Mahdi M. Ramsan

Impact of Artemisinin-Based Combination Therapy and Insecticide-Treated Nets on Malaria Burden in Zanzibar

Background The Roll Back Malaria strategy recommends a combination of interventions for malaria control. Zanzibar implemented artemisinin-based combination therapy (ACT) for uncomplicated malaria in late 2003 and long-lasting insecticidal nets (LLINs) from early 2006. ACT is provided free of charge to all malaria patients, while LLINs are distributed free to children under age 5 y (“under five”) and pregnant women. We investigated temporal trends in Plasmodium falciparum prevalence and malaria-related health parameters following the implementation of these two malaria control interventions in Zanzibar. Methods and Findings Cross-sectional clinical and parasitological surveys in children under the age of 14 y were conducted in North A District in May 2003, 2005, and 2006. Survey data were analyzed in a logistic regression model and adjusted for complex sampling design and potential confounders. Records from all 13 public health facilities in North A District were analyzed for malaria-related outpatient visits and admissions. Mortality and demographic data were obtained from District Commissioners Office. P. falciparum prevalence decreased in children under five between 2003 and 2006; using 2003 as the reference year, odds ratios (ORs) and 95% confidence intervals (CIs) were, for 2005, 0.55 (0.28–1.08), and for 2006, 0.03 (0.00–0.27); p for trend < 0.001. Between 2002 and 2005 crude under-five, infant (under age 1 y), and child (aged 1–4 y) mortality decreased by 52%, 33%, and 71%, respectively. Similarly, malaria-related admissions, blood transfusions, and malaria-attributed mortality decreased significantly by 77%, 67% and 75%, respectively, between 2002 and 2005 in children under five. Climatic conditions favorable for malaria transmission persisted throughout the observational period. Conclusions Following deployment of ACT in Zanzibar 2003, malaria-associated morbidity and mortality decreased dramatically within two years. Additional distribution of LLINs in early 2006 resulted in a 10-fold reduction of malaria parasite prevalence. The results indicate that the Millennium Development Goals of reducing mortality in children under five and alleviating the burden of malaria are achievable in tropical Africa with high coverage of combined malaria control interventions.

Mass Screening and Treatment on the Basis of Results of a Plasmodium falciparum-Specific Rapid Diagnostic Test Did Not Reduce Malaria Incidence in Zanzibar

BACKGROUNDnSeasonal increases in malaria continue in hot spots in Zanzibar. Mass screening and treatment (MSAT) may help reduce the reservoir of infection; however, it is unclear whether rapid diagnostic tests (RDTs) detect a sufficient proportion of low-density infections to influence subsequent transmission.nnnMETHODSnTwo rounds of MSAT using Plasmodium falciparum-specific RDT were conducted in 5 hot spots (population, 12 000) in Zanzibar in 2012. In parallel, blood samples were collected on filter paper for polymerase chain reaction (PCR) analyses. Data on confirmed malarial parasite infections from health facilities in intervention and hot spot control areas were monitored as proxy for malaria transmission.nnnRESULTSnApproximately 64% of the population (7859) were screened at least once. P. falciparum prevalence, as measured by RDT, was 0.2% (95% confidence interval [CI], .1%-.3%) in both rounds, compared with PCR measured prevalences (for all species) of 2.5% (95% CI, 2.1%-2.9%) and 3.8% (95% CI, 3.2%-4.4%) in rounds 1 and 2, respectively. Two fifths (40%) of infections detected by PCR included non-falciparum species. Treatment of RDT-positive individuals (4% of the PCR-detected parasite carriers) did not reduce subsequent malaria incidence, compared with control areas.nnnCONCLUSIONSnHighly sensitive point-of-care diagnostic tools for detection of all human malaria species are needed to make MSAT an effective strategy in settings where malaria elimination programs are in the pre-elimination phase.

System effectiveness of a targeted free mass distribution of long lasting insecticidal nets in Zanzibar, Tanzania.

