Access to prompt and effective malaria treatment in the Kilombero Valley, Tanzania

Malaria is the most important parasitic infection in humans, causing an estimated one million deaths annually. Most cases occur in young children in sub-Saharan Africa, supporting the vicious circle of disease and poverty. Current control strategies have so far failed to reduce the disease in most parts of sub-Saharan Africa. Insecticide-treated mosquito nets (ITN) are effective in preventing malaria episodes and efficacious drugs (such as artemisinin-based combination therapies or ACTs) exist to cure malaria. However, a major problem is the delivery of quality health services, including life-saving drugs, to the ones in need. A variety of inter-linked factors influences patients’ access to prompt and effective treatment. While growing resistance against commonly used antimalarials such as chloroquine or sulphadoxine-pyrimethamine (SP) is being addressed with the introduction of ACTs, obstacles to effective malaria treatment have been identified at the levels of the households (the demand side), the health system (the supply side), and in health policy. The present thesis aimed at contributing to a better understanding of factors influencing access to malaria treatment in a positive or a negative way. The insights gained should inform the development of targeted interventions to improve access to malaria treatment and help to develop a general access framework. The research was carried out as part of the ACCESS Programme, which aims to understand and improve access to effective malaria treatment in the districts of Kilombero and Ulanga, in south-eastern Tanzania. The ACCESS strategy is based on a set of integrated interventions, including (1) social marketing for improved care seeking at community level, (2) strengthening the quality of case-management in health facilities, and (3) strengthening the commercial drug retail sector. The interventions are accompanied by a comprehensive set of monitoring and evaluation activities. Quantitative, semi-quantitative and qualitative methods were used for data collection in the area of the local Demographic Surveillance System (DSS) and the nearby semi-urban centre of Ifakara. Between 2004 and 2006, community-based surveys were conducted to investigate treatment-seeking behaviour and estimate communityeffectiveness of malaria treatment. A shop census and mystery shoppers (simulated clients) were used to monitor drug availability and the performance of shopkeepers in the retail sector. The DSS served as sampling frame for the community-based studies and provided demographic indicators, including morbidity and mortality data. The investigation of treatment-seeking and illness perception revealed a better overlap of local and biomedical illness concepts than reported in earlier studies from the same area. This is likely to reflect the intensive social marketing and health education campaigns carried out during the past decade. Modern medicine was clearly preferred by most patients and 87.5% (95% CI 78.2-93.8) of the fever cases in children and 80.7% (68.1-90.0) in adults were treated with one of the recommended antimalarials (at the time SP, amodiaquine or quinine). However, an estimation of community-effectiveness revealed that only 22.5% (13.9-33.2) of the children and 10.5% (4.0-21.5) of the adults received prompt and appropriate antimalarial treatment, despite high health facility usage rates. Quality of case-management was not satisfactory and the exemption mechanism for under-fives was not functional. Consequently, the commercial drug retail sector played an important complementary role in the provision of malaria treatment. In order to increase treatment effectiveness and maintain the high efficacy of the recently introduced ACT, both treatment sources should be strengthened and their quality should be improved. The seasonal movement of families to distant farming sites did not increase the risk of family members contracting malaria. In the fields, 97.9% (95.2-100) of all people were protected with mosquito nets but since few households stocked antimalarials at home, treatment had to be sought from distant health facilities or drug stores. Of the episodes that happened in the fields, 88.2% (72.6-96.7) were finally treated with an antimalarial, indicating that households made a considerable effort to obtain malaria treatment. It appeared that during the farming season, difficulties to mobilize resources coupled with the long distance to treatment sources led to delays in treatment-seeking. In this context, a comprehensive approach should be considered to improve access to treatment while at the same time assuring rational use of medicines and protecting fragile livelihoods. Investigations in the retail sector found that antimalarial availability had decreased by almost 50% in commercial shops following the policy change from chloroquine to SP as first-line treatment in 2001. This decline was noted mainly in general shops, which were not tolerated any more to sell SP (while they could generally sell chloroquine prior to the policy-change). In 2004, five out of 25 studied villages with a total population of 13,506 (18%) had neither a health facility, nor a shop as source of malaria treatment. While there was no immediately apparent impact on overall antimalarial use, the decline may have disproportionately affected the poorest and most remote groups in the community. In the light of the policy change to ACT these issues need to be addressed urgently if the benefits of these efficacious drugs are to be extended to the whole population. The assessment of shop keepers knowledge and behaviour revealed that drug store keepers had better knowledge of malaria and its treatment than their peers in general shops. In drug stores, mystery shoppers were more likely to receive an appropriate treatment (OR=9.6, 95% CI 1.5-60.5), even though at a higher price. As a distribution channel for ACTs, complementary to health facilities, upgraded drug stores may be the most realistic option. However, shopkeepers in drug stores need to be trained on the provision of correct malaria treatment. At the same time, the role of general shops as first contact points for malaria patients needs to be re-considered. Taking the importance of shops into account, interventions to increase the availability of ACTs in the retail sector are urgently required within the existing legal framework. The insights gained in the ACCESS studies helped to design a generic access framework embedded into the context of livelihood insecurity. This framework links social science and public health research with broader approaches to poverty alleviation. Apart from offering an analytical frame for further scientific research, it suggests access policies and interventions that reach beyond health services. In conclusion, the findings of this thesis underline the need for a comprehensive approach to analyze and improve access to treatment. In this setting, health systems factors appear to be major obstacles to treatment, while local disease perceptions did not appear to have a big influence on treatment access. There is an urgent need to improve quality of care at all levels and new avenues have to be explored to achieve equitable coverage with essential health interventions. Health policies need to be formulated and implemented in a way that they effectively improve the quality of services for all population groups. Considering the close link of disease and poverty, any health intervention is unlikely to succeed without taking the demand side into consideration. A comprehensive approach should therefore not only include measures that enable patients to access providers of good quality care, but also contribute to the strengthening of household economies. In order to achieve a decline in malaria morbidity and mortality in Africa, a concerted effort of all stakeholders is required to translate efficacious tools into effective, equitable and sustainable interventions

