Weather-based prediction of Plasmodium falciparum malaria in epidemic-prone regions of Ethiopia I. Patterns of lagged weather effects reflect biological mechanisms

Background

Introducing sustainability and self-reliance is essential in chronic humanitarian emergencies before financial assistance is phased out. In Pakistan-based Afghan refugee camps, this was attempted through shifting from indoor residual spraying (IRS) to the subsidized sale of insecticide-treated nets (ITNs) for prevention of malaria and anthroponotic cutaneous leishmaniasis (ACL). Here we outline the strategy and document the progress to provide guidance for replication of similar approaches in other chronic refugee situations.

Methods

The operational monitoring data presented were collected through: (i) two surveys of knowledge, attitude and practice (KAP); (ii) routine sales reporting of health-care providers; (iii) records completed during field visits; and (iv) registers used during annual re-treatment campaigns.

Results

From 2000 until 2003, subsidized ITN sales expanded from 17 to 44 camps. Based on 2003 sales records, maximum coverage from subsidized sales exceeded 50% in 13 camps and 20% in an additional 14 camps. Free annual treatment campaigns showed that many refugees were in possession of non-programme nets, which were either locally-made or had leaked from an ITN programme in Afghanistan. Estimated re-treatment coverage of sold and existing nets through annual campaigns exceeded 43% in all camps and was above 70% in the majority.

Conclusion

Subsidized sales of ITNs have effectively introduced the components of sustainability and self-reliance to the prevention of malaria and ACL in Afghan refugee camps. Similar approaches should be investigated in other chronic refugee situations to discourage expectations of continuing humanitarian donations that cannot be fulfilled.     

Evaluation of the effectiveness of insecticide treated materials for household level dengue vector control

Objective

To assess the operational effectiveness of long-lasting insecticide treated materials (ITMs), when used at household level, for the control of Aedes aegypti in moderately infested urban and suburban areas.

Methods

In an intervention study, ITMs consisting of curtains and water jar-covers (made from PermaNet) were distributed under routine field conditions in 10 clusters (5 urban and 5 suburban), with over 4000 houses, in Trujillo, Venezuela. Impact of the interventions were determined by comparing pre-and post-intervention measures of the Breteau index (BI, number of positive containers/100 houses) and pupae per person index (PPI), and by comparison with indices from untreated areas of the same municipalities. The effect of ITM coverage was modeled.

Results

At distribution, the proportion of households with ≥1 ITM curtain was 79.7% in urban and 75.2% in suburban clusters, but decreased to 32.3% and 39.0%, respectively, after 18 months. The corresponding figures for the proportion of jars using ITM covers were 34.0% and 50.8% at distribution and 17.0% and 21.0% after 18 months, respectively. Prior to intervention, the BI was 8.5 in urban clusters and 42.4 in suburban clusters, and the PPI was 0.2 and 0.9, respectively. In both urban and suburban clusters, the BI showed a sustained 55% decrease, while no discernable pattern was observed at the municipal level. After controlling for confounding factors, the percentage ITM curtain coverage, but not ITM jar-cover coverage, was significantly associated with both entomological indices (Incidence Rate Ratio = 0.98; 95%CI 0.97–0.99). The IRR implied that ITM curtain coverage of at least 50% was necessary to reduce A. aegypti infestation levels by 50%.

Conclusion

Deployment of insecticide treated window curtains in households can result in significant reductions in A. aegypti levels when dengue vector infestations are moderate, but the magnitude of the effect depends on the coverage attained, which itself can decline rapidly over time.     

Field-adapted sampling of whole blood to determine the levels of amodiaquine and its metabolite in children with uncomplicated malaria treated with amodiaquine plus artesunate combination

Background

Malaria remains a major public health problem in Ethiopia. Pyrethroid-treated mosquito nets are one of the major tools available for the prevention and control of malaria transmission. PermaNet^® is a long-lasting insecticide-treated net (LLIN) recommended by WHO for malaria control.

Objective

The objective of the study was to assess utilization and retention of PermaNet^® nets distributed for malaria control in Buie and Fentalie districts and monitor the bio-efficacy of the nets using the WHO cone bioassay test procedures.

