Risk Factors (GBD) 2010 Study. Global anemia prevalence in 2010 was 32.9%, causing 68.36 (95% uncertainty interval UI, 40.98 to 107.54) million years lived with disability (8.8% of total for all conditions 95% UI, 6.3% to 11.7%). Prevalence dropped for both sexes from 1990 to 2010, although more for males. Prevalence in females was higher in most regions and age groups. South Asia and Central, West, and East sub-Saharan Africa had the highest burden, while East, Southeast, and South Asia saw the greatest reductions. Iron-deficiency anemia was the top cause globally, although 10 different conditions were among the top 3 in regional rankings. Malaria, schistosomiasis, and chronic kidney disease–related anemia were the only conditions to increase in prevalence. Hemoglobinopathies made significant contributions in most populations. Burden was highest in children under age 5, the only age groups with negative trends from 1990 to 2010.
•Anemia accounted for 8.8% of the total disability from all conditions in 2010. Children <5 years and women still have the highest burden.•Although iron-deficiency anemia is the most common etiology globally, other leading causes of anemia vary widely by geography, age, and sex.
Zinc deficiency is commonly prevalent in children in developing countries and plays a role in decreased immunity and increased risk of infection. Preventive zinc supplementation in healthy children ...can reduce mortality due to common causes like diarrhea, pneumonia and malaria. The main objective was to determine all-cause mortality and cause-specific mortality and morbidity in children under five in developing countries for preventive zinc supplementation. DATA SOURCES/ REVIEW METHODS: A literature search was carried out on PubMed, the Cochrane Library and the WHO regional databases to identify RCTs on zinc supplementation for greater than 3 months in children less than 5 years of age in developing countries and its effect on mortality was analyzed.
The effect of preventive zinc supplementation on mortality was given in eight trials, while cause specific mortality data was given in five of these eight trials. Zinc supplementation alone was associated with a statistically insignificant 9% (RR = 0.91; 95% CI: 0.82, 1.01) reduction in all cause mortality in the intervention group as compared to controls using a random effect model. The impact on diarrhea-specific mortality of zinc alone was a non-significant 18% reduction (RR = 0.82; 95% CI: 0.64, 1.05) and 15% for pneumonia-specific mortality (RR = 0.85; 95% CI: 0.65, 1.11). The incidence of diarrhea showed a 13% reduction with preventive zinc supplementation (RR = 0.87; 95% CI: 0.81, 0.94) and a 19% reduction in pneumonia morbidity (RR = 0.81; 95% CI: 0.73, 0.90). Keeping in mind the direction of effect of zinc supplementation in reducing diarrhea and pneumonia related morbidity and mortality; we considered all the outcomes for selection of effectiveness estimate for inclusion in the LiST model. After application of the CHERG rules with consideration to quality of evidence and rule # 6, we used the most conservative estimates as a surrogate for mortality. We, therefore, conclude that zinc supplementation in children is associated with a reduction in diarrhea mortality of 13% and pneumonia mortality of 15% for inclusion in the LiST tool. Preventive zinc supplementation had no effect on malaria specific mortality (RR = 0.90; 95% CI: 0.77, 1.06) or incidence of malaria (RR = 0.92; 95 % CI 0.82-1.04).
Zinc supplementation results in reductions in diarrhea and pneumonia mortality.
