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Background: Despite a global decrease in malaria burden worldwide, malaria remains a major public health concern, especially in Benin children, the most vulnerable group. A better understanding of malaria's spatial and age-dependent characteristics can help provide durable disease control and elimination. This study aimed to analyze the spatial distribution of Plasmodium falciparum malaria infection and disease among children under five years of age in Benin, West Africa.Methods: A cross-sectional epidemiological and clinical survey was conducted using parasitological examination and rapid diagnostic tests (RDT) in Benin. Interviews were done with 10,367 children from 72 villages across two health districts in Benin. The prevalence of infection and clinical cases was estimated according to age. A Bayesian spatial binomial model was used to estimate the prevalence of malaria infection, and clinical cases were adjusted for environmental and demographic covariates. It was implemented in R using Integrated Nested Laplace Approximations (INLA) and Stochastic Partial Differentiation Equations (SPDE) techniques.Results: The prevalence of P. falciparum infection was moderate in the south (34.6%) of Benin and high in the northern region (77.5%). In the south, the prevalence of P. falciparum infection and clinical malaria cases were similar according to age. In northern Benin children under six months of age were less frequently infected than children aged 6-11, 12-23, 24-60 months, (p < 0.0001) and had the lowest risk of malaria cases compared to the other age groups (6-12), (13-23) and (24-60): OR = 3.66 [2.21-6.05], OR = 3.66 [2.21-6.04], and OR = 2.83 [1.77-4.54] respectively (p < 0.0001). Spatial model prediction showed more heterogeneity in the south than in the north but a higher risk of malaria infection and clinical cases in the north than in the south.Conclusion: Integrated and periodic risk mapping of Plasmodium falciparum infection and clinical cases will make interventions more evidence-based by showing progress or a lack in malaria control. [ABSTRACT FROM AUTHOR]

Background: Low adoption of effective health technologies increases illness morbidity and mortality worldwide. In the case of malaria, effective tools such as malaria rapid diagnostic tests (RDTs) and artemisinin-combination therapies (ACTs) are both under-used and used inappropriately. Individuals' confidence in RDTs and ACTs likely affects the uptake of these tools.Methods: In a cohort of 36 households (280 individuals) in Western Kenya observed for 30 months starting in June 2017, we examined if experience with RDTs and ACTs changes people's beliefs about these technologies and how those beliefs affect treatment behavior. Household members requested a free RDT from the study team any time they suspected a malaria illness, and positive RDT results were treated with a free ACT. We conducted annual, monthly, and sick visit surveys to elicit beliefs about the accuracy of malaria RDT results and the effectiveness of ACTs. Beliefs were elicited on a 5-point Likert scale from "very unlikely" to "very likely."Results: Over the study period, the percentage of survey respondents that said a hypothetical negative RDT result was "very likely" to be correct increased from approximately 55% to 75%. Controlling for initial beliefs, people who had been tested at least once with an RDT in the past year had 3.6 times higher odds (95% CI [1 1.718 7.679], P = 0.001) of saying a negative RDT was "very likely" to be correct. Confidence in testing was associated with treatment behavior: those who believed a negative RDT was "very likely" to be correct had 1.78 times higher odds (95% CI [1.079 2.934], P = 0.024) of adhering to a negative RDT result (by not taking ACTs) than those who were less certain about the accuracy of negative RDTs. Adherence to a negative test also affected subsequent beliefs: controlling for prior beliefs, those who had adhered to their previous test result had approximately twice the odds (OR = 2.19, 95% CI [1.661 2.904], P < 0.001) of saying that a hypothetical negative RDT was "very likely" to be correct compared to those who had not adhered.Conclusions: Our results suggest that greater experience with RDTs can not only increase people's confidence in their accuracy but also improve adherence to the test result. [ABSTRACT FROM AUTHOR]

Background: Malaria is a persistent public health challenge among miners and other hard-to-reach populations in Guyana's hinterland, specifically in Regions 1, 7, 8, and 9. Despite an overall decrease in malaria prevalence throughout Guyana, it remains common among mining populations whose work conditions both contribute toward malaria transmission and make it difficult to seek timely, Ministry of Health (MoH) approved malaria testing and treatment services. In an effort to develop innovative approaches to address this public health challenge, an interdisciplinary team of public health professionals, designers, and mining organizations collaborated using a human-centered design (HCD) process facilitated by the USAID-funded Breakthrough ACTION Guyana project in partnership with the MoH.Methods: This paper describes two phases: [1] Define and [2] Design & Test. In the Define phase, following a literature review, we conducted 108 qualitative interviews with miners, camp managers, trained malaria testers, health workers, and other key stakeholders to understand experiences and challenges when seeking malaria testing and treatment services. These interviews were synthesized into 11 insights on issues such as risk perception, malaria knowledge, preventive behaviors, traditional and self-treatment, adherence to the correct treatment, testing, and coordination and communication gaps. From these insights, during the Design & Test phase, we developed 33 "How might we…?" questions which led to 792 ideas, of which eight emergent concepts were prototyped and refined in the field with 145 miners, camp managers, and stakeholders.Results: The five final prototypes included: "Little Mosquito, Big Problem" social behavior change campaign; rapid counseling cards; branded malaria testing and treatment services; innovations in treatment adherence; and a participants, content, and logistics approach.Conclusion: When applying HCD to public health issues, there are both opportunities and challenges to reconcile gaps that may exist between the two disciplines. However, HCD provides additional tools and mindsets to generatively work with migrant and mobile mining communities to encourage malaria testing and treatment services. [ABSTRACT FROM AUTHOR]

Background: Encouraged by the previous success in malaria control and prevention strategies, the Ethiopian ministry of health launched malaria elimination with a stepwise approach by primarily targeting the low-transmission Districts and their adjacent areas/zones in order to shrink the country's malaria map progressively. Hence, this community survey was conducted to establish baseline malaria information at the preliminary phase of elimination at targeted settings.Methods: A community-based cross-sectional survey was conducted at 20 malaria-elimination targeted Districts selected from five Regional states and one city administration in Ethiopia. The GPS-enabled smartphones programmed with Open Data Kit were used to enumerate 9326 study households and collect data from 29,993 residents. CareStart™ Malaria PAN (pLDH) Rapid Diagnostic Tests (RDTs) were used for blood testing at the field level. Armpit digital thermometers were used to measure axillary temperature.Result: Overall malaria prevalence by RDTs was 1.17% (339/28973). The prevalence at District levels ranged from 0.0 to 4.7%. The proportion of symptomatic cases (axillary temperature > 37.5oc) in the survey was 9.2% (2760/29993). Among the 2510 symptomatic individuals tested with RDTs, only 3.35% (84/2510) were malaria positive. The 75.2% (255/339) of all malaria positives were asymptomatic. Of the total asymptomatic malaria cases, 10.2% (26/255) were under-five children and 89.8% (229/255) were above 5 years of age.Conclusion: The study shows a decrease in malaria prevalence compared to the reports of previous malaria indicator surveys in the country. The finding can be used as a baseline for measuring the achievement of ongoing malaria elimination efforts. Particularly, the high prevalence of asymptomatic individuals (0.88%) in these transmission settings indicates there may be sustaining hidden transmission. Therefore, active case detection with more sensitive diagnostic techniques is suggested to know more real magnitude of residual malaria in the elimination-targeted areas. [ABSTRACT FROM AUTHOR]

Background: Prompt diagnosis and treatment prevents a mild case of malaria from developing into severe disease and death. Unfortunately, parasitological testing of febrile children is greater in the public and formal private sector than in the informal private sector in sub-Saharan Africa.Methods: A mixed method study was carried out to determine factors limiting test-based management of suspected malaria cases among caregivers of febrile children and Over-the-Counter medicine sellers (OTCMS) in eight rural communities in Ghana. Structured questionnaires were used to interview 254 adult caregivers. Fourteen in-depth interviews were conducted with OTCMS. The interviews were audio-recorded, transcribed verbatim, and analysed thematically.Results: The most frequently sought health providers by caregivers of febrile children in descending order were Community Health-Based Planning Services (CHPS) compounds; drug vendors; and OTCMS. Malaria parasitological testing rate of febrile children was highest (94.9%) at the CHPS compound and lowest (10.5%) at the OTCMS shops. Proportion of febrile children not subjected to malaria blood test is 28.3%. Among caregivers who did not ask for malaria blood test, 15.2% reported that healthcare provider did not offer a malaria blood test; 21.7% were financially handicapped to visit the Health Centre; and 63% lacked knowledge of malaria blood test and where to get it. From OTCMS point of view, clients' inability to pay for malaria blood test, community perception that OTCMS are unqualified to perform malaria blood test, financial loss when unused RDT kits expires, clients' demand for half dose of ACT, and activities of drug peddlers are factors limiting adherence to WHO recommended policy on testing before treating uncomplicated malaria cases.Conclusion: The study results suggest the need to implement community friendly interventions aimed at improving test-based management of suspected malaria in febrile children. These may include educating caregivers and community members on the need to test and confirm malaria in febrile children before treating them, and supply of subsidized RDT kits to OTCMS and re-training them to provide testing services to their clients. Further studies pertaining to influence of gender roles on healthcare seeking attitude for febrile children is also suggested. [ABSTRACT FROM AUTHOR]

Background: In Chad, malaria remains a significant public health concern, particularly among nomadic populations. Geographical factors and the mobility of human populations have shown to be associated with the diversity of Plasmodium species. The study aims to describe the malaria prevalence among nomadic children and to investigate its associated factors., Methods: A cross-sectional study was conducted in February and October 2021 among nomadic communities in Chad. Blood sample were collected and tested from 187 Arab, Fulani and Dazagada nomadic children aged 3-59 months using malaria rapid diagnostic test (RDT). A structured electronic questionnaire was administered to their parents to collect information about the socio‑economic data. Malaria testing results were categorized according to the SD BIOLINE Malaria Ag Pf/Pan RDT procedures. Logistic regression analysis was used to determine key risk factors explaining the prevalence of malaria. STATA version IC 13 was used for statistical analysis., Results: The overall malaria prevalence in nomadic children was 24.60%, with 65.20% being Plasmodium falciparum species and 34.8% mixed species. Boys were twice as likely (COR = 1.83; 95% CI, 0.92-3.62; p = 0.083) to have malaria than girls. Children whose parents used to seek traditional drugs were five times more likely (AOR = 5.59; 95% CI, 1.40-22.30, p = 0.015) to have malaria than children whose parents used to seek health facilities. Children whose parents reported spending the last night under a mosquito net were one-fifth as likely (AOR = 0.17; 95% CI, 0.03-0.90, p = 0.037) to have malaria compared to children whose parents did not used a mosquito net. Furthermore, Daza children were seventeen times (1/0.06) less likely (AOR = 0.06; 95% CI, 0.01-0.70, p = 0.024) to have malaria than Fulani children and children from households piped water as the main source were seven times more likely (AOR = 7.05; 95% CI, 1.69-29.45; p = 0.007) to have malaria than those using surface water., Conclusions: Malaria remains a significant public health issue in the nomadic communities of Chad. Community education and sensitization programs within nomad communities are recommended to raise awareness about malaria transmission and control methods, particularly among those living in remote rural areas. The National Malaria Control Program (NMCP) should increase both the coverage and use of long-lasting insecticidal nets (LLINs) and seasonal malaria chemoprevention (SMC) in addition to promoting treatment-seeking behaviors in nomadic communities., (© 2024. The Author(s).)

