Malaria Control and Elimination in Sri Lanka: Documenting Progress and Success Factors in a Conflict Setting

<div><h3>Background</h3><p>Sri Lanka has a long history of malaria control, and over the past decade has had dramatic declines in cases amid a national conflict. A case study of Sri Lanka's malaria programme was conducted to characterize the programme and explain recent progress.</p> <h3>Methods</h3><p>The case study employed qualitative and quantitative methods. Data were collected from published and grey literature, district-level and national records, and thirty-three key informant interviews. Expenditures in two districts for two years – 2004 and 2009 – were compiled.</p> <h3>Findings</h3><p>Malaria incidence in Sri Lanka has declined by 99.9% since 1999. During this time, there were increases in the proportion of malaria infections due to <em>Plasmodium vivax</em>, and the proportion of infections occurring in adult males. Indoor residual spraying and distribution of long-lasting insecticide-treated nets have likely contributed to the low transmission. Entomological surveillance was maintained. A strong passive case detection system captures infections and active case detection was introduced. When comparing conflict and non-conflict districts, vector control and surveillance measures were maintained in conflict areas, often with higher coverage reported in conflict districts. One of two districts in the study reported a 48% decline in malaria programme expenditure per person at risk from 2004 to 2009. The other district had stable malaria spending.</p> <h3>Conclusions/Significance</h3><p>Malaria is now at low levels in Sri Lanka – 124 indigenous cases were found in 2011. The majority of infections occur in adult males and are due to <em>P. vivax</em>. Evidence-driven policy and an ability to adapt to new circumstances contributed to this decline. Malaria interventions were maintained in the conflict districts despite an ongoing war. Sri Lanka has set a goal of eliminating malaria by the end of 2014. Early identification and treatment of infections, especially imported ones, together with effective surveillance and response, will be critical to achieving this goal.</p> </div

Decision Tree Model for Second-Line Ipilimumab: See format and conventions described in <b>Figure 1</b>.

<p>Decision Tree Model for Second-Line Ipilimumab: See format and conventions described in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0107255#pone-0107255-g001" target="_blank"><b>Figure 1</b></a>.</p

Yield of community-based tuberculosis targeted testing and treatment in foreign-born populations in the United States: A systematic review

<div><p>Objective</p><p>To synthesize outputs and outcomes of community-based tuberculosis targeted testing and treatment (TTT) programs in foreign-born populations (FBP) in the United States (US).</p><p>Methods</p><p>We systematically searched five bibliographic databases and other key resources. Two reviewers independently applied eligibility criteria to screen citations and extracted data from included studies. We excluded studies that contained <50% FBP participants or that examined steps only after diagnosis of latent TB infection (LTBI). We stratified studies as majority FBP (50–90%) and predominantly FBP (>90%). We used random-effects meta-analytic models to calculate pooled proportions and 95% confidence intervals (CI) for community-based TTT cascade steps (e.g., recruited, tested and treated), and used them to create two hypothetical cascades for 100 individuals.</p><p>Results</p><p>Fifteen studies conducted in 10 US states met inclusion criteria. Studies were heterogeneous in recruitment strategies and mostly recruited participants born in Latin America. Of 100 hypothetical participants (predominantly FBP) reached by community-based TTT, 40.4 (95% CI 28.6 to 50.1) would have valid test results, 15.7 (95% CI 9.9 to 21.8) would test positive, and 3.6 (95% CI 1.4 to 6.0) would complete LTBI treatment. Likewise, of 100 hypothetical participants (majority FBP) reached, 77.9 (95% CI 54.0 to 92.1) would have valid test results, 26.5 (95% CI 18.0 to 33.5) would test positive, and 5.4 (95% CI 2.1 to 9.0) would complete LTBI treatment. Of those with valid test results, pooled proportions of LTBI test positive for predominantly FBP and majority FBP were 38.9% (95% CI 28.6 to 49.8) and 34.3% (95% CI 29.3 to 39.5), respectively.</p><p>Conclusions</p><p>We observed high attrition throughout the care cascade in FBP participating in LTBI community-based TTT studies. Few studies included cascade steps prior to LTBI diagnosis, limiting our review findings. Moreover, Asia-born populations in the US are substantially underrepresented in the FBP community-based TTT literature.</p></div

Map of Annual Parasite Incidence (API) (confirmed infections/1,000 population at risk) by district, 2000, 2005, and 2010.

<p>API per 1,000/population at risk. The costing analysis was conducted in Anuradhapura and Kurunegala districts. Key informant interviews were conducted with representatives from Ampara, Anuradhapura, and Kurunegala districts. The Malaria Atlas Project (MAP) and the Sri Lanka Ministry of Health provided the base district-level map of Sri Lanka. MAP is committed to disseminating information on malaria risk, in partnership with malaria endemic countries, to guide malaria control and elimination globally.</p

Malaria transmission factors in Sri Lanka.

<p>Malaria transmission factors in Sri Lanka.</p

Cost-Effectiveness of Treatment Strategies for <i>BRAF - Table 1 </i>-Mutated Metastatic Melanoma

<p>Source numbers reflect the corresponding citation in the references section of this article. A source of “UCSF” refers to data from the UCSF Medicare reimbursement rates for cost inputs, and consensus among clinicians at the UCSF melanoma center for clinical inputs.</p><p>Cost-Effectiveness of Treatment Strategies for <i>BRAF - Table 1 </i>-Mutated Metastatic Melanoma</p

Decision Tree Model: The decision tree model used to estimate outcomes for the first year following treatment initiation.

<p>The decision nodes list the strategies modeled and the chance nodes list the probabilities of different clinical events during the first year. The path probability is the chance a patient will follow each specific path. The QALY and cost numbers in the “for terminal nodes” column is the average values over the course of a year for each patient taking that path, and the “intermediate product” column shows those individual averages adjusted for the proportion of people taking that path. Beneath these columns is the summation of the columns, representing to average costs and QALYs associated with the strategy. Beneath these averages in the second and third strategies are the differences and ICERs comparing each strategy to the strategy directly above it.</p

Total confirmed infections from Active and Passive Case Detection, Sri Lanka, 1995 to 2011.

<p>Total confirmed infections from Active and Passive Case Detection, Sri Lanka, 1995 to 2011.</p

Costs per person at risk in 2004 and 2009 by intervention category, in $USD, two districts.

<p>Costs per person at risk in 2004 and 2009 by intervention category, in $USD, two districts.</p

PRISMA flowchart depicting screening process.

<p>PRISMA flowchart depicting screening process.</p