Modeling the Cost Effectiveness of Malaria Control Interventions in the Highlands of Western Kenya

Introduction

Tools that allow for in silico optimization of available malaria control strategies can assist the decision-making process for prioritizing interventions. The OpenMalaria stochastic simulation modeling platform can be applied to simulate the impact of interventions singly and in combination as implemented in Rachuonyo South District, western Kenya, to support this goal.

Methods

Combinations of malaria interventions were simulated using a previously-published, validated model of malaria epidemiology and control in the study area. An economic model of the costs of case management and malaria control interventions in Kenya was applied to simulation results and cost-effectiveness of each intervention combination compared to the corresponding simulated outputs of a scenario without interventions. Uncertainty was evaluated by varying health system and intervention delivery parameters.

Results

The intervention strategy with the greatest simulated health impact employed long lasting insecticide treated net (LLIN) use by 80% of the population, 90% of households covered by indoor residual spraying (IRS) with deployment starting in April, and intermittent screen and treat (IST) of school children using Artemether lumefantrine (AL) with 80% coverage twice per term. However, the current malaria control strategy in the study area including LLIN use of 56% and IRS coverage of 70% was the most cost effective at reducing disability-adjusted life years (DALYs) over a five year period.

Conclusions

All the simulated intervention combinations can be considered cost effective in the context of available resources for health in Kenya. Increasing coverage of vector control interventions has a larger simulated impact compared to adding IST to the current implementation strategy, suggesting that transmission in the study area is not at a level to warrant replacing vector control to a school-based screen and treat program. These results have the potential to assist malaria control program managers in the study area in adding new or changing implementation of current interventions.     

Shading by Napier Grass Reduces Malaria Vector Larvae in Natural Habitats in Western Kenya Highlands

Increased human population in the Western Kenya highlands has led to reclamation of natural swamps resulting in the creation of habitats suitable for the breeding of Anopheles gambiae, the major malaria vector in the region. Here we report on a study to restore the reclaimed swamp and reverse its suitability as a habitat for malaria vectors. Napier grass-shaded and non-shaded water channels in reclaimed sites in Western Kenya highlands were studied for the presence and density of mosquito larvae, mosquito species composition, and daily variation in water temperature. Shading was associated with 75.5% and 88.4% (P < 0.0001) reduction in anopheline larvae densities and 78.1% and 88% (P < 0.0001) reduction in Anopheles gambiae sensu lato (s.l.) densities in two sites, respectively. Shading was associated with a 5.7°C, 5.0°C, and 4.7°C, and 1.6°C, 3.9°C, and 2.8°C (for maximum, minimum, and average temperatures, respectively) reduction (P < 0.0001) in water temperatures in the two locations, respectively. An. gambiae s.l. was the dominant species, constituting 83.2% and 73.1%, and 44.5% and 42.3%, of anophelines in non-shaded and shaded channels, respectively, in the two sites, respectively. An. gambiae sensu stricto (s.s.) constituted the majority (97.4%) of An. gambiae s.l., while the rest (2.6%) comprised of Anopheles arabiensis. Minimum water temperature decreased with increasing grass height (P = 0.0039 and P = 0.0415 for Lunyerere and Emutete sites, respectively). The results demonstrate how simple environmental strategies can have a strong impact on vector densities.     

Identification of regime shifts in time series using neighborhood statistics

Sudden and significant changes in biotic and abiotic variables have been observed across a variety of systems. The identification of such regime shifts in time series includes both model-fitting and statistical approaches. We introduce two methods that use state- or measurement-space neighborhood statistics to pick out regime shifts. Analysis of simulated and real data sets shows that these methods can be an effective means of identifying regime shifts for single variable as well as multivariable time series. In addition, these methods can be used on systems with non-equilibrium steady states. However, care must be taken in interpreting results as these methods do respond to changes in time series that are not consistent with the regime shift concept.     