Background: Anhui Province is currently facing an increase in imported malaria cases as a result of globalization and international travel. In response, Anhui Province has implemented a comprehensive adaptive framework to effectively address this threat., Methods: This study collected surveillance data from 2012 to 2022 in Anhui Province. Descriptive statistics were used to analyze the epidemiological characteristics of imported malaria cases. Additionally, multivariate logistic regression was employed to identify factors associated with severe malaria. Documents were reviewed to document the evolution of the adaptive framework designed to combat imported malaria. The effectiveness of the adaptive framework was evaluated based on the rates of timely medical visits, timely diagnosis, and species identification., Results: During the study period, a total of 1008 imported malaria cases were reported across 77 out of 105 counties in Anhui Province, representing a coverage of 73.33%. It was found that 10.52% of imported cases went undiagnosed for more than seven days after onset. The multivariate analysis revealed several potential risk factors for severe malaria, including increasing age (OR = 1.049, 95%CI:1.015-1.083), occupation (waitperson vs. worker, OR = 2.698, 95%CI:1.054-6.906), a longer time interval between onset and the initial medical visit (OR = 1.061, 95%CI:1.011-1.114), and misdiagnosis during the first medical visit (OR = 5.167, 95%CI:2.535-10.533). Following the implementation of the adaptive framework, the rates of timely medical visits, timely diagnosis, and species identification reached 100.00%, 78.57%, and 100.00%, respectively., Conclusions: Anhui Province has successfully developed and implemented an adaptive framework for addressing imported malaria, focusing on robust surveillance, prompt diagnosis, and standardized treatment. The experiences gained from this initiative can serve as a valuable reference for other non-endemic areas., (© 2024. The Author(s).)

Background: Prompt and effective malaria diagnosis and treatment is a cornerstone of malaria control. Case management guidelines recommend confirmatory testing of suspected malaria cases, then prescription of specific drugs for uncomplicated malaria and for severe malaria. This study aims to describe case management practices for children aged 1-59 months seeking treatment with current or recent fever from public and private, rural and urban health providers in Mali.Methods: Data were collected at sites in Sikasso Region and Bamako. Health workers recorded key information from the consultation including malaria diagnostic testing and result, their final diagnosis, and all drugs prescribed. Children with signs of severe diseases were ineligible. Consultations were not independently observed. Appropriate case management was defined as both 1) tested for malaria using rapid diagnostic test or microscopy, and 2) receiving artemisinin combination therapy (ACT) and no other antimalarials if test-positive, or receiving no antimalarials if test-negative.Results: Of 1602 participating children, 23.7% were appropriately managed, ranging from 5.3% at public rural facilities to 48.4% at community health worker sites. The most common reason for 'inappropriate' management was lack of malaria diagnostic testing (50.4% of children). Among children with confirmed malaria, 50.8% received a non-ACT antimalarial (commonly artesunate injection or artemether), either alone or in combination with ACT. Of 215 test-negative children, 44.2% received an antimalarial drug, most commonly ACT. Prescription of multiple drugs was common: 21.7% of all children received more than one type of antimalarial, while 51.9% received an antibiotic and antimalarial. Inappropriate case management increased in children with increasing axillary temperatures and those seeking care over weekends.Conclusions: Multiple limitations in management of febrile children under five were identified, including inconsistent use of confirmatory testing and apparent use of severe malaria drugs for uncomplicated malaria. While we cannot confirm the reasons for these shortcomings, there is a need to address the high use of non-ACT antimalarials in this context; to minimize potential for drug resistance, reduce unnecessary expense, and preserve life-saving treatment for severe malaria cases. These findings highlight the challenge of managing febrile illness in young children in a high transmission setting. [ABSTRACT FROM AUTHOR]

Background: In Ethiopia, malaria is one of the public health problems, and it is still among the ten top leading causes of morbidity and mortality among under-five children. However, the studies conducted in the country have been inconclusive and inconsistent. Thus, this study aimed to assess factors associated with malaria among under-five children in Ethiopia.Methods: We retrieved secondary data from the malaria indicator survey data collected from September 30 to December 10, 2015, in Ethiopia. A total of 8301 under-five-year-old children who had microscopy test results were included in the study. Bayesian multilevel logistic regression models were fitted and Markov chain Monte Carlo simulation was used to estimate the model parameters using Gibbs sampling. Adjusted Odd Ratio with 95% credible interval in the multivariable model was used to select variables that have a significant association with malaria.Results: In this study, sleeping under the insecticide-treated bed nets during bed time (ITN) [AOR 0.58,95% CI, 0.31-0.97)], having 2 and more ITN for the household [AOR 0.43, (95% CI, 0.17-0.88)], have radio [AOR 0.41, (95% CI, 0.19-0.78)], have television [AOR 0.19, (95% CI, 0.01-0.89)] and altitude [AOR 0.05, (95% CI, 0.01-0.13)] were the predictors of malaria among under-five children.Conclusions: The study revealed that sleeping under ITN, having two and more ITN for the household, altitude, availability of radio, and television were the predictors of malaria among under-five children in Ethiopia. Thus, the government should strengthen the availability and utilization of ITN to halt under-five mortality due to malaria. [ABSTRACT FROM AUTHOR]

Background: Early diagnosis and treatment of malaria symptoms reduces the risk of severe complication and malaria transmission. However, delay in malaria diagnosis and treatment is a major public health problem in India. The primary aim of the study was to determine cut-off for the delay in seeking treatment of fever, and the secondary aim was to identify the factors associated with delay in malaria-endemic areas of Assam, Northeast India.Methods: The present study analysed data from two prior cross-sectional surveys (community- and hospital-based) that was conducted to study the health-seeking behaviour of people residing in high malaria-endemic areas of Assam, Northeast India. The hospital-based survey data were used to determine optimal cut-off for the delay in reporting, and further, used to identify the factors associated with delay using community-based data.Results: Mean age of fever cases was similar in both community- and hospital-based surveys (23.1 years vs 24.2 years, p = 0.229). Delay in reporting fever was significantly higher among hospital inpatients compared to community-based fever cases (3.6 ± 2.1 vs 4.0 ± 2.6 days; p = 0.006). Delay of > 2 days showed higher predictive ability (sensitivity: 96.4%, and ROC area: 67.5%) compared to other cut-off values (> 3, > 4, and > 5 days). Multivariable logistic regression analysis revealed that the adjusted odds ratio (aOR) of delay was significantly higher for people living in rural areas (1.52, 95%CI: 1.11-2.09), distance (> 5 km) to health facility (1.93, 95%CI: 1.44-2.61), engaged in agriculture work (2.58, 95%CI: 1.97-3.37), and interaction effect of adult male aged 20-40 years (1.71, 95%CI: 1.06-2.75).Conclusion: The delay (> 2 days) in seeking treatment was likely to be twice among those who live in rural areas and travel > 5 km to assess health care facility. The findings of the study are useful in designing effective intervention programmes for early treatment of febrile illness to control malaria. [ABSTRACT FROM AUTHOR]

Background: In South Africa malaria is endemic in Mpumalanga, Limpopo and the north-eastern areas of KwaZulu-Natal provinces. South Africa has set targets to eliminate malaria by 2018 and research into complementary vector control tools such as the Sterile Insect Technique (SIT) is ongoing. It is important to understand community perceptions regarding malaria transmission and control interventions to enable development of community awareness campaign messages appropriate to the needs of the community. We aimed to assess knowledge, attitudes, and practices regarding malaria transmission to inform a public awareness campaign for SIT in Jozini Local Municipality, Mamfene in KwaZulu-Natal province.Methods: We conducted a cross-sectional survey in three communities in Mamfene, KwaZulu-Natal during 2015. A structured field piloted questionnaire was administered to 400 randomly selected heads of households. Descriptive statistics were used to summarize data.Results: Of the 400 participants interviewed, 99% had heard about malaria and correctly associated it with mosquito bites. The sources of malaria information were the local health facility (53%), radio (16%) and community meetings (7%). Approximately 63% of the participants were able to identify three or four symptoms of malaria. The majority (76%) were confident that indoor residual spraying (IRS) kills mosquitoes and prevents infection. Bed nets were used by 2% of the participants. SIT knowledge was poor (9%), however 63% of the participants were supportive of mosquito releases for research purposes. The remaining 37% raised concerns and fears, including fear of the unknown and lack of information on the SIT.Conclusion: Appropriate knowledge, positive attitude and acceptable treatment-seeking behaviour for malaria were demonstrated by members of the community. Community involvement will be crucial in achieving success of the SIT and future studies should further investigate concerns raised by the community. The existing communication channels used by the malaria control program can be used; however additional channels should be investigated. [ABSTRACT FROM AUTHOR]

Background: Malaria is one of the most important causes of morbidity and mortality in sub-Saharan Africa. The disease is prevalent in over 75% of the country's area making it the leading public health problems in the country. Information on the prevalence of malaria and its associated factors is vital to focus and improve malaria interventions.Methods: A cross-sectional study was carried out from October to November 2012 in East Shewa zone of Oromia Regional State, Ethiopia. Adults aged 16 or more years with suspected malaria attending five health centers were eligible for the study. Logistic regression models were used to examine the effect of each independent variable on risk of subsequent diagnosis of malaria.Results: Of 810 suspected adult malaria patients who participated in the study, 204 (25%) had microscopically confirmed malaria parasites. The dominant Plasmodium species were P. vivax (54%) and P. falciparum (45%), with mixed infection of both species in one patient. A positive microscopic result was significantly associated with being in the age group of 16 to 24 years [Adjusted Odds Ratio aOR 6.7; 95% CI: 2.3 to 19.5], 25 to 34 years [aOR 4.2; 95% CI: 1.4 to 12.4], and 35 to 44 years [aOR 3.7; 95% CI: 1.2-11.4] compared to 45 years or older; being treated at Meki health center [aOR 4.1; 95% CI: 2.4 to 7.1], being in Shashemene health center [aOR = 2.3; 95% CI: 1.5 to 4.5], and living in a rural area compared to an urban area [aOR 1.7; 95% CI: 1.1 to 2.6)].Conclusion: Malaria is an important public health problem among adults in the study area with a predominance of P. vivax and P. falciparum infection. Thus, appropriate health interventions should be implemented to prevent and control the disease. [ABSTRACT FROM AUTHOR]

Background: The World Health Organization recommends parasitological confirmation of malaria prior to treatment. Malaria rapid diagnostic tests (RDTs) represent one diagnostic method that is used in a variety of contexts to overcome limitations of other diagnostic techniques. Malaria RDTs increase the availability and feasibility of accurate diagnosis and may result in improved quality of care. Though RDTs are used in a variety of contexts, no studies have compared how well or effectively RDTs are used across these contexts. This review assesses the diagnostic use of RDTs in four different contexts: health facilities, the community, drug shops and schools.Methods: A comprehensive search of the Pubmed database was conducted to evaluate RDT execution, test accuracy, or adherence to test results in sub-Saharan Africa. Original RDT and Plasmodium falciparum focused studies conducted in formal health care facilities, drug shops, schools, or by CHWs between the year 2000 and December 2016 were included. Studies were excluded if they were conducted exclusively in a research laboratory setting, where staff from the study team conducted RDTs, or in settings outside of sub-Saharan Africa.Results: The literature search identified 757 reports. A total of 52 studies were included in the analysis. Overall, RDTs were performed safely and effectively by community health workers provided they receive proper training. Analogous information was largely absent for formal health care workers. Tests were generally accurate across contexts, except for in drug shops where lower specificities were observed. Adherence to RDT results was higher among drug shop vendors and community health workers, while adherence was more variable among formal health care workers, most notably with negative test results.Conclusions: Malaria RDTs are generally used well, though compliance with test results is variable - especially in the formal health care sector. If low adherence rates are extrapolated, thousands of patients may be incorrectly diagnosed and receive inappropriate treatment resulting in a low quality of care and unnecessary drug use. Multidisciplinary research should continue to explore determinants of good RDT use, and seek to better understand how to support and sustain the correct use of this diagnostic tool. [ABSTRACT FROM AUTHOR]

