Carl H. Campbell

Comparative field performance and adherence to test results of four malaria rapid diagnostic tests among febrile patients more than five years of age in Blantyre, Malawi

BackgroundMalaria rapid diagnostics tests (RDTs) can increase availability of laboratory-based diagnosis and improve the overall management of febrile patients in malaria endemic areas. In preparation to scale-up RDTs in health facilities in Malawi, an evaluation of four RDTs to help guide national-level decision-making was conducted.MethodsA cross sectional study of four histidine rich-protein-type-2- (HRP2) based RDTs at four health centres in Blantyre, Malawi, was undertaken to evaluate the sensitivity and specificity of RDTs, assess prescriber adherence to RDT test results and explore operational issues regarding RDT implementation. Three RDTs were evaluated in only one health centre each and one RDT was evaluated in two health centres. Light microscopy in a reference laboratory was used as the gold standard.ResultsA total of 2,576 patients were included in the analysis. All of the RDTs tested had relatively high sensitivity for detecting any parasitaemia [Bioline SD (97%), First response malaria (92%), Paracheck (91%), ICT diagnostics (90%)], but low specificity [Bioline SD (39%), First response malaria (42%), Paracheck (68%), ICT diagnostics (54%)]. Specificity was significantly lower in patients who self-treated with an anti-malarial in the previous two weeks (odds ratio (OR) 0.5; p-value < 0.001), patients 5-15 years old versus patients > 15 years old (OR 0.4, p-value < 0.001) and when the RDT was performed by a community health worker versus a laboratory technician (OR 0.4; p-value < 0.001). Health workers correctly prescribed anti-malarials for patients with positive RDT results, but ignored negative RDT results with 58% of patients with a negative RDT result treated with an anti-malarial.ConclusionsThe results of this evaluation, combined with other published data and global recommendations, have been used to select RDTs for national scale-up. In addition, the study identified some key issues that need to be further delineated: the low field specificity of RDTs, variable RDT performance by different cadres of health workers and the need for a robust quality assurance system. Close monitoring of RDT scale-up will be needed to ensure that RDTs truly improve malaria case management.

Socio-cultural predictors of health-seeking behaviour for febrile under-five children in Mwanza-Neno district, Malawi

BackgroundPrompt access to effective treatment for malaria is unacceptably low in Malawi. Less than 20% of children under the age of five with fever receive appropriate anti-malarial treatment within 24 hours of fever onset. This study assessed socio-cultural factors associated with delayed treatment of children with fever in Mwanza district, Malawi.MethodologyIt was a qualitative study using focus group discussions and key informant interviews.ResultsA total of 151 caregivers and 46 health workers participated in the focus group discussions. The majority of caregivers were able to recognize fever and link it to malaria. Despite high knowledge of malaria, prompt treatment and health-seeking behaviour were poor, with the majority of children first being managed at home with treatment regimens other than effective anti-malarials. Traditional beliefs about causes of fever, unavailability of anti-malarial drugs within the community, barriers to accessing the formal health care system, and trust in traditional medicine were all associated with delays in seeking appropriate treatment for fever.ConclusionThe study has demonstrated important social cultural factors that negatively influence for caregivers of children under five. To facilitate prompt and appropriate health-seeking behaviour, behavioral change messages must address the prevailing local beliefs about causes of fever and the socio-economic barriers to accessing health care.

Socially marketed insecticide-treated nets effectively reduce Plasmodium infection and anaemia among children in urban Malawi

Background  Use of insecticide‐treated nets (ITNs) has become a central focus for the Roll Back Malaria campaign, and many countries in Africa have now embarked on large‐scale public health programmes aimed at making ITNs available to those at greatest risk. However, the effectiveness of these programmes has rarely been evaluated.