Height Change Feature Based Free Space Detection

In the context of autonomous forklifts, ensuring non-collision during travel, pick, and place operations is crucial. To accomplish this, the forklift must be able to detect and locate areas of free space and potential obstacles in its environment. However, this is particularly challenging in highly dynamic environments, such as factory sites and production halls, due to numerous industrial trucks and workers moving throughout the area. In this paper, we present a novel method for free space detection, which consists of the following steps. We introduce a novel technique for surface normal estimation relying on spherical projected LiDAR data. Subsequently, we employ the estimated surface normals to detect free space. The presented method is a heuristic approach that does not require labeling and can ensure real-time application due to high processing speed. The effectiveness of the proposed method is demonstrated through its application to a real-world dataset obtained on a factory site both indoors and outdoors, and its evaluation on the Semantic KITTI dataset [2]. We achieved a mean Intersection over Union (mIoU) score of 50.90 % on the benchmark dataset, with a processing speed of 105 Hz. In addition, we evaluated our approach on our factory site dataset. Our method achieved a mIoU score of 63.30 % at 54 H

Health Worker Compliance with a 'Test And Treat' Malaria Case Management Protocol in Papua New Guinea

The Papua New Guinea (PNG) Department of Health introduced a 'test and treat' malaria case management protocol in 2011. This study assesses health worker compliance with the test and treat protocol on a wide range of measures, examines self-reported barriers to health worker compliance as well as health worker attitudes towards the test and treat protocol. Data were collected by cross-sectional survey conducted in randomly selected primary health care facilities in 2012 and repeated in 2014. The combined survey data included passive observation of current or recently febrile patients (N = 771) and interviewer administered questionnaires completed with health workers (N = 265). Across the two surveys, 77.6% of patients were tested for malaria infection by rapid diagnostic test (RDT) or microscopy, 65.6% of confirmed malaria cases were prescribed the correct antimalarials and 15.3% of febrile patients who tested negative for malaria infection were incorrectly prescribed an antimalarial. Overall compliance with a strictly defined test and treat protocol was 62.8%. A reluctance to test current/recently febrile patients for malaria infection by RDT or microscopy in the absence of acute malaria symptoms, reserving recommended antimalarials for confirmed malaria cases only and choosing to clinically diagnose a malaria infection, despite a negative RDT result were the most frequently reported barriers to protocol compliance. Attitudinal support for the test and treat protocol, as assessed by a nine-item measure, improved across time. In conclusion, health worker compliance with the full test and treat malaria protocol requires improvement in PNG and additional health worker support will likely be required to achieve this. The broader evidence base would suggest any such support should be delivered over a longer period of time, be multi-dimensional and multi-modal

Assessing the impact of malaria interventions on morbidity through a community-based surveillance system

Background The ACCESS Programme aims at understanding and improving access to prompt and effective malaria treatment in rural Tanzania with a set of integrated interventions targeting both users and providers. The aim of this article is to evaluate the programme's impact on the community and health facility burden of malaria and to investigate the value of community-based reporting for routine malaria control programme monitoring. Methods This work was implemented within the Ifakara Demographic Surveillance System (DSS) between 2004 and 2008. At community level the DSS staff routinely collected data on reported history of fever and severe malaria (convulsions) based on a 2-week recall. In parallel, we collected in-patient and out-patient fever