Background: In many low- and middle-income countries, community health volunteers (CHVs) are employed as a key element of the public health system in rural areas with poor accessibility. However, few studies have assessed the effectiveness of CHVs in improving child health in sub-Saharan Africa through randomized controlled trials. The present study aims to measure the impact of health promotion and case management implemented by CHVs on the health of under-5 children in Ghana.Methods/design: This study presents the protocol of a cluster-randomized controlled trial assessing the impacts of CHVs, in which the community was used as the randomization unit. A phase-in design will be adopted, and the intervention arm will be implemented in the intervention arm during the first phase and in the control arm during the second phase. The key intervention is the deployment of CHVs, who provide health education, provide oral rehydration solutions and zinc tablets to children with diarrhea, and diagnose malaria using a thermometer and a rapid diagnostic test kit during home visits. The primary endpoints of the study are the prevalence of diarrhea and fever/malaria in children under 5 years of age, as well as the proportion of affected children receiving case management for diarrhea and malaria. The first and second rounds of household surveys to collect data will be conducted in the first phase, and the final round will be conducted during the second phase.Discussion: With growing attention paid to the roles of CHVs as an essential part of the community health system in low-income countries, this study will contribute valuable information to the body of knowledge on the effects of CHVs.Trial Registration: ISRCTN49236178 . (June 16th, 2015). [ABSTRACT FROM AUTHOR]

Background: Health facility data are more readily accessible for operational planning and evaluation of disease control programmes. The importance, potential challenges and limitations of using facility based survey as an alternative tool for monitoring changes in local malaria epidemiology were examined.Methods: The study involved six areas within the administrative divisions of The Gambia. The areas were selected to reflect socioeconomic and malaria transmission intensities across the country. The study design involved an age stratified cross sectional surveys that were conducted during the wet season in 2008 and in the 2009 during the dry season. Participants were patients attending clinics in six health centres and the representative populations from the catchment communities of the health centres.Results: Overall participants' characteristics were mostly not comparable in the two methodological approaches in the different seasons and settings. More females than males were enrolled (55.8 vs. 44.2 %) in all the surveys. Malaria infection was higher in the surveys in health centres than in the communities (p < 0.0001) and also in males than in females (OR = 1.3; p < 0.001). Males were less likely than females to sleep under an insecticide treated net in the communities (OR = 1.6; 95 % CI 1.3, 1.9) and in the health centres (OR = 1.3; 95 % CI 1.1, 1.5). Representativeness of the ethnic groups was better in the health centre surveys than in the community surveys when compared to the 2003 national population census in The Gambia.Conclusion: Health facility based survey though a potential tool for monitoring changes in the local epidemiology of malaria will require continuous validation of the facility and participants sociodemograhic characteristics as these may change over time. The effects of health seeking practices on service utilization and health facility surveys as an approach will also need continuous review. [ABSTRACT FROM AUTHOR]

Background: Malaria and malnutrition are the major causes of morbidity and mortality in under-five children in developing countries such as Ethiopia. Malnutrition is the associated cause for about half of the deaths that occur among under-five children in developing countries. However, the relationship between malnutrition and malaria is controversial still, and it has also not been well documented in Ethiopia. The aim of this study was to assess whether malnutrition is associated with malaria among under-five children.Methods: A case-control study was conducted in Adami Tulu District of East Shewa Zone in Oromia Regional State, Ethiopia. Cases were all under-five children who are diagnosed with malaria at health posts and health centres. The diagnosis was made using either rapid diagnostic tests or microscopy. Controls were apparently healthy under-five children recruited from the community where cases resided. The selection of the controls was based on World Health Organization (WHO) cluster sampling method. A total of 428 children were included. Mothers/caretakers of under-five children were interviewed using pre-tested structured questionnaire prepared for this purpose. The nutritional status of the children was assessed using an anthropometric method and analyzed using WHO Anthro software. A multivariate logistic analysis model was used to determine predictors of malaria.Results: Four hundred twenty eight under-five children comprising 107 cases and 321 controls were included in this study. Prevalence of wasting was higher among cases (17.8%) than the controls (9.3%). Similarly, the prevalence of stunting was 50.5% and 45.2% among cases and controls, respectively. Severe wasting [Adjusted Odds Ratio (AOR) =2.9, 95% CI (1.14, 7.61)] and caretakers who had no education [AOR = 3, 95% CI (1.27, 7.10)] were independently associated with malarial attack among under-five children.Conclusion: Children who were severely wasted and had uneducated caretakers had higher odds of malarial attack. Therefore, special attention should be given for severely wasted children in the prevention and control of malaria. [ABSTRACT FROM AUTHOR]

Background: Although early diagnosis and prompt treatment is important in preventing mortality from malaria, presentation of symptomatic individuals is often relatively late. One possible contributing factor is that fear of covert human immunodeficiency virus (HIV) testing delays presentation in adults. We aimed to survey the magnitude of such concerns and their association with delayed presentation with suspected malaria.Methods: The study design was a health facility-based cross-sectional survey. The study population consisted of adults with suspected malaria who presented to health centres in central Ethiopia. Data were collected on attitudes to HIV testing and the duration between onset of symptoms and treatment seeking for suspected malaria.Results: Eight hundred and ten individuals provided data. Of these, 406 (50 %) perceived that HIV testing was routinely done on blood donated for malaria diagnosis, and 327 (40 %) considered that community members delayed seeking medical advice because of these concerns. Concerns about HIV testing were associated with delays in attending for malaria diagnosis and treatment, with 117 individuals (29 %) of those with concerns about covert HIV testing waiting for 4 days or more, compared to 89 (22 %) of those who did not have any such concerns (p = 0.03). One hundred and twenty nine (16 %) individuals stated that concern about HIV testing was the main reason for the delay in seeking treatment, and 46 % of these individuals presented after experiencing symptoms of malaria infection for three days or more compared to 22 % of the 681 individuals who had no such concerns (p < 0.001). Analysis stratified by health centre demonstrated that these associations were a consequence of Meki health centre (odds ratio for duration of symptoms greater than 3 days if patient has concerns about HIV testing was 8.72; 95 % confidence intervals 3.63 to 20.97).Conclusions: In adults living in central Ethiopia, the perception that HIV testing accompanied the investigation of suspected malaria was common. This is likely to impede presentation for early medical treatment in some areas and represents a reversible risk factor that deserves further study. [ABSTRACT FROM AUTHOR]

Background: Syndromic surveillance is a supplementary approach to routine surveillance, using pre-diagnostic and non-clinical surrogate data to identify possible infectious disease outbreaks. To date, syndromic surveillance has primarily been used in high-income countries for diseases such as influenza--however, the approach may also be relevant to resource-poor settings. This study investigated the potential for monitoring school absenteeism and febrile illness, as part of a school-based surveillance system to identify localised malaria epidemics in Ethiopia.Methods: Repeated cross-sectional school- and community-based surveys were conducted in six epidemic-prone districts in southern Ethiopia during the 2012 minor malaria transmission season to characterise prospective surrogate and syndromic indicators of malaria burden. Changes in these indicators over the transmission season were compared to standard indicators of malaria (clinical and confirmed cases) at proximal health facilities. Subsequently, two pilot surveillance systems were implemented, each at ten sites throughout the peak transmission season. Indicators piloted were school attendance recorded by teachers, or child-reported recent absenteeism from school and reported febrile illness.Results: Lack of seasonal increase in malaria burden limited the ability to evaluate sensitivity of the piloted syndromic surveillance systems compared to existing surveillance at health facilities. Weekly absenteeism was easily calculated by school staff using existing attendance registers, while syndromic indicators were more challenging to collect weekly from schoolchildren. In this setting, enrolment of school-aged children was found to be low, at 54%. Non-enrolment was associated with low household wealth, lack of parental education, household size, and distance from school.Conclusions: School absenteeism is a plausible simple indicator of unusual health events within a community, such as malaria epidemics, but the sensitivity of an absenteeism-based surveillance system to detect epidemics could not be rigorously evaluated in this study. Further piloting during a demonstrated increase in malaria transmission within a community is recommended. [ABSTRACT FROM AUTHOR]

Background: With increasing levels of enrolment, primary schools present a pragmatic opportunity to improve the access of school children to timely diagnosis and treatment of malaria, increasingly recognised as a major health problem within this age group. The expanded use of malaria rapid diagnostic tests (RDTs) and artemisinin combination therapy (ACT) by community health workers (CHWs) has raised the prospect of whether teachers can provide similar services for school children. We describe and evaluate the training of primary school teachers to use a first aid kit containing malaria RDTs and ACT for the diagnosis and treament of uncomplicated malaria in school children in southern Malawi.Methods: We outline the development of the intervention as: (1) conception and design, (2) pilot training, (3) final training, and (4) 7-month follow up. The training materials were piloted at a four-day workshop in July 2013 following their design at national stakeholders meetings. The evaluation of the pilot training and materials were assessed in relation to increased knowledge and skill sets using checklist evaluations and questionnaires, the results of which informed the design of a final seven-day training programme held in December 2013. A follow up of trained teachers was carried out in July 2014 following 7 months of routine implementation. A total of 15 teachers were evaluated at four stages: pilot training, two weeks following pilot, final training and seven months following final training.Results: A total of 15 and 92 teachers were trained at the pilot and final training respectively. An average of 93 % of the total steps required to use RDTs were completed correctly at the final training, declining to 87 % after 7 months. All teachers were observed correctly undertaking safe blood collection and handling, accurate RDT interpretation, and correct dispensing of ACT. The most commonly observed errors were a failure to wait 20 minutes before reading the test result, and adding an incorrect volume of buffer to the test cassette.Conclusion: Following training, teachers are able to competently use RDTs and ACTs test and treat children at school for uncomplicated malaria safely and accurately. Teachers demonstrate a comparable level of RDT use relative to non-health professional users of RDTs, and sustain this competency over a period of seven months during routine implementation. [ABSTRACT FROM AUTHOR]

