The relative roles of ANC and EPI in the continuous distribution of LLINs: a qualitative study in four countries.

Background: The continuous distribution of long-lasting insecticidal nets (LLINs) for malaria prevention, through the antenatal care (ANC) and the Expanded Programme on Immunizations (EPI), is recommended by the WHO to improve and maintain LLIN coverage. Despite these recommendations, little is known about the relative strengths and weaknesses of the ANC and EPI-based LLIN distribution. This study aimed to explore and compare the roles of the ANC and EPI for LLIN distribution in four African countries. Methods: In a qualitative evaluation of continuous distribution through the ANC and EPI, semi-structured, individual and group interviews were conducted in Kenya, Malawi, Mali, and Rwanda. Respondents included national, sub-national, and facility-level health staff, and were selected to capture a range of roles related to malaria, ANC and EPI programmes. Policies, guidelines, and data collection tools were reviewed as a means of triangulation to assess the structure of LLIN distribution, and the methods of data collection and reporting for malaria, ANC and EPI programmes. Results: In the four countries visited, distribution of LLINs was more effectively integrated through ANC than through EPI because of a) stronger linkages and involvement between malaria and reproductive health programmes, as compared to malaria and EPI, and b) more complete programme monitoring for ANC-based distribution, compared to EPI-based distribution. Conclusions: Opportunities for improving the distribution of LLINs through these channels exist, especially in the case of EPI. For both ANC and EPI, integrated distribution of LLINs has the potential to act as an incentive, improving the already strong coverage of both these essential services. The collection and reporting of data on LLINs distributed through the ANC and EPI can provide insight into the performance of LLIN distribution within these programmes. Greater attention to data collection and use, by both the global malaria community, and the integrated programmes, can improve this distribution channel strength and effectiveness

Monitoring of the Sensitivity In Vivo of Plasmodium falciparum to Artemether-Lumefantrine in Mali

International audienceIn Mali, since 2007, artemether-lumefantrine has been the first choice against uncomplicated malaria. Despite its effectiveness, a rapid selection of markers of resistance to partner drugs has been documented. This work evaluated the treatment according to the World Health Organization's standard 28-day treatment method. The primary endpoint was the clinical and parasitological response corrected by a polymerase chain reaction. It was more than 99.9 percent, the proportion of patients with anemia significantly decrease compared to baseline (p < 0.001), and no serious events were recorded. Plasmodium falciparum remains sensitive to artemether-lumefantrine in Mali

Impact evaluation of malaria control interventions on morbidity and all-cause child mortality in Mali, 2000–2012

Abstract Background Major investments have been made since 2001, with intensification of malaria control interventions after 2006. Interventions included free distribution of insecticide-treated nets (ITN) to pregnant women and children under 5 years old, the introduction of artemisinin combination therapy (ACT) for malaria treatment, and indoor residual spraying of insecticides. Funders include the Government of Mali, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the US President’s Malaria Initiative. Methods Data from nationally representative household surveys conducted from 2000 to 2015 was used to performed the trend analysis for malaria intervention coverage, prevalence of morbidities among children under 5 years old [parasitemia and severe anaemia (< 8 g/dl)], and all-cause mortality of children under 5 (ACCM). Prevalence of contextual factors likely to contribute to ACCM were also assessed. The impact of these interventions was assessed on malaria morbidity and mortality using a plausibility argument. With the assumption that malaria contributes significantly to under-five mortality in settings with high malaria transmission, associations between malaria control interventions and all-cause under-five mortality (ACCM) were assessed taking into account other contextual factors related to child survival. Results Intervention coverage improved significantly from 2006 to 2012. Household ownership of ITN increased from 49% in 2006 to 84% in 2012. ITN use also increased over the same period, from 26% in 2006 to 69% in 2012 among children under 5 and from 28% in 2006 to 73% in 2012 among pregnant women. The coverage of intermittent preventive treatment in pregnancy (IPTp) using two or more doses of SP increased from 10% in 2006 to 29% in 2012. In 2010, 23% of febrile children under 5 received ACT, as opposed to 19% in 2012. The prevalence of Plasmodium falciparum infection increased from 2010 (38.6%) to 2012 (51.6%), followed by a decrease in 2015 (35.8%). The prevalence of severe anaemia decreased from 2010 (26.3%) to 2012 (20.6%) and continued to decline in 2015 (19.9%). An impressive decline in ACCM was observed, from 225 in 1997–2001 to 192 in 2002–2006 and 95 in 2008–2012. Changes in contextual factors such as climate, socio-economic, nutrition, and coverage of maternal and child health interventions over the evaluation period did not favour reductions in ACCM, and are therefore unlikely to explain the observed results. Conclusions Taken as a whole, the evidence supports the conclusion that malaria control interventions substantially contributed to the observed decline in ACCM in Mali from 2000 to 2012, even in the context of continued high prevalence of parasitaemia explained by contextual factors such as climate change and political instability

Measuring malaria diagnosis and treatment coverage in population-based surveys: a recall validation study in Mali among caregivers of febrile children under 5 years

Abstract Background Nationally-representative household surveys are the standard approach to monitor access to and treatment with artemisinin-based combination therapy (ACT) among children under 5 years (U5), however these indicators are dependent on caregivers’ recall of the treatment received. Methods A prospective case–control study was performed in Mali to validate caregivers’ recall of treatment received by U5s when seeking care for fever from rural and urban public health facilities, community health workers and urban private facilities. Clinician-recorded consultation details were the gold standard. Consenting caregivers were followed-up for interview at home within 2 weeks using standard questions from Demographic and Health Surveys and Malaria Indicator Surveys. Results Among 1602 caregivers, sensitivity of recalling that the child received a finger/heel prick was 91.5%, with specificity 85.7%. Caregivers’ recall of a positive malaria test result had sensitivity 96.2% with specificity 59.7%. Irrespective of diagnostic test result, the sensitivity and specificity of caregivers’ recalling a malaria diagnosis made by the health worker were 74.3% and 74.9%, respectively. Caregivers’ recall of ACT being given had sensitivity of 43.2% and specificity 90.2%, while recall that any anti-malarial was given had sensitivity 59.0% and specificity 82.7%. Correcting caregivers’ response of treatment received using a combination of a visual aid with photographs of common drugs for fever, prescription documents and retained packaging changed ACT recall sensitivity and specificity to 91.5% and 71.1%, respectively. Conclusions These findings indicate that caregivers’ responses during household surveys are valid when assessing if a child received a finger/heel prick during a consultation in the previous 2 weeks, and if the malaria test result was positive. Recall of ACT treatment received by U5s was poor when based on interview response only, but was substantially improved when incorporating visual aids, prescriptions and drug packaging review

Operational challenges to continuous LLIN distribution: a qualitative rapid assessment in four countries

Guides developed to support semi-structured interviews performed as part of an assessment of distribution of long-lasting insecticidal nets (LLINs) in Kenya, Malawi, Mali, and Rwanda