Exploiting the Potential of Integrated Vector Management for Combating Malaria in Africa

Integrated Vector Management (IVM) is advocated by the World Health Organization (WHO) as the pivotal platform for vector control. The threat for malaria and emerging and re-emerging vector borne diseases is increasing. However, adoption and deployment of the IVM strategy has been minimal. Though malaria endemic countries are embracing and consolidating the IVM approach, real time entomological data on transmission risk and targeting the right vector with the appropriate intervention is lacking. IVM could be harnessed for circumventing operational constraints for vector control. Herein IVM for combating malaria and other insect-borne diseases is reviewed and ways to maximize its potential and benefits are proposed. IVM promotes operational research for evidence-based, cost-effective and optimally sustainable vector control with judicious integration of available options, improves management of insecticides, and effective mitigation of potential negative health and environmental impacts. IVM enhances institutional arrangements including accountability, collaboration and coordination of stakeholders. IVM will require policies and frameworks to maximize intervention impact; and infrastructure and human resources capacity, community involvement and information sharing, strengthened regulation for registration and quality assurance, procurement, financial management and supply chain management for commodities. However, national health system-based response among stakeholders and political commitment is needed for optimal IVM implementation

Scotland Chikwawa Health Initiative - improving health from community to hospital

The Scotland Chikwawa Health Initiative is a three year programme funded by the Scottish Executive International Development Fund which aims to achieve measurable reductions in major causes of disease and death in four villages within the Chikwawa District of Malawi alongside improving the hospital environment for the good of both staff and patients. The initiative has developed a holistic approach to health improvements through the provision of infrastructure at both health facilities and within communities, and training of government personnel and community volunteers. Specific areas targeted have included water and sanitation, maternal health, and communicable disease control with provision of training and materials to facilitate interventions and health education. At the end of the second year the programme has already seen reductions in diarrhoeal disease (30% overall in target communities), improved access to safe water, an increase in the uptake of growth monitoring and immunisations in children under the age of five years (15% increase since training volunteers), improved safe delivery of babies within the community (245 babies delivered safely in target communities with 25 referred due to complications) and increased community health activity (training and integration of village health committees, water point committees, traditional birthing attendants and health surveillance assistants). The programme hopes to act as a model for the District to follow in other communities to achieve it’s obligations under the Malawi Ministry of Health Essential Health Package

Ecological sanitation - Implementation, opportunities and challenges in Chikwawa

Ecological sanitation (EcoSan) in not a new technology but rather a recognition that human excreta is a valuable natural resource (not a waste to be disposed of), containing plant nutrients which after containment and sanitization can be recycled in agriculture to enhance food production, with minimal risk of pollution of the environment and with minimal threat to human health. Various organizations are implementing EcoSan technologies in Malawi. Chikwawa is a rural district that is currently implementing EcoSan initiatives with resources from the Scotland Chikwawa Health Initiative and the US Ambassador’s Self Help Fund. The benefits from EcoSan are clear. For example, EcoSan systems help reduce the risk of spreading diseases by containing and treating human excreta before collecting it; minimising surface and groundwater contamination and recylcing the nutrients found in excreta and returning them to soil to enhance food production. However, EcoSan poses some challenges in its implementation such as a correct utilization, acceptability and sustainability of the concept

Epidemiology of cryptosporidiosis in rural Malawi

A hospital and community based study was conducted in Malawi, within a rural population over a 23 month period, to identify the incidence, causative species and possible determinants for cryptosporidiosis in under fives. 5.9% (25/423) of samples collected were positive for Cryptosporidium oocysts of which 18 amplified by PCR-RFLP indicating the following species: C. hominis, C. parvum, C. meleagridis and C. andersoni. Consenting positive cases were included in a case control study. 96 home interviews were conducted in 24 communities (cases n=24; unmatched controls n=72). A total of 61 risk factors were investigated with a questionnaire, and combined with quantitative data from samples of domesticated animal stools and drinking water. Oocysts were not isolated from domesticated animals or water samples. Multivariate logistic regression of questionnaire data revealed an increased risk of cryptosporidiosis associated with ownership of pigs (OR 7.2, 95%CI 1.9–27.5, p=0.004), presence of diarrhoea in the household (OR 8.8, 95%CI 1.8–53.4, p=0.008), bathing in the river (OR 76.7, 95%CI 1.1–23.8, p=0.037) and no education within the household (OR 3.6, 95%CI 1.1–11.8, p=0.038). Bacteriological results indicating faecal contamination of both drinking water stored within the home (76%), and the surface of guardians’ hands (75%) were indicative of poor hygienic practices and potential sources of infection

Public Health Recommendations for the Control of Arboviral Diseases in the Caribbean

