A participatory approach for malaria control in southern Malawi : Effects of the environment and community on larval source management

Current trends in the fight against malaria suggest that further progress will be difficult with  the use of insecticide-based control measures alone. Without major reductions in the burden of malaria registered in the past few years, the use of additional interventions with synergistic effects on the current standard measures is required. Currently, interest in employing Larval Source Management (LSM) as a complementary tool is growing as it has shown to significantly reduce larval densities and consequently adult populations in settings where it has been applied along other interventions. LSM is commonly executed via 1) habitat modification, which includes physical transformation of a larval habitat through draining, filling and land levelling and 2) larviciding, commonly using an endotoxin-producing bacterial larvicide, Bacillus thuringiensis var. israelensis (Bti). Knowledge on the ecology of anopheline larval habitats is therefore important as it informs where LSM should be targeted. Also, knowledge about community acceptance and participation in LSM is important as it affects the scalability and future sustainability of the intervention. The study described in this thesis focused on the potential of community-led LSM in Malawi. Chapter 2 describes the habitat ecology of malaria vectors in the Majete area, southern Malawi. In this area, anopheline larvae develop in habitats with little silt, surrounded by bare-grounds and occupied by culicine larvae. I conclude that larval control should be directed towards such anopheline-productive habitats which sustain malaria transmission. In Chapter 3, I investigated whether application of Bti induces discrimination of treated sites by gravid females seeking oviposition sites. I found that treatment of the sites with the bacterial larvicide does not repel ovipositing females from laying eggs in such sites. This finding implies that the female mosquitoes did not detect the presence of the larvicide in aquatic sites. In Chapter 4, we explored whether application of lower doses (sublethal) of Bti in larval habitats can negatively affect fitness parameters of malaria vectors and hence their ability to successfully transmit malaria. Sublethal Bti doses are likely to occur when applications are done under field conditions, especially by local communities who may lack the desired expertise in comparison with trained experts. Immature and adult life history parameters, including larval survival, adult longevity, wing size and oviposition of An. coluzzii, an important African malaria vector, were assessed in a laboratory setting. Our results show that larval densities were reduced when exposed to the sublethal doses. When exposed to Bti LC70 as larvae, the proportional hazard rate for mortality as adult females was about three times higher than in the control group. At the same LC70 dose rate, the mean wing length of the adult females increased by 12% compared to that of the control group. These findings are valuable as they demonstrate that larval exposure to Bti, even at lower doses, reduces the longevity of emerging adults which also reduces their vectorial capacity as they may not live long enough to effectively transmit the malaria parasite. In Chapter 5, we assessed whether communities would  accept and are willing to participate in community-led LSM activities. Specifically, we explored factors that would motivate community acceptance and participation in LSM. Our results show that community involvement in LSM as an additional tool for malaria control increases local awareness of malaria as a health problem, its risk factors and control strategies. The results also show that specially trained members of the community easily accepted the intervention and were more willing to participate in the associated activities than the rest of the community. Further, the findings highlight the need to make activities less demanding in terms of time and labour. It was also observed that the community needs incentives to participate in community-led interventions but though critical, forms and modes of delivery of incentives need to be further studied. In Chapter 6, we investigated whether community involvement in LSM is feasible and can result in reduced larval vector densities. Our results showed that groups from the community, which received tailored training from the research team, participated more actively in the LSM activities than the rest of the community. Also, larviciding using Bti was the more preferred component of LSM by the community than habitat modification. Interestingly, application of Bti reduced larval densities in intervention villages. The findings of this study suggest that community involvement in LSM is only feasible when the community understands their malaria risk factors and control methods. Also, the study demonstrates that community involvement in application of Bti has the potential to reduce larval densities but should be implemented after proper training of the spraying teams. In Chapter 7, the key findings of this research and the implications for community-led LSM in Malawi are addressed and recommendations for future investigations are provided. In conclusion, the results of the research described in this thesis show that participation of communities in LSM is feasible and can reduce the malaria burden via reduced larval densities

