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Introduction The decision-making process for malaria control and elimination strategies has become more challenging. Interventions need to be targeted at council level to allow for changing malaria epidemiology and an increase in the number of possible interventions. Models of malaria dynamics can support this process by simulating potential impacts of multiple interventions in different settings and determining appropriate packages of interventions for meeting specific expected targets. Methods The OpenMalaria model of malaria dynamics was calibrated for all 184 councils in mainland Tanzania using data from malaria indicator surveys, school parasitaemia surveys, entomological surveillance, and vector control deployment data. The simulations were run for different transmission intensities per region and five interventions, currently or potentially included in the National Malaria Strategic Plan, individually and in combination. The simulated prevalences were fitted to council specific prevalences derived from geostatistical models to obtain council specific predictions of the prevalence and number of cases between 2017 and 2020. The predictions were used to evaluate in silico the feasibility of the national target of reaching a prevalence of below 1% by 2020, and to suggest alternative intervention stratifications for the country. Results The historical prevalence trend was fitted for each council with an agreement of 87% in 2016 (95%CI: 0.84–0.90) and an agreement of 90% for the historical trend (2003–2016) (95%CI: 0.87–0.93) The current national malaria strategy was expected to reduce the malaria prevalence between 2016 and 2020 on average by 23.8% (95% CI: 19.7%-27.9%) if current case management levels were maintained, and by 52.1% (95% CI: 48.8%-55.3%) if the case management were improved. Insecticide treated nets and case management were the most cost-effective interventions, expected to reduce the prevalence by 25.0% (95% CI: 19.7%-30.2) and to avert 37 millio

Distributions of the intensities of helminth infections within their host populations are invariably aggregated. In the case of the intestinal nematodes, the degrees of aggregation have been shown to be species specific, and constant for any given species despite geographical variation in study sites. This species-specific aggregation can be quantified and used as a tool in planning control interventions. One practical application is that the prevalence of infection can be used to predict the prevalence of heavy infection and thus the risks of morbidity. This paper investigates the patterns of aggregation in schistosome egg counts in different endemic areas in Africa (data sets were obtained from Burundi, Cameroon, Tanzania, Zambia and Zaire). The analysis demonstrates that the degree of parasite aggregation, for both Schistosoma mansoni and S. haematobium, differs amongst the different study localities. This is probably due to area-specific differences in host exposure and immunity. This implies that for these schistosome species, it is not possible to predict egg count distributions or morbidity levels from prevalence data alone

Planning of the control of Plasmodium falciparum malaria leads to a need for models of malaria epidemiology that provide realistic quantitative prediction of likely epidemiological outcomes of a wide range of control strategies. Predictions of the effects of control often ignore medium- and long-term dynamics. The complexities of the Plasmodium life-cycle, and of within-host dynamics, limit the applicability of conventional deterministic malaria models. We use individual-based stochastic simulations of malaria epidemiology to predict the impacts of interventions on infection, morbidity, mortality, health services use and costs. Individual infections are simulated by stochastic series of parasite densities, and naturally acquired immunity acts by reducing densities. Morbidity and mortality risks, and infectiousness to vectors, depend on parasite densities. The simulated infections are nested within simulations of individuals in human populations, and linked to models of interventions and health systems. We use numerous field datasets to optimise parameter estimates. By using a volunteer computing system we obtain the enormous computational power required for model fitting, sensitivity analysis, and exploration of many different intervention strategies. The project thus provides a general platform for comparing, fitting, and evaluating different model structures, and for quantitative prediction of effects of different interventions and integrated control programmes

A spatial analysis was carried out to identify factors related to geographic differences in infant mortality risk in Mali by linking data from two spatially structured databases: the Demographic and Health Surveys of 1995-1996 and the Mapping Malaria Risk in Africa database for Mali. Socioeconomic factors measured directly at the individual level and site-specific malaria prevalence predicted for the Demographic and Health Surveys' locations by a spatial model fitted to the Mapping Malaria Risk in Africa database were examined as possible risk factors. The analysis was carried out by fitting a Bayesian hierarchical geostatistical logistic model to infant mortality risk, by Markov chain Monte Carlo simulation. It confirmed that mother's education, birth order and interval, infant's sex, residence, and mother's age at infant's birth had a strong impact on infant mortality risk in Mali. The residual spatial pattern of infant mortality showed a clear relation to well-known foci of malaria transmission, especially the inland delta of the Niger River. No effect of estimated parasite prevalence could be demonstrated. Possible explanations include confounding by unmeasured covariates and sparsity of the source malaria data. Spatial statistical models of malaria prevalence are useful for indicating approximate levels of endemicity over wide areas and, hence, for guiding intervention strategies. However, at points very remote from those sampled, it is important to consider prediction error

