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Background: The human papilloma virus is a global problem that affects sexually active women and men, with cervical cancer being the most serious associated disease. Most cervical cancer cases can be prevented by vaccination against the human papilloma virus early in life. The objective of this study was to assess the knowledge, attitudes, and practices among physicians working in Qatar, regarding the human papilloma virus, infection, and prevention using vaccines., Study-Design: This was a cross-sectional study using quantitative data collection., Methodology: An online survey targeting physicians working in Qatar was conducted, using a web-based pretested questionnaire. The questionnaire comprised four sections capturing a few demographic details, 33 questions in the Knowledge Section, 12 questions eliciting the attitude, and 14 practice-related questions. Mean knowledge score was calculated and those with a score more than the mean score were considered to have sufficient knowledge. Association between knowledge and attitude/practices/independent variables were looked for using bivariate and multivariate analysis. Logistic regression was used to identify the predictors for recommending human papilloma virus vaccines., Results: Of the 557 physicians who participated, 83.7% had sufficient knowledge, but only 69.1% knew that human papilloma virus vaccines were available in Qatar. The majority (89.4%) knew that human papilloma virus infection could be asymptomatic and 96.1% knew at least one symptom; 77% believed the human papilloma virus vaccine would substantially decrease the chances of human papilloma virus infection and related cancers and 46.5% felt physicians were less motivated to promote the human papilloma virus vaccine. The perceived barriers to community acceptance of the human papilloma virus vaccine were lack of awareness regarding the relationship between human papilloma virus and cervical cancer (61.6%), doubts regarding efficacy (32.5%), fear regarding safety (26.9%), concern that the human papilloma virus vaccination may encourage risky sexual behavior (26.8%), and perceived low-risk (23.3%) and cost (24.6%). Only 21.5% commonly discussed sexual health with their clients. More than one-third were not interested in recommending the human papilloma virus vaccine. Bivariate analysis showed nationality, specialization, discussing with patients, and recommending vaccine to be significantly associated with knowledge. Bivariate and regression analysis identified that female gender and physician's religion were significant predictors to recommend the human papilloma virus vaccine., Conclusion: Most physicians have good knowledge. Less than one-fourth commonly discussed sexual health with their clients. More than one-third were not interested in recommending the human papilloma virus vaccine. This issue might affect the human papilloma virus vaccination program implementation if not well addressed.

Background: Scale-up of insecticide-based interventions has averted more than 500 million malaria cases since 2000. Increasing insecticide resistance could herald a rebound in disease and mortality. We aimed to investigate whether insecticide resistance was associated with loss of effectiveness of long-lasting insecticidal nets and increased malaria disease burden., Methods: This WHO-coordinated, prospective, observational cohort study was done at 279 clusters (villages or groups of villages in which phenotypic resistance was measurable) in Benin, Cameroon, India, Kenya, and Sudan. Pyrethroid long-lasting insecticidal nets were the principal form of malaria vector control in all study areas; in Sudan this approach was supplemented by indoor residual spraying. Cohorts of children from randomly selected households in each cluster were recruited and followed up by community health workers to measure incidence of clinical malaria and prevalence of infection. Mosquitoes were assessed for susceptibility to pyrethroids using the standard WHO bioassay test. Country-specific results were combined using meta-analysis., Findings: Between June 2, 2012, and Nov 4, 2016, 40 000 children were enrolled and assessed for clinical incidence during 1·4 million follow-up visits. 80 000 mosquitoes were assessed for insecticide resistance. Long-lasting insecticidal net users had lower infection prevalence (adjusted odds ratio [OR] 0·63, 95% CI 0·51-0·78) and disease incidence (adjusted rate ratio [RR] 0·62, 0·41-0·94) than did non-users across a range of resistance levels. We found no evidence of an association between insecticide resistance and infection prevalence (adjusted OR 0·86, 0·70-1·06) or incidence (adjusted RR 0·89, 0·72-1·10). Users of nets, although significantly better protected than non-users, were nevertheless subject to high malaria infection risk (ranging from an average incidence in net users of 0·023, [95% CI 0·016-0·033] per person-year in India, to 0·80 [0·65-0·97] per person year in Kenya; and an average infection prevalence in net users of 0·8% [0·5-1·3] in India to an average infection prevalence of 50·8% [43·4-58·2] in Benin)., Interpretation: Irrespective of resistance, populations in malaria endemic areas should continue to use long-lasting insecticidal nets to reduce their risk of infection. As nets provide only partial protection, the development of additional vector control tools should be prioritised to reduce the unacceptably high malaria burden., Funding: Bill & Melinda Gates Foundation, UK Medical Research Council, and UK Department for International Development., (Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Progress in reducing the malaria disease burden through the substantial scale up of insecticide-based vector control in recent years could be reversed by the widespread emergence of insecticide resistance. The impact of insecticide resistance on the protective effectiveness of insecticide-treated nets (ITN) and indoor residual spraying (IRS) is not known. A multi-country study was undertaken in Sudan, Kenya, India, Cameroon and Benin to quantify the potential loss of epidemiological effectiveness of ITNs and IRS due to decreased susceptibility of malaria vectors to insecticides. The design of the study is described in this paper., Methods: Malaria disease incidence rates by active case detection in cohorts of children, and indicators of insecticide resistance in local vectors were monitored in each of approximately 300 separate locations (clusters) with high coverage of malaria vector control over multiple malaria seasons. Phenotypic and genotypic resistance was assessed annually. In two countries, Sudan and India, clusters were randomly assigned to receive universal coverage of ITNs only, or universal coverage of ITNs combined with high coverage of IRS. Association between malaria incidence and insecticide resistance, and protective effectiveness of vector control methods and insecticide resistance were estimated, respectively., Results: Cohorts have been set up in all five countries, and phenotypic resistance data have been collected in all clusters. In Sudan, Kenya, Cameroon and Benin data collection is due to be completed in 2015. In India data collection will be completed in 2016., Discussion: The paper discusses challenges faced in the design and execution of the study, the analysis plan, the strengths and weaknesses, and the possible alternatives to the chosen study design.