Procjena mikrostrukture alatnog čelika za hladni rad nakon pretaljivanja pulsirajućim laserom

The aim of this study is the investigation of micro-structural behaviour of a Mat. No. 1.2379 (EN-X160CrMoV121; AISI D2) cold work tool steel after remelting with a precise pulsed Nd:YAG laser. The investigated steel is one of the most hard to weld tool steels, due to large amount of alloying elements. The analysis was done on single spots remelted with specific laser pulse shape and parameters, assuring crack-less solidification. Re-solidifi ed areas were investigated with microscopy, hardness measurements, X-ray spectroscopy and diffraction method. Laser treatment causes rapid solidification leading into a formation of a fine dendritic microstructures containing high amount of retained austenite causing a significant decrease of hardness.Namjena ove studije je ispitivanje ponašanja mikro strukture alatnoga čelika za rad na hladno Mat. No.1.2379 (ENX160CrMoV121; AISI D2) po pretaljivanju s preciznim pulsiranim Nd:YAG laserom. Zbog velike količine legirnih elemenata istraživani materijal spada u grupu vrlo teško zavarljivih alatnih čelika. Analiza je provedena na pojedinim pretaljenim točkama korištenjem specifi čnog oblika i parametara laserskog impulsa koji osiguravaju skrućivanje bez pukotina. Pretaljena područja su ispitivana mikroskopom, mjerenjem mikro tvrdoće, rendgenskom spektroskopijom i defrakcijskom metodom. Tretman laserom uzrokvao je brzo skrućivanje koja dovodi do formiranja fi ne dendritičke strukture s velikim udjelom zaostalog austenita što uzrokuje bitno smanjivanje tvrdoće

Cost of community-led larval source management and house improvement for malaria control: a cost analysis within a cluster-randomized trial in a rural district in Malawi

Background House improvement (HI) to prevent mosquito house entry, and larval source management (LSM) targeting aquatic mosquito stages to prevent development into adult forms, are promising complementary interventions to current malaria vector control strategies. Lack of evidence on costs and cost-effectiveness of community-led implementation of HI and LSM has hindered wide-scale adoption. This study presents an incremental cost analysis of community-led implementation of HI and LSM, in a cluster-randomized, factorial design trial, in addition to standard national malaria control interventions in a rural area (25,000 people), in southern Malawi. Methods In the trial, LSM comprised draining, filling, and Bacillus thuringiensis israelensis-based larviciding, while house improvement (henceforth HI) involved closing of eaves and gaps on walls, screening windows/ventilation spaces with wire mesh, and doorway modifications. Communities implemented all interventions. Costs were estimated retrospectively using the ‘ingredients approach’, combining ‘bottom-up’ and ‘top-down approaches’, from the societal perspective. To estimate the cost of independently implementing each intervention arm, resources shared between trial arms (e.g. overheads) were allocated to each consuming arm using proxies developed based on share of resource input quantities consumed. Incremental implementation costs (in 2017 US$) are presented for HI-only, LSM-only and HI + LSM arms. In sensitivity analyses, the effect of varying costs of important inputs on estimated costs was explored. Results The total economic programme costs of community-led HI and LSM implementation was$626,152. Incremental economic implementation costs of HI, LSM and HI + LSM were estimated as $27.04,$25.06 and $33.44, per person per year, respectively. Project staff, transport and labour costs, but not larvicide or screening material, were the major cost drivers across all interventions. Costs were sensitive to changes in staff costs and population covered. Conclusions In the trial, the incremental economic costs of community-led HI and LSM implementation were high compared to previous house improvement and LSM studies. Several factors, including intervention design, year-round LSM implementation and low human population density could explain the high costs. The factorial trial design necessitated use of proxies to allocate costs shared between trial arms, which limits generalizability where different designs are used. Nevertheless, costs may inform planners of similar intervention packages where cost-effectiveness is known

Community Participation in Habitat Management and Larviciding for the Control of Malaria Vectors in Southern Malawi

