In the context of malaria elimination, interventions will need to target high burden areas to further reduce transmission. Current tools to monitor and report disease burden lack the capacity to ...continuously detect fine-scale spatial and temporal variations of disease distribution exhibited by malaria. These tools use random sampling techniques that are inefficient for capturing underlying heterogeneity while health facility data in resource-limited settings are inaccurate. Continuous community surveys of malaria burden provide real-time results of local spatio-temporal variation. Adaptive geostatistical design (AGD) improves prediction of outcome of interest compared to current random sampling techniques. We present findings of continuous malaria prevalence surveys using an adaptive sampling design.
We conducted repeated cross sectional surveys guided by an adaptive sampling design to monitor the prevalence of malaria parasitaemia and anaemia in children below five years old in the communities living around Majete Wildlife Reserve in Chikwawa district, Southern Malawi. AGD sampling uses previously collected data to sample new locations of high prediction variance or, where prediction exceeds a set threshold. We fitted a geostatistical model to predict malaria prevalence in the area.
We conducted five rounds of sampling, and tested 876 children aged 6-59 months from 1377 households over a 12-month period. Malaria prevalence prediction maps showed spatial heterogeneity and presence of hotspots-where predicted malaria prevalence was above 30%; predictors of malaria included age, socio-economic status and ownership of insecticide-treated mosquito nets.
Continuous malaria prevalence surveys using adaptive sampling increased malaria prevalence prediction accuracy. Results from the surveys were readily available after data collection. The tool can assist local managers to target malaria control interventions in areas with the greatest health impact and is ready for assessment in other diseases.
Remotely sensed data can serve as an independent source of information about the location of residential structures in areas under demographic and health surveillance. We report on results obtained ...combining satellite imagery, imported from Bing, with location data routinely collected using the built-in GPS sensors of tablet computers, to assess completeness of population coverage in a Health and Demographic Surveillance System in Malawi. The Majete Malaria Project Health and Demographic Surveillance System, in Malawi, started in 2014 to support a project with the aim of studying the reduction of malaria using an integrated control approach by rolling out insecticide treated nets and improved case management supplemented with house improvement and larval source management. In order to support the monitoring of the trial a Health and Demographic Surveillance System was established in the area that surrounds the Majete Wildlife Reserve (1600 km2), using the OpenHDS data system. We compared house locations obtained using GPS recordings on mobile devices during the demographic surveillance census round with those acquired from satellite imagery. Volunteers were recruited through the crowdcrafting.org platform to identify building structures on the images, which enabled the compilation of a database with coordinates of potential residences. For every building identified on these satellite images by the volunteers (11,046 buildings identified of which 3424 (ca. 30%) were part of the censused area), we calculated the distance to the nearest house enumerated on the ground by fieldworkers during the census round of the HDSS. A random sample of buildings (85 structures) identified on satellite images without a nearby location enrolled in the census were visited by a fieldworker to determine how many were missed during the baseline census survey, if any were missed. The findings from this ground-truthing effort suggest that a high population coverage was achieved in the census survey, however the crowd-sourcing did not locate many of the inhabited structures (52.3% of the 6543 recorded during the census round). We conclude that using auxiliary data can play a useful role in quality assurance in population based health surveillance, but improved algorithms would be needed if crowd-sourced house locations are to be used as the basis of population databases.
Malaria hotspots have been the focus of public health managers for several years due to the potential elimination gains that can be obtained from targeting them. The identification of hotspots must ...be accompanied by the description of the overall network of stable and unstable hotspots of malaria, especially in medium and low transmission settings where malaria elimination is targeted. Targeting hotspots with malaria control interventions has, so far, not produced expected benefits. In this work we have employed a mechanistic-stochastic algorithm to identify clusters of super-spreader houses and their related stable hotspots by accounting for mosquito flight capabilities and the spatial configuration of malaria infections at the house level. Our results show that the number of super-spreading houses and hotspots is dependent on the spatial configuration of the villages. In addition, super-spreaders are also associated to house characteristics such as livestock and family composition. We found that most of the transmission is associated with winds between 6pm and 10pm although later hours are also important. Mixed mosquito flight (downwind and upwind both with random components) were the most likely movements causing the spread of malaria in two out of the three study areas. Finally, our algorithm (named MALSWOTS) provided an estimate of the speed of malaria infection progression from house to house which was around 200-400 meters per day, a figure coherent with mark-release-recapture studies of Anopheles dispersion. Cross validation using an out-of-sample procedure showed accurate identification of hotspots. Our findings provide a significant contribution towards the identification and development of optimal tools for efficient and effective spatio-temporal targeted malaria interventions over potential hotspot areas.