Summary Background Low birthweight is a significant risk factor for neonatal and infant death. A prominent cause of low birthweight is infection with Plasmodium falciparum during pregnancy. ...Antimalarial intermittent preventive therapy in pregnancy (IPTp) and insecticide-treated mosquito nets (ITNs) significantly reduce the risk of low birthweight in regions of stable malaria transmission. We aimed to assess the effectiveness of malaria prevention in pregnancy (IPTp or ITNs) at preventing low birthweight and neonatal mortality under routine programme conditions in malaria endemic countries of Africa. Methods We used a retrospective birth cohort from national cross-sectional datasets in 25 African countries from 2000–10. We used all available datasets from multiple indicator cluster surveys, demographic and health surveys, malaria indicator surveys, and AIDS indicator surveys that were publically available as of 2011. We tried to limit confounding bias through exact matching on potential confounding factors associated with both exposure to malaria prevention (ITNs or IPTp with sulfadoxine–pyrimethamine) in pregnancy and birth outcomes, including local malaria transmission, neonatal tetanus vaccination, maternal age and education, and household wealth. We used a logistic regression model to test for associations between malaria prevention in pregnancy and low birthweight, and a Poisson model for the outcome of neonatal mortality. Both models incorporated the matched strata as a random effect, while accounting for additional potential confounding factors with fixed effect covariates. Findings We analysed 32 national cross-sectional datasets. Exposure of women in their first or second pregnancy to full malaria prevention with IPTp or ITNs was significantly associated with decreased risk of neonatal mortality (protective efficacy PE 18%, 95% CI 4–30; incidence rate ratio IRR 0·820, 95% CI 0·698–0·962), compared with newborn babies of mothers with no protection, after exact matching and controlling for potential confounding factors. Compared with women with no protection, exposure of pregnant women during their first two pregnancies to full malaria prevention in pregnancy through IPTp or ITNs was significantly associated with reduced odds of low birthweight (PE 21%, 14–27; IRR 0·792, 0·732–0·857), as measured by a combination of weight and birth size perceived by the mother, after exact matching and controlling for potential confounding factors. Interpretation Malaria prevention in pregnancy is associated with substantial reductions in neonatal mortality and low birthweight under routine malaria control programme conditions. Malaria control programmes should strive to achieve full protection in pregnant women by both IPTp and ITNs to maximise their benefits. Despite an attempt to mitigate bias and potential confounding by matching women on factors thought to be associated with access to malaria prevention in pregnancy and birth outcomes, some level of confounding bias possibly remains. Funding Malaria Control and Evaluation Partnership in Africa (MACEPA), Bill & Melinda Gates Foundation.
In November 2010, Sierra Leone distributed over three million long-lasting insecticide-treated nets (LLINs) with the objective of providing protection from malaria to individuals in all households in ...the country.
We conducted a nationally representative survey six months after the mass distribution campaign to evaluate its impact on household insecticide-treated net (ITN) ownership and use. We examined factors associated with household ITN possession and use with logistic regression models.
The survey included 4,620 households with equal representation in each of the 14 districts. Six months after the campaign, 87.6% of households own at least one ITN, which represents an increase of 137% over the most recent estimate of 37% in 2008. Thirty-six percent of households possess at least one ITN per two household members; rural households were more likely than urban households to have ≥ 1:2 ITN to household members, but there was no difference by socio-economic status or household head education. Among individuals in households possessing ≥ 1 ITN, 76.5% slept under an ITN the night preceding the survey. Individuals in households where the household head had heard malaria messaging, had correct knowledge of malaria transmission, and where at least one ITN was hanging, were more likely to have slept under an ITN.
The mass distribution campaign was effective at achieving high coverage levels across the population, notably so among rural households where the malaria burden is higher. These important gains in equitable access to malaria prevention will need to be maintained to produce long-term reductions in the malaria burden.