Voluntary Counseling and Testing

allows individuals to learn their HIV status through preand post-test counseling and an HIV test. VCT is client-initiated, as opposed to provider-initiated testing and counseling (PITC) when health care providers initiate discussion of HIV testing with clients who are seeking health care for other reasons. VCT can be provided through stand-alone clinics or offered through community-based approaches, such as mobile or home-based HIV testing. In addition, counseling for VCT may take place at the individual, couple, or group level. VCT was originally implemented as an individual-level, clinic-based procedure. Different modalities evolved, including communitybased and couple-based approaches, to increase access and uptake. Across all of these different strategies, by combining personalized counseling with knowledge of one’s HIV status, VCT is designed to motivate people to change their behaviors to prevent the acquisition and transmission of HIV, reduce anxiety over possible infection, facilitate safe disclosure of infection status and future planning, and improve access to HIV prevention and treatment services. From 2007-2008, the number of facilities offering VCT increased 35% globally; however, the majority of people globally remain unaware of their HIV status.1 Despite decades of VCT implementation, additional research is needed to understand the best approaches for increasing uptake of VCT and reduction of HIV-related risks in the context of VCT.

Comparison of anaemia and parasitaemia as indicators of malaria control in household and EPI-health facility surveys in Malawi

BackgroundThe World Health Organization has recommended that anaemia be used as an additional indicator to monitor malaria burden at the community level as malaria interventions are nationally scaled up. To date, there are no published evaluations of this recommendation.MethodsTo evaluate this recommendation, a comparison of anaemia and parasitaemia among 6-30 month old children was made during two repeated cross-sectional household (HH) and health facility (HF) surveys in six districts across Malawi at baseline (2005) and in a follow-up survey (2008) after a scale up of malaria control interventions.ResultsHH net ownership did not increase between the years (50.5% vs. 49.8%), but insecticide treated net (ITN) ownership increased modestly from 41.5% (95% CI: 37.2%-45.8%) in 2005 to 45.3% (95% CI: 42.6%-48.0%) in 2008. ITN use by children 6-30 months old, who were living in HH with at least one net, increased from 73.6% (95% CI:68.2%-79.1%) to 80.0% (95% CI:75.9%-84.1%) over the three-year period. This modest increase in ITN use was associated with a decrease in moderate to severe anaemia (Hb <8 g/dl) from 18.4% (95% CI:14.9%-21.8%) in 2005 to 15.4% (13.2%-17.7%) in 2008, while parasitaemia, measured as positive-slide microscopy, decreased from 18.9% (95% CI:14.7%-23.2%) to 16.9% (95% CI:13.8%-20.0%), a relative reduction of 16% and 11%, respectively. In HF surveys, anaemia prevalence decreased from 18.3% (95% CI: 14.9%-21.7%) to 15.4% (95% CI: 12.7%-18.2%), while parasitaemia decreased from 30.6% (95% CI: 25.7%-35.5%) to 13.2% (95% CI: 10.6%-15.8%), a relative reduction of 15% and 57%, respectively.ConclusionIncreasing access to effective malaria prevention was associated with a reduced burden of malaria in young Malawian children. Anaemia measured at the HF level at time of routine vaccination may be a good surrogate indicator for its measurement at the HH level in evaluating national malaria control programmes.

Integration of insecticide-treated net distribution into routine immunization services in Malawi: a pilot study

Objectives  To determine the feasibility of distributing insecticide‐treated nets (ITNs) through routine immunization services, to increase ownership and use of ITNs among high‐risk groups, whereas maintaining or improving timely completion of routine vaccinations.

Impact of Health Facility-Based Insecticide Treated Bednet Distribution in Malawi: Progress and Challenges towards Achieving Universal Coverage

Background High levels of insecticide treated bednet (ITN) use reduce malaria burden in countries with intense transmission such as Malawi. Since 2007 Malawi has implemented free health facility-based ITN distribution for pregnant women and children <5 years old (under-5s). We evaluated the progress of this targeted approach toward achieving universal ITN coverage. Methods We conducted a cross-sectional household survey in eight districts in April 2009. We assessed household ITN possession, ITN use by all household members, and P. falciparum asexual parasitemia and anemia (hemoglobin <11 grams/deciliter) in under-5s. Results We surveyed 7,407 households containing 29,806 persons. Fifty-nine percent of all households (95% confidence interval [95% CI]: 56–62), 67% (95% CI: 64–70) of eligible households (i.e., households with pregnant women or under-5s), and 40% (95% CI: 36–45) of ineligible households owned an ITN. In households with at least one ITN, 76% (95% CI: 74–78) of all household members, 88% (95% CI: 87–90) of under-5s and 90% (95% CI: 85–94) of pregnant women used an ITN the previous night. Of 6,677 ITNs, 92% (95% CI: 90–94) were used the previous night with a mean of 2.4 persons sleeping under each ITN. In multivariable models adjusting for district, socioeconomic status and indoor residual spraying use, ITN use by under-5s was associated with a significant reduction in asexual parasitemia (adjusted odds ratio (aOR) 0.79; 95% CI: 0.64–0.98; p-value 0.03) and anemia (aOR 0.79; 95% CI 0.62–0.99; p-value 0.04). Of potential targeted and non-targeted mass distribution strategies, a campaign distributing 1 ITN per household might increase coverage to 2.1 household members per ITN, and thus achieve near universal coverage often defined as 2 household members per ITN. Conclusions Malawi has substantially increased ITN coverage using health facility-based distribution targeting pregnant women and under-5s, but needs to supplement these activities with non-targeted mass distribution campaigns to achieve universal coverage and maximum public health impact.