Regime shifts in a social-ecological system

Ecological regime shifts are rarely purely ecological. Not only is the regime shift frequently triggered by human activity, but the responses of relevant actors to ecological dynamics are often crucial to the development and even existence of the regime shift. Here, we show that the dynamics of human behaviour in response to ecological changes can be crucial in determining the overall dynamics of the system. We find a social–ecological regime shift in a model of harvesters of a common-pool resource who avoid over-exploitation of the resource by social ostracism of non-complying harvesters. The regime shift, which can be triggered by several different drivers individually or also in combination, consists of a breakdown of the social norm, sudden collapse of co-operation and an over-exploitation of the resource. We use the approach of generalized modeling to study the robustness of the regime shift to uncertainty over the specific forms of model components such as the ostracism norm and the resource dynamics. Importantly, the regime shift in our model does not occur if the dynamics of harvester behaviour are not included in the model. Finally, we sketch some possible early warning signals for the social–ecological regime shifts we observe in the models.     

Changing patterns of malaria epidemiology between 2002 and 2010 in Western Kenya: the fall and rise of malaria

Background

The impact of insecticide treated nets (ITNs) on reducing malaria incidence is shown mainly through data collection from health facilities. Routine evaluation of long-term epidemiological and entomological dynamics is currently unavailable. In Kenya, new policies supporting the provision of free ITNs were implemented nationwide in June 2006. To evaluate the impacts of ITNs on malaria transmission, we conducted monthly surveys in three sentinel sites with different transmission intensities in western Kenya from 2002 to 2010.

Methods and Findings

Longitudinal samplings of malaria parasite prevalence in asymptomatic school children and vector abundance in randomly selected houses were undertaken monthly from February 2002. ITN ownership and usage surveys were conducted annually from 2004 to 2010. Asymptomatic malaria parasite prevalence and vector abundances gradually decreased in all three sites from 2002 to 2006, and parasite prevalence reached its lowest level from late 2006 to early 2007. The abundance of the major malaria vectors, Anopheles funestus and An. gambiae, increased about 5–10 folds in all study sites after 2007. However, the resurgence of vectors was highly variable between sites and species. By 2010, asymptomatic parasite prevalence in Kombewa had resurged to levels recorded in 2004/2005, but the resurgence was smaller in magnitude in the other sites. Household ITN ownership was at 50–70% in 2009, but the functional and effective bed net coverage in the population was estimated at 40.3%, 49.4% and 28.2% in 2010 in Iguhu, Kombewa, and Marani, respectively.

Conclusion

The resurgence in parasite prevalence and malaria vectors has been observed in two out of three sentinel sites in western Kenya despite a high ownership of ITNs. The likely factors contributing to malaria resurgence include reduced efficacy of ITNs, insecticide resistance in mosquitoes and lack of proper use of ITNs. These factors should be targeted to avoid further resurgence of malaria transmission.     

Physical,Chemical and Biological Characteristics in Habitats of High and Low Presence of Anopheline Larvae in Western Kenya Highlands

Background

Characteristics of aquatic habitats determine whether mosquitoes will oviposit, hatch, develop, pupate and successfully emerge into adults or not, thus influencing which mosquito species will occupy a habitat. This study determined whether physiochemical and biological characteristics differ between habitats with high and low presence of anopheline larvae.

Methods

Physical, chemical and biological characteristics were evaluated in selected habitats twice per month within three highland valleys in western Kenya. Aquatic macro-organisms were sampled using a sweep-net. Colorimetric methods were used to determine levels of iron, phosphate, nitrate, ammonium and nitrite in water samples. Generalized Estimating Equations (GEE) was used to compare parameters between the two categories of anopheline presence.

Results

Habitats with high anopheline presence had greater abundance of mosquito aquatic stages and tadpoles and two times more levels of nitrate in water, whereas habitats with low anopheline presence had wider biofilm cover and higher levels of iron in water.

Conclusion

Habitats of high and low presence of anopheline larvae, which differed in a number of physical, chemical and biological characteristics, were identified in valleys within western Kenya highlands. Differences in habitat characteristics are critical in determining the number of anopheline larvae that will fully develop and emerge into adults.     