and malaria diagnoses data from the 15 health facilities in the area. Treatment-seeking surveys conducted in the study area and nationally representative data were used to validate our measure of community fever. Results Between 2005 and 2008, community-reported fever incidence rates in children under the age of 5 years declined by 34%, from 4.9 to 3.2 average cases per child per year, whereas convulsions, a marker of severe malaria morbidity in children, decreased by 46%, from 4263 to 2320 cases for every 100 000 children per year. The decrease in the community rates was paralleled by a decrease in the health facility fever rates, although the number of fever cases seen in health facilities did not change because of population growth. Our data showed very good internal and external consistency with independent local and national surveys. Conclusions There is an evidence of a substantial decline in the community burden of malaria morbidity between 2005 and 2008 in the Kilombero and Ulanga DSS areas in Tanzania, most likely as a result of malaria control efforts. The good internal and external consistency of the data shows that history of fever in the previous 2 weeks in children under the age of 5 years can be used as a morbidity monitoring too

Acceptability – a neglected dimension of access to health care : findings from a study on childhood convulsions in rural Tanzania

ABSTRACT: BACKGROUND: Acceptability is a poorly conceptualized dimension of access to health care. Using a study on childhood convulsion in rural Tanzania, we examined social acceptability from a user perspective. The study design is based on the premise that a match between health providers' and clients' understanding of disease is an important dimension of social acceptability, especially in trans-cultural communication, for example if childhood convulsions are not linked with malaria and local treatment practices are mostly preferred. The study was linked to health interventions with the objective of bridging the gap between local and biomedical understanding of convulsions. METHODS: The study combined classical ethnography with the cultural epidemiology approach using EMIC (Explanatory Model Interview Catalogue) tool. EMIC interviews were conducted in a 2007/08 convulsion study (n = 88) and results were compared with those of an earlier 2004/06 convulsion study (n = 135). Earlier studies on convulsion in the area were also examined to explore longer-term changes in treatment practices. RESULTS: The match between local and biomedical understanding of convulsions was already high in the 2004/06 study. Specific improvements were noted in form of (1) 46% point increase among those who reported use of mosquito nets to prevent convulsion (2) 13% point decrease among caregivers who associated convulsion with 'evil eye and sorcery', 3) 14% point increase in prompt use of health facility and 4)16% point decrease among those who did not use health facility at all. Such changes can be partly attributed to interventions which explicitly aimed at increasing the match between local and biomedical understanding of malaria. Caregivers, mostly mothers, did not seek advice on where to take an ill child. This indicates that treatment at health facility has become socially acceptable for severe febrile with convulsion. CONCLUSION: As an important dimension of access to health care 'social acceptability' seems relevant in studying illnesses that are perceived not to belong to the biomedical field, specifically in trans-cultural societies. Understanding the match between local and biomedical understanding of disease is fundamental to ensure acceptability of health care services, successful control and management of health problems. Our study noted some positive changes in community knowledge and management of convulsion episodes, changes which might be accredited to extensive health education campaigns in the study area. On the other hand it is difficult to make inference out of the findings as a result of small sample size involved. In return, it is clear that well ingrained traditional beliefs can be modified with communication campaigns, provided that this change resonates with the beneficiaries