Background: Artemisinin-based combination therapy (ACT) following a confirmed parasitological diagnosis is recommended by the World Health Organization (WHO) and the Congolese National Malaria Control Program (NMCP). However, commitment and competence of all stakeholders (patients, medical professionals, governments and funders) is required to achieve effective case management and secure the "useful therapeutic life" of the recommended drugs. The health seeking behaviour of patients and health care professionals' practices for malaria management were assessed. Methods: This was an observational study embedded in a two-stage cluster randomized survey conducted in one health centre (HC) in each of the 12 selected health zones in Kinshasa city. All patients with clinical malaria diagnosis were eligible. Their health seeking behaviour was recorded on a specific questionnaire, as well as the health care practitioners' practices. The last were not aware that their practices would be assessed. Results: Six hundred and twenty four patients were assessed, of whom 136 (21.8%) were under five years. Three hundred and thirty five (55%) had taken medication prior to the current consultation (self -medication with any product or visiting another HC) of whom 47(14%) took an antimalarial drug, and 56 (9%) were treated presumptively. Among those, 53.6% received monotherapy either with quinine, artesunate, phytomedicines, sulfadoxine-pyrimethamine or amodiaquine. On the other side, when clinicians were informed about laboratory results, monotherapy was prescribed in 39.9% of the confirmed malaria cases. Only 285 patients (45.7%) were managed in line with WHO and NMCP guidelines, of whom 120 (19.2%) were prescribed an ACT after positive blood smear and 165 (26.4%) received no antimalarial after a negative result. Conclusion: This study shows the discrepancy between malaria policies and the reality on the field in Kinshasa, regarding patients' health seeking behaviour and health professionals' practices. Consequently, the poor compliance to the policies may contribute to the genesis and spread of antimalarial drug resistance and also have a negative impact on the burden of the disease. [ABSTRACT FROM AUTHOR]

Background: Well-functioning surveillance systems are crucial for effective disease control programs. The Integrated Disease Surveillance and Response (IDSR) strategy was developed and adopted in 1998 for Africa as a comprehensive public health approach and subsequently, Ghana adopted the IDSR technical guidelines in 2002. Since 2012, the IDSR data is reported through the new District Health Information Management System II (DHIMS2) network. The objective was to evaluate the Integrated Disease Surveillance and Response (IDSR) system in northern Ghana. Methods: This was an observational study using mixed methods. Weekly and monthly IDSR data on selected infectious diseases were downloaded and analyzed for 2011, 2012 and 2013 (the years before, of and after DHIMS2 implementation) from the DHIMS2 databank for the Upper East Region (UER) and for two districts of UER. In addition, key informant interviews were conducted among local and regional health officers on the functioning of the IDSR. Results: Clinically diagnosed malaria was the most prevalent disease in UER, with an annual incidence rate close to 1. Around 500 suspected HIV/AIDS cases were reported each year. The highest incidence of cholera and meningitis was reported in 2012 (257 and 392 cases respectively). Three suspected cases of polio and one suspected case of guinea worm were reported in 2013. None of the polio and guinea worm cases and only a fraction of the reported cases of the other diseases were confirmed. A major observation was the large and inconclusive difference in reported cases when comparing weekly and monthly reports. This can be explained by the different reporting practice for the sub-systems. Other challenges were low priority for surveillance, ill-equipped laboratories, rare supervision and missing feedback. Conclusions: The DHIMS2 has improved the availability of IDSR reports, but the quality of data reported is not sufficient. Particularly the inconsistencies between weekly and monthly data need to be addressed. Moreover, support for and communication within the IDSR system is inadequate and calls for attention. [ABSTRACT FROM AUTHOR]

Background: In Gabon, a new national malaria control policy was implemented in 2003. It resulted in a decrease in the number of malaria cases in the country. In March 2020, the disruption of routine health services due to the COVID-19 pandemic has led to an increase in cases and deaths due to malaria. However, in Franceville, south-east Gabon, no data on malaria cases recorded before, during and after the COVID-19 epidemic has been published. Thus, the objective of this study was to determine the epidemiological characteristics of malaria in Franceville from 2019 to 2021., Methods: A retrospectively study of malaria cases was performed at the Hôpital de l'Amitié Sino-Gabonaise (HASG). Information regarding age, gender, malaria diagnosis by microscopy and hematology cell count were collected from laboratory registers from June 2019 to December 2021. Malaria data were analyzed and correlated with seasonal variations., Results: The data of 12,695 febrile patients were collected from the laboratory registers of the HASG, among which 4252 (33.5%) patients were found positive for malaria. The malaria prevalence was 37.5% in 2020 year. This prevalence was highest compared to the 2019 (29.6%) and 2021 (31.5%) year (p < 0.001). During the short rainy season (October to December), a large increase in malaria cases was observed all three year, from 2019 to 2021 (p > 0.05)., Conclusion: The prevalence of malaria in Franceville was very high during COVID-19 pandemic. It is therefore necessary to strengthen existing interventions and implement more effective interventions., (© 2022. The Author(s).)

Background With the incidence of malaria in Sri Lanka declining, intensive parasitological surveillance has been identified as a key strategy to achieve elimination by end 2014. Tropical and Environmental Diseases and Health Associates Private Limited (TEDHA) in collaboration with the Anti-Malaria Campaign established 43 malaria diagnostic laboratories (MDL) in four post-conflict districts of the Northern and Eastern Provinces. This study assesses the patterns of referral of patients with fever for malaria diagnosis by health care providers (HCPs) in four government hospitals in one of the districts of the Northern Province, and patient satisfaction with the laboratory services offered. Methods In this prospective descriptive study, data was collected on the proportion of fever patients being referred by the HCP in hospitals for malaria screening, and the proportion thereof who underwent screening. An interviewer-administered questionnaire was also used to assess patient satisfaction among those attending MDL, which was graded on a scale of 0-4. Results Of patients presenting to the hospitals with fever, only 44.3% were referred for malaria screening; 81.7% of them underwent screening. Referral depended largely on the presence of a permanent staff HCP. Satisfaction levels were high, with 86.55% giving an overall rating of 4. Comfort within the laboratory was rated satisfactory in three of the four hospitals. Conclusions This study demonstrates the success of a public-private partnership in the malaria control programme in Sri Lanka. Malaria is considered low on the differential diagnosis in patients with fever even in previously malaria-endemic areas, due to the declining incidence of malaria and the increase in other febrile illnesses in these areas during the recent past. Private sector run malaria diagnostic services provided free of charge within government hospitals are viable and effective, and had good patient satisfaction ratings. In a country on the brink of eliminating malaria, there should be further emphasis on ensuring that HCPs refer patients for malaria diagnosis, in order to prevent a resurgence of the disease. [ABSTRACT FROM AUTHOR]

Background The commonly accepted gold standard diagnostic method for detecting malaria is a microscopic reading of Giemsa-stained blood films. However, symptomatic diagnosis remains the basis of therapeutic care for the majority of febrile patients in malaria endemic areas. This study aims to compare the discrepancy in malaria and anaemia burdens between symptomatic diagnosed patients with those diagnosed through the laboratory. Methods Data were collected from Western Kenya during a follow-up study of 887 children with suspected cases of malaria visiting the health facilities. In the laboratory, blood samples were analysed for malaria parasite and haemoglobin levels. Differences in malaria prevalence between symptomatic diagnosis and laboratory diagnosis were analysed by Chi-square test. Bayesian probabilities were used for the approximation of the malaria and anaemia burdens. Regression analysis was applied to: (1) determine the relationships between haemoglobin levels, and malaria parasite density and (2) relate the prevalence of anaemia and the prevalence of malaria. Results The prevalence of malaria and anaemia ranged from 10% to 34%, being highest during the rainy seasons. The predominant malaria parasite was P. falciparum (92.3%), which occurred in higher density in children aged 2-5 years. Fever, high temperature, sweating, shivering, vomiting and severe headache symptoms were associated with malaria during presumptive diagnosis. After conducting laboratory diagnosis, lower malaria prevalence was reported among the presumptively diagnosed patients. Surprisingly, there were no attempts to detect anaemia in the same cohort. There was a significant negative correlation between Hb levels and parasite density. We also found a positive correlation between the prevalence of anaemia and the prevalence of malaria after laboratory diagnosis indicating possible co-occurrence of malaria and anaemia. Conclusion Symptomatic diagnosis of malaria overestimates malaria prevalence, but underestimates the anaemia burden in children. Good clinical practice dictates that a laboratory should confirm the presence of parasites for all suspected cases of malaria. [ABSTRACT FROM AUTHOR]

Background More than 75% of the total of Ethiopia is malarious. Therefore, malaria is a leading public health problem in Ethiopia. This study aims to identify socio-economic, geographic and demographic factors contributing to the spread of malaria and is based on the results of a malaria Rapid Diagnosis Test survey. Methods The data used in this study originates from the baseline malaria indicator survey, conducted in the Amhara, Oromiya and Southern Nation Nationalities and People (SNNP) regions of Ethiopia from December 2006 to January 2007. The study applies the method of generalized additive mixed model (GAMM) to analyse data. The response variable is the presence or absence of malaria, using the malaria Rapid Diagnosis Test (RDT). Results The results provide an improved insight into the distribution of malaria in relation to the age of affected people, the altitude, the total number of rooms, the total number of mosquito nets, family size, and the number of months that their rooms have been sprayed. The results confirm that positive malaria RDT test results are high for children under 15 years and for older persons. Gender, source of drinking water, time needed to fetch water, toilet facilities, main materials used for the construction of walls, floors and roofs, and use of mosquito nets were all found to have a significant impact on the results of the malaria rapid diagnosis test. Conclusion The result of the analysis identifies poor socio-economic conditions as a major contributing factor or determinant for the spread of malaria. With the correct use of mosquito nets, indoor residual spraying with insecticide and other preventative measures, the incidence of malaria could be decreased. In addition, improving housing conditions is a means to reduce the risk of malaria. Other measures such as creating awareness of the use of mosquito nets, indoor residual spraying with insecticide, and malaria transmission, can lead to a further reduction in the number of malaria cases. [ABSTRACT FROM AUTHOR]

Background: In areas where visceral leishmaniasis (VL) and malaria are co-endemic, co-infections are common. Clinical implications range from potential diagnostic delay to increased disease-related morbidity, as compared to VL patients. Nevertheless, public awareness of the disease remains limited. In VL-endemic areas with unstable and seasonal malaria, vulnerability to the disease persists through all age-groups, suggesting that in these populations, malaria may easily co-occur with VL, with potentially severe clinical effects. Methods: A retrospective case-control study was performed using medical records of VL patients admitted to Tabarakallah and Gedarif Teaching Hospitals (Gedarif State) and Al`Azaza kala-azar Clinic (Sennar State), Sudan (2005-2010). Patients positively diagnosed with VL and malaria were identified as cases, and VL patients without microscopy-detectable malaria as controls. Associations between patient characteristics and the occurrence of the co-infection were investigated using logistic regression analysis. Confirmation of epidemiological outcomes was obtained with an independently collected dataset, composed by Médecins Sans Frontières (MSF) at Um-el-Kher and Kassab Hospitals, Gedarif State (1998). Results: The prevalence of malaria co-infection among VL surveyed patients ranged from 3.8 to 60.8%, with a median of 26.2%. Co-infected patients presented at hospital with deteriorated clinical pictures. Emaciation (Odds Ratio (OR): 2.46; 95% Confidence Interval (95% CI): 1.72-3.50), jaundice (OR: 2.52; 95% CI: 1.04-6.09) and moderate anemia (OR: 1.58; 95% CI: 1.10-2.28) were found to be positively associated with the co-infection, while severity of splenomegaly (OR: 0.53; 95% CI: 0.35-0.81) and, to a less extent, hepatomegaly (OR: 0.52; 95% CI: 0.27-1.01) appeared to be reduced by concomitant VL and malaria. The in-hospital case-fatality rates did not significantly differ between co- and mono-infected patients (OR: 1.13; 95% CI: 0.59-2.17). Conversely, a significantly increased mortality rate (OR: 4.38; 95% CI: 1.83-10.48) was observed by MSF amongst co-infected patients enrolled at Um-el-Kher and Kassab Hospitals, who also suffered an enhanced risk of severe anemia (OR: 3.44; 95% CI: 1.68-7.02) compared to VL monoinfections. Conclusions: In endemic VL areas with unstable seasonal malaria, like eastern Sudan, VL patients are highly exposed to the risk of developing concomitant malaria. Prompt diagnosis and effective treatment of malaria are essential to ensure that its co-infection does not result into poor prognoses. [ABSTRACT FROM AUTHOR]