Larval source management (LSM) could reduce malaria transmission when executed alongside core vector control strategies. Involving communities in LSM could increase intervention coverage, reduce operational costs, and promote sustainability via community buy-in. We assessed the effectiveness of community-led LSM to reduce anopheline larval densities in 26 villages along the perimeter of Majete Wildlife Reserve in southern Malawi. The communities formed LSM committees which coordinated LSM activities in their villages following specialized training. Effectiveness of larviciding by LSM committees was assessed via pre- and post-spray larval sampling. The effect of community-led LSM on anopheline larval densities in intervention villages was assessed via comparisons with densities in non-LSM villages over a period of 14 months. Surveys involving 502 respondents were undertaken in intervention villages to explore community motivation and participation, and factors influencing these outcomes. Larviciding by LSM committees reduced anopheline larval densities in post-spray sampling compared with pre-spray sampling (P < 0.0001). No differences were observed between anopheline larval densities during pre-spray sampling in LSM villages and those in non-LSM villages (P = 0.282). Knowledge about vector biology and control, and someone’s role in LSM motivated community participation in the vector control program. Despite reducing anopheline larval densities in LSM villages, the impact of the community-led LSM could not be detected in our study setting because of low mosquito densities after scale-up of core malaria control interventions. Still, the contributions of the intervention in increasing a community’s knowledge of malaria, its risk factors, and its control methods highlight potential benefits of the approach

Community factors affecting participation in larval source management for malaria control in Chikwawa District, Southern Malawi

BACKGROUND: To further reduce malaria, larval source management (LSM) is proposed as a complementary strategy to the existing strategies. LSM has potential to control insecticide resistant, outdoor biting and outdoor resting vectors. Concerns about costs and operational feasibility of implementation of LSM at large scale are among the reasons the strategy is not utilized in many African countries. Involving communities in LSM could increase intervention coverage, reduce costs of implementation and improve sustainability of operations. Community acceptance and participation in community-led LSM depends on a number of factors. These factors were explored under the Majete Malaria Project in Chikwawa district, southern Malawi. METHODS: Separate focus group discussions (FGDs) were conducted with members from the general community (n = 3); health animators (HAs) (n = 3); and LSM committee members (n = 3). In-depth interviews (IDIs) were conducted with community members. Framework analysis was employed to determine the factors contributing to community acceptance and participation in the locally-driven intervention. RESULTS: Nine FGDs and 24 IDIs were held, involving 87 members of the community. Widespread knowledge of malaria as a health problem, its mode of transmission, mosquito larval habitats and mosquito control was recorded. High awareness of an association between creation of larval habitats and malaria transmission was reported. Perception of LSM as a tool for malaria control was high. The use of a microbial larvicide as a form of LSM was perceived as both safe and effective. However, actual participation in LSM by the different interviewee groups varied. Labour-intensiveness and time requirements of the LSM activities, lack of financial incentives, and concern about health risks when wading in water bodies contributed to lower participation. CONCLUSION: Community involvement in LSM increased local awareness of malaria as a health problem, its risk factors and control strategies. However, community participation varied among the respondent groups, with labour and time demands of the activities, and lack of incentives, contributing to reduced participation. Innovative tools that can reduce the labour and time demands could improve community participation in the activities. Further studies are required to investigate the forms and modes of delivery of incentives in operational community-driven LSM interventions.</p

