Risk factors for Anopheles mosquitoes in rural and urban areas of Blantyre District, southern Malawi

BackgroundAlthough urban malaria transmission is low and seasonal, it remains a major public health problem. This study aimed at demonstrating the presence of Anopheles mosquitoes and their potential to transmit malaria in urban settings.MethodsTwo cross-sectional surveys were carried out in Blantyre District, Malawi, during the dry and wet seasons of 2008 and 2010, respectively. A map of Blantyre was divided into a grid of 400 cells, of which 60 cells were randomly selected. Five households located within 100 m from the centre of each selected cell were enrolled, a standard questionnaire was administered, and indoor resting mosquitoes were sampled.ResultsIn 2008 and 2010, a total of 960 and 1045 mosquitoes were collected,  respectively. Anopheles funestus comprised 9.9% (n = 95) and 10.3% (n = 108) during the two surveys, respectively. Anopheles gambiae sensu lato (s.l.) was rarely detected during the second survey (n = 6; 0.6%). Molecular identification was performed on samples collected during the first survey, and An. funestus sensu stricto (s.s.) was the only sibling species detected. All the Anopheles mosquitoes were collected from households located in rural areas of Blantyre and none from urban areas. In univariate analysis, the presence of open eaves was associated with increased Anopheles prevalence, both during the dry (incidence rate ratio, IRR = 4.3; 95% CI 2.4 – 7.6) and wet (IRR = 2.47; 95% CI 1.7 – 3.59) seasons.  Chances of detecting Anopheles spp. decreased with increasing altitude (IRR = 0.996; 95% CI 0.995 – 0.997) and during the dry season, but increased during the wet season (IRR = 1.0017; 95% CI 1.0012 – 1.0023). These factors remained significant following a multiple Poisson regression analysis. No association was found between insecticide-treated bednet ownership and the number of Anopheles mosquitoes detected.ConclusionsThe presence of An. funestus s.s and An. gambiae s.l. in the periphery of Blantyre city was an indication that malaria transmission was potentially taking place in these areas

Patient-, health worker-, and health facility-level determinants of correct malaria case management at publicly funded health facilities in Malawi: results from a nationally representative health facility survey

BACKGROUND: Prompt and effective case management is needed to reduce malaria morbidity and mortality. However, malaria diagnosis and treatment is a multistep process that remains problematic in many settings, resulting in missed opportunities for effective treatment as well as overtreatment of patients without malaria. METHODS: Prior to the widespread roll-out of malaria rapid diagnostic tests (RDTs) in late 2011, a national, cross-sectional, complex-sample, health facility survey was conducted in Malawi to assess patient-, health worker-, and health facility-level factors associated with malaria case management quality using multivariate Poisson regression models. RESULTS: Among the 2,019 patients surveyed, 34% had confirmed malaria defined as presence of fever and parasitaemia on a reference blood smear. Sixty-seven per cent of patients with confirmed malaria were correctly prescribed the first-line anti-malarial, with most cases of incorrect treatment due to missed diagnosis; 31% of patients without confirmed malaria were overtreated with an anti-malarial. More than one-quarter of patients were not assessed for fever or history of fever by health workers. The most important determinants of correct malaria case management were patient-level clinical symptoms, such as spontaneous complaint of fever to health workers, which increased both correct treatment and overtreatment by 72 and 210%, respectively (p < 0.0001). Complaint of cough was associated with a 27% decreased likelihood of correct malaria treatment (p = 0.001). Lower-level cadres of health workers were more likely to prescribe anti-malarials for patients, increasing the likelihood of both correct treatment and overtreatment, but no other health worker or health facility-level factors were significantly associated with case management quality. CONCLUSIONS: Introduction of RDTs holds potential to improve malaria case management in Malawi, but health workers must systematically assess all patients for fever, and then test and treat accordingly, otherwise, malaria control programmes might miss an opportunity to dramatically improve malaria case management, despite better diagnostic tools

Impact of health facility-based insecticide treated bednet distribution in Malawi: progress and challenges towards achieving universal coverage.

