Costs and effects of two public sector delivery channels for long-lasting insecticidal nets in Uganda.

BACKGROUND: In Uganda, long-lasting insecticidal nets (LLIN) have been predominantly delivered through two public sector channels: targeted campaigns or routine antenatal care (ANC) services. Their combination in a mixed-model strategy is being advocated to quickly increase LLIN coverage and maintain it over time, but there is little evidence on the efficiency of each system. This study evaluated the two delivery channels regarding LLIN retention and use, and estimated the associated costs, to contribute towards the evidence-base on LLIN delivery channels in Uganda. METHODS: Household surveys were conducted 5-7 months after LLIN distribution, combining questionnaires with visual verification of LLIN presence. Focus groups and interviews were conducted to further investigate determinants of LLIN retention and use. Campaign distribution was evaluated in Jinja and Adjumani while ANC distribution was evaluated only in the latter district. Costs were calculated from the provider perspective through retrospective analysis of expenditure data, and effects were estimated as cost per LLIN delivered and cost per treated-net-year (TNY). These effects were calculated for the total number of LLINs delivered and for those retained and used. RESULTS: After 5-7 months, over 90% of LLINs were still owned by recipients, and between 74% (Jinja) and 99% (ANC Adjumani) were being used. Costing results showed that delivery was cheapest for the campaign in Jinja and highest for the ANC channel, with economic delivery cost per net retained and used of USD 1.10 and USD 2.31, respectively. Financial delivery costs for the two channels were similar in the same location, USD 1.04 for campaign or USD 1.07 for ANC delivery in Adjumani, but differed between locations (USD 0.67 for campaign delivery in Jinja). Economic cost for ANC distribution were considerably higher (USD 2.27) compared to campaign costs (USD 1.23) in Adjumani. CONCLUSIONS: Targeted campaigns and routine ANC services can both achieve high LLIN retention and use among the target population. The comparatively higher economic cost of delivery through ANC facilities was at least partially due to the relatively short time this system had been in existence. Further studies comparing the cost of well-established ANC delivery with LLIN campaigns and other delivery channels are thus encouraged

Epidemic of Plasmodium falciparum Malaria Involving Substandard Antimalarial Drugs, Pakistan, 2003

To prevent future epidemics, enhanced quality assurance is essential

Defining Plasmodium falciparum Treatment in South West Asia: A Randomized Trial Comparing Artesunate or Primaquine Combined with Chloroquine or SP

INTRODUCTION: Antimalarial resistance has led to a global policy of artemisinin-based combination therapy. Despite growing resistance chloroquine (CQ) remained until recently the official first-line treatment for falciparum malaria in Pakistan, with sulfadoxine-pyrimethamine (SP) second-line. Co-treatment with the gametocytocidal primaquine (PQ) is recommended for transmission control in South Asia. The relative effect of artesunate (AS) or primaquine, as partner drugs, on clinical outcomes and gametocyte carriage in this setting were unknown. METHODS: A single-blinded, randomized trial among Afghan refugees in Pakistan compared six treatment arms: CQ; CQ+(single-dose)PQ; CQ+(3 d)AS; SP; SP+(single-dose)PQ, and SP+(3 d)AS. The objectives were to compare treatment failure rates and effect on gametocyte carriage, of CQ or SP monotherapy against the respective combinations (PQ or AS). Outcomes included trophozoite and gametocyte clearance (read by light microscopy), and clinical and parasitological failure. FINDINGS: A total of 308 (87%) patients completed the trial. Failure rates by day 28 were: CQ 55/68 (81%); CQ+AS 19/67 (28%), SP 4/41 (9.8%), SP+AS 1/41 (2.4%). The addition of PQ to CQ or SP did not affect failure rates (CQ+PQ 49/67 (73%) failed; SP+PQ 5/33 (16%) failed). AS was superior to PQ at clearing gametocytes; gametocytes were seen on d7 in 85% of CQ, 40% of CQ+PQ, 21% of CQ+AS, 91% of SP, 76% of SP+PQ and 23% of SP+AS treated patients. PQ was more effective at clearing older gametocyte infections whereas AS was more effective at preventing emergence of mature gametocytes, except in cases that recrudesced. CONCLUSIONS: CQ is no longer appropriate by itself or in combination. These findings influenced the replacement of CQ with SP+AS for first-line treatment of uncomplicated falciparum malaria in the WHO Eastern Mediterranean Region. The threat of SP resistance remains as SP monotherapy is still common. Three day AS was superior to single-dose PQ for reducing gametocyte carriage. TRIAL REGISTRATION: ClinicalTrials.gov NCT00959517

Spatial epidemiology of Plasmodium vivax, Afghanistan.