BackgroundInsecticide-treated nets (ITN) and long-lasting insecticidal nets (LLIN) are important means of malaria prevention. Although there is consensus regarding their importance, there is uncertainty as to which delivery strategies are optimal for dispensing these life saving interventions. A targeted mass distribution of free LLINs to children under five and pregnant women was implemented in Zanzibar between August 2005 and January 2006. The outcomes of this distribution among children under five were evaluated, four to nine months after implementation.MethodsTwo cross-sectional surveys were conducted in May 2006 in two districts of Zanzibar: Micheweni (MI) on Pemba Island and North A (NA) on Unguja Island. Household interviews were conducted with 509 caretakers of under-five children, who were surveyed for socio-economic status, the net distribution process, perceptions and use of bed nets. Each step in the distribution process was assessed in all children one to five years of age for unconditional and conditional proportion of success. System effectiveness (the accumulated proportion of success) and equity effectiveness were calculated, and predictors for LLIN use were identified.ResultsThe overall proportion of children under five sleeping under any type of treated net was 83.7% (318/380) in MI and 91.8% (357/389) in NA. The LLIN usage was 56.8% (216/380) in MI and 86.9% (338/389) in NA. Overall system effectiveness was 49% in MI and 87% in NA, and equity was found in the distribution scale-up in NA. In both districts, the predicting factor of a child sleeping under an LLIN was caretakers thinking that LLINs are better than conventional nets (OR = 2.8, p = 0.005 in MI and 2.5, p = 0.041 in NA), in addition to receiving an LLIN (OR = 4.9, p < 0.001 in MI and in OR = 30.1, p = 0.001 in NA).ConclusionsTargeted free mass distribution of LLINs can result in high and equitable bed net coverage among children under five. However, in order to sustain high effective coverage, there is need for complimentary distribution strategies between mass distribution campaigns. Considering the communitys preferences prior to a mass distribution and addressing the communities concerns through information, education and communication, may improve the LLIN usage.

Distribution and spread of pyrethroid and DDT resistance among the Anopheles gambiae complex in Tanzania

The development of insecticide resistance is a threat to the control of malaria in Africa. We report the findings of a national survey carried out in Tanzania in 2011 to monitor the susceptibility of malaria vectors to pyrethroid, organophosphate, carbamate and DDT insecticides, and compare these findings with those identified in 2004 and 2010. Standard World Health Organization (WHO) methods were used to detect knock‐down and mortality rates in wild female Anopheles gambiae s.l. (Diptera: Culicidae) collected from 14 sentinel districts. Diagnostic doses of the pyrethroids deltamethrin, lambdacyhalothrin and permethrin, the carbamate propoxur, the organophosphate fenitrothion and the organochlorine DDT were used. Anopheles gambiae s.l. was resistant to permethrin in Muleba, where a mortality rate of 11% [95% confidence interval (CI) 6–19%] was recorded, Muheza (mortality rate of 75%, 95% CI 66–83%), Moshi and Arumeru (mortality rates of 74% in both). Similarly, resistance was reported to lambdacyhalothrin in Muleba, Muheza, Moshi and Arumeru (mortality rates of 31–82%), and to deltamethrin in Muleba, Moshi and Muheza (mortality rates of 28–75%). Resistance to DDT was reported in Muleba. No resistance to the carbamate propoxur or the organophosphate fenitrothion was observed. Anopheles gambiae s.l. is becoming resistant to pyrethoids and DDT in several parts of Tanzania. This has coincided with the scaling up of vector control measures. Resistance may impair the effectiveness of these interventions and therefore demands close monitoring and the adoption of a resistance management strategy.

Efficacy, persistence and vector susceptibility to pirimiphos-methyl (Actellic® 300CS) insecticide for indoor residual spraying in Zanzibar

BackgroundIndoor residual spraying (IRS) of households with insecticide is a principal malaria vector control intervention in Zanzibar. In 2006, IRS using the pyrethroid lambda-cyhalothrine was introduced in Zanzibar. Following detection of pyrethroid resistance in 2010, an insecticide resistance management plan was proposed, and IRS using bendiocarb was started in 2011. In 2014, bendiocarb was replaced by pirimiphos methyl. This study investigated the residual efficacy of pirimiphos methyl (Actellic® 300CS) sprayed on common surfaces of human dwellings in Zanzibar.MethodsThe residual activity of Actellic 300CS was determined over 9xa0months through bioassay tests that measured the mortality of female Anopheles mosquitoes, exposed to sprayed surfaces under a WHO cone. The wall surfaces included; mud wall, oil or water painted walls, lime washed wall, un-plastered cement block wall and stone blocks. Insecticide susceptibility testing was done to investigate the resistance status of local malaria vectors against Actellic 300CS using WHO protocols; Anopheline species were identified using PCR methods.ResultsBaseline tests conducted one-day post-IRS revealed 100xa0% mortality on all sprayed surfaces. The residual efficacy of Actellic 300CS was maintained on all sprayed surfaces up to 8xa0months post-IRS. However, the bioassay test conducted 9xa0months post-IRS showed the 24xa0h mortality rate to be ≤80xa0% for lime wash, mud wall, water paint and stone block surfaces. Only oil paint surface retained the recommended residual efficacy beyond 9xa0months post-IRS, with mortality maintained at ≥97xa0%. Results of susceptibility tests showed that malaria vectors in Zanzibar were fully (100xa0%) susceptible to Actellic 300CS. The predominant mosquito vector species was An. arabiensis (76.0xa0%) in Pemba and An. gambiae (83.5xa0%) in Unguja.ConclusionThe microencapsulated formulation of pirimiphos methyl (Actellic 300CS) is a highly effective and appropriate insecticide for IRS use in Zanzibar as it showed a relatively prolonged residual activity compared to other products used for the same purpose. The insecticide extends the residual effect of IRS thereby making it possible to effectively protect communities with a single annual spray round reducing overall costs. The insecticide proved to be a useful alternative in insecticide resistance management plans.