Background Insecticide-treated mosquito nets (ITNs) and indoor-residual spraying (IRS) are recommended strategies for preventing malaria in children. While their impact on all-cause child mortality ...is well documented, their impact on reducing malaria-attributable mortality has not been quantified. While the impact of intermittent preventive therapy in pregnant women (IPTp) and ITNs in pregnancy for improving birth outcomes is also well established, their impact on preventing neonatal or child mortality has not been quantified. Methods We performed two systematic literature reviews in Plasmodium falciparum endemic settings; one to estimate the effect of ITNs and IRS on preventing malaria-attributable mortality in children 1–59 months, and another to estimate the effect of ITNs and IPTp on preventing neonatal and child mortality through improvements in birth outcomes. Results We estimate the protective efficacy (PE) of ITNs and IRS on reducing malaria-attributable mortality 1–59 months to be 55%, with a range of 49–61%, in P. falciparum settings. We estimate malaria prevention interventions in pregnancy (IPTp and ITNs) to have a pooled PE of 35% (95% confidence interval: 23–45%) on reducing the prevalence of low birth weight (LBW) in the first or second pregnancy in areas of stable P. falciparum transmission. Conclusion This systematic review quantifies the PE of ITNs for reducing malaria-attributable mortality in children, and the PE of IPTp and ITNs during pregnancy for reducing LBW. It is assumed the impact of IRS is equal to that of ITNs on reducing malaria-attributable mortality in children. These data will be used in the Lives Saved Tool (LiST) model for estimating the impact of malaria prevention interventions. These data support the continued scale-up of these malaria prevention interventions in endemic settings that will prevent a considerable number of child deaths due directly and indirectly to malaria.
Summary Background Pregnant women in malaria-endemic countries in sub-Saharan Africa are especially vulnerable to malaria. Recommended prevention strategies include intermittent preventive treatment ...with two doses of sulfadoxine–pyrimethamine and the use of insecticide-treated nets. However, progress with implementation has been slow and the Roll Back Malaria Partnership target of 80% coverage of both interventions by 2010 has not been met. We aimed to review the coverage of intermittent preventive treatment, insecticide-treated nets, and antenatal care for pregnant women in sub-Saharan Africa and to explore associations between coverage and individual and country-level factors, including the role of funding for malaria prevention. Methods We used data from nationally representative household surveys from 2009–11 to estimate coverage of intermittent preventive treatment, use of insecticide-treated nets, and attendance at antenatal clinics by pregnant women in sub-Saharan Africa. Using demographic data for births and published data for malaria exposure, we also estimated the number of malaria-exposed births (livebirths and stillbirths combined) for 2010 by country. We used meta-regression analysis to investigate the factors associated with coverage of intermittent preventive treatment and use of insecticide-treated nets. Results Of the 21·4 million estimated malaria-exposed births across 27 countries in 2010, an estimated 4·6 million (21·5%, 95% CI 19·3–23·7) were born to mothers who received intermittent preventive treatment. Insecticide-treated nets were used during pregnancy for 10·5 million of 26·9 million births across 37 countries (38·8%, 34·6–43·0). Antenatal care was attended at least once by 16·3 of 20·8 million women in 2010 (78·3%, 75·2–81·4; n=26 countries) and at least twice by 14·7 of 19·6 million women (75·1%, 72·9–77·3; n=22 countries). For the countries with previous estimates for 2007, coverage of intermittent preventive treatment increased from 13·1% (11·9–14·3) to 21·2% (18·9–23·5; n=14 countries) and use of insecticide-treated nets increased from 17·9% (15·1–20·7) to 41·6% (37·2–46·0; n=24 countries) in 2010. A fall in coverage by more than 10% was seen in two of 24 countries for intermittent preventive treatment and in three of 30 countries for insecticide-treated nets. High disbursement of funds for malaria control and a long time interval since adoption of the relevant policy were associated with the highest coverage of intermittent preventive treatment. High disbursement of funds for malaria control and high total fertility rate were associated with the greatest use of insecticide-treated nets, whereas a high per-head gross domestic product (GDP) was associated with less use of nets than was a lower GDP. Coverage of intermittent preventive treatment showed greater inequity overall than use of insecticide-treated nets, with richer, educated, and urban women more likely to receive preventive treatment than their poorer, uneducated, rural counterparts. Interpretation Although coverage of intermittent preventive treatment and use of insecticide-treated nets by pregnant women has increased in most countries, coverage remains far below international targets, despite fairly high rates of attendance at antenatal clinics. The effect of the implementation of WHO's 2012 policy update for intermittent preventive treatment, which aims to simplify the message and align preventive treatment with the focused antenatal care schedule, should be assessed to find out whether it leads to improvements in coverage. Funding Bill & Melinda Gates Foundation.