Understanding the dynamics of gametocyte production in polyclonal Plasmodium falciparum infections requires a genotyping method that detects distinct gametocyte clones and estimates their relative ...frequencies. Here, a marker was identified and evaluated to genotype P. falciparum mature gametocytes using amplicon deep sequencing.
A data set of polymorphic regions of the P. falciparum genome was mined to identify a gametocyte genotyping marker. To assess marker resolution, the number of unique haplotypes in the marker region was estimated from 95 Malawian P. falciparum whole genome sequences. Specificity of the marker for detection of mature gametocytes was evaluated using reverse transcription-polymerase chain reaction of RNA extracted from NF54 mature gametocytes and rings from a non-gametocyte-producing strain of P. falciparum. Amplicon deep sequencing was performed on experimental mixtures of mature gametocytes from two distinct parasite clones, as well as gametocyte-positive P. falciparum field isolates to evaluate the quantitative ability and determine the limit of detection of the genotyping approach.
A 400 bp region of the pfs230 gene was identified as a gametocyte genotyping marker. A larger number of unique haplotypes was observed at the pfs230 marker (34) compared to the sera-2 (18) and ama-1 (14) markers in field isolates from Malawi. RNA and DNA genotyping accurately estimated gametocyte and total parasite clone frequencies when evaluating agreement between expected and observed haplotype frequencies in gametocyte mixtures, with concordance correlation coefficients of 0.97 95% CI: 0.92-0.99 and 0.92 95% CI: 0.83-0.97, respectively. The detection limit of the genotyping method for male gametocytes was 0.41 pfmget transcripts/µl 95% CI: 0.28-0.72 and for female gametocytes was 1.98 ccp4 transcripts/µl 95% CI: 1.35-3.68.
A region of the pfs230 gene was identified as a marker to genotype P. falciparum gametocytes. Amplicon deep sequencing of this marker can be used to estimate the number and relative frequency of parasite clones among mature gametocytes within P. falciparum infections. This gametocyte genotyping marker will be an important tool for studies aimed at understanding dynamics of gametocyte production in polyclonal P. falciparum infections.
Understanding the blood feeding preferences and resting habits of malaria vectors is important for assessing and designing effective malaria vector control tools. The presence of livestock, such as ...cattle, which are used as blood meal hosts by some malaria vectors, may impact malaria parasite transmission dynamics. The presence of livestock may provide sufficient blood meals for the vectors, thereby reducing the frequency of vectors biting humans. Alternatively, the presence of cattle may enhance the availability of blood meals such that infectious mosquitoes may survive longer, thereby increasing the risk of malaria transmission. This study assessed the effect of household-level cattle presence and distribution on the abundance of indoor and outdoor resting malaria vectors.
Houses with and without cattle were selected in Chikwawa district, southern Malawi for sampling resting malaria vectors. Prokopack aspirators and clay pots were used for indoor and outdoor sampling, respectively. Each house was sampled over two consecutive days. For houses with cattle nearby, the number of cattle and the distances from the house to where the cattle were corralled the previous night were recorded. All data were analysed using generalized linear models fitted with Poisson distribution.
The malaria vectors caught resting indoors were Anopheles gambiae sensu stricto (s.s.), Anopheles arabiensis and Anopheles funestus s.s. Outdoor collections consisted primarily of An. arabiensis. The catch sizes of indoor resting An. gambiae sensu lato (s.l.) were not different in houses with and without cattle (P = 0.34). The presence of cattle near a house was associated with a reduction in the abundance of indoor resting An. funestus s.l. (P = 0.04). This effect was strongest when cattle were kept overnight ≤ 15 m away from the houses (P = 0.03). The blood meal hosts varied across the species.
These results highlight differences between malaria vector species and their interactions with potential blood meal hosts, which may have implications for malaria risk. Whereas An. arabiensis remained unaffected, the reduction of An. funestus s.s. in houses near cattle suggests a potential protective effect of cattle. However, the low abundance of mosquitoes reduced the power of some analyses and limited the generalizability of the results to other settings. Therefore, further studies incorporating the vectors' host-seeking behaviour/human biting rates are recommended to fully support the primary finding.
Despite significant success in the fight against malaria over the past two decades, malaria control programmes rely on only two insecticidal methods: indoor residual spraying and insecticidal-treated ...nets. House improvement (HI) can complement these interventions by reducing human-mosquito contact, thereby reinforcing the gains in disease reduction. This study assessed the implementation fidelity, which is the assessment of how closely an intervention aligns with its intended design, feasibility, and sustainability of community-led HI in southern Malawi.