Methods

A cross sectional study was carried out by interviewing household heads or their representative in Buie and Fentalie districts. The two districts were selected based on a priori knowledge of variations on ethnic background and housing construction. Clusters of houses were chosen within each of the study villages for selection of households. 20 households that had received one or more PermaNet^® nets were chosen randomly from the clusters in each village. A total of eight used PermaNet^® nets were collected for the bio-efficacy test. The bio-efficacy of PermaNet^® nets was monitored according to the standard WHO procedures using a susceptible colony of Anopheles arabiensis to deltamethrin.

Results

A total of 119 household heads were interviewed during the study. The retention rate of nets that were distributed in 2005 and 2006 season was 72%. A total of 62.2% of the interviewees claimed children under five years of age slept under LLIN, while only 50.7% of the nets were observed to be hanged inside houses when used as a proxy indicator of usage of LLIN. For the bio-efficacy test the mean knock-down was 94% and 100%, while the mean mortality rate observed after 24 hr holding period was 72.2% and 67% for Buie and Fentalie districts respectively.

Conclusion

The study revealed a moderately high retention of PermaNet^® in the study villages and effectiveness of the nets when tested according to the standard WHO procedure.     

Participation of African social scientists in malaria control: identifying enabling and constraining factors

Background

Insecticide-treated nets represent currently a key malaria control strategy, but low insecticide re-treatment rates remain problematic. Olyset? nets are currently one of two long-lasting insecticidal nets recommended by WHO. An assessment was carried out of the effect of Olyset? nets after seven years of use in rural Tanzania.

Methods

A survey of Olyset? nets was conducted in two Tanzanian villages to examine their insecticide dosage, bioassay efficacy and desirability compared with ordinary polyester nets.

Results

Of 103 randomly selected nets distributed in 1994 to 1995, 100 could be traced. Most nets were in a condition likely to offer protection against mosquito biting. Villagers appreciated mainly the durability of Olyset? nets and insecticide persistence. People disliked the small size of these nets and the light blue colour and preferred a smaller mesh size, features that can easily be modified. At equal price, 51% said they would prefer to buy an Olyset? net and 49% opted for an ordinary polyester net. The average permethrin content was 33%-41% of the initial insecticide dose of 20,000 mg/Kg. Bioassay results indicated high knock-down rates at 60 minutes, but the mosquito mortality after 24 hours was rather low (mean: 34%). No significant correlation was found between bioassay results and insecticide concentration in and on the net.

Conclusions

Olyset? nets are popular, durable and with a much longer insecticide persistence than ordinary polyester nets. Hence, Olyset? nets are one of the best choices for ITN programmes in rural malaria-endemic areas.     

Increasing coverage of insecticide-treated nets in rural Nigeria: implications of consumer knowledge, preferences and expenditures for malaria prevention

Background

The coverage of insecticide-treated nets (ITNs) remains low despite existing distribution strategies, hence, it was important to assess consumers' preferences for distribution of ITNs, as well as their perceptions and expenditures for malaria prevention and to examine the implications for scaling-up ITNs in rural Nigeria.

Methods

Nine focus group discussions (FGDs) and questionnaires to 798 respondents from three malaria hyper-endemic villages from Enugu state, south-east Nigeria were the study tools.

Results

There was a broad spectrum of malaria preventive tools being used by people. The average monthly expenditure on malaria prevention per household was 55.55 Naira ($0.4). More than 80% of the respondent had never purchased any form of untreated mosquito net. People mostly preferred centralized community-based sales of the ITNS, with instalment payments.

Conclusion

People were knowledgeable about malaria and the beneficial effects of using nets to protect themselves from the disease. The mostly preferred community-based distribution of ITNs implies that the strategy is a potential untapped additional channel for scaling-up ITNs in Nigeria and possibly other parts of sub-Saharan Africa.     

Antibacterial activity against β- lactamase producing Methicillin and Ampicillin-resistants Staphylococcus aureus: fractional Inhibitory Concentration Index (FICI) determination

Background

The present study reports the antibacterial capacity of alkaloid compounds in combination with Methicillin and Ampicillin-resistants bacteria isolated from clinical samples. The resistance of different bacteria strains to the current antibacterial agents, their toxicity and the cost of the treatment have led to the development of natural products against the bacteria resistant infections when applied in combination with conventional antimicrobial drugs.