Relapsing malaria infection acquired in Kenya

An American physician-traveler to East Africa presented with manifestations of cerebral malaria and was treated with intravenous quinidine for chloroquine-resistant falciparum malaria. He later relapsed with Plasmodium ovale infection, despite previous primaquine therapy. Treatment of chloroquine-resistant malaria is discussed. The difficulty in diagnosing P. ovale infections and the predominance of this malaria species over P. vivax in East Africa are reviewed.     

Regime shifts in marine ecosystems: detection, prediction and management

Regime shifts are abrupt changes between contrasting, persistent states of any complex system. The potential for their prediction in the ocean and possible management depends upon the characteristics of the regime shifts: their drivers (from anthropogenic to natural), scale (from the local to the basin) and potential for management action (from adaptation to mitigation). We present a conceptual framework that will enhance our ability to detect, predict and manage regime shifts in the ocean, illustrating our approach with three well-documented examples: the North Pacific, the North Sea and Caribbean coral reefs. We conclude that the ability to adapt to, or manage, regime shifts depends upon their uniqueness, our understanding of their causes and linkages among ecosystem components and our observational capabilities.     

Remote sensing-based time series models for malaria early warning in the highlands of Ethiopia

ABSTRACT: BACKGROUND: Malaria is one of the leading public health problems in most of sub-Saharan Africa, particularly in Ethiopia. Almost all demographic groups are at risk of malaria because of seasonal and unstable transmission of the disease. Therefore, there is a need to develop malaria early-warning systems to enhance public health decision making for control and prevention of malaria epidemics. Data from orbiting earth-observing sensors can monitor environmental risk factors that trigger malaria epidemics. Remotely sensed environmental indicators were used to examine the influences of climatic and environmental variability on temporal patterns of malaria cases in the Amhara region of Ethiopia. METHODS: In this study seasonal auto regressive integrated moving average (SARIMA) models were used to quantify the relationship between malaria cases and remotely sensed environmental variables, including rainfall, land-surface temperature (LST), vegetation indices (NDVI and EVI), and actual evapotranspiration (ETa) with lags ranging from one to three months. Predictions from the best model with environmental variables were compared to the actual observations from the last 12 months of the time series. RESULTS: Malaria cases exhibited positive associations with LST at a lag of one month and positive associations with indicators of moisture (rainfall, EVI and ETa) at lags from one to three months. SARIMA models that included these environmental covariates had better fits and more accurate predictions, as evidenced by lower AIC and RMSE values, than models without environmental covariates. CONCLUSIONS: Malaria risk indicators such as satellite-based rainfall estimates, LST, EVI, and ETa exhibited significant lagged associations with malaria cases in the Amhara region and improved model fit and prediction accuracy. These variables can be monitored frequently and extensively across large geographic areas using data from earth-observing sensors to support public health decisions.     

Regime shifts and weakened environmental gradients in open oak and pine ecosystems

Fire suppression allows tree species that are intolerant of fire stress to increase their distribution, potentially resulting in disruption of historical species-environmental relationships. To measure changes between historical General Land Office surveys (1815 to 1850) and current USDA Forest Inventory and Assessment surveys (2004 to 2008), we compared composition, distribution, and site factors of 21 tree species or species groups in the Missouri Ozarks. We used 24 environmental variables and random forests as a classification method to model distributions. Eastern redcedar, elms, maples, and other fire-sensitive species have increased in dominance in oak forests, with concurrent reductions by oak species; specific changes varied by ecological subsection. Ordinations displayed loss of separation between formerly distinctive oak and fire-sensitive tree species groups. Distribution maps showed decreased presence of disturbance-dependent oak and pine species and increased presence of fire-sensitive species that generally expanded from subsections protected from fire along rivers to upland areas, except for eastern redcedar, which expanded into these subsections. Large scale differences in spatial gradients between past and present communities paralleled reduced influence of local topographic gradients in the varied relief of the Missouri Ozarks, as fire-sensitive species have moved to higher, drier, and sunnier sites away from riverine corridors. Due to changes in land use, landscapes in the Missouri Ozarks, eastern United States, and world-wide are changing from open oak and pine-dominated ecosystems to novel oak-mixed species forests, although at fine scales, forests are becoming more diverse in tree species today. Fire suppression weakened the influence by environmental gradients over species dominance, allowing succession from disturbance-dependent oaks to an alternative state of fire-sensitive species. Current and future research and conservation that rely on historical relationships and ecological principles based on disturbance across the landscape will need to incorporate modern interactions among species for resources into management plans and projections.     