Characterisation of anopheline larval habitats in southern Malawi

Introduction: Increasing the knowledgebase of anopheline larval ecology could enable targeted deployment of malaria control efforts and consequently reduce costs of implementation. In Malawi, there exists a knowledge gap in anopheline larval ecology and, therefore, basis for targeted deployment of larval source management (LSM) for malaria control, specifically larvicides. We set out to characterize anopheline larval habitats in the Majete area of Malawi on the basis of habitat ecology and anopheline larval productivity to create a basis for larval control initiatives in the country. Methods: Longitudinal surveys were conducted in randomly selected larval habitats over a period of fifteen months in Chikwawa district, southern Malawi. Biotic and abiotic parameters of the habitats were modelled to determine their effect on the occurrence and densities of anopheline larvae. Results: Seventy aquatic habitats were individually visited between 1-7 times over the study period. A total of 5,123 immature mosquitoes (3,359 anophelines, 1,497 culicines and 267 pupae) were collected. Anopheline and culicine larvae were observed in sympatry in aquatic habitats. Of the nine habitat types followed, dams, swamps, ponds, borehole runoffs and drainage channels were the five most productive habitat types for anopheline mosquitoes. Anopheline densities were higher in aquatic habitats with bare soil making up part of the surrounding land cover (p<0.01) and in aquatic habitats with culicine larvae (p<0.01) than in those surrounded by vegetation and not occupied by culicine larvae. Anopheline densities were significantly lower in highly turbid habitats than in clearer habitats (p<0.01). Presence of predators in the aquatic habitats significantly reduced the probability of anopheline larvae being present (p=0.04). Conclusions: Anopheline larval habitats are widespread in the study area. Presence of bare soil, culicine larvae, predators and the level of turbidity of water are the main determinants of anopheline larval densities in aquatic habitats in Majete, Malawi. While the most productive aquatic habitats should be prioritised, for the most effective control of vectors in the area all available aquatic habitats should be targeted, even those that are not characterized by the identified predictors. Further research is needed to determine whether targeted LSM would be cost-effective when habitat characterisation is included in cost analyses and to establish what methods would make the characterisation of habitats easier

Effects of larval exposure to sublethal doses of Bacillus thuringiensis var. israelensis on body size, oviposition and survival of adult Anopheles coluzzii mosquitoes

Background: Application of the larvicide Bacillus thuringiensis var. israelensis (Bti) is a viable complementary strategy for malaria control. Efficacy of Bti is dose-dependent. There is a knowledge gap on the effects of larval exposure to sublethal Bti doses on emerging adult mosquitoes. The present study examined the effect of larval exposure to sublethal doses of Bti on the survival, body size and oviposition rate in adult Anopheles coluzzii. Methods: Third-instar An. coluzzii larvae were exposed to control and sublethal Bti concentrations at LC20, LC50 and LC70 for 48 h. Surviving larvae were reared to adults under standard colony conditions. Thirty randomly selected females from each treatment were placed in separate cages and allowed to blood feed. Twenty-five gravid females from the blood-feeding cages were randomly selected and transferred into new cages where they were provided with oviposition cups. Numbers of eggs laid in each cage and mortality of all adult mosquitoes were recorded daily. Wing lengths were measured of 570 mosquitoes as a proxy for body size. Results: Exposure to LC70 Bti doses for 48 h as third-instar larvae reduced longevity of adult An. coluzzii mosquitoes. Time to death was 2.58 times shorter in females exposed to LC70 Bti when compared to the control females. Estimated mortality hazard rates were also higher in females exposed to the LC50 and LC20 treatments, but these differences were not statistically significant. The females exposed to LC70 concentrations had 12% longer wings than the control group (P < 0.01). No differences in oviposition rate of the gravid females were observed between the treatments. Conclusions: Exposure of An. coluzzii larvae to sublethal Bti doses reduces longevity of resultant adults and is associated with larger adult size and unclear effect on oviposition. These findings suggest that anopheline larval exposure to sublethal Bti doses, though not recommended, could reduce vectorial capacity for malaria vector populations by increasing mortality of resultant adults.[Figure not available: See fulltext.]</p

Community-based malaria control in southern Malawi : A description of experimental interventions of community workshops, house improvement and larval source management