Method

The antibacterial assays in this study were performed by using inhibition zone diameters, MIC, MBC methods, the time-kill assay and the Fractional Inhibitory Concentration Index (FICI) determination. On the whole, fifteen Gram-positive bacterial strains (MRSA/ARSA) were used. Negative control was prepared using discs impregnated with 10 % DMSO in water and commercially available Methicillin and Ampicillin from Alkom Laboratories LTD were used as positive reference standards for all bacterial strains.

Results

We noticed that the highest activities were founded with the combination of alkaloid compounds and conventional antibiotics against all bacteria strains. Then, results showed that after 7 h exposition there was no viable microorganism in the initial inoculums.

Conclusion

The results of this study showed that alkaloid compounds in combination with conventional antibiotics (Methicillin, Ampicillin) exhibited antimicrobial effects against microorganisms tested. These results validate the ethno-botanical use of Cienfuegosia digitata Cav. (Malvaceae) in Burkina Faso. Moreover, this study demonstrates the potential of this herbaceous as a source of antibacterial agent that could be effectively used for future health care purposes.     

Study protocol of the YOU CALL - WE CALL TRIAL: impact of a multimodal support intervention after a "mild" stroke

Background

More than 60% of new strokes each year are "mild" in severity and this proportion is expected to rise in the years to come. Within our current health care system those with "mild" stroke are typically discharged home within days, without further referral to health or rehabilitation services other than advice to see their family physician. Those with mild stroke often have limited access to support from health professionals with stroke-specific knowledge who would typically provide critical information on topics such as secondary stroke prevention, community reintegration, medication counselling and problem solving with regard to specific concerns that arise. Isolation and lack of knowledge may lead to a worsening of health problems including stroke recurrence and unnecessary and costly health care utilization. The purpose of this study is to assess the effectiveness, for individuals who experience a first "mild" stroke, of a sustainable, low cost, multimodal support intervention (comprising information, education and telephone support) - "WE CALL" compared to a passive intervention (providing the name and phone number of a resource person available if they feel the need to) - "YOU CALL", on two primary outcomes: unplanned-use of health services for negative events and quality of life.

Method/Design

We will recruit 384 adults who meet inclusion criteria for a first mild stroke across six Canadian sites. Baseline measures will be taken within the first month after stroke onset. Participants will be stratified according to comorbidity level and randomised to one of two groups: YOU CALL or WE CALL. Both interventions will be offered over a six months period. Primary outcomes include unplanned use of heath services for negative event (frequency calendar) and quality of life (EQ-5D and Quality of Life Index). Secondary outcomes include participation level (LIFE-H), depression (Beck Depression Inventory II) and use of health services for health promotion or prevention (frequency calendar). Blind assessors will gather data at mid-intervention, end of intervention and one year follow up.

Discussion

If effective, this multimodal intervention could be delivered in both urban and rural environments. For example, existing infrastructure such as regional stroke centers and existing secondary stroke prevention clinics, make this intervention, if effective, deliverable and sustainable.

Trial Registration

ISRCTN95662526     

The burden of malaria in Sudan: incidence, mortality and disability – adjusted life – years

Background

The goal of Roll Back Malaria (RBM) is to reduce malaria morbidity and mortality by 50% by the year 2010, and still further thereafter until the disease becomes no more a threat to public health. To contribute to the monitoring and evaluation process of this goal, two surveys were carried out in 2000 and 2003 in households and health facilities in the Kassena-Nankana district, northern Ghana using the RBM-WHO/AFRO monitoring and evaluation tools for malaria control activities.

Methods

Data were collected from mothers/caretakers on signs/symptoms of the most recent malaria attack for their under five year old children; the management actions that they took and their perception of health services provided at the health facilities, bednet use, antenatal attendance and place of delivery for the most recent pregnancy, malaria prophylaxis during their last pregnancy. Community health workers and herbalist/traditional healers were also interviewed about the types of health services they provide to community members.