Pregnant women and infants as sentinel populations to monitor prevalence of malaria: results of pilot study in Lake Zone of Tanzania.

BackgroundAs malaria control interventions are scaled-up, rational approaches are needed for monitoring impact over time. One proposed approach includes monitoring the prevalence of malaria infection among pregnant women and children at the time of routine preventive health facility (HF) visits. This pilot explored the feasibility and utility of tracking the prevalence of malaria infection in pregnant women attending their first antenatal care (ANC) visit and infants presenting at 9–12xa0months of age for measles vaccination.MethodsPregnant women attending first ANC and infants nine to 12xa0months old presenting for measles vaccination at a non-probability sample of 54 HFs in Tanzania’s Lake Zone (Mara, Mwanza and Kagera Regions) were screened for malaria infection using a malaria rapid diagnostic test (RDT) from December 2012 to November 2013, regardless of symptoms. Participants who tested positive were treated for malaria per national guidelines. Data were collected monthly.ResultsOverall 89.9 and 78.1xa0% of expected monthly reports on malaria infection prevalence were received for pregnant women and infants, respectively. Among 51,467 pregnant women and 35,155 infants attending routine preventive HF visits, 41.2 and 37.3xa0% were tested with RDT, respectively. Malaria infection prevalence was 12.8xa0% [95xa0% confidence interval (CI) 11.3–14.3] among pregnant women and 11.0xa0% (95xa0% CI 9.5–12.5) among infants, and varied by month. There was good correlation of the prevalence of malaria among pregnant women and infants at the HF level (Spearman rhoxa0=xa00.6; pxa0<xa00.001). This approach is estimated to cost

School Distribution as Keep-Up Strategy to Maintain Universal Coverage of Long-Lasting Insecticidal Nets: Implementation and Results of a Program in Southern Tanzania

1.28 for every person tested, with the RDT accounting for 72xa0% of the cost.ConclusionsMalaria infection was common and well correlated among pregnant women and infants attending routine health services. Routine screening of these readily accessible populations may offer a practical strategy for continuously tracking malaria trends, particularly seasonal variation. Positivity rates among afebrile individuals presenting for routine care offer an advantage as they are unaffected by the prevalence of other causes of febrile illness, which could influence positivity rates among febrile patients presenting to outpatient clinics. The data presented here suggest that in addition to contributing to clinical management, ongoing screening of pregnant women could be used for routine surveillance and detection of hotspots.

The impact of different sprayable surfaces on the effectiveness of indoor residual spraying using a micro encapsulated formulation of lambda-cyhalothrin against Anopheles gambiae s.s.

A school-based net distribution program, piloted in the Southern Zone of Tanzania to sustain ≥80% universal net coverage previously attained through mass campaigns, successfully issued nets to nearly all eligible students and teachers. Keys to success included: Effective collaboration between the Ministry of Health, local government, and implementing partners Social mobilization to sensitize the community about the importance of net use Development of a mobile application to facilitate data collection and analysis A school-based net distribution program, piloted in the Southern Zone of Tanzania to sustain ≥80% universal net coverage previously attained through mass campaigns, successfully issued nets to nearly all eligible students and teachers. Keys to success included: Effective collaboration between the Ministry of Health, local government, and implementing partners Social mobilization to sensitize the community about the importance of net use Development of a mobile application to facilitate data collection and analysis ABSTRACT Tanzania successfully scaled up coverage of long-lasting insecticidal nets (LLINs) through mass campaigns. To sustain these gains, a school-based approach was piloted in the country’s Southern Zone starting in 2013, called the School Net Program 1 (SNP1). We report on the design, implementation, monitoring, and outputs of the second round (SNP2) undertaken in 2014. SNP2 was conducted in all schools in Lindi, Mtwara, and Ruvuma regions, targeting students in primary (Standards 1, 3, 5, and 7) and secondary (Forms 2 and 4) schools and all teachers. In Lindi region, 2 additional classes (Standards 2 and 4) were targeted. LLIN distribution data were managed using an Android software application called SchoolNet. SNP2 included 2,337 schools, 473,700 students, and 25,269 teachers. A total of 5,070 people were trained in LLIN distribution (487 trainers and 4,583 distributors), and 4,392 (434 ward and 3,958 village) community change agents undertook sensitization and mobilization. A total of 507,775 LLINs were distributed to schools, with 464,510 (97.9% of those registered) students and 24,206 (95.8% of those registered) school teachers receiving LLINs. LLIN ownership and use is expected to have increased, potentially further reducing the burden of malaria in the Southern Zone of Tanzania.