Mosquito-borne viral (arboviral) infections, such as dengue, chikungunya, and Zika, are of significant public health importance in the Caribbean. These viruses cause significant morbidity in affected communities. Further, arboviral outbreaks can affect economies due to their prevalence in the tourist-based economic Caribbean. Currently, these viruses do not have therapeutic treatments or licensed vaccines to prevent infection. As such, the best prevention measures involve an aspect of integrated vector management, community participation in source reduction of mosquito breeding sites and individuals following measures for protection from biting mosquitoes. Mosquito Awareness Week, a yearly program supported by the Pan American Health Organization, aims to build community capacity by supporting participating countries in providing their communities with education in mosquito control and arboviral diseases prevention methods. Building off of the reported activities by participating countries, this paper gives public health recommendations for future Mosquito Awareness Week programs as well as general recommendations for mosquito control and arboviral diseases prevention in the Caribbean. Included in the recommendations are to improve surveillance systems, ensure the incorporation of the community in source reduction activities so as to build capacity, developing methods for assessing retention of educational materials, strengthening the healthcare system, and ensuring transparent communication

Shrinking the Malaria Map: A Prospectus on Malaria Elimination

\ud Thirty-nine countries across the world are making progress toward malaria elimination. Some are committed to nationwide elimination, while others are pursuing spatially progressive elimination within their borders. Influential donor and multilateral organizations are supporting their goals of achieving malaria-free status. With elimination back on the global agenda, countries face a myriad of questions. Should they change their programs to eliminate rather than control malaria? What tools are available? What policies need to be put into place? How will they benefit from elimination? Unfortunately, answers to these questions, and resources for agencies and country program managers considering or pursuing elimination, are scarce. The 39 eliminating countries are all positioned along the endemic margins of the disease, yet they naturally experience a variety of country characteristics and epidemiologies that make their malaria situations different from one another. The Malaria Elimination Group (MEG) and this Prospectus recognize\ud that there is no single solution, strategy, or time line that will be appropriate for every country, and each is encouraged to initiate a comprehensive evaluation of its readiness and strategy for elimination. The Prospectus is designed to guide countries in conducting these assessments. The Prospectus provides detailed and informed discussion on the practical means of achieving and sustaining zero transmission. It is designed as a road map, providing direction and options from which to choose an appropriate path. As on all maps, the destination is clearly marked, but the possible routes to reach it are numerous. The Prospectus is divided into two sections: Section 1 Eliminating Malaria comprises four chapters covering the strategic components important to the periods before, during, and after an elimination program. Section 2 Tools for the Job, comprises six chapters that outline basic information about how interventions in an elimination program will be different from those in a control setting. Chapter 1, Making the Decision, evaluates the issues that a country should consider when deciding whether or not to eliminate malaria. The chapter begins with a discussion about the quantitative and qualitative benefits that a country could expect from eliminating malaria and then recommends a thorough feasibility assessment. The feasibility assessment is based on three major components: operational, technical, and financial feasibility. Cross-border and regional collaboration is a key subject in this chapter. Chapter 2, Getting to Zero, describes changes that programs must consider when moving from sustained control to an elimination goal. The key strategic issues that must be addressed are considered, including supply chains, surveillance systems, intersectoral collaboration, political will, and legislative framework. Cross-border collaboration is again a key component in Getting to Zero. Chapter 3, Holding the Line, provides recommendations on how to conduct an assessment of two key factors that will affect preventing the reemergence of malaria once transmission is interrupted: outbreak risk and importation risk. The chapter emphasizes the need for a strong surveillance system in order to prevent and, if necessary, respond to imported cases. Chapter 4, Financing Elimination, reviews the cost-effectiveness of elimination as compared with sustained control and then presents the costs of selected elimination programs as examples. It evaluates four innovative financing mechanisms that must support elimination, emphasizing the need for predictable and stable financing. Case studies from Swaziland and two provinces in China are provided. Chapter 5, Understanding Malaria, considers malaria from the point of view of elimination and provides a concise overview of the current burden of the disease, malaria transmission, and the available interventions that can be used in an elimination program. Chapter 6, Learning from History, extracts important lessons from the Global Malaria Eradication Program and analyzes some elimination efforts that were successful and some that were unsuccessful. The chapter also reviews how the malaria map has been shrinking since 1900. xiv A Prosp ectus on Mala ria Elimi natio n\ud Chapter 7, Measuring Malaria for Elimination, provides a precise language for discussing malaria and gives the elimination discussion a quantitative structure. The chapter also describes the role of epidemiological theory and mathematical modeling in defining and updating an elimination agenda for malaria. Chapter 8, Killing the Parasite, outlines the importance of case detection and management in an elimination setting. Options for diagnosis, the hidden challenge of Plasmodium vivax in an elimination setting, and the impact of immunity are all discussed. Chapter 9, Suppressing the Vector, explores vector control, a necessary element of any malaria program. It considers optimal methods available to interrupt transmission and discusses potential changes, such as insecticide resistance, that may affect elimination efforts. Chapter 10, Identifying the Gaps — What We Need to Know, reviews the gaps in our understanding of what is required for elimination. The chapter outlines a short-term research agenda with a focus on the operational needs that countries are facing today. The Prospectus reviews the operational, technical, and financial feasibility for those working on the front lines and considers whether, when, and how to eliminate malaria. A companion document, A Guide on Malaria Elimination for Policy Makers, is provided for those countries or agencies whose responsibility is primarily to make the policy decisions on whether to pursue or support a malaria elimination strategy. The Guide is available at www.malaria eliminationgroup.org