Results

The results revealed a significant improvement in knowledge among mothers/caretakers over the three-year period; this affected caretakers' initial management of illnesses of their young children. The management in terms of the type and dosage of drugs used also improved significantly (p < 0.0001) over the period. Reported insecticide-treated bed net use among children under-five years and pregnant women significantly increased between 2000 and 2003 (p < 0.0001). Health professionals had improved on adoption of their quality of care roles. The intensification of malaria control activities and awareness creation in this district over a three year period had started demonstrating positive results towards reducing malaria disease burden.

Conclusion

Periodic performance assessments through surveys as described and prompt feedback of results to stakeholders in the locality serves as a catalyst to improving malaria control in malaria-endemic countries.     

Training community resource center and clinic personnel to prompt patients in listing questions for doctors: Follow-up interviews about barriers and facilitators to the implementation of consultation planning

Background

Behavioral health services for children and adolescents in the U.S. are lacking in accessibility, availability and quality. Evidence-based interventions for emotional and behavioral disorders can improve quality, yet few studies have systematically examined their implementation in routine care settings.

Methods

Using quantitative and qualitative data, we evaluated a multi-faceted implementation strategy to implement cognitive-behavioral therapy (CBT) for depressed adolescents into two publicly-funded mental healthcare centers. Extent of implementation during the study's duration and variables influencing implementation were explored.

Results

Of the 35 clinicians eligible to participate, 25 (71%) were randomized into intervention (n = 11) or usual care (n = 14). Nine intervention clinicians completed the CBT training. Sixteen adolescents were enrolled in CBT with six of the intervention clinicians; half of these received at least six CBT manually-based sessions. Multiple barriers to CBT adoption and sustained use were identified by clinicians in qualitative interviews.

Conclusion

Strategies to implement evidence-based interventions into routine clinical settings should include multi-method, pre-implementation assessments of the clinical environment and address multiple barriers to initial uptake as well as long-term sustainability.     

The costs and effects of a nationwide insecticide-treated net programme: the case of Malawi

Background

Insecticide-treated nets (ITNs) are a proven intervention to reduce the burden of malaria, yet there remains a debate as to the best method of ensuring they are universally utilized. This study is a cost-effectiveness analysis of an intervention in Malawi that started in 1998, in Blantyre district, before expanding nationwide. Over the 5-year period, 1.5 million ITNs were sold.

Methods

The costs were calculated retrospectively through analysis of expenditure data. Costs and effects were measured as cost per treated-net year (cost/TNY) and cost per net distributed.

Results

The mean cost/TNY was calculated at $4.41, and the mean cost/ITN distributed at $2.63. It also shows evidence of economies of scale, with the cost/TNY falling from $7.69 in year one (72,196 ITN) to $3.44 in year five (720,577 ITN). Cost/ITN distributed dropped from $5.04 to $1.92.

Conclusion

Combining targeting and social marketing has the potential of being both cost-effective and capable of achieving high levels of coverage, and it is possible that increasing returns to scale can be achieved.     

Implementation of an insecticide-treated net subsidy scheme under a public-private partnership for malaria control in Tanzania – challenges in implementation

Background

In the past decade there has been increasing visibility of malaria control efforts at the national and international levels. The factors that have enhanced this scenario are the availability of proven interventions such as artemisinin-based combination therapy, the wide scale use of insecticide-treated nets (ITNs) and a renewed emphasis in indoor residual house-spraying. Concurrently, there has been a window of opportunity of financial commitments from organizations such as the Global Fund for HIV/AIDS, Tuberculosis and Malaria (GFATM), the President's Malaria Initiative and the World Bank Booster programme.

Methods

The case study uses the health policy analysis framework to analyse the implementation of a public-private partnership approach embarked upon by the government of Tanzania in malaria control – 'The Tanzania National Voucher Scheme'- and in this synthesis, emphasis is on the challenges faced by the scheme during the pre-implementation (2001 – 2004) and implementation phases (2004 – 2005). Qualitative research tools used include: document review, interview with key informants, stakeholder's analysis, force-field analysis, time line of events, policy characteristic analysis and focus group discussions. The study is also complemented by a cross-sectional survey, which was conducted at the Rufiji Health Demographic Surveillance Site, where a cohort of women of child-bearing age were followed up regarding access and use of ITNs.