Long-term acceptability, durability and bio-efficacy of ZeroVector(®) durable lining for vector control in Papua New Guinea

This study examined the acceptability, durability and bio-efficacy of pyrethroid-impregnated durable lining (DL) over a three-year period post-installation in residential homes across Papua New Guinea (PNG).; ZeroVector(®) ITPS had previously been installed in 40 homes across four study sites representing a cross section of malaria transmission risk and housing style. Structured questionnaires, DL visual inspections and group interviews (GIs) were completed with household heads at 12- and 36-months post-installation. Three DL samples were collected from all households in which it remained 36-months post-installation to evaluate the bio-efficacy of DL on Anopheles mosquitoes. Bio-efficacy testing followed WHO guidelines for the evaluation of indoor residual spraying.; The DL was still intact in 86 and 39% of study homes at the two time periods, respectively. In homes in which the DL was still intact, 92% of household heads considered the appearance at 12-months post installation to be the same as, or better than, that at installation compared to 59% at 36-months post-installation. GIs at both time points confirmed continuing high acceptance of DL, based in large part of the perceived attractiveness and functionality of the material. However, participants frequently asserted that they, or their family members, had ceased or reduced their use of mosquito nets as a result of the DL installation. A total of 16 houses were sampled for bio-efficacy testing across the 4 study sites at 36-months post-installation. Overall, combining all sites and samples, both knock-down at 30 min and mortality at 24 h were 100%.; The ZeroVector(®) DL installation remained highly acceptable at 36-months post-installation, the material and fixtures proved durable and the efficacy against malaria vectors did not decrease. However, the DL material had been removed from over 50% of the original study homes 3 years post-installation, largely due to deteriorating housing infrastructure. Furthermore, the presence of the DL installation appeared to reduce ITN use among many participating householders. The study findings suggest DL may not be an appropriate vector control method for large-scale use in the contemporary PNG malaria control programme

Changes in malaria burden and transmission in sentinel sites after the roll-out of long-lasting insecticidal nets in Papua New Guinea

Papua New Guinea exhibits a complex malaria epidemiology due to diversity in malaria parasites, mosquito vectors, human hosts, and their natural environment. Heterogeneities in transmission and burden of malaria at various scales are likely to affect the success of malaria control interventions, and vice-versa. This manuscript assesses changes in malaria prevalence, incidence and transmission in sentinel sites following the first national distribution of long-lasting insecticidal nets (LLINs).; Before and after the distribution of LLINs, data collection in six purposively selected sentinel sites included clinical surveillance in the local health facility, household surveys and entomological surveys. Not all activities were carried out in all sites. Mosquitoes were collected by human landing catches. Diagnosis of malaria infection in humans was done by rapid diagnostic test, light microscopy and PCR for species confirmation.; Following the roll-out of LLINs, the average monthly malaria incidence rate dropped from 13/1,000 population to 2/1,000 (incidence rate ratio = 0.12; 95 % CI: 0.09-0.17; P < 0.001). The average population prevalence of malaria decreased from 15.7 % pre-LLIN to 4.8 % post-LLIN (adjusted odds ratio = 0.26; 95 % CI: 0.20-0.33; P < 0.001). In general, reductions in incidence and prevalence were more pronounced in infections with P. falciparum than with P. vivax. Additional morbidity indicators (anaemia, splenomegaly, self-reported fever) showed a decreasing trend in most sites. Mean Anopheles man biting rates decreased from 83 bites/person/night pre-LLIN to 31 post-LLIN (P = 0.008). Anopheles species composition differed between sites but everywhere diversity was lower post-LLIN. In two sites, post-LLIN P. vivax infections in anophelines had decreased but P. falciparum infections had increased despite the opposite observation in humans.; LLIN distribution had distinct effects on P. falciparum and P. vivax. Higher resilience of P. vivax may be attributed to relapses from hypnozoites and other biological characteristics favouring the transmission of P. vivax. The effect on vector species composition varied by location which is likely to impact on the effectiveness of LLINs. In-depth and longer-term epidemiological and entomological investigations are required to understand when and where residual transmission occurs and whether observed changes are sustained