The study, conducted in 22 villages (2730 households), employed a mixed-methods approach. Implementation fidelity was assessed using a modified framework, with longitudinal surveys collecting data on HI coverage indicators. Quantitative analysis, employing descriptive statistics, evaluated the adherence to HI implementation. Qualitative data came from in-depth interviews, key informant interviews, and focus groups involving project beneficiaries and implementers. Qualitative data were analysed using content analysis guided by the implementation fidelity model to explore facilitators, challenges, and factors affecting intervention feasibility.
The results show that HI was implemented as planned. There was good adherence to the intended community-led HI design; however, the adherence could have been higher but gradually declined over time. In terms of intervention implementation, 74% of houses had attempted to have eaves closed in 2016-17 and 2017-18, compared to 70% in 2018-19. In 2016-17, 42% of houses had all four sides of the eaves closed, compared to 33% in 2018-19. Approximately 72% of houses were screened with gauze wire in 2016-17, compared to 57% in 2018-19. High costs, supply shortages, labour demands, volunteers' poor living conditions and adverse weather were reported to hinder the ideal HI implementation. Overall, the community described community-led HI as feasible and could be sustained by addressing these socioeconomic and contextual challenges.
Our study found that although HI was initially implemented as planned, its fidelity declined over time. Using trained volunteers facilitated the fidelity and feasibility of implementing the intervention. A combination of rigorous community education, consistent training, information, education and communication, and intervention modifications may be necessary to address the challenges and enhance the intervention's fidelity, feasibility, and sustainability.
To further reduce malaria, larval source management (LSM) is proposed as a complementary strategy to the existing strategies. LSM has potential to control insecticide resistant, outdoor biting and ...outdoor resting vectors. Concerns about costs and operational feasibility of implementation of LSM at large scale are among the reasons the strategy is not utilized in many African countries. Involving communities in LSM could increase intervention coverage, reduce costs of implementation and improve sustainability of operations. Community acceptance and participation in community-led LSM depends on a number of factors. These factors were explored under the Majete Malaria Project in Chikwawa district, southern Malawi.
Separate focus group discussions (FGDs) were conducted with members from the general community (n = 3); health animators (HAs) (n = 3); and LSM committee members (n = 3). In-depth interviews (IDIs) were conducted with community members. Framework analysis was employed to determine the factors contributing to community acceptance and participation in the locally-driven intervention.
Nine FGDs and 24 IDIs were held, involving 87 members of the community. Widespread knowledge of malaria as a health problem, its mode of transmission, mosquito larval habitats and mosquito control was recorded. High awareness of an association between creation of larval habitats and malaria transmission was reported. Perception of LSM as a tool for malaria control was high. The use of a microbial larvicide as a form of LSM was perceived as both safe and effective. However, actual participation in LSM by the different interviewee groups varied. Labour-intensiveness and time requirements of the LSM activities, lack of financial incentives, and concern about health risks when wading in water bodies contributed to lower participation.
Community involvement in LSM increased local awareness of malaria as a health problem, its risk factors and control strategies. However, community participation varied among the respondent groups, with labour and time demands of the activities, and lack of incentives, contributing to reduced participation. Innovative tools that can reduce the labour and time demands could improve community participation in the activities. Further studies are required to investigate the forms and modes of delivery of incentives in operational community-driven LSM interventions.
Abstract
Background
Current standard interventions are not universally sufficient for malaria elimination. The effects of community-based house improvement (HI) and larval source management (LSM) as ...supplementary interventions to the Malawi National Malaria Control Programme (NMCP) interventions were assessed in the context of an intensive community engagement programme.
Methods
The study was a two-by-two factorial, cluster-randomized controlled trial in Malawi. Village clusters were randomly assigned to four arms: a control arm; HI; LSM; and HI + LSM. Malawi NMCP interventions and community engagement were used in all arms. Household-level, cross-sectional surveys were conducted on a rolling, 2-monthly basis to measure parasitological and entomological outcomes over 3 years, beginning with one baseline year. The primary outcome was the entomological inoculation rate (EIR). Secondary outcomes included mosquito density,
Plasmodium falciparum
prevalence, and haemoglobin levels. All outcomes were assessed based on intention to treat, and comparisons between trial arms were conducted at both cluster and household level.
Results
Eighteen clusters derived from 53 villages with 4558 households and 20,013 people were randomly assigned to the four trial arms. The mean nightly EIR fell from 0.010 infectious bites per person (95% CI 0.006–0.015) in the baseline year to 0.001 (0.000, 0.003) in the last year of the trial. Over the full trial period, the EIR did not differ between the four trial arms (p = 0.33). Similar results were observed for the other outcomes: mosquito density and
P. falciparum
prevalence decreased over 3 years of sampling, while haemoglobin levels increased; and there were minimal differences between the trial arms during the trial period.
