Impact of a malaria intervention package in schools on Plasmodium infection, anaemia and cognitive function in schoolchildren in Mali: a pragmatic cluster-randomised trial.

BACKGROUND: School-aged children are rarely targeted by malaria control programmes, yet the prevalence of Plasmodium infection in primary school children often exceeds that seen in younger children and could affect haemoglobin concentration and school performance. METHODS: A cluster-randomised trial was carried out in 80 primary schools in southern Mali to evaluate the impact of a school-based malaria intervention package. Intervention schools received two interventions sequentially: (1) teacher-led participatory malaria prevention education, combined with distribution of long-lasting insecticidal nets (LLINs), followed 7 months later at the end of the transmission season by (2) mass delivery of artesunate and sulfadoxine-pyrimethamine administered by teachers, termed intermittent parasite clearance in schools (IPCs). Control schools received LLINs as part of the national universal net distribution programme. The impact of the interventions on malaria and anaemia was evaluated over 20 months using cross-sectional surveys in a random subset of 38 schools(all classes), with a range of cognitive measures (sustained attention, visual search, numeracy, vocabulary and writing) assessed in a longitudinal cohort of children aged 9-12 years in all 80 schools. RESULTS: Delivery of a single round of IPCs was associated with dramatic reductions in malaria parasitaemia (OR 0.005, 95% CI 0.002 to 0.011, p<0.001) and gametocyte carriage (OR 0.02, 95% CI 0.00 to 0.17, p<0.001) in intervention compared with control schools. This effect was sustained for 6 months until the beginning of the next transmission season. IPCs was also associated with a significant decrease in anaemia (OR 0.56, 95% CI 0.40 to 0.78, p=0.001), and increase in sustained attention (difference +0.23, 95% CI 0.10 to 0.36, p<0.001). There was no evidence of impact on other cognitive measures. CONCLUSION: The combination of malaria prevention education, LLINs and IPCs can reduce anaemia and improve sustained attention of school children in areas of highly seasonal transmission. These findings highlight the impact of asymptomatic malaria infection on cognitive performance in schoolchildren and the benefit of IPCs in reducing this burden. Additionally, malaria control in schools can help diminish the infectious reservoir that sustains Plasmodium transmission

The scope of coverage under the Rotterdam Rules - Unimodal and multimodal aspects

U radu se proučavaju, raščlanjuju i interpretiraju sve relevantne odredbe o polju primjene Roterdamskih pravila. Analizira se njihovo opće polje primjene, govori se o ugovorima, prijevozima te subjektima prijevoznih poslova na koje se Roterdamska pravila primjenjuju. Proučavaju se i specifične odredbe o posebnim isključenjima. Tumači se u kojem opsegu Roterdamska pravila pokrivaju multimodalni prijevoz te se govori o multimodalnosti kao obilježju suvremenog prijevoza i unifikaciji multimodalnog prijevoza. Pomno se ulazi u sadržaj i doseg odredbi kojima se propisuju uvjeti koji moraju biti ispunjeni da bi odredbe druge međunarodne prijevozne konvencije imale prednost u odnosu na odredbe Roterdamskih pravila. Nastoji se ukazati i na razlike u pogledu njezinog polja primjene i polja primjene međunarodnih konvencija koje su na snazi, a kojima se uređuje prijevoz stvari morem. Odredbe o polju primjene iznimno su važne i zadiru u bit nove konvencije, njezinu koncepciju, temeljna načela i ciljeve novog pravnog uređenja koje Konvencija propisuje. Najvažnije novine polja primjene Roterdamskih pravila u odnosu na međunarodne konvencije koje su na snazi, a koje uređuju prijevoz stvari morem jesu proširenje polja primjene na prijevoze “od vrata do vrata” i novo uređenje prijevoznih isprava. Cilj rada je skrenuti pažnju na polje primjene kao važno pitanje koje utječe na recepciju Roterdamskih pravila i istaknuti ona rješenja koja se najviše kritiziraju i za koja se osnovano može pretpostaviti da predstavljaju zapreku za njihovu recepciju.This paper considers the application of provisions of the United Nations Convention on Contracts for the International Carriage of Goods Wholly or Partly by Sea (the Rotterdam Rules). The scope of coverage issues go to the heart of the new Convention. This article highlights the major topics relating to the scope of coverage. All aspects of this key issue are examined here: the general scope of application; criteria that must be satisfied for the Convention to be applied; types of transactions that the Convention might govern; application to certain parties. Some of these questions have been particularly controversial. Moreover, this paper addresses the circumstances under which the Rotterdam Rules give way to other conventions. The author discusses issues that may arise from the fact that the Convention will cover both the inward and the outward carriage. It further considers specific exclusions from the Convention. Differences between the Rotterdam Rules and the international legislation in force are pointed out. One of the most significant changes introduced by the Rotterdam Rules to the existing law is the expansion of its scope of coverage to include the door-to-door transport. The Convention covers both the inbound and the outbound international shipments to or from a Contracting State. The Convention applies to contracts in both the liner and the non-liner trades, but not to charterparties and other contracts for the use of a ship or of any space thereon. Volume contract, to which the Convention applies, may provide for greater or lesser obligations and liabilities than those imposed by the Rotterdam Rules

Overall and Gender-Specific Effects of Intermittent Preventive Treatment of Malaria with Artemisinin-Based Combination Therapies among Schoolchildren in Mali: A Three-Group Open Label Randomized Controlled Trial.

Intermittent preventive treatment of malaria among schoolchildren (IPTsc) reduces clinical malaria, asymptomatic parasitemia, and anemia. The effects of IPTsc by gender have not been studied longitudinally. We investigated overall IPTsc efficacy and conducted a secondary analysis to explore gender-