Background: There have been few investigations evaluating the burden of malaria disease at district level in the Republic of Congo since the introduction of artemisinin-based combination therapies (ACTs). The main objective of this study was to document laboratory-confirmed cases of malaria using microscopy and/or rapid diagnostic tests (RDTs) in children and pregnant women attending selected health facilities in Brazzaville and Pointe Noire, the two main cities of the country. Secondly, P. falciparum genetic diversity and multiplicity of infection during the malaria transmission season of October 2011 to February 2012 in these areas were described. Methods: Three and one health facilities were selected in Brazzaville and Pointe-Noire as sentinel sites for malaria surveillance. Children under 15 years of age and pregnant women were enrolled if study criteria were met and lab technicians used RDT and/or microscopy to diagnose malaria. In order to determine the multiplicity of infection, parasite DNA was extracted from RDT cassette and msp2 P.falciparum genotyped. Results: Malaria prevalence among more than 3,000 children and 700 pregnant women ranged from 8 to 29%, and 8 to 24% respectively depending on health center locality. While health workers did not optimize use of RDTs, microscopy remained a reference diagnostic tool. Quality control of malaria diagnosis at the reference laboratory showed acceptable health centre performances. P. falciparum genetic diversity determination using msp2 gene marker ranged from 9 to 20 alleles and remains stable while multiplicity of infection (mean of 1.7clone/infected individual) and parasite densities in clinical isolates were lower than previously reported. Conclusions: These findings are consistent with a reduction of malaria transmission in the two areas. This study raises the issue of targeted training for health workers and sustained availability of RDTs in order to improve quality of care through optimal use of RDTs. [ABSTRACT FROM AUTHOR]

Background: Ethiopia's National Malaria Control and Elimination Program aims to diagnose all suspected malaria cases within 24 h of fever onset and provide prompt treatment for confirmed cases. This study explored psychosocial factors associated with no-, delayed- and prompt- care-seeking among female caregivers of children under five years with fever in rural Ethiopia., Methods: Household surveys were conducted from 2016-2019 among female caregivers (N = 479) of children under five years old with fever in Oromia; Amhara; Southern Nations, Nationalities, and Peoples Region (SNNPR); and Tigray. Prompt and delayed care-seeking were defined as seeking treatment within ≤ 24 h or > 24 h of symptom onset respectively. Contextual factors explored included sociodemographic factors, household supply of bed nets, exposure to health messages, and household vulnerability (a measure of financial access to food, shelter, schooling, and medical treatment). Ideational factors included psychosocial factors related to care-seeking (knowledge, self-efficacy, response efficacy, attitudes, involvement in decision-making, and household social support)., Results: The prevalence of fever among children under five years was 18% (ranging from 9% in Tigray to 34% in SNNPR. Overall, 45% of caregivers of children with fever sought care promptly, while 23% delayed care-seeking and 32% sought no care. Prompt care-seeking rates were higher among caregivers with positive attitudes toward prompt care-seeking (48%), involved in decision-making (48%) or perceived equitable gender norms in the community (65%). Caregivers with a high care-seeking ideation had increased odds of prompt care-seeking (aOR: 2.65; 95% CI: 1.74-4.02). Significant contextual factors included residence in the Oromia region (aOR: 2.99; 95% CI:1.40-6.41), caregivers age 35-49 years (aOR: 0.49; 95% CI: 0.26-0.95), residence in vulnerable households (aOR: 2.01; 95% CI: 1.28-3.18)., Conclusions: Among this rural Ethiopian population, prompt care-seeking was low but positively influenced by both ideational and contextual psychosocial factors occurring at the caregiver level. Multi-sectoral interventions at the individual, community, and health facility levels are needed to improve prompt care-seeking. These include social behavior change interventions to improve ideation, complemented by health facility interventions to ensure provision of high-quality services and structural interventions to increase educational attainment in these rural settings., (© 2022. The Author(s).)

Background: A novel strategy to combat malaria was tested using a methodology adapted to a complex setting in the Amazon region and a hard-to-reach, mobile community. The intervention strategy tested was the distribution, after training, of malaria self-management kits to gold miners who cross the Surinamese and Brazilian borders with French Guiana to work illegally in the remote mining sites in the forest of this French overseas entity., Main Text: This article aims at presenting all process and implementation outcomes following the Conceptual Framework of Implementation Fidelity i.e. adherence, including content and exposure, and moderators, comprising participant responsiveness, quality of delivery, facilitation strategies, and context. The information sources are the post-intervention survey, data collected longitudinally during the intervention, a qualitative study, data collected during an outreach mission to a remote gold mining site, supervisory visit reports, in-depth feedback from the project implementers, and videos self-recorded by facilitators based on opened ended questions. As expected, being part of or close to the study community was an essential condition to enable deliverers, referred to as "facilitators", to overcome the usual wariness of this gold mining population. Overall, the content of the intervention was in line with what was planned. With an estimated one third of the population reached, exposure was satisfactory considering the challenging context, but improvable by increasing ad hoc off-site distribution according to needs. Participant responsiveness was the main strength of the intervention, but could be enhanced by reducing the duration of the process to get a kit, which could be disincentive in some places. Regarding the quality of delivery, the main issue was the excess of information provided to participants rather than a lack of information, but this was corrected over time. The expected decrease in malaria incidence became a source of reduced interest in the kit. Expanding the scope of facilitators' responsibilities could be a suitable response. Better articulation with existing malaria management services is recommended to ensure sustainability., Conclusions: These findings supplement the evaluation outcomes for assessing the relevance of the strategy and provide useful information to perpetuate and transfer it in comparable contexts., Trial Registration: ClinicalTrials.gov.  NCT03695770 . 10/02/2018 "Retrospectively registered"., (© 2022. The Author(s).)

Introduction: Malaria accounts for more than one-tenth of sub-Saharan Africa's 2.8 million annual childhood deaths, and remains a leading cause of post-neonatal child mortality in Uganda. Despite increased community-based treatment in Uganda, children continue to die because services fail to reach those most at risk. This study explores the influence of two key equity factors, socioeconomic position and rurality, on whether children with fever in eastern Uganda receive timely access to appropriate treatment for suspected malaria., Methods: This was a cross-sectional study in which data were collected from 1094 caregivers of children aged 6-59 months on: illness and care-seeking during the previous two weeks, treatment received, and treatment dosing schedule. Additional data on rurality and household socioeconomic position were extracted from the Iganga-Mayuge Health and Demographic Surveillance Site (HDSS) database. A child was considered to have received prompt and appropriate care for symptoms of malaria if they received the recommended drug in the recommended dosing schedule on the day of symptom onset or the next day. Unadjusted and adjusted logistic regression models were developed to explore associations of the two equity factors with the outcome. The STROBE checklist for observational studies guided reporting., Results: Seventy-four percent of children had symptoms of illness in the preceding two weeks, of which fever was the most common. Children from rural households were statistically more likely to receive prompt and appropriate treatment with artemisinin-combination therapy than their semi-urban counterparts (OR 2.32, CI 1.17-4.59, p = 0.016). This association remained significant following application of an adjusted regression model that included the age of the child, caregiver relationship, and household wealth index (OR 2.4, p = 0.036). Wealth index in its own right did not exert a significant effect for children with reported fever (OR for wealthiest quintile = 1.02, CI 0.48-2.15, p = 0.958)., Conclusions: The findings from this study help to identify the role and importance of two key equity determinants on care seeking and treatment receipt for fever in children. Whilst results should be interpreted within the limitations of data and context, further studies have the potential to assist policy makers to target inequitable social and spatial variations in health outcomes as a key strategy in ending preventable child morbidity and mortality., (© 2021. The Author(s).)

Background: Providing at-risk communities with uninterrupted access to early diagnosis and treatment is a key component in reducing malaria transmission and achieving elimination. As programmes approach malaria elimination targets it is critical that each case is tested and treated early, which may present a challenge when the burden of malaria is reduced. In this paper we investigate whether malaria testing rates decline over time and assess the impacts of integrating malaria and non-malaria services on testing rates in the malaria elimination task force (METF) programme in the Kayin state of Myanmar., Methods: A retrospective analysis was conducted using weekly collected data on testing rates from a network of more than 1200 malaria posts during the period from 2014 to 2020. To determine whether monthly testing rates changed over the years of programme operations, and whether integrating malaria and non-malaria services impacted these testing rates, we fitted negative binomial mixed-effects regression models to aggregate monthly data, accounting for malaria seasonal variation., Results: In the first year of malaria post operation, testing rates declined, correlating with a decline in attendance by people from outside the malaria post catchment area, but then remained fairly constant (the Rate Ratio (RR) for 2nd versus 1st year open ranged from 0.68 to 0.84 across the four townships included in the analysis, the RR for 3rd to 6th year versus 1st year open were similar, ranging from 0.59-0.78). The implementation of a training programme, which was intended to expand the role of the malaria post workers, had minimal impact on testing rates up to 24 months after training was delivered (RR for integrated versus malaria-only services ranged from 1.00 to 1.07 across METF townships)., Conclusion: Despite the decline in malaria incidence from 2014 to 2020, there has been no decline in the malaria testing rate in the METF programme after the establishment of the complete malaria post network in 2016. While the integration of malaria posts with other health services provides benefits to the population, our evaluation questions the necessity of integrated services in maintaining malaria testing rates in areas approaching elimination of malaria., (© 2021. The Author(s).)