Conclusions
In the context of high insecticide-treated bed net use, neither community-based HI, LSM, nor HI + LSM contributed to further reductions in malaria transmission or prevalence beyond the reductions observed over two years across all four trial arms. This was the first trial, as far as the authors are aware, to test the potential complementary impact of LSM and/or HI beyond levels achieved by standard interventions. The unexpectedly low EIR values following intervention implementation indicated a promising reduction in malaria transmission for the area, but also limited the usefulness of this outcome for measuring differences in malaria transmission among the trial arms.
Trial registration
PACTR, PACTR201604001501493, Registered 3 March 2016,
https://pactr.samrc.ac.za/
.
Increased engagement of communities has been emphasized in global plans for malaria control and elimination. Three interventions to reinforce and complement national malaria control recommendations ...were developed and applied within the context of a broad-based development initiative, targeting a rural population surrounding a wildlife reserve. The interventions, which were part of a 2-year research trial, and assigned to the village level, were implemented through trained local volunteers, or 'health animators', who educated the community and facilitated collective action.
Community workshops on malaria were designed to increase uptake of national recommendations; a manual was developed, and training of health animators conducted, with educational content and analytical tools for a series of fortnightly community workshops in annual cycles at village level. The roll-back malaria principle of diagnosis, treatment and use of long-lasting insecticidal nets was a central component of the workshops. Structural house improvement to reduce entry of malaria vectors consisted of targeted activities in selected villages to mobilize the community into voluntarily closing the eaves and screening the windows of their houses; the project provided wire mesh for screening. Corrective measures were introduced to respond to field challenges. Committees were established at village level to coordinate the house improvement activities. Larval source management (LSM) in selected villages consisted of two parts: one on removal of standing water bodies by the community at large; and one on larviciding with bacterial insecticide Bacillus thuringiensis israelensis by trained village committees. Community workshops on malaria were implemented as 'core intervention' in all villages. House improvement and LSM were implemented in addition to community workshops on malaria in selected villages.
Three novel interventions for community mobilization on malaria prevention and control were described. The interventions comprised local organizational structure, education and collective action, and incorporated elements of problem identification, planning and evaluation. These methods could be applicable to other countries and settings.
Abstract
Background
House improvement (HI) to prevent mosquito house entry, and larval source management (LSM) targeting aquatic mosquito stages to prevent development into adult forms, are promising ...complementary interventions to current malaria vector control strategies. Lack of evidence on costs and cost-effectiveness of community-led implementation of HI and LSM has hindered wide-scale adoption. This study presents an incremental cost analysis of community-led implementation of HI and LSM, in a cluster-randomized, factorial design trial, in addition to standard national malaria control interventions in a rural area (25,000 people), in southern Malawi.
Methods
In the trial, LSM comprised draining, filling, and
Bacillus thuringiensis israelensis-
based larviciding, while house improvement (henceforth HI) involved closing of eaves and gaps on walls, screening windows/ventilation spaces with wire mesh, and doorway modifications. Communities implemented all interventions. Costs were estimated retrospectively using the ‘ingredients approach’, combining ‘bottom-up’ and ‘top-down approaches’, from the societal perspective. To estimate the cost of independently implementing each intervention arm, resources shared between trial arms (e.g. overheads) were allocated to each consuming arm using proxies developed based on share of resource input quantities consumed. Incremental implementation costs (in 2017 US$) are presented for HI-only, LSM-only and HI + LSM arms. In sensitivity analyses, the effect of varying costs of important inputs on estimated costs was explored.
Results
The total economic programme costs of community-led HI and LSM implementation was $626,152. Incremental economic implementation costs of HI, LSM and HI + LSM were estimated as $27.04, $25.06 and $33.44, per person per year, respectively. Project staff, transport and labour costs, but not larvicide or screening material, were the major cost drivers across all interventions. Costs were sensitive to changes in staff costs and population covered.
Conclusions
In the trial, the incremental economic costs of community-led HI and LSM implementation were high compared to previous house improvement and LSM studies. Several factors, including intervention design, year-round LSM implementation and low human population density could explain the high costs. The factorial trial design necessitated use of proxies to allocate costs shared between trial arms, which limits generalizability where different designs are used. Nevertheless, costs may inform planners of similar intervention packages where cost-effectiveness is known.
Trial registration
Not applicable. The original trial was registered with The Pan African Clinical Trials Registry on 3 March 2016, trial number PACTR201604001501493
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