Results

The major challenges observed include: the re-introduction of taxes on mosquito nets and related products, procurement and tendering procedures in the implementation of the GFATM, and organizational arrangements and free delivery of mosquito nets through a Presidential initiative.

Conclusion

The lessons gleaned from this synthesis include: (a) the consistency of the stakeholders with a common vision, was an important strength in overcoming obstacles, (b) senior politicians often steered the policy agenda when the policy in question was a 'crisis event', the stakes and the visibility were high, (c) national stakeholders in policy making have an advantage in strengthening alliances with international organizations, where the latter can become extremely influential in solving bottlenecks as the need arises, and (d) conflict can be turned into an opportunity, for example the Presidential initiative has inadvertently provided Tanzania with important lessons in the organization of 'catch-up' campaigns.     

Preparation and use of plant medicines for farmers' health in Southwest Nigeria: socio-cultural,magico-religious and economic aspects

Background

Little is known about the use of bush medicine and traditional healing among Aboriginal Australians for their treatment of cancer and the meanings attached to it. A qualitative study that explored Aboriginal Australians' perspectives and experiences of cancer and cancer services in Western Australia provided an opportunity to analyse the contemporary meanings attached and use of bush medicine by Aboriginal people with cancer in Western Australia

Methods

Data collection occurred in Perth, both rural and remote areas and included individual in-depth interviews, observations and field notes. Of the thirty-seven interviews with Aboriginal cancer patients, family members of people who died from cancer and some Aboriginal health care providers, 11 participants whose responses included substantial mention on the issue of bush medicine and traditional healing were selected for the analysis for this paper.

Results

The study findings have shown that as part of their healing some Aboriginal Australians use traditional medicine for treating their cancer. Such healing processes and medicines were preferred by some because it helped reconnect them with their heritage, land, culture and the spirits of their ancestors, bringing peace of mind during their illness. Spiritual beliefs and holistic health approaches and practices play an important role in the treatment choices for some patients.

Conclusions

Service providers need to acknowledge and understand the existence of Aboriginal knowledge (epistemology) and accept that traditional healing can be an important addition to an Aboriginal person's healing complementing Western medical treatment regimes. Allowing and supporting traditional approaches to treatment reflects a commitment by modern medical services to adopting an Aboriginal-friendly approach that is not only culturally appropriate but assists with the cultural security of the service.     

Natural products as starting points for future anti-malarial therapies: going back to our roots?

Background

Population movements along the Thailand-Cambodia border, particularly among highly mobile and hard-to-access migrant groups from Cambodia and Myanmar, are assumed to play a key role in the spread of artemisinin resistance. Data on treatment-seeking behaviours, knowledge and perceptions about malaria, and use of preventive measures is lacking as characteristics of this population prevent them from being represented in routine surveillance and the lack of a sampling frame makes reliable surveys challenging.

Methods

A survey of migrant populations from Cambodia and Myanmar was implemented in five selected rural locations in Thailand along the Thai-Cambodian border using respondent driven sampling (RDS) to determine demographic characteristics of the population, migratory patterns, knowledge about malaria, and health-care -seeking behaviours.

Results

The majority of migrants from Myanmar are long-term residents (98%) with no plans to move back to Myanmar, understand spoken Thai (77%) and can therefore benefit from health messages in Thai, have Thai health insurance (99%) and accessed public health services in Thailand (63%) for their last illness. In comparison, the majority of Cambodian migrants are short-term (72%). Of the short-term Cambodian migrants, 92% work in agriculture, 18% speak Thai, 3.4% have Thai health insurance, and the majority returned to Cambodia for treatment (45%), self-treated (11%), or did not seek treatment for their last illness (27%).

Conclusion

Most highly mobile migrants along the Thai-Cambodia border are not accessing health messages or health treatment in Thailand, increasing their risk of malaria and facilitating the spread of potentially resistant Plasmodium falciparum as they return to Cambodia to seek treatment. Reaching out to highly mobile migrants with health messaging they can understand and malaria diagnosis and treatment services they can access is imperative in the effort to contain the spread of artemisinin-resistant P. falciparum.