Mathematical modelling of the impact of expanding levels of malaria control interventions on Plasmodium vivax

Plasmodium vivax poses unique challenges for malaria control and elimination, notably the potential for relapses to maintain transmission in the face of drug-based treatment and vector control strategies. We developed an individual-based mathematical model of P. vivax transmission calibrated to epidemiological data from Papua New Guinea (PNG). In many settings in PNG, increasing bed net coverage is predicted to reduce transmission to less than 0.1% prevalence by light microscopy, however there is substantial risk of rebounds in transmission if interventions are removed prematurely. In several high transmission settings, model simulations predict that combinations of existing interventions are not sufficient to interrupt P. vivax transmission. This analysis highlights the potential options for the future of P. vivax control: maintaining existing public health gains by keeping transmission suppressed through indefinite distribution of interventions; or continued development of strategies based on existing and new interventions to push for further reduction and towards elimination

Access to Health Care in Contexts of Livelihood Insecurity: A Framework for Analysis and Action

The authors present a framework for analysis and action to explore and improve access to health care in resource-poor countries, especially in Africa

The impact of the scale-up of malaria rapid diagnostic tests on the routine clinical diagnosis procedures for febrile illness : a series of repeated cross-sectional studies in Papua New Guinea

This paper examines the impact of the scale-up of malaria rapid diagnostic tests (RDT) on routine clinical diagnosis procedures for febrile illness in primary healthcare settings in Papua New Guinea.; Repeat, cross-sectional surveys in randomly selected primary healthcare services were conducted. Surveys included passive observation of consecutive febrile case management cases and were completed immediately prior to RDT scale-up (2011) and at 12- (2012) and 60-months (2016) post scale-up. The frequency with which specified diagnostic questions and procedures were observed to occur, with corresponding 95% CIs, was calculated for febrile patients prescribed anti-malarials pre- and post-RDT scale-up and between febrile patients who tested either negative or positive for malaria infection by RDT (post scale-up only).; A total of 1809 observations from 120 health facilities were completed across the three survey periods of which 915 (51%) were prescribed an anti-malarial. The mean number of diagnostic questions and procedures asked or performed, leading to anti-malarial prescription, remained consistent pre- and post-RDT scale-up (range 7.4-7.7). However, alterations in diagnostic content were evident with the RDT replacing body temperature as the primary diagnostic procedure performed (observed in 5.3 and 84.4% of cases, respectively, in 2011 vs. 77.9 and 58.2% of cases in 2016). Verbal questioning, especially experience of fever, cough and duration of symptoms, remained the most common feature of a diagnostic examination leading to anti-malarial prescription irrespective of RDT use (observed in 96.1, 86.8 and 84.8% of cases, respectively, in 2011 vs. 97.5, 76.6 and 85.7% of cases in 2016). Diagnostic content did not vary substantially by RDT result.; Rapid diagnostic tests scale-up has led to a reduction in body temperature measurement. Investigations are very limited when malaria infection is ruled out as a cause of febrile illness by RDT