Epidemiology and control of malaria in Papua New Guinea : from small-scale heterogeneity to large-scale surveillance and targeted response

Papua New Guinea (PNG), with a total estimated population of 8.8 million by 2019, has great environmental and cultural diversity which is mirrored by a complex malaria epidemiology. The geographic landscape in PNG is very diverse and in places extremely rugged. Malaria is endemic across most parts of Papua New Guinea and heterogeneous levels of endemicity characterize different areas of the country, from areas with intense transmission to unstable transmission areas with low levels of endemicity and even areas with “anophelism sans malaria”. Heterogeneity in endemicity has been attributed to factors within the human, the vector and the parasite. For instance, it has been documented that abundance of alternative hosts such as dogs and pigs together with historic and current control have given rise to significant small-scale heterogeneities in morbidity. In 2004, control efforts were re-intensified with funding from the Global Fund to Fight AIDS, Tuberculosis and Malaria. Countrywide campaigns distributed free LLINs at the household level and, starting late 2011, improved diagnosis by microscopy and RDTs together with the introduction of ACT have been provided progressively at more public and church-run health facilities. In addition the programme was complemented by advocacy and behaviour change campaigns. As a result, the prevalence of malaria decreased from 11.1% (95% confidence interval, CI: 8.5–14.3) in 2008–2009 to 5.1% (95% CI 3.6–7.4) in 2010–2011 and 0.9% (95% CI 0.6–1.5) in 2013–2014, an unprecedented reduction in PNG. In 2017, the latest national survey registered prevalence levels higher than those in 2010/11. In only three years, the estimated number of malaria infections across PNG increased 8.6-fold to 7.1% (95% CI 5.0, 10.1). Four different species of human malaria have been identified in PNG. Of these four, the two dominant species are P. falciparum and P. vivax. Overall, Plasmodium falciparum has remained the dominant species over P. vivax, but their distribution has not been even across the country. In addition, substantial heterogeneity in the prevalence of malaria across PNG has been consistently found over the years with marked differences even between nearby villages. The aim of this work is to provide a better understanding of the heterogeneous malaria transmission and the dynamics of Plasmodium, humans and interventions rolled-out by the Papua New Guinea National Malaria Control Program. This work comprises two major components: 1) a retrospective analysis of incidence of malaria cases in selected sentinel health facilities including a visualization of trends over time in different Sentinel Health Facilities (SHFs), and 2) a cross-sectional malaria survey complemented by a community based qualitative behavioural study. The retrospective analysis of incidence found that malaria incidence in different sites initially ranged from 20 to 115/1,000 population; subsequent trends varied by site. Overall, LLIN distributions had a cumulative effect, reducing the number of malaria cases with each round (incidence rate ratio range 0.12 to 0.53 in five sites). No significant reduction was associated with ACT introduction. Plasmodium falciparum remained the dominant parasite in all sentinel health facilities from 2010 to 2014. Resurgence was observed in one site in which a shift to early and outdoor biting of anophelines had previously been documented. LLINs distributions, but not ACT, were associated with reductions of malaria cases in a range of settings, but sustainability of the gains appear to depend on local factors. Malaria programmes covering diverse transmission settings such as PNG must consider local heterogeneity when choosing interventions and ensure continuous monitoring of trends. The visualization of incidence trends and other information (net use and residence of patients) extracted from a routinely implemented surveillance system proved useful to inform local malaria control programs to better target interventions. The visualization approach added a geospatial component to health facility data in order to understand differences in malaria burden between villages and identify communities that would benefit from targeted interventions or investigations. However, a functional simple tool for calculating and mapping malaria case incidence at district or sub-district level (e.g. eNHIS or similar) is required to operationalize the approach, along with the capacity, policies, and mechanisms required to implement targeted response action at the respective operational level. The qualitative behavioural investigation identified seven behavioural groups (or demographic groups exhibiting similar behaviours) and highlighted the substantial amount of time spent outdoors or in non-secure structures when ‘indoors’ as a major risk of exposure. Between 4pm and 8am, all age groups in both study sites were likely to be exposed to mosquito bites across all types of activities; sleeping under a LLIN was the exception. Such findings highlight the potential of ‘outdoor biting’ to hamper malaria control and elimination efforts if not addressed appropriately since people spent a remarkable amount of time outdoors without protection from mosquito biting. Targeting groups, places and activities in order to prevent outdoor biting in the early hours of the evening and the morning seems crucial towards elimination. This work also reveals spatial heterogeneity in the prevalence distribution of malaria and LLIN use between study sites. Malaria prevalence in the Mugil area was 3.7 fold higher than in the Lemakot area. Interestingly, LLIN-use was 2.4 times higher in the Mugil area compared to the Lemakot area. Spatial heterogeneity of malaria was also observed at a village and households level. Prevalence between villages ranged from 0.8% to 19.5% and between households from 0% to 66.6%. In the Mugil area identified risk factor related to behavioural groups (adult women were at lower risk and school children at higher risk) and housing (screened windows and traditional houses were associated with lower exposure) while in the Lemakot area LLIN ownership was a predictor for infection. The identification of site-specific risk factors provides evidence to potentially inform complementary interventions in a local scale that target specific groups or areas. Heterogeneity of malaria trends was consistent throughout this work. The retrospective analysis and the cross-sectional malaria survey identified: i) heterogeneous effects of malaria interventions across the country, and ii) a heterogeneous distribution of malaria cases over space and time. The cross-sectional malaria survey highlighted varying prevalence between study sites and between neighbouring villages within sites. These findings emphasize the need for locally informed strategies toward improved control. Some communities could still benefit from improved LLIN ownership and use, whereas others might need to complement control with alternatives to LLINs. Targeted interventions in areas of higher transmission has been proposed by modelling and some field studies as opposed to untargeted community-based approaches, but the evidence comparing their effectiveness is scarce. Future research in PNG could address this gap and compare the effect of different control strategies that combine targeted and untargeted interventions. In addition, outdoor and earlier biting of Anopheles species has been identified as a threat to LLINs effectiveness in PNG and other settings. Studies in PNG have described a shift in mosquito biting to earlier hours following the first LLIN distribution (the peak exposure time to infective bites shifted from later than 9pm in 2008 to between 6 and 7 pm in 2011). Our results identified and increase in the number of cases in one site by 2014 despite consistently high LLIN ownership and use in the area. The behavioural investigation identified potential exposure to mosquito bites on the amount of time spent outdoors (when not asleep) or in non-protected structures. Therefore, it is possible that the reduced efficacy of LLINs in synergy with human behaviour and ACT stock outs led to the observed increase especially in places with historically high mosquito densities. During the course of this work, malaria elimination from PNG by 2030 became less likely than when it was originally envisioned in the National Malaria Strategic Plan 2014-2018. The resurgence in malaria is likely to worsen unless malaria control is re-intensified and maintained. Structuring programmes in response to evidence of the local malaria burden together with an analysis of transmission will enable adapting the strategy to the local context and optimize the use of resources. However a strong and functional surveillance & response system is needed to monitor the local burden and inform control efforts. Evidence in this study documented reasonable high LLIN ownership across study sites; however LLINs use can be improved in some areas. RDTs and ACTs were not always available in the health facilities therefore efforts need to be made to assure availability especially in areas with higher transmission. Since outdoor biting was consistently identified as an exposure risk and specific groups and areas at higher risk were also identified targeted complementary interventions could be explored and piloted in PNG. Further studies could address the current evidence gap on the effectiveness of targeted interventions