Productivity of malaria vectors from different habitat types in the western Kenya highlands

Background

Mosquito Larval Source Management (LSM) could be a valuable additional tool for integrated malaria vector control especially in areas with focal transmission like the highlands of western Kenya if it were not for the need to target all potential habitats at frequent intervals. The ability to determine the productivity of malaria vectors from identified habitats might be used to target LSM only at productive ones.

Methods

Each aquatic habitat within three highland sites in western Kenya was classified as natural swamp, cultivated swamp, river fringe, puddle, open drain or burrow pit. Three habitats of each type were selected in each site in order to study the weekly productivity of adult malaria vectors from February to May 2009 using a sweep-net and their habitat characteristics recorded.

Results

All surveyed habitat types produced adult malaria vectors. Mean adult productivity of Anopheles gambiae sensu lato in puddles (1.8/m²) was 11–900 times higher than in the other habitat types. However, puddles were the most unstable habitats having water at 43% of all sampling occasions and accounted for 5% of all habitats mapped in the study areas whereas open drains accounted for 72%. Densities of anopheline late instars larvae significantly increased with the presence of a biofilm but decreased with increasing surface area or when water was flowing. Taking stability and frequency of the habitat into account, puddles were still the most productive habitat types for malaria vectors but closely followed by open drains.

Conclusion

Even though productivity of An. gambiae s.l. was greatest in small and unstable habitats, estimation of their overall productivity in an area needs to consider the more stable habitats over time and their surface extension. Therefore, targeting only the highly productive habitats is unlikely to provide sufficient reduction in malaria vector densities.     

Regime shifts between free-floating plants and phytoplankton: a review

Field studies evidence shifts between phytoplankton and free-floating plant regimes; yet, it is unclear what drives these shifts and if they are critical transitions (alternative stable states). In this review, we synthesized field and experimental data on free-floating plants (of varying size and phylogenies) and phytoplankton regimes, to assess the effects of these producers on the environment. Nutrient-rich environments promote free-floating plants dominance—regardless of life form—which causes dark and anoxic environments, and nutrient release from sediments. This reinforces free-floating plants dominance, but controls phytoplankton biomass by strong shading (despite high nutrients and low grazing). Phytoplankton dominance renders turbid and oxygen-rich (when producing) environments. We also searched for case studies of regime shifts for free-floating plants and phytoplankton dominance. Most studies showed that when free-floating plants dominance was interrupted, phytoplankton biomass (usually Cyanobacteria) rose steeply. Likewise, when phytoplankton-dominated, the development of dense mats of free-floating plants covers usually controlled phytoplankton. Field evidence that suggests critical transitions include abrupt regime transitions in time and space; yet, evidence including indoor controlled experiments and mathematical models is needed for conclusive evidence of alternative stable states to be drawn.     

Regime shifts in vegetation composition of Baltic Sea coastal lagoons

Vegetation communities, morphometric and water quality variables were sampled in 62 undisturbed coastal lagoons along a natural land-uplift gradient in the northern Baltic Sea. The lagoons had a morphological inlet threshold reflecting habitat isolation (i.e. the diminished connectedness of the lagoon to the sea) and located in different parts of the archipelago (corresponding to altering wave exposure). We used indirect multivariate methods to find changes in vegetation composition, and axes derived from the analyses were used in correlation and stepwise multiple regression analyses together with environmental variables. Habitat isolation proved to be the strongest predictor for vegetation composition. To identify significant change-points we used a method, which detects regime shifts by accounting for differences in chronological series and gives a regime shift index. Significant shifts in habitat isolation, average depth and total nitrogen were followed by shifts in species variables (i.e. dominant species, cover and species richness) and salinity, total phosphorus and turbidity. Of the species, especially Chara tomentosa showed a shift of high magnitude. Also a shift in wave exposure mirroring position of lagoons in the archipelago structured the species, but this division was seen only for less isolated lagoons. Our results suggest that lagoons are primarily structured by habitat isolation forming two structurally different regimes: one of less isolated lagoons dominated by a diverse array of vascular plants and marine algae of both outer and inner archipelago characters, and one with isolated lagoons dominated by high vegetation cover and dominance of Chara. In addition, vegetation seemed to stabilize water quality in the isolated regime by reducing turbidity and phosphorus, indicating a potential feed-back mechanism and a shift in structuring disturbances from abiotic to biotic factors with habitat isolation.     