Plasmodium vivax is endemic to many areas of Afghanistan. Geographic analysis helped highlight areas of malaria risk and clarified ecologic risk factors for transmission. Remote sensing enabled development of a risk map, thereby providing a valuable tool to help guide malaria control strategies

Malaria rapid diagnostic test performance: Results of WHO product testing of malaria RDTs: round 7 (2015-2016)

WHO estimates that 3.2 billion people are at risk for malaria. In 2015, there were an estimated 212 million new cases (with an uncertainty range of 148 million to 304 million) and an estimated 429 000 deaths (with an uncertainty range of 235 000 to 639 000). Approximately 90% of these deaths occurred in sub-Saharan Africa and just over 70% were of children under 5 years. Malaria remains endemic in 91 countries and territories and while parasite-based diagnosis is increasing, national surveys between 2013 and 2015 suggest approximately 31% of suspected malaria cases in sub-Saharan Africa were not confirmed with a diagnostic test, resulting in over-use of antimalarial drugs and poor disease monitoring (1). WHO recommends that malaria case management be based on parasite diagnosis in all cases (2). The use of antigendetecting rapid diagnostic tests (RDTs) is a vital part of this strategy, forming the basis for extending access to malaria diagnosis by providing parasite-based diagnosis in areas where good-quality microscopy cannot be maintained. The number of RDTs available and the scale of their use have increased rapidly over the past few years. However, limitations of field trials and the heterogeneous nature of malaria transmission have limited the availability of the good-quality data on performance that national malaria programmes require to make informed decisions on procurement and implementation, and it is difficult to extrapolate the results of field trials to different populations and times. Therefore, in 2006, the WHO Special Programme for Research and Training in Tropical Diseases (TDR) and the Foundation for Innovative New Diagnostics (FIND) launched a programme to systematically evaluate and compare the performance of commercially available malaria RDTs. T he results of WHO’s malaria RDT product testing have been published annually since 2009 and form the basis of the procurement criteria of WHO, other United Nations agencies, the Global Fund to Fight AIDS, Tuberculosis and Malaria, national governments and non-governmental organizations. The data have guided procurement decisions, which, in turn, have shifted markets towards better-performing tests (1) and are driving overall improvements in the quality of manufacturing

Malaria control in Afghanistan: progress and challenges.

From the 1950s until 1979 malaria control in Afghanistan was implemented through a vertical programme managed by the government, but little of the original programme remained functional by the early 1990s. Delivery of basic health care including malaria diagnosis and treatment was done by non-governmental organisations (NGOs) and UN agencies, which organised cross-border operations from Pakistan and Iran and placed much less emphasis on vertical programming. From 1992 the situation in the east of Afghanistan became stable enough to allow the establishment of a network of NGO-supported clinics and to introduce standardised training and monitoring of microscopists and clinical staff, coordinated by a lead agency specialising in malaria. After the collapse of the Taliban in 2001 and the subsequent establishment of an interim government, the first steps in health-system rehabilitation have been taken. The gradual integration of malaria control into routine health-care delivery is planned. This process should be guided by the knowledge and experience gained during the complex emergency and a focus on malaria should be maintained until the disease is brought under control

Geometric mean gametocyte density (+CI) after treatment in chloroquine (A) and SP treatment arms (B).

<p>Note the different scales on the Y-axis. Where the CI bars are absent, only 1 patient had gametocytes.</p

Enrolment characteristics of the treatment groups.

<p>Notes: (1) PCV was not recorded for all patients; a microcentrifuge was only available at one of the 3 clinics. For PCV percentages in the 6 treatment groups: CQ n = 10; CQ+PQ n = 19; CQ+AS n = 13; SP n = 19; SP+PQ n = 15, SP+AS n = 15.</p