Multi-Disease Data Management System Platform for Vector-Borne Diseases

Background Emerging information technologies present new opportunities to reduce the burden of malaria, dengue and other infectious diseases. For example, use of a data management system software package can help disease control programs to better manage and analyze their data, and thus enhances their ability to carry out continuous surveillance, monitor interventions and evaluate control program performance. Methods and Findings We describe a novel multi-disease data management system platform (hereinafter referred to as the system) with current capacity for dengue and malaria that supports data entry, storage and query. It also allows for production of maps and both standardized and customized reports. The system is comprised exclusively of software components that can be distributed without the user incurring licensing costs. It was designed to maximize the ability of the user to adapt the system to local conditions without involvement of software developers. Key points of system adaptability include 1) customizable functionality content by disease, 2) configurable roles and permissions, 3) customizable user interfaces and display labels and 4) configurable information trees including a geographical entity tree and a term tree. The system includes significant portions of functionality that is entirely or in large part re-used across diseases, which provides an economy of scope as new diseases downstream are added to the system at decreased cost. Conclusions We have developed a system with great potential for aiding disease control programs in their task to reduce the burden of dengue and malaria, including the implementation of integrated vector management programs. Next steps include evaluations of operational implementations of the current system with capacity for dengue and malaria, and the inclusion in the system platform of other important vector-borne diseases