Temperature and malaria trends in highland East Africa

There has been considerable debate on the existence of trends in climate in the highlands of East Africa and hypotheses about their potential effect on the trends in malaria in the region. We apply a new robust trend test to mean temperature time series data from three editions of the University of East Anglia's Climatic Research Unit database (CRU TS) for several relevant locations. We find significant trends in the data extracted from newer editions of the database but not in the older version for periods ending in 1996. The trends in the newer data are even more significant when post-1996 data are added to the samples. We also test for trends in the data from the Kericho meteorological station prepared by Omumbo et al. We find no significant trend in the 1979-1995 period but a highly significant trend in the full 1979-2009 sample. However, although the malaria cases observed at Kericho, Kenya rose during a period of resurgent epidemics (1994-2002) they have since returned to a low level. A large assembly of parasite rate surveys from the region, stratified by altitude, show that this decrease in malaria prevalence is not limited to Kericho.     

Identifying cardinal dates in phytoplankton time series to enable the analysis of long-term trends

Phenology and seasonal succession in aquatic ecosystems are strongly dependent on physical factors. In order to promote investigations into this coupling, methods of characterising annual time series of phytoplankton were derived and applied to a 31-year data set from Saidenbach Reservoir (Saxony, Germany). Field data are often scarce and irregularly sampled, particularly in the transition period from winter to spring, so reliable methods of determining cardinal dates in the time series are necessary. The proposed methods were used to determine the beginning, maximum and end of the spring mass development of phytoplankton by estimating the inflexion points (A), fitting a Weibull-type function (B) and fitting linear segments to the logarithmic values (C). For the data set from Saidenbach Reservoir, all three methods proved to be relevant to the analysis of long-term trends. Differences between the maxima determined by the different methods seemed small, but there were deviations when the maximum was related to physical factors such as ice-out. The Weibull-type fit gave the most reliable and comprehensible results and is recommended for trend analyses. For all methods, long-term analysis of the duration of the spring mass development and the duration of the spring full circulation revealed a period of consistently low values (1975-1990) followed by a period of higher values (1990-2005). These periods were also identified for the date of ice-out, although in this case there was a period of high values followed by a period of low values. A sensitivity analysis that compared results from subsampled time series with increasing time intervals indicated that a minimum of one sample every three weeks is needed to obtain reliable results.     

Sodium and gating current time shifts resulting from changes in initial conditions

The sodium and gating currents of the squid giant axon elicited by a depolarizing pulse are delayed, with little change in shape, as a result of a hyperpolarizing prepulse. The delays are almost completely saturated, at approximately 45 microseconds, for prepulses to -140 mV. At 8 degrees C they develop with time constants of between 60 and 180 microseconds for prepulses in the -130- to -150-mV range. There is a correlation between the extra charge moved during the gating current and the increase in the time delay of the sodium current as the magnitude of the hyperpolarizing prepulse is increased. These results strengthen the conclusion that the gating current is indeed closely associated with the process of sodium channel opening and provide information concerning the kinetics of the early steps, which are hidden in ionic current measurements. The main features of the gating and sodium current time shifts and the correlation between charge movement and time shifts are duplicated by a sequential six-state model for sodium activation.     

Worldwide incidence of malaria in 2009: estimates, time trends, and a critique of methods

Background

Measuring progress towards Millennium Development Goal 6, including estimates of, and time trends in, the number of malaria cases, has relied on risk maps constructed from surveys of parasite prevalence, and on routine case reports compiled by health ministries. Here we present a critique of both methods, illustrated with national incidence estimates for 2009.