In order to determine reported signs and symptoms that may predict an intestinal parasitic infection, 241 schoolchildren in western Côte d'Ivoire were interviewed with a simple questionnaire and their stool specimens were examined over several consecutive days. Special emphasis was placed on (i) assessing infections by Entamoeba histolytica/E. dispar, Giardia duodenalis and by intestinal worms, (ii) looking for associations between these parasites, and (iii) looking for associations between these parasites and commonly perceived intestinal signs and symptoms. Complete questionnaire results, intestinal helminth infections derived from 4 Kato-Katz thick smears, and intestinal protozoa infections assessed on a single day by a formalin-ether concentration procedure were obtained from 209 children (87%). A logistic regression modelling approach showed that an infection with E. histolytica/E. dispar was significantly associated with an Entamoeba coli infection. However, for G. duodenalis, hookworm and Ascaris lumbricoides, no association was found between any of these parasites and other intestinal parasites. In a multivariate analysis reported diarrhoea was the only symptom positively associated with an E. histolytica/E. dispar infection (P = 0·028). Its diagnostic performance showed a low sensitivity (28%), a high specificity (85%) and moderate positive and negative predictive values (52% and 67%, respectively). Surprisingly, reported ‘turning stomach' was less often reported by children infected with G. duodenalis (borderline significance, P = 0·057). It is concluded that reported diarrhoea could be a symptom worth exploring further for the rapid identification of schoolchildren infected with E. histolytica/E. dispar

Entamoeba histolytica has been separated in recent years into 2 morphologically identical species: the apathogenic E. dispar and the pathogenic E. histolytica, only the latter being pathogenic. Although various laboratory techniques allow discrimination between the 2 species there is a lack of field data about the suitability of available diagnostic tests for use in epidemiological studies and few epidemiological studies using species-specific diagnosis have been performed at community level in endemic areas, especially in sub-Saharan Africa. We conducted a repeated cross-sectional study of 967 schoolchildren in central Côte d'Ivoire to compare and evaluate light microscopy, 2 different antigen detection assays, and one polymerase chain reaction (PCR) assay. Microscopy and a non-specific antigen capture Entamoeba enzyme-linked immunosorbent assay (ELISA) were used for the primary screening of all children (time t0). The prevalence of the E. histolytica/E. dispar species complex at t0 was 18 · 8% by single microscopical examination and 31 · 4% using the non-specific ELISA. Approximately 2 months after the initial screening, fresh stool specimens were collected on 2 consecutive days (t1, and t2) from (i) all the children who were positive by microscopy at t0 (n = 182) and (ii) 155 randomly selected children who were negative at the primary screening. These samples were tested with a second antigen detection ELISA specific for E. histolytica (n = 238) and with a species-specific PCR assay (n = 193). The second and third examinations (t1, and t2) revealed an additional 43 infections with the species complex E. histolytica/E. dispar, so that the cumulative microscopical prevalence for t1 and t2 was 27 · 7%. The overall prevalence of E. histolytica by species-specific ELISA antigen detection was low (0 · 83%), while the prevalence of E. dispar was 15%. When analysing only microscopically positive samples by PCR (n = 129), the ratio E. histolytica: E. dispar was very low (

Background Case-control studies have been proposed as an appropriate tool for health impact evaluation of insecticide-treated nets (ITN) programmes. Methods A dispensary-based case-control study was carried out in one village in Tanzania. Each case of fever and parasitaemia in a child under 5 years was paired with one community and one dispensary control without fever and parasitaemia. Cases and controls were compared with regard to ITN ownership and other factors assessed by a questionnaire. A cross-sectional survey of factors associated with parasitaemia, including ITN use, was carried out during the study. Dispensary attendance rates of the study children were calculated using passive case detection data. Results Cases and dispensary controls had higher dispensary attendance rates compared to community controls and children with nets attended more for most of the illness events. A comparison of cases and community controls showed a strong and statistically significant association between untreated net use and being a case (odds ratio [OR] = 2.1, 95% CI : 1.3-3.4). For those with ITN there was a smaller and weaker association between risk of being a case and ITN use (OR =1.4, 95% CI : 0.9-2.2). Comparison of cases and dispensary controls showed no association between untreated or treated nets and the risk of being a case (for treated nets OR = 0.9, 95% CI : 0.5-1.4 and for untreated nets OR = 1.2, 95% CI : 0.7-2.0). These results are contrary to those from the cross-sectional assessment, where children with ITN had a lower prevalence of parasitaemia than those with no nets (OR = 0.5, 95% CI : 0.3-0.9), and also contrary to other assessments of the health impact of ITN in this population. Conclusion The positive association between mild malaria and net ownership is counter-intuitive and best explained by attendance bias, since children with nets attended more frequently for all curative and preventive services at the dispensary than those without nets. Dispensary-b