Artemisinin-based combination therapies (ACT) are now being adopted as first-line treatments against uncomplicated malaria in sub-Saharan Africa. Between December 2009 and February 2010, the efficacies of two ACT - dihydroartemisinin-piperaquine (DHA-P) and artemether-lumefantrine (AL) - in the treatment of uncomplicated Plasmodium falciparum malaria were compared in Sinnar, central Sudan. Overall, 149 patients (75 given DHA-P and 74 given AL) completed the 28 days of follow-up. All the patients were found to be afebrile and aparasitaemic on day 3. By day 28, only one patient, who had been given AL, showed late treatment and parasitological failures, while each of the other 148 patients showed an adequate treatment response. After the results of a PCR-based assay confirmed that the recrudescent parasitaemia was probably the result of treatment failure, the frequencies of cure by day 28 were calculated as 100% for DHA-P and 98.7% for AL (P>0.05). None of the patients was found gametocytaemic during the follow-up, and the adverse effects observed were mild (nausea, vomiting, abdominal pain, dizziness and/or rash), resolved spontaneously and occurred in only five patients in each treatment arm. Thus, both treatments appeared effective and safe for the treatment of uncomplicated P. falciparum malaria in central Sudan, although treatment with DHA-P (which requires a simpler dosing regimen) might be preferred to treatment with AL.

Although artemisinin and its derivatives are widely used for the treatment of malaria, they also have antischistosomal activity. In a small study in eastern Sudan, the effects of the treatment of uncomplicated, Plasmodium falciparum malaria with artesunate-sulfamethoxypyrazine-pyrimethamine (AS-SMP) and artemether-lumefantrine (AT-LU) on co-infections with Schistosoma mansoni were therefore investigated. Faecal samples from 14 of the 306 patients screened on presentation, at the start of a clinical trial of antimalarial treatment, were found to contain Schistosoma mansoni eggs. For the treatment of their malaria, the 14 egg-positive cases, who were aged 6-40 years (mean = 13.7 years), were each subsequently treated with three tablets of a fixed combination of AS-SMP, with a 12-h (six patients) or 24-h interval (five patients) between each tablet, or with six doses of AT-LU given over 3 days. When checked 28 and 29 days after the initiation of treatment, all 14 patients were found stool-negative for schistosome eggs. These results indicate that AS-SMP and AT-LU are currently very effective treatments not only for uncomplicated, P. falciparum malaria but also for S. mansoni infections.

Artemisinin-based combination therapy (ACT) is increasingly being adopted as the first-line treatment for malaria in sub-Saharan Africa. In September-November 2005, in New Halfa, eastern Sudan, the efficacy of artesunate-sulfadoxine-pyrimethamine (AS-SP) for the treatment of uncomplicated, Plasmodium falciparum was compared with that of artesunate-amodiaquine (AS-AQ). The artesunate was given at 4 mg/kg. day on days 0-2, with either a single dose of SP (25 mg sulfadoxine/kg) given on day 0, or AQ, at 10 mg/kg. day, given on days 0-2. Eighty-two of the patients treated (40 given AS-SP and 42 given AS-AQ) completed the 28 days of follow-up. On day 3 all the patients were afebrile and only one patient, in the AS-AQ group, was still parasitaemic. AS-SP appeared slightly more efficacious than AS-AQ but the differences were not statistically significant. Only one patient (2.5%) given AS-SP but four (9.5%) of those given AS-AQ were initially considered to be late treatment and parasitological failures, with all other patients showing an adequate treatment response. The PCR-corrected frequencies of cure were 97.5% for AS-SP and 95.2% for AS-AQ (P>0.05). No gametocytaemias were observed during the follow-up and, although mild adverse effects (nausea, vomiting, abdominal pain, dizziness and/or rash) were detected in 14 patients, they occurred at the same frequency in each treatment arm. It therefore appears that the AS-SP and AS-AQ combinations were both effective and safe for the treatment of uncomplicated, P. falciparum malaria in eastern Sudan.

Background: In Sudan, chloroquine (CQ) remains the most frequently used drug for falciparum malaria for more than 40 years. The change to artemisinin-based combination therapy (ACT) was initiated in 2004 using the co-blister of artesunate + sulfadoxine/pyrimethamine (AS+SP) and artemether + lumefantrine (ART+LUM), as first- and second-line, respectively. This article describes the evidence-base, the process for policy change and it reflects the experience of one year implementation. Relevant published and unpublished documents were reviewed. Data and information obtained were compiled into a structured format., Case Description: Sudan has used evidence to update its malaria treatment to ACTs. The country moved without interim period and proceeded with country-wide implementation instead of a phased introduction of the new policy. The involvement of care providers and key stakeholders in a form of a technical advisory committee is considered the key issue in the process. Development and distribution of guidelines, training of care providers, communication to the public and provision of drugs were given great consideration. To ensure presence of high quality drugs, a system for post-marketing drugs surveillance was established. Currently, ACTs are chargeable and chiefly available in urban areas. With the input from the Global Fund to fight AIDs, Tuberculosis and Malaria, AS+SP is now available free of charge in 10 states., Conclusion: Implementation of the new policy is affected by the limited availability of the drugs, their high cost and limited pre-qualified manufacturers. Substantial funding needs to be mobilized by all partners to increase patients' access for this life-saving intervention.