Methods and Findings

We compiled information on the number of cases reported by National Malaria Control Programs in 99 countries with ongoing malaria transmission. For 71 countries we estimated the total incidence of Plasmodium falciparum and P. vivax by adjusting the number of reported cases using data on reporting completeness, the proportion of suspects that are parasite-positive, the proportion of confirmed cases due to each Plasmodium species, and the extent to which patients use public sector health facilities. All four factors varied markedly among countries and regions. For 28 African countries with less reliable routine surveillance data, we estimated the number of cases from model-based methods that link measures of malaria transmission with case incidence. In 2009, 98% of cases were due to P. falciparum in Africa and 65% in other regions. There were an estimated 225 million malaria cases (5th–95th centiles, 146–316 million) worldwide, 176 (110–248) million in the African region, and 49 (36–68) million elsewhere. Our estimates are lower than other published figures, especially survey-based estimates for non-African countries.

Conclusions

Estimates of malaria incidence derived from routine surveillance data were typically lower than those derived from surveys of parasite prevalence. Carefully interpreted surveillance data can be used to monitor malaria trends in response to control efforts, and to highlight areas where malaria programs and health information systems need to be strengthened. As malaria incidence declines around the world, evaluation of control efforts will increasingly rely on robust systems of routine surveillance. Please see later in the article for the Editors'' Summary     

Distinguishing error from chaos in ecological time series

Over the years, there has been much discussion about the relative importance of environmental and biological factors in regulating natural populations. Often it is thought that environmental factors are associated with stochastic fluctuations in population density, and biological ones with deterministic regulation. We revisit these ideas in the light of recent work on chaos and nonlinear systems. We show that completely deterministic regulatory factors can lead to apparently random fluctuations in population density, and we then develop a new method (that can be applied to limited data sets) to make practical distinctions between apparently noisy dynamics produced by low-dimensional chaos and population variation that in fact derives from random (high-dimensional) noise, such as environmental stochasticity or sampling error. To show its practical use, the method is first applied to models where the dynamics are known. We then apply the method to several sets of real data, including newly analysed data on the incidence of measles in the United Kingdom. Here the additional problems of secular trends and spatial effects are explored. In particular, we find that on a city-by-city scale measles exhibits low-dimensional chaos (as has previously been found for measles in New York City), whereas on a larger, country-wide scale the dynamics appear as a noisy two-year cycle. In addition to shedding light on the basic dynamics of some nonlinear biological systems, this work dramatizes how the scale on which data is collected and analysed can affect the conclusions drawn.     

Highly heterogeneous residual malaria risk in western Thailand

Over the past decades, the malaria burden in Thailand has substantially declined. Most infections now originate from the national border regions. In these areas, the prevalence of asymptomatic infections is still substantial and poses a challenge for the national malaria elimination program. To determine epidemiological parameters as well as risk factors for malaria infection in western Thailand, we carried out a cohort study in Kanchanaburi and Ratchaburi provinces on the Thailand-Myanmar border. Blood samples from 999 local participants were examined for malaria infection every 4 weeks between May 2013 and Jun 2014. Prevalence of Plasmodium falciparum and Plasmodium vivax was determined by quantitative PCR (qPCR) and showed a seasonal variation with values fluctuating from 1.7% to 4.2% for P. vivax and 0% to 1.3% for P. falciparum. Ninety percent of infections were asymptomatic. The annual molecular force of blood-stage infection (_molFOB) was estimated by microsatellite genotyping to be 0.24 new infections per person-year for P. vivax and 0.02 new infections per person-year for P. falciparum. The distribution of infections was heterogenous, that is, the vast majority of infections (>80%) were found in a small number of individuals (<8% of the study population) who tested positive at multiple timepoints. Significant risk factors were detected for P. vivax infections, including previous clinical malaria, occupation in agriculture and travel to Myanmar. In contrast, indoor residual spraying was associated with a protection from infection. These findings provide a recent landscape of malaria epidemiology and emphasize the importance of novel strategies to target asymptomatic and imported infections.