We present a large-scale social marketing programme of insecticide-treated nets in 2 rural districts in south-western Tanzania (population 350 000) and describe how the long-term child health and survival impact will be assessed. Formative and market research were conducted in order to understand community perceptions, knowledge, attitudes and practice with respect to the products to be socially marketed. We identified Zuia Mbu (Kiswahili for ‘prevent mosquitoes') as a suitable brand name for both treated nets and single-dose insecticide treatment sachets. A mix of public and private sales outlets is used for distribution. In the first stage of a stepped introduction 31 net agents were appointed and trained in 18 villages: 15 were shop owners, 14 were village leaders, 1 was a parish priest and 1 a health worker. For net treatment 37 young people were appointed in the same villages and trained as agents. Further institutions in both districts such as hospitals, development projects and employers were also involved in distribution. Promotion for both products was intense and used a variety of channels. A total of 22 410 nets and 8072 treatments were sold during the first year: 18 months after launching, 46% of 312 families with children aged under 5 years reported that their children were sleeping under treated nets. A strong evaluation component in over 50 000 people allows assessment of the long-term effects of insecticide-treated nets on child health and survival, anaemia in pregnancy, and the costs of the intervention. This evaluation is based on cross-sectional surveys, and case-control and cohort studies

BACKGROUND: Anopheles plumbeus has been recognized as a minor vector for human malaria in Europe since the beginning of the 20th century. In recent years this tree hole breeding mosquito species appears to have exploited novel breeding sites, including large and organically rich man-made containers, with consequently larger mosquito populations in close vicinity to humans. This lead to investigate whether current populations of An. plumbeus would be able to efficiently transmit Plasmodium falciparum, the parasite responsible for the most deadly form of malaria. METHODS: Anopheles plumbeus immatures were collected from a liquid manure pit in Switzerland and transferred as adults to the CEPIA (Institut Pasteur, France) where they were fed on P. falciparum gametocytes produced in vitro. Anopheles gambiae mosquitoes served as controls. Development of P. falciparum in both mosquito species was followed by microscopical detection of oocysts on mosquito midguts and by sporozoite detection in the head/thorax by PCR and microscopy. RESULTS: A total of 293 wild An. plumbeus females from four independent collections successfully fed through a membrane on blood containing P. falciparum gametocytes. Oocysts were observed in mosquito midguts and P. falciparum DNA was detected in head-thorax samples in all four experiments, demonstrating, on a large mosquito sample, that An. plumbeus is indeed receptive to P. falciparum NF54 and able to produce sporozoites. Importantly, the proportion of sporozoites-infected An. plumbeus was almost similar to that of An. gambiae (31 to 88% An. plumbeus versus 67 to 97% An. gambiae). However, the number of sporozoites produced was significantly lower in infected An. plumbeus. CONCLUSION: The results show that a sample of field-caught An. plumbeus has a moderate to high receptivity towards P. falciparum. Considering the increased mobility of humans between Europe and malaria endemic countries and changes in environment and climate, these data strong