Background: Parasitological diagnosis generates data to assist malaria-endemic countries determine their status within the malaria elimination continuum and also inform the deployment of proven interventions to yield maximum impact. This study determined prevalence of malaria parasitaemia and mRDT performances among febrile patients in selected health care facilities across Ghana.Methods: This study was a cross-sectional survey conducted in the previously 10 regions of Ghana from May to August 2018. Each patient suspected to have uncomplicated malaria was tested using microscopy and two malaria rapid diagnostic tests (mRDTs): routinely used CareStart™ Malaria HRP2 (Pf) and SD Bioline Malaria Ag Pf (HRP2/pLDH). Main outcome variables were malaria slide and CareStart™ Malaria HRP2 (Pf) positivity rates; and diagnostic accuracy of CareStart™ Malaria HRP2 (Pf) and SD Bioline Malaria Ag Pf (HRP2/pLDH) using microscopy as "gold standard".Results: Overall parasite positivity rates were 32.3% (6266/19402) by mRDT and 16.0% (2984/18616) by microscopy, with Plasmodium falciparum mono-infection accounting for 98.0% of all infections. The odds of parasitaemia by microscopy was significantly lower among female patients compared with males (OR = 0.78; 95% CI: 0.66-0.91), and among patients with history of previous antimalarial intake compared with those with no such history (OR = 0.72; 95% CI: 0.54-0.95). Overall sensitivity of CareStart™ Malaria HRP2 (Pf) was statistically similar to that of the HRP2 band of SD Bioline Malaria Ag Pf (HRP2/pLDH) combo kit (95.4%; 95% CI: 94.6-96.1 vs 94.3%; 95% CI: 93.4-95.1; p = 0.065) but significantly higher than the pLDH band (89.3%; 95% CI: 88.1-90.4; p < 0.001). The same pattern was observed for negative predictive value.Conclusions: Malaria control interventions should be targeted at the general population, and history of antimalarial intake considered a key predictor of malaria slide negativity. Furthermore, HRP2-based mRDTs remain effective diagnostic tool in the management of suspected uncomplicated malaria in the country. [ABSTRACT FROM AUTHOR]

Background: Trend analysis of malaria surveillance data is essential to inform stakeholders on progress towards malaria control. From the total 387,096 cases of malaria reported in Amhara region in 2017, 167,079 (43.2%) cases were in Central, North and West Gondar zones. From this total figure of zones, 15,445 (9.2%) were ≤ 5 years which contributes 4% of cases in the region. So, the purpose of this study was to analyze trends of malaria parasite in Selected Zones of Amhara Region, Northwest Ethiopia. Methods: A Retrospective study was conducted on purposely selected Central, North and West Gondar zones from July 1–30/ 2018. Data were collected, entered, cleaned, analyzed and interpreted using Microsoft Excel-2010. Different tables, figures and maps were used to present results. Result: A total of 2,827,722 cases have been received a diagnostic test of; Microscopy 1,712,193(60.56%) and Rapid Diagnostic Test (RDT) 1,115,529(39.44%). Trends of total patients treated as confirmed and clinical malaria cases in July 2017–June 2018 were decreased to 139,297 (14%) as compared from July 2015–June 2016, 249,571(25%). From total cases received diagnostic tests only 1,003,391 (36%) were confirmed and clinical cases treated with antimalaria. Of these Plasmodium falciparum and vivax malaria cases were confirmed to be 1002,946 (99.96%) and clinical malaria cases were 445(0.04%), respectively. Conclusion: Risk of infection and diagnostic effort were high in West Gondar Zone. The Amhara public health institute including health Bureau, stakeholders and all responsible bodies should give special standing to highest malaria districts of West Gondar zone. [ABSTRACT FROM AUTHOR]

Background: Asymptomatic falciparum and non-falciparum malaria infections are major challenges to malaria control interventions, as they remain a source of continual infection in the community. This becomes even more important as the debate moves towards elimination and eradication. This study sought to quantify the burden of Plasmodium malaria infection in seven communities in the Eastern Region of Ghana.Methods: The cross-sectional study recruited 729 participants aged 85 years old and below from 7 closely linked communities. Finger pricked blood was used to prepare thick and thin blood smears as well as spot filter paper and an histidine rich protein 2 (HRP2) rapid diagnostic test kit (RDT). Genomic DNA was extracted from the filter paper dry blood spot (DBS) and used in PCR to amplify the Plasmodium 18S rRNA gene using species specific PCR.Results: 96.6% of the participants were identified as afebrile, with axillary temperatures below 37.5 °C. PCR identified 66% of the participants to harbor malaria parasites, with 9 P. malariae and 7 P. ovale mono-infections accounting for 2.2% and P. falciparum combined with either 36 P. malariae or 25 P. ovale infections, accounting for 13.3%. Parasite prevalence by microscopy (32%) was similar to the RDT positivity rate (33%). False positive RDT results ranged from 64.6% in children aged between 5 and 9 years to 10% in adults aged 20 years and above. No significant differences were observed in falciparum and non-falciparum parasite carriage at the community level, however young adults aged between 15 and 19 years had the highest prevalence (34.8% (16/46)) of P. falciparum and P. malariae parasite carriage whilst children aged between 5 and 9 years had the highest level (11.4% (14/123)) of P. ovale carriage.Conclusion: The high rate of misidentification of non-falciparum parasites and the total absence of detection of P. ovale by microscopy suggests that more sensitive malaria diagnostic tools including molecular assays are required to accurately determine the prevalence of carriers of non-falciparum parasites and low density P. falciparum infections, especially during national surveillance exercises. Additionally, malaria control interventions targeting the non-falciparum species P. malariae and P. ovale parasites are needed. [ABSTRACT FROM AUTHOR]

Background: Despite remarkable progress in the reduction of malaria incidence, this disease remains a public health threat to a significant portion of the world's population. Surveillance, combined with early detection algorithms, can be an effective intervention strategy to inform timely public health responses to potential outbreaks. Our main objective was to compare the potential for detecting malaria outbreaks by selected event detection methods., Methods: We used historical surveillance data with weekly counts of confirmed Plasmodium falciparum (including mixed) cases from the Amhara region of Ethiopia, where there was a resurgence of malaria in 2019 following several years of declining cases. We evaluated three methods for early detection of the 2019 malaria events: 1) the Centers for Disease Prevention and Control (CDC) Early Aberration Reporting System (EARS), 2) methods based on weekly statistical thresholds, including the WHO and Cullen methods, and 3) the Farrington methods., Results: All of the methods evaluated performed better than a naïve random alarm generator. We also found distinct trade-offs between the percent of events detected and the percent of true positive alarms. CDC EARS and weekly statistical threshold methods had high event sensitivities (80-100% CDC; 57-100% weekly statistical) and low to moderate alarm specificities (25-40% CDC; 16-61% weekly statistical). Farrington variants had a wide range of scores (20-100% sensitivities; 16-100% specificities) and could achieve various balances between sensitivity and specificity., Conclusions: Of the methods tested, we found that the Farrington improved method was most effective at maximizing both the percent of events detected and true positive alarms for our dataset (> 70% sensitivity and > 70% specificity). This method uses statistical models to establish thresholds while controlling for seasonality and multi-year trends, and we suggest that it and other model-based approaches should be considered more broadly for malaria early detection.

Background: Despite WHO advocating for an integrated approach to antenatal care (ANC), testing coverage for conditions other than HIV remains low and women are referred to distant laboratories for testing. Using point-of-care tests (POCTs) at peripheral dispensaries could improve access to testing and timely treatment. However, the effect of providing additional services on nurse workload and client wait times are unknown. We use discrete-event simulation (DES) modelling to understand the effect of providing four point-of-care tests for ANC on nurse utilization and wait times for women seeking maternal and child health (MCH) services., Methods: We collected detailed time-motion data over 20 days from one high volume dispensary in western Kenya during the 8-month implementation period (2014-2015) of the intervention. We constructed a simulation model using empirical arrival distributions, activity durations and client pathways of women seeking MCH services. We removed the intervention from the model to obtain wait times, length-of-stay and nurse utilization rates for the baseline scenario where only HIV testing was offered for ANC. Additionally, we modelled a scenario where nurse consultations were set to have minimum durations for sufficient delivery of all WHO-recommended services., Results: A total of 183 women visited the dispensary for MCH services and 14 of these women received point-of-care testing (POCT). The mean difference in total waiting time was 2 min (95%CI: < 1-4 min, p = 0.026) for MCH women when integrated POCT was given, and 9 min (95%CI: 4-14 min, p < 0.001) when integrated POCT with adequate ANC consult times was given compared to the baseline scenario. Mean length-of-stay increased by 2 min (95%CI: < 1-4 min, p = 0.015) with integrated POCT and by 16 min (95%CI: 10-21 min, p < 0.001) with integrated POCT and adequate consult times compared to the baseline scenario. The two nurses' overall daily utilization in the scenario with sufficient minimum consult durations were 72 and 75%., Conclusion: The intervention had a modest overall impact on wait times and length-of-stay for women seeking MCH services while ensuring pregnant women received essential diagnostic testing. Nurse utilization rates fluctuated among days: nurses experienced spikes in workload on some days but were under-utilized on the majority of days. Overall, our model suggests there was sufficient time to deliver all WHO's required ANC activities and offer integrated testing for ANC first and re-visits with the current number of healthcare staff. Further investigations on improving healthcare worker, availability, performance and quality of care are needed. Delivering four point-of-care tests together for ANC at dispensary level would be a low burden strategy to improve ANC.

Background: A clear understanding of the epidemiology of malaria and dengue co-infection is essential for informed decisions on appropriate control strategies for dengue and malaria. This systematic review synthesized evidence on the relationship of malaria and dengue co-infection and related it to alterations in platelet, hemoglobin, hematocrit, aspartate aminotransferase (AST), and alanine aminotransferase (ALT) levels when compared to malaria mono-infection., Methods: A systematic review in accordance with PRISMA guidelines was conducted. All published articles available in PubMed and Web of Science (ISI) databases before October 21, 2017 were recruited. All epidemiological studies except case reports on the prevalence or incidence of malaria and dengue co-infection among patients visiting hospitals with febrile illness were included. Studies that involved conference abstracts, protocols, systematic reviews, only mono-dengue or mono-malaria infections, and only animal or in vitro studies were excluded after screening the titles, abstracts, and body texts. Studies were additionally excluded after full text review when they lacked epidemiologic data on malaria and dengue co-infection. Two reviewers independently screened, reviewed, and assessed all the studies. Cochrane Q (Chi-square) and Moran's I 2 were used to assess heterogeneity, and the funnel plot was used to examine publication bias. The summary odds ratio (OR) and 95% confidence intervals (CI) were estimated using a fixed-effects model. Thirteen cross-sectional and two retrospective studies were eligible to be included in the systematic review and meta-analysis., Results: Out of the 2269 citations screened, 15 articles were eligible to be included in the systematic review and meta-analysis. The 15 studies involved 13,798 (10,373 cases with malaria and 3425 with dengue) patients in 9 countries. Thirteen studies compared the incidence and odds of Plasmodium sp. infection, five studies compared the odds of mean platelet, three studies compared Plasmodium parasite density, and four studies compared the odds of hemoglobin, hematocrit, AST, and ALT levels among co-infected groups and single-malaria-infected groups., Conclusions: This study showed that dengue and malaria co-infection was associated with decreased odds of malaria infection, malaria parasitemia, AST, and ALT levels when compared to malaria mono-infection. However, malaria and dengue co-infection was associated with increased odds of platelet and hemoglobin levels when compared to malaria mono-infection.