Associations between Peripheral Plasmodium falciparum Malaria Parasitemia, Human Immunodeficiency Virus, and Concurrent Helminthic Infection among Pregnant Women in Malawi

Approximately 2 billion persons worldwide are infected with schistosomiasis and soil-transmitted helminths (STH), many in areas where endemic malaria transmission coexists. Few data exist on associations between these infections. Nested within a larger clinical trial, primigravid and secundigravid women provided blood samples for human immunodeficiency virus (HIV) testing and peripheral malaria films and stool and urine for evaluation of STH and Schistosoma spp. during their initial antenatal clinic visit. The most common parasitic infections were malaria (37.6%), S. haematobium (32.3%), and hookworm (14.4%); 14.2% of women were HIV-infected. S. haematobium infection was associated with lower malarial parasite densities (344 versus 557 parasites/μL blood; P < 0.05). In multivariate analysis, HIV and hookworm infection were independently associated with malaria infection (adjusted odds ratio = 1.9 and 95% confidence interval = 1.2-3.0 for HIV; adjusted odds ratio = 1.9 and 95% confidence interval = 1.03-3.5 for hookworm). Concurrent helminthic infection had both positive and negative effects on malaria parasitemia among pregnant women in Malawi.

Impact of Indoor Residual Spraying with Lambda-Cyhalothrin on Malaria Parasitemia and Anemia Prevalence among Children Less than Five Years of Age in an Area of Intense, Year-Round Transmission in Malawi

Little is known about the impact of indoor residual spraying (IRS) in areas with intense malaria transmission such as sub-Saharan Africa. In Malawi, IRS with lambda-cyhalothrin has been applied annually in an area of intense year-long transmission since 2007. We evaluated the impact of IRS on parasitemia and anemia prevalence in children less than five years of age by using a cross-sectional household survey conducted in 2009, six months after the second IRS spray round. We measured malaria parasitemia and anemia (hemoglobin level < 11 g/dL) in 899 children less than five years of age and used binomial regression to assess the impact of IRS by comparing children living in a household sprayed with IRS (direct IRS) with those in a household not sprayed with IRS, but in an IRS area (indirect IRS) and those living in a household not sprayed with IRS and not in an IRS area (no IRS). In the IRS area, 77% of households reported receiving IRS. Adjusting for bed net use, house construction, and socioeconomic status, we found that receiving direct IRS and indirect IRS were significantly associated with a 33% (95% confidence interval [CI] = 1–54%) and 46% (95% CI = 20–64%) reduction in parasitemia and a 21% (95% CI = 4–34%) and 30% (95% CI = 12–45%) reduction in anemia prevalence, respectively.

Developing national treatment policy for falciparum malaria in Africa: Malawi experience

The emergence and spread across sub-Saharan Africa of Plasmodium falciparum resistant to the inexpensive antimalarials chloroquine and sulfadoxine-pyrimethamine has worsened the health and hampered the socio-economic development of affected countries, a situation that calls for urgent review of malaria treatment policies in these countries. The Roll Back Malaria (RBM) initiative promotes strong partnerships for implementing effective malaria control measures. The development of clear policies to guide such implementation at country level offers a way of assessing the achievement of set milestones in this collaborative venture. In this article we describe the policy development process for the treatment of falciparum malaria in Africa, based on experience in Malawi, where the first-line drug treatment was recently changed from sulfadoxine-pyrimethamine to an artemisinin combination therapy.