Use of insecticide quantification kits to investigate the quality of spraying and decay rate of bendiocarb on different wall surfaces in Kagera region, Tanzania.

BackgroundThe type of sprayable surface impacts on residual efficacy of insecticide used in indoor residual spraying (IRS). However, there is limited data on common types of wall surfaces sprayed in Zanzibar and mainland Tanzania where IRS began in 2006 and 2007 respectively. The study investigated residual efficacy of micro-encapsulated lambda-cyhalothrin sprayed on common surfaces of human dwellings and domestic animal shelters in Zanzibar and mainland Tanzania.MethodsAn experimental hut was constructed with different types of materials simulating common sprayable surfaces in Zanzibar and mainland Tanzania. Surfaces included cement plastered wall, mud-daub, white-wash, wood, palm-thatch, galvanized iron-sheets, burnt-bricks, limestone and oil-paint. The World Health Organization (WHO) procedure for IRS was used to spray lambda-cyhalothrin on surfaces at the dose of 20–25xa0mg/m2. Residual efficacy of insecticide was monitored through cone bioassay using laboratory-reared mosquitoes; Kisumu strain (R–70) of Anopheles gambiae ss. Cone bioassay was done every fortnight for a period of 152xa0days. The WHO Pesticide Evaluation Scheme (WHOPES) threshold (80% mortality) was used as cut-off point for acceptable residual efficacy.ResultsA total of 5,800 mosquitoes were subjected to contact cone bioassay to test residual efficacy of lambda-cyhalothrin. There was a statistically significant variation in residual efficacy between the different types of wall surfaces (ru2009=u20090.24; pu2009<u20090.001). Residual efficacy decreased with increasing pH of the substrate (ru2009=u2009−0.5; pu2009<u20090.001). Based on WHOPES standards, shorter residual efficacy (42-56 days) was found in wall substrates made of cement, limestone, mud-daub, oil paint and white wash. Burnt bricks retained the residual efficacy up to 134xa0days while galvanized iron sheets, palm thatch and wood retained the recommended residual efficacy beyond 152xa0days.ConclusionThe study revealed a wide variation in residual efficacy of micro encapsulated formulation of lambda-cyhalothrin across the different types of wall surfaces studied. In areas where malaria transmission is bimodal and wall surfaces with short residual efficacy compriseu2009>u200920% of sprayable structures, two rounds of IRS using lambda-cyhalothrin should be considered. Further studies are required to investigate the impact of sprayable surfaces on residual efficacy of other insecticides commonly used for IRS in Zanzibar and mainland Tanzania.

Indoor residual spraying with micro-encapsulated pirimiphos-methyl (Actellic ® 300CS) against malaria vectors in the Lake Victoria basin, Tanzania

BackgroundBendiocarb was introduced for the first time for Indoor Residual Spraying (IRS) in Tanzania in 2012 as part of the interim national insecticide resistance management plan. This move followed reports of increasingly alarming levels of pyrethroid resistance across the country. This study used the insecticide quantification kit (IQK) to investigate the intra-operational IRS coverage and quality of spraying, and decay rate of bendiocarb on different wall surfaces in Kagera region.MethodsTo assess intra-operational IRS coverage and quality of spraying, 104 houses were randomly selected out of 161,414 sprayed houses. A total of 509 samples (218 in Muleba and 291 in Karagwe) were obtained by scraping the insecticide samples from wall surfaces. To investigate decay rate, 66 houses (36 in Muleba and 30 in Karagwe) were selected and samples were collected monthly for a period of five months. Laboratory testing of insecticide concentration was done using IQKTM [Innovative Vector Control Consortium].ResultsOf the 509 samples, 89.5% met the World Health Organization (WHO) recommended concentration (between 100–400xa0mg/m2) for IRS target dosage. The proportion of samples meeting WHO standards varied between Karagwe (84.3%) and Muleba (96.3%) (pu2009<u20090.001). Assessment of quality of spraying at house level revealed that Muleba (84.8%) had a significantly higher proportion of households that met the expected target dosage (100–400xa0mg/m2) compared to Karagwe (68.9%) (pu2009<u20090.001). The quality of spraying varied across different wall substrates in both districts. Evaluation of bendiocarb decay showed that the proportion of houses with recommended concentration declined from 96.9%, 93.5% and 76.2% at months one, two, and three post IRS, respectively (p-trendu2009=u20090.03). The rate of decay increased in the fourth and fifth month post spraying with only 55.9% and 26.3% houses meeting the WHO recommendations, respectively.ConclusionIQK is an important tool for assessing IRS coverage and quality of spraying. The study found adequate coverage of IRS; however, residual life of bendiocarb was observed to be three months. Results suggest that in order to maintain the recommended concentrations with bendiocarb, a second spray cycle should be carried out after three months.