Background: Access to long-lasting insecticidal nets (LLINs) has increased and malaria has decreased globally, but malaria transmission remains high in parts of sub-Saharan Africa and insecticide resistance threatens current progress. Eave tubes are a new tool for the targeted delivery of insecticides against mosquitoes attempting to enter houses. The primary objective of this trial is to test whether screening plus eave tubes (SET) provides protection against malaria, on top of universal coverage with LLINs in an area of intense pyrethroid resistance. The trial will also assess acceptability and cost-effectiveness of the intervention.Methods/design: A two-armed, cluster randomized controlled trial will be conducted to evaluate the effect of SET on clinical malaria incidence in children living in central Côte d'Ivoire. Forty villages will be selected based on population size and the proportion of houses suitable for modification with SET. Using restricted randomization, half the villages will be assigned to the treatment arm (SET + LLINs) and the remainder will be assigned to the control arm (LLINs only). In both arms, LLINs will be distributed and in the treatment arm, householders will be offered SET. Fifty children aged six months to eight years old will be enrolled from randomly selected households in each of the 40 villages. Cohorts will be cleared of malaria parasites at the start of the study and one year after recruitment, and will be monitored for clinical malaria case incidence by active case detection over two years. Mosquito densities will be assessed using CDC light traps and human landing catches and a subset of Anopheles mosquitoes will be examined for parity status and tested for sporozoite infection. Acceptability of SET will be monitored using surveys and focus groups. Cost-effectiveness analysis will measure the incremental cost per case averted and per disability-adjusted life year (DALY) averted of adding SET to LLINs. Economic and financial costs will be estimated from societal and provider perspective using standard economic evaluation methods.Discussion: This study will be the first evaluation of the epidemiological impact of SET. Trial findings will show whether SET is a viable, cost-effective technology for malaria control in Côte d'Ivoire and possibly elsewhere.Trial Registration: ISRCTN18145556 , registered on 01 February 2017 - retrospectively registered. [ABSTRACT FROM AUTHOR]

Background: Local malaria transmission has decreased rapidly since the National Malaria Elimination Action Plan was launched in China in 2010. However, imported malaria cases from Africa and Southeast Asia still occur in China due to overseas laborers. Diagnosis by microscopy is the gold standard for malaria and is used in most hospitals in China. However, the current capacity of microscopists to manage malaria cases in hospitals and public health facilities to meet the surveillance needs to eliminate and prevent the reintroduction of malaria is unknown.Methods: Malaria diagnoses were assessed by comparing the percentage of first visit and confirmed malaria diagnoses at Centers for Disease Control and Prevention (CDCs) and hospitals. The basic personnel information for public health departments and hospitals at different levels was investigated. The skills of microscopists for blood smear preparation and slide interpretation were also examined at the county and township levels.Results: Inaccurate rate with 13.49% and 7.32%, respectively, in 2013 and 2014, from 341 and 355 reported cases from sub-provincial levels in Jiangsu province. Most of the 523 malaria cases reported in Nantong Prefecture from 2000 to 2014 involved patients who first visited county CDCs seeking treatment, however, none of these cases received confirmed diagnosis of malaria in townships or villages.The staff at county CDCs and hospitals with a higher education background performed better at making and interpreting blood smears than staff from townships.Conclusions: The network for malaria elimination in an entire province has been well established. However, an insufficient capacity for malaria diagnosis was observed, especially the preparing and reading the blood smears at the township and village levels, which is a challenge to achieving and maintaining malaria elimination. [ABSTRACT FROM AUTHOR]

Background: Antibiotic resistance is an issue of growing global concern. One key strategy to minimise further development of resistance is the rational use of antibiotics, by providers and patients alike. Through integrated community case management (iCCM), children diagnosed with suspected pneumonia are treated with antibiotics; one component of an essential package to reduce child mortality and increase access to health care for remote populations. Through the use of clinical algorithms, supportive supervision and training, iCCM also offers the opportunity to improve the rational use of antibiotics and limit the spread of resistance in resource-poor contexts. This study provides evidence on antibiotic use by community health workers (CHWs) and caregivers to inform iCCM programmes, safeguarding current treatments whilst maximising access to care.Methods: 1497 CHW consultations were directly observed by non-clinical researchers, with measurement of respiratory rate by CHWs recorded by video. Videos were used to conduct a retrospective reference standard assessment of respiratory rate by experts. Fifty-five caregivers whose children were prescribed a 5-day course of antibiotics for suspected pneumonia were followed up on day six to assess adherence through structured interviews and pill counts. Six focus group discussions and nine in depth interviews were conducted with CHWs and caregivers to supplement quantitative findings.Results: The findings indicate that CHWs adhered to treatment guidelines for 92 % of children seen, prescribing treatment corresponding to their assessment. However, only 65 % of antibiotics prescribed were given for children with experts' confirmed fast breathing pneumonia. Qualitative data indicates that CHWs have a good understanding of pneumonia diagnosis, and although caregivers sometimes applied pressure to receive drugs, CHWs stated that treatment decisions were not influenced. 46 % of caregivers were fully adherent and gave their child the full 5-day course of dispersible amoxicillin. If caregivers who gave treatment for 3 to 5 days were considered, adherence increased to 76 %.Conclusions: CHWs are capable of prescribing treatment corresponding to their assessment of respiratory rate. However, rational use of antibiotics could be strengthened through improved respiratory rate assessment, and better diagnostic tools. Furthermore, a shorter course of dispersible amoxicillin could potentially improve caregiver adherence, reducing risk of resistance and cost. [ABSTRACT FROM AUTHOR]

Background: Malaria case management remains a vital component of malaria control strategies. Despite the introduction of national malaria treatment guidelines and scale-up of malaria control interventions in Nigeria, anecdotal evidence shows some deviations from the guidelines in malaria case management. This study assessed factors influencing adherence to malaria diagnosis and treatment guidelines among healthcare workers in public and private sectors in Ogun State, Nigeria.Methods: A comparative cross-sectional study was carried out among 432 (216 public and 216 private) healthcare workers selected from nine Local Government Areas using a multistage sampling technique. A pre-tested interviewer administered questionnaire was used to collect information on availability and use of malaria Rapid Diagnostic Test (mRDT) and artemisinin combination therapy (ACT), for management of uncomplicated malaria. Adherence was defined as when choice of antimalarials for parasitological confirmed malaria cases was restricted to recommended antimalarial medicines. Association between adherence and independent variables were tested using Chi-square at 5 % level of significance.Results: Malaria RDT was available in 81.9 % of the public health facilities and 19.4 % of the private health facilities (p = 0.001). Its use was higher among public healthcare workers (85.2 %) compared to 32.9 % in private facilities (p = 0.000). Presumptive diagnosis of malaria was higher among private healthcare workers (94.9 %) compared to 22.7 % public facilities (p = <0.0001). The main reason for non-usage of mRDT among private healthcare workers was its perceived unreliability of mRDT (40.9 %). Monotherapy including artesunate (58.3 % vs 12.5 %), amodiaquine (38.9 % vs 8.3 %) and chloroquine (26.4 % vs 4.2 %) were significantly more available in private than public health facilities, respectively. Adherence to guidelines was significantly higher among public healthcare workers (60.6 %) compared to those in private facilities (27.3 %). Availability of antimalarial medicine was the main factor that influenced treatment prescription in both healthcare settings (p = 0.27). However, drug promotion by manufactures (45.8 %) has a major influence on private healthcare workers' prescription practice.Conclusion: The findings of this study demonstrate significant difference between public and private healthcare workers on adherence to national malaria diagnosis and treatment guidelines. Interventions to improve private sector engagement in implementation of the guidelines, training and supply of recommended antimalarial medicines should be intensified. [ABSTRACT FROM AUTHOR]

Background: In many low- and middle-income countries, community health volunteers (CHVs) are employed as a key element of the public health system in rural areas with poor accessibility. However, few studies have assessed the effectiveness of CHVs in improving child health in sub-Saharan Africa through randomized controlled trials. The present study aims to measure the impact of health promotion and case management implemented by CHVs on the health of under-5 children in Ghana., Methods/design: This study presents the protocol of a cluster-randomized controlled trial assessing the impacts of CHVs, in which the community was used as the randomization unit. A phase-in design will be adopted, and the intervention arm will be implemented in the intervention arm during the first phase and in the control arm during the second phase. The key intervention is the deployment of CHVs, who provide health education, provide oral rehydration solutions and zinc tablets to children with diarrhea, and diagnose malaria using a thermometer and a rapid diagnostic test kit during home visits. The primary endpoints of the study are the prevalence of diarrhea and fever/malaria in children under 5 years of age, as well as the proportion of affected children receiving case management for diarrhea and malaria. The first and second rounds of household surveys to collect data will be conducted in the first phase, and the final round will be conducted during the second phase., Discussion: With growing attention paid to the roles of CHVs as an essential part of the community health system in low-income countries, this study will contribute valuable information to the body of knowledge on the effects of CHVs., Trial Registration: ISRCTN49236178 . (June 16th, 2015).

Background: Integrated Infectious Diseases Capacity Building Evaluation (IDCAP) teams designed and implemented two health worker in-service training approaches: 1) an off-site classroom-based integrated management of infectious diseases (IMID) course with distance learning aspects, and 2) on-site support (OSS), an educational outreach intervention. We tested the effects of OSS on workload and 12 facility performance indicators for emergency triage assessment and treatment, HIV testing, and malaria and pneumonia case management among outpatients by two subgroups: 1) mid-level practitioners (MLP) who attended IMID training (IMID-MLP) and 2) health workers who did not (No-IMID).Methods: Thirty-six health facilities participated in the IDCAP trial, with 18 randomly assigned to Arm A and 18 to Arm B. Two MLP in both arms received IMID. All providers at Arm A facilities received nine monthly OSS visits from April to December 2010 while Arm B did not. From November 2009 to December 2010, 777,667 outpatient visits occurred. We analyzed 669,580 (86.1 %) outpatient visits, where provider cadre was reported. Treatment was provided by 64 IMID-MLP and 1,515 No-IMID providers. The effect of OSS was measured by the difference in pre/post changes across arms after controlling for covariates (adjusted ratio of relative risks = a RRR).Results: The effect of OSS on patients-per-provider-per-day (workload) among IMID-MLP (aRRR = 1.21; p = 0.48) and No-IMID (aRRR = 0.90; p = 0.44) was not statistically significant. Among IMID-MLP, OSS was effective for three indicators: malaria cases receiving an appropriate antimalarial (aRRR = 1.26, 99 % CI = 1.02-1.56), patients with negative malaria test result prescribed an antimalarial (aRRR = 0.49, 99 % CI = 0.26-0.92), and patients with acid-fast bacilli smear negative result receiving empiric treatment for acute respiratory infection (aRRR = 2.04, 99 % CI = 1.06-3.94). Among No-IMID, OSS was effective for two indicators: emergency and priority patients admitted, detained or referred (aRRR = 2.12, 99 % CI = 1.05-4.28) and emergency patients receiving at least one appropriate treatment (aRRR = 1.98, 99 % CI = 1.21-3.24).Conclusion: Effects of OSS on workload were not statistically significant. Significant OSS effects on facility performance across subgroups were heterogeneous. OSS supported MLP who diagnosed and treated patients to apply IMID knowledge. For other providers, OSS supported team work to manage emergency patients. This evidence on OSS effectiveness could inform interventions to improve health workers' capacity to deliver better quality infectious diseases care. [ABSTRACT FROM AUTHOR]

Background: Integrated Infectious Diseases Capacity Building Evaluation (IDCAP) teams designed and implemented two health worker in-service training approaches: 1) an off-site classroom-based integrated management of infectious diseases (IMID) course with distance learning aspects, and 2) on-site support (OSS), an educational outreach intervention. We tested the effects of OSS on workload and 12 facility performance indicators for emergency triage assessment and treatment, HIV testing, and malaria and pneumonia case management among outpatients by two subgroups: 1) mid-level practitioners (MLP) who attended IMID training (IMID-MLP) and 2) health workers who did not (No-IMID)., Methods: Thirty-six health facilities participated in the IDCAP trial, with 18 randomly assigned to Arm A and 18 to Arm B. Two MLP in both arms received IMID. All providers at Arm A facilities received nine monthly OSS visits from April to December 2010 while Arm B did not. From November 2009 to December 2010, 777,667 outpatient visits occurred. We analyzed 669,580 (86.1 %) outpatient visits, where provider cadre was reported. Treatment was provided by 64 IMID-MLP and 1,515 No-IMID providers. The effect of OSS was measured by the difference in pre/post changes across arms after controlling for covariates (adjusted ratio of relative risks = a RRR)., Results: The effect of OSS on patients-per-provider-per-day (workload) among IMID-MLP (aRRR = 1.21; p = 0.48) and No-IMID (aRRR = 0.90; p = 0.44) was not statistically significant. Among IMID-MLP, OSS was effective for three indicators: malaria cases receiving an appropriate antimalarial (aRRR = 1.26, 99 % CI = 1.02-1.56), patients with negative malaria test result prescribed an antimalarial (aRRR = 0.49, 99 % CI = 0.26-0.92), and patients with acid-fast bacilli smear negative result receiving empiric treatment for acute respiratory infection (aRRR = 2.04, 99 % CI = 1.06-3.94). Among No-IMID, OSS was effective for two indicators: emergency and priority patients admitted, detained or referred (aRRR = 2.12, 99 % CI = 1.05-4.28) and emergency patients receiving at least one appropriate treatment (aRRR = 1.98, 99 % CI = 1.21-3.24)., Conclusion: Effects of OSS on workload were not statistically significant. Significant OSS effects on facility performance across subgroups were heterogeneous. OSS supported MLP who diagnosed and treated patients to apply IMID knowledge. For other providers, OSS supported team work to manage emergency patients. This evidence on OSS effectiveness could inform interventions to improve health workers' capacity to deliver better quality infectious diseases care.