Background: Increased engagement of communities has been emphasized in global plans for malaria control and elimination. Three interventions to reinforce and complement national malaria control recommendations were developed and applied within the context of a broad-based development initiative, targeting a rural population surrounding a wildlife reserve. The interventions, which were part of a 2-year research trial, and assigned to the village level, were implemented through trained local volunteers, or 'health animators', who educated the community and facilitated collective action. Results: Community workshops on malaria were designed to increase uptake of national recommendations; a manual was developed, and training of health animators conducted, with educational content and analytical tools for a series of fortnightly community workshops in annual cycles at village level. The roll-back malaria principle of diagnosis, treatment and use of long-lasting insecticidal nets was a central component of the workshops. Structural house improvement to reduce entry of malaria vectors consisted of targeted activities in selected villages to mobilize the community into voluntarily closing the eaves and screening the windows of their houses; the project provided wire mesh for screening. Corrective measures were introduced to respond to field challenges. Committees were established at village level to coordinate the house improvement activities. Larval source management (LSM) in selected villages consisted of two parts: one on removal of standing water bodies by the community at large; and one on larviciding with bacterial insecticide Bacillus thuringiensis israelensis by trained village committees. Community workshops on malaria were implemented as 'core intervention' in all villages. House improvement and LSM were implemented in addition to community workshops on malaria in selected villages. Conclusions: Three novel interventions for community mobilization on malaria prevention and control were described. The interventions comprised local organizational structure, education and collective action, and incorporated elements of problem identification, planning and evaluation. These methods could be applicable to other countries and settings.</p

Community Participation in Habitat Management and Larviciding for the Control of Malaria Vectors in Southern Malawi

Larval source management (LSM) could reduce malaria transmission when executed alongside core vector control strategies. Involving communities in LSM could increase intervention coverage, reduce operational costs, and promote sustainability via community buy-in. We assessed the effectiveness of community-led LSM to reduce anopheline larval densities in 26 villages along the perimeter of Majete Wildlife Reserve in southern Malawi. The communities formed LSM committees which coordinated LSM activities in their villages following specialized training. Effectiveness of larviciding by LSM committees was assessed via pre- and post-spray larval sampling. The effect of community-led LSM on anopheline larval densities in intervention villages was assessed via comparisons with densities in non-LSM villages over a period of 14 months. Surveys involving 502 respondents were undertaken in intervention villages to explore community motivation and participation, and factors influencing these outcomes. Larviciding by LSM committees reduced anopheline larval densities in post-spray sampling compared with pre-spray sampling (P < 0.0001). No differences were observed between anopheline larval densities during pre-spray sampling in LSM villages and those in non-LSM villages (P = 0.282). Knowledge about vector biology and control, and someone’s role in LSM motivated community participation in the vector control program. Despite reducing anopheline larval densities in LSM villages, the impact of the community-led LSM could not be detected in our study setting because of low mosquito densities after scale-up of core malaria control interventions. Still, the contributions of the intervention in increasing a community’s knowledge of malaria, its risk factors, and its control methods highlight potential benefits of the approach

Identifying Plasmodium falciparum transmission patterns through parasite prevalence and entomological inoculation rate

Background: Monitoring malaria transmission is a critical component of efforts to achieve targets for elimination and eradication. Two commonly monitored metrics of transmission intensity are parasite prevalence (PR) and the entomological inoculation rate (EIR). Comparing the spatial and temporal variations in the PR and EIR of a given geographical region and modelling the relationship between the two metrics may provide a fuller picture of the malaria epidemiology of the region to inform control activities. Methods: Using geostatistical methods, we compare the spatial and temporal patterns of Plasmodium falciparum EIR and PR using data collected over 38 months in a rural area of Malawi. We then quantify the relationship between EIR and PR by using empirical and mechanistic statistical models. Results: Hotspots identified through the EIR and PR partly overlapped during high transmission seasons but not during low transmission seasons. The estimated relationship showed a 1-month delayed effect of EIR on PR such that at lower levels of EIR, increases in EIR are associated with rapid rise in PR, whereas at higher levels of EIR, changes in EIR do not translate into notable changes in PR. Conclusions: Our study emphasises the need for integrated malaria control strategies that combine vector and human host managements monitored by both entomological and parasitaemia indices