Abstract Background Attractive Targeted Sugar Baits (ATSBs) offer a complementary vector control strategy to interventions targeting blood feeding or larval control by attacking the sugar feeding ...behaviour of adult mosquitoes using an attract-and-kill approach. Western Zambia was the first location to receive and deploy ATSB Sarabi version 1.2 stations in a Phase III cluster randomized controlled trial. This paper describes ATSB station installation, monitoring, removal, and disposal, quantifies ATSB station coverage, and reports major reasons for ATSB station replacement. Methods ATSB stations were deployed during two annual transmission seasons, through scheduled installation and removal campaigns. During deployment, monitoring was conducted per protocol to maintain high coverage of the ATSB stations in good condition. Routine monitoring visits during the trial captured details on ATSB station damage necessitating replacement following pre-defined replacement criteria. Annual cross-sectional household surveys measured ATSB station coverage during peak malaria transmission. Results A total of 67,945 ATSB stations were installed in Year 1 (41,695 initially installed+ 26,250 installed during monitoring) and 69,494 ATSB stations were installed in Year 2 (41,982 initially installed+ 27,512 installed during monitoring) across 35 intervention clusters to maintain high coverage of two ATSB stations in good condition per eligible household structure. The primary reasons for ATSB station replacement due to damage were holes/tears and presence of mold. Cross-sectional household surveys documented high coverage of ATSB stations across Year 1 and Year 2 with 93.1% of eligible structures having ≥ 2 ATSB stations in any condition. Discussion ATSB station deployment and monitoring efforts were conducted in the context of a controlled cRCT to assess potential product efficacy. Damage to ATSB stations during deployment required replacement of a subset of stations. High coverage of eligible structures was maintained over the two-year study despite replacement requirements. Additional research is needed to better understand the impact of damage on ATSB station effectiveness under programmatic conditions, including thresholds of threats to physical integrity and biological deterioration on product efficacy. Conclusions Optimizing ATSB stations to address causes of damage and conducting implementation research to inform optimal delivery and cost-effective deployment will be important to facilitate scale-up of ATSB interventions.
Funding from external agencies for malaria control in Africa has increased dramatically over the past decade resulting in substantial increases in population coverage by effective malaria prevention ...interventions. This unprecedented effort to scale-up malaria interventions is likely improving child survival and will likely contribute to meeting Millennium Development Goal (MDG) 4 to reduce the < 5 mortality rate by two thirds between 1990 and 2015.
The Lives Saved Tool (LiST) model was used to quantify the likely impact that malaria prevention intervention scale-up has had on malaria mortality over the past decade (2001-2010) across 43 malaria endemic countries in sub-Saharan African. The likely impact of ITNs and malaria prevention interventions in pregnancy (intermittent preventive treatment IPTp and ITNs used during pregnancy) over this period was assessed.
The LiST model conservatively estimates that malaria prevention intervention scale-up over the past decade has prevented 842,800 (uncertainty: 562,800-1,364,645) child deaths due to malaria across 43 malaria-endemic countries in Africa, compared to a baseline of the year 2000. Over the entire decade, this represents an 8.2% decrease in the number of malaria-caused child deaths that would have occurred over this period had malaria prevention coverage remained unchanged since 2000. The biggest impact occurred in 2010 with a 24.4% decrease in malaria-caused child deaths compared to what would have happened had malaria prevention interventions not been scaled-up beyond 2000 coverage levels. ITNs accounted for 99% of the lives saved.
The results suggest that funding for malaria prevention in Africa over the past decade has had a substantial impact on decreasing child deaths due to malaria. Rapidly achieving and then maintaining universal coverage of these interventions should be an urgent priority for malaria control programmes in the future. Successful scale-up in many African countries will likely contribute substantially to meeting MDG 4, as well as succeed in meeting MDG 6 (Target 1) to halt and reverse malaria incidence by 2015.
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