Background The communities of Namawala and Idete villages in southern Tanzania experienced extremely high malaria transmission in the 1990s. By 2001-03, following high usage rates (75% of all age groups) of untreated bed nets, a 4.2-fold reduction in malaria transmission intensity was achieved. Since 2006, a national-scale programme has promoted the use of longer-lasting insecticide treatment kits (consisting of an insecticide plus binder) co-packaged with all bed nets manufactured in the country. Methods The entomological inoculation rate (EIR) was estimated through monthly surveys in 72 houses randomly selected in each of the two villages. Mosquitoes were caught using CDC light traps placed beside occupied bed nets between January and December 2008 (n = 1,648 trap nights). Sub-samples of mosquitoes were taken from each trap to determine parity status, sporozoite infection and Anopheles gambiae complex sibling species identity. Results Compared with a historical mean EIR of ~1400 infectious bites/person/year (ib/p/y) in 1990-94; the 2008 estimate of 81 ib/p/y represents an 18-fold reduction for an unprotected person without a net. The combined impact of longer-lasting insecticide treatments as well as high bed net coverage was associated with a 4.6-fold reduction in EIR, on top of the impact from the use of untreated nets alone. The scale-up of bed nets and subsequent insecticidal treatment has reduced the density of the anthropophagic, endophagic primary vector species, Anopheles gambiae sensu stricto, by 79%. In contrast, the reduction in density of the zoophagic, exophagic sibling species Anopheles arabiensis was only 38%. Conclusion Insecticide treatment of nets reduced the intensity of malaria transmission in addition to that achieved by the untreated nets alone. Impacts were most pronounced against the highly anthropophagic, endophagic primary vector, leading to a shift in the sibling species composition of the A. gambiae complex

BACKGROUND: For companies operating in malaria endemic countries, malaria represents a substantial risk to workers and their dependants, and can lead to significantly reduced worker productivity. This study provides an overview of the malaria epidemiology within an oil palm plantation in Popondetta, south-eastern Papua New Guinea, its implication for the company with its employees and their families and the potential for control. METHODS: In 2006, we carried out a cross-sectional study within six company villages, which included the determination of parasite rates by conventional microscopy, interviews and haemoglobin measurements. Passive surveillance data were collected from the 13 company aid posts for the years 2005 and 2006. RESULTS: Malaria prevalence was found to be high: all-age prevalence was 33.5% (95% CI 30.1-37.0) in 723 individuals. Plasmodium falciparum was the dominant species, followed by Plasmodium vivax and Plasmodium malariae. Children between five and nine years of age were most affected (40.3%, 95% CI 0.32-0.49). Haemoglobin levels were found to be low; 11.0 g/dl (95% CI 10.8-11.1) for men and 10.4 g/dl (95% CI 10.3-10.5) for women, respectively. Plasmodium falciparum infections were significantly associated with anaemia (Hb < 10 g/dl). At the aid posts, all malaria cases in 2005 and January-March 2006 were diagnosed by symptoms only, while from April 2006 onwards most cases were tested by rapid diagnostic tests. Between 2005 and 2006, 22,023 malaria cases were diagnosed at the aid posts and malaria accounted for 30-40% of all clinical cases. Of the malaria cases, 13-20% were HOP employees. On average, an employee sick with malaria was absent for 1.8 days, resulting in a total of 9,313 workdays lost between 2005 and 2006. Sleeping outside of the house did not increase the risk of a malaria infection, neither did getting up before 7 am. CONCLUSION: Malaria was found to be a major health burden in the Higaturu Oil Palm plantation, posing a high ri

Background. Five large insecticide-treated net (ITN) programmes and two indoor residual spraying (IRS) programmes were compared using a standardized costing methodology. Methods. Costs were measured locally or derived from existing studies and focused on the provider perspective, but included the direct costs of net purchases by users, and are reported in 2005 USD. Effectiveness was estimated by combining programme outputs with standard impact indicators. Findings. Conventional ITNs: The cost per treated net-year of protection ranged from USD 1.21 in Eritrea to USD 6.05 in Senegal. The cost per child death averted ranged from USD 438 to USD 2,199 when targeting to children was successful. Long-lasting insecticidal nets (LLIN) of five years duration: The cost per treated-net year of protection ranged from USD 1.38 in Eritrea to USD 1.90 in Togo. The cost per child death averted ranged from USD 502 to USD 692. IRS: The costs per person-year of protection for all ages were USD 3.27 in KwaZulu Natal and USD 3.90 in Mozambique. If only children under five years of age were included in the denominator the cost per person-year of protection was higher: USD 23.96 and USD 21.63. As a result, the cost per child death averted was higher than for ITNs: USD 3,933-4,357. Conclusion. Both ITNs and IRS are highly cost-effective vector control strategies. Integrated ITN free distribution campaigns appeared to be the most efficient way to rapidly increase ITN coverage. Other approaches were as or more cost-effective, and appeared better suited to "keep-up" coverage levels. ITNs are more cost-effective than IRS for highly endemic settings, especially if high ITN coverage can be achieved with some demographic targeting. © 2008 Yukich et al; licensee BioMed Central Ltd.

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