Background: Home management of uncomplicated malaria (HMM) is now integrated into the community case management of childhood illness (CCM), an approach that requires parasitological diagnosis before treatment. The success of CCM in resource-constrained settings without access to parasitological testing significantly depends on the caregiver's ability to recognise malaria in children under five years (U5), assess its severity, and initiate early treatment with the use of effective antimalarial drugs in the appropriate regimen at home. Little is known about factors that influence effective presumptive treatment of malaria in U5 by caregivers in resource-constrained malaria endemic areas. This study examined the factors associated with appropriate HMM in U5 by caregivers in rural Kassena-Nankana district, northern Ghana., Methods: A cross-sectional household survey was conducted among 811 caregivers recruited through multistage sampling. A caregiver was reported to have practiced appropriate HMM if an antimalarial drug was administered to a febrile child in the recommended regimen (correct dose and duration for the child's age). Binary logistic regression was used to determine factors associated with appropriate HMM., Results: Of the 811 caregivers, 87% recognised the symptoms of uncomplicated malaria in U5, and 49% (n = 395) used antimalarial drugs for the HMM. Fifty percent (n = 197) of caregivers who administered antimalarial drugs used the appropriate regimen. In the multivariate logistic regression, caregivers with secondary (OR = 1.71, 95% CI: 1.03, 2.83) and tertiary (OR = 3.58, 95% CI: 1.08, 11.87) education had increased odds of practicing appropriate HMM compared with those with no formal education. Those who sought treatment in the hospital for previous febrile illness in U5 had increased odds of practicing appropriate HMM (OR = 2.24, 95% CI: 1.12, 4.60) compared with those who visited the health centres., Conclusions: Half of caregivers who used antimalarial drugs practiced appropriate HMM. Educational status and utilisation of hospitals in previous illness were associated with appropriate HMM. Health education programmes that promote the use of the current first line antimalarial drugs in the appropriate regimen should be targeted at caregivers with no education in order to improve HMM in communities where parasitological diagnosis of malaria may not be feasible.

Background: Artemisinin-based combination therapy (ACT) following a confirmed parasitological diagnosis is recommended by the World Health Organization (WHO) and the Congolese National Malaria Control Program (NMCP). However, commitment and competence of all stakeholders (patients, medical professionals, governments and funders) is required to achieve effective case management and secure the "useful therapeutic life" of the recommended drugs. The health seeking behaviour of patients and health care professionals' practices for malaria management were assessed., Methods: This was an observational study embedded in a two-stage cluster randomized survey conducted in one health centre (HC) in each of the 12 selected health zones in Kinshasa city. All patients with clinical malaria diagnosis were eligible. Their health seeking behaviour was recorded on a specific questionnaire, as well as the health care practitioners' practices. The last were not aware that their practices would be assessed., Results: Six hundred and twenty four patients were assessed, of whom 136 (21.8%) were under five years. Three hundred and thirty five (55%) had taken medication prior to the current consultation (self -medication with any product or visiting another HC) of whom 47(14%) took an antimalarial drug, and 56 (9%) were treated presumptively. Among those, 53.6% received monotherapy either with quinine, artesunate, phytomedicines, sulfadoxine-pyrimethamine or amodiaquine. On the other side, when clinicians were informed about laboratory results, monotherapy was prescribed in 39.9% of the confirmed malaria cases. Only 285 patients (45.7%) were managed in line with WHO and NMCP guidelines, of whom 120 (19.2%) were prescribed an ACT after positive blood smear and 165 (26.4%) received no antimalarial after a negative result., Conclusion: This study shows the discrepancy between malaria policies and the reality on the field in Kinshasa, regarding patients' health seeking behaviour and health professionals' practices. Consequently, the poor compliance to the policies may contribute to the genesis and spread of antimalarial drug resistance and also have a negative impact on the burden of the disease.

Background: Diabetes mellitus is an emerging public health problem in Tanzania. For the community and the health system to respond adequately to this problem, it is important that we understand the meanings given to its symptoms, and the care-seeking practices of individuals., Methods: To explore collective views on the meanings given to diabetes symptoms, we conducted nine focus group discussions with adult diabetes patients and members of the general community. To gain a better understanding of how the meanings in the community inform the care-seeking practices of individuals, 19 in-depth interviews were conducted with diabetes patients. The data were analyzed using principles of grounded theory and applying cultural schema theory as a deductive framework., Results: In the communities and among the patients, knowledge and awareness of diabetes are limited. Both people with diabetes and community members referred to their prevailing cultural meaning systems and schemas for infectious diseases to interpret and assign meaning to the emerging symptoms. Diabetes patients reported that they had initially used anti-malarial medicines because they believed their symptoms-like headache, fever, and tiredness-were suggestive of malaria. Schemas for body image informed the meaning given to diabetes symptoms similar to those of HIV, like severe weight loss. Confusion among members of the community about the diabetes symptoms instigated tension, causing patients to be mistrusted and stigmatized. The process of meaning-giving and the diagnosis of the diabetes symptoms was challenging for both patients and health care professionals. Diabetes patients reported being initially misdiagnosed and treated for other conditions by medical professionals. The inability to assign meaning to the symptoms and determine their etiologies informed the decision made by some patients to consult traditional healers, and to associate their symptoms with witchcraft causes., Conclusion: The meanings given to diabetes symptoms and the care-seeking practices described in the study are shaped by the prevailing cultural schemas for infectious diseases and their treatments. Efforts to educate people about the symptoms of diabetes and to encourage them to seek out appropriate care should build on the prevailing cultural meaning system and schemas for diseases, health and illness.

Background: The morbidity of malaria has steady declined in the urban regions of Gabon between 2000 and 2008, but caution should be exercised before generalizing this trend to the whole country because this finding has not been systematically confirmed in remote rural provinces., Methods: We conducted a retrospective survey using data on malaria cases recorded in North Eastern Gabon between 2006 and 2013 at health facilities in Makokou. Malaria data were analyzed, and associations with annual variations and patient age were assessed., Results: A global increase in clinical and confirmed malaria cases was observed over the study period. The rate of infection was significantly higher in children aged between 0 to 4 years than in children of 5 years and above, and in adults. Contrary to prior observations in urban and semi-urban areas of Gabon, malaria burden remained mostly unchanged or even increased in Makokou in the Ogooué-Ivindo province during these last 8 years., Conclusions: The persistence of Plasmodium falciparum pockets of sustained malaria transmission in rural Gabon may be related to an inadequate coverage of key interventions, to poor treatment seeking behavior and/or to a decline efficacy of treatments. Our results highlight the need to better adapt malaria control strategies to local epidemiological contexts and to environmental constraints. Equitable delivery of health service to hard-to-reach populations constitutes a challenging issue for the health authorities of Gabon.

Background: The research community relies heavily on measures of healthcare utilization from household surveys to understand health seeking choices and to evaluate interventions in developing countries. Such measures are known to suffer from recall problems but there is limited evidence of whether the method of data collection affects evaluation findings. We compared the results of a randomized trial of free healthcare using utilization data from two sources., Methods: Data are from a study in Ghana, in which 2,194 households containing 2,592 children under 5 y old were randomized into a prepayment scheme providing free primary and some referral care, or to a control group whose families paid user fees for healthcare. Data on morbidity and health seeking behaviour were collected using a standard household survey administered at endline and a pictorial diary given to households over a six month period, collected at monthly intervals., Results: Self-reported measures of morbidity and healthcare utilization were substantially lower in the household survey than the pictorial diary when the recall period was over a month. Introducing free healthcare had a positive effect on primary care visits based on the pictorial diary and a non-significant negative effect according to the household survey. Using any clinic visit in the past month as the outcome, the difference in the effect of free care between the two data collection methods was 3.6 percentage points (p = 0.078)., Conclusions: The findings raise methodological concerns about measures of healthcare utilization from household surveys, particularly in the evaluation of health financing interventions.

Background: Malaria mortality is mainly a direct consequence of inadequate and/or delayed diagnosis and case management. Some important control interventions (e.g. long-lasting insecticidal nests) have contributed to reduce malaria morbidity and mortality in different parts of the world. Moreover, the development and effective use of rapid diagnostic tests (RDTs) hold promise to further enhance the control and elimination of malaria, particularly in areas where health services are deficient. The aim of this study was to determine knowledge, attitudes, practices and beliefs in relation to RDTs for malaria in rural Côte d'Ivoire., Methods: One hundred individuals from Bozi and Yoho who sought care at the health centre in Bozi and were offered an RDT for malaria were interviewed in April 2010 using a pre-tested questionnaire on practice and perceptions in relation to RDTs for malaria. The relationships between acceptance of RDTs and factors related to opinions were identified, using generalized linear mixed models. Qualitative data from open-ended questions complemented the quantitative analysis., Results: Only 34 out of 100 patients who were offered an RDT for malaria were willing to undergo the test. People who perceived blood as a sacred body fluid were less likely to comply with an RDT. The concurrent availability and use of RDTs for HIV and malaria was associated with an unwilling attitude towards RDTs for malaria (Fisher's exact test, p <0.001). The initial willingness of patients to accept malaria testing with RDTs was significantly related to general fear and wanting to know malaria infection status. For further and regular use of RDTs, a strong relationship was observed between acceptance and the idea that an RDT is a pretext used by health worker to know HIV status (odds ratio (OR) = 16.61, 95% confidence interval (CI) = 1.03-268.5). Those thinking that blood samples were useful for medical diagnoses were 8.31-times (95% CI = 2.22-31.1) more likely to undergo an RDT compared to those rejecting blood sampling as a diagnostic strategy., Conclusion: Socio-cultural factors might be barriers for accepting RDTs in general health services. There are social representations of malaria and HIV/AIDS, symbolic for blood or experiences in relation to blood taking and blood-related diseases in relation to the introduction and routine use of RDTs. Special attention should be given to these barriers as otherwise the promotion of RDTs for prompt and effective diagnosis and subsequent management of malaria is hampered.