High levels of insecticide treated bednet (ITN) use reduce malaria burden in countries with intense transmission such as Malawi. Since 2007 Malawi has implemented free health facility-based ITN distribution for pregnant women and children <5 years old (under-5s). We evaluated the progress of this targeted approach toward achieving universal ITN coverage.We conducted a cross-sectional household survey in eight districts in April 2009. We assessed household ITN possession, ITN use by all household members, and P. falciparum asexual parasitemia and anemia (hemoglobin <11 grams/deciliter) in under-5s.We surveyed 7,407 households containing 29,806 persons. Fifty-nine percent of all households (95% confidence interval [95% CI]: 56-62), 67% (95% CI: 64-70) of eligible households (i.e., households with pregnant women or under-5s), and 40% (95% CI: 36-45) of ineligible households owned an ITN. In households with at least one ITN, 76% (95% CI: 74-78) of all household members, 88% (95% CI: 87-90) of under-5s and 90% (95% CI: 85-94) of pregnant women used an ITN the previous night. Of 6,677 ITNs, 92% (95% CI: 90-94) were used the previous night with a mean of 2.4 persons sleeping under each ITN. In multivariable models adjusting for district, socioeconomic status and indoor residual spraying use, ITN use by under-5s was associated with a significant reduction in asexual parasitemia (adjusted odds ratio (aOR) 0.79; 95% CI: 0.64-0.98; p-value 0.03) and anemia (aOR 0.79; 95% CI 0.62-0.99; p-value 0.04). Of potential targeted and non-targeted mass distribution strategies, a campaign distributing 1 ITN per household might increase coverage to 2.1 household members per ITN, and thus achieve near universal coverage often defined as 2 household members per ITN.Malawi has substantially increased ITN coverage using health facility-based distribution targeting pregnant women and under-5s, but needs to supplement these activities with non-targeted mass distribution campaigns to achieve universal coverage and maximum public health impact

Quality of Malaria Case Management in Malawi: Results from a Nationally Representative Health Facility Survey

<div><p>Background</p><p>Malaria is endemic throughout Malawi, but little is known about quality of malaria case management at publicly-funded health facilities, which are the major source of care for febrile patients.</p><p>Methods</p><p>In April–May 2011, we conducted a nationwide, geographically-stratified health facility survey to assess the quality of outpatient malaria diagnosis and treatment. We enrolled patients presenting for care and conducted exit interviews and re-examinations, including reference blood smears. Moreover, we assessed health worker readiness (e.g., training, supervision) and health facility capacity (e.g. availability of diagnostics and antimalarials) to provide malaria case management. All analyses accounted for clustering and unequal selection probabilities. We also used survey weights to produce estimates of national caseloads.</p><p>Results</p><p>At the 107 facilities surveyed, most of the 136 health workers interviewed (83%) had received training on malaria case management. However, only 24% of facilities had functional microscopy, 15% lacked a thermometer, and 19% did not have the first-line artemisinin-based combination therapy (ACT), artemether-lumefantrine, in stock. Of 2,019 participating patients, 34% had clinical malaria (measured fever or self-reported history of fever plus a positive reference blood smear). Only 67% (95% confidence interval (CI): 59%, 76%) of patients with malaria were correctly prescribed an ACT, primarily due to missed malaria diagnosis. Among patients without clinical malaria, 31% (95% CI: 24%, 39%) were prescribed an ACT. By our estimates, 1.5 million of the 4.4 million malaria patients seen in public facilities annually did not receive correct treatment, and 2.7 million patients without clinical malaria were inappropriately given an ACT.</p><p>Conclusions</p><p>Malawi has a high burden of uncomplicated malaria but nearly one-third of all patients receive incorrect malaria treatment, including under- and over-treatment. To improve malaria case management, facilities must at minimum have basic case management tools, and health worker performance in diagnosing malaria must be improved.</p></div

Map of surveyed health facilities.

<p>Note: Each yellow dot represents one surveyed facility.</p

Factors associated with insecticide treated bednet (ITN) use by person who reside in households with at least one ITN in eight districts, Malawi, 2009 (N = 18,967).

a<p>95% confidence interval.</p

Estimated household insecticide treated bednet (ITN) possession using different campaign-based distribution strategies in eight districts, Malawi, 2009.

<p>Note: Based on total population of 4,339,876 persons in the eight surveyed districts according to the 2008 Malawi census.</p>a<p>Estimated number of ITNs currently in the eight surveyed districts.</p>b<p>Estimated 1.91 sleeping spaces per household in the eight surveyed districts.</p>c<p>In households with an odd number of household members, number of ITNs distributed is equal to number of household members divided by two plus one additional ITN (e.g. a household with 5 persons will receive 3 ITNs).</p

Malaria diagnosis and treatment among outpatients attending publically-funded health facilities in Malawi, 2011.

<p>*Includes positive responses for: 1) patient says illness involved a fever, 2) patient spontaneously mentioned fever complaint to health worker, 3) patient reported a symptom of fever to surveyor when probed, or temperature on re-examination was > = 37.5°C.</p><p>**If patient does not spontaneously report to health worker.</p>¶<p>Spontaneously reported by patient to health worker, reported by patient when prompted, or temperature ≥37.5°C according to health worker’s recorded temperature.</p>†<p>ACT refers to ACT (most patients) or oral quinine for pregnant women in their first trimester or patients weighing less than 5 kg.</p><p>Note: Numbers in parentheses are based on 25–49 unweighted cases.</p>∧<p>Chi-squared test with Rao-Scott correction unable to be performed to be performed due to stratum with single sampling unit.</p

Malaria and case management among outpatients attending publicly-funded health facilities in Malawi (N = 2019).

<p>Note: Percentages are weighted. * Includes 1 pregnant patient in her first trimester who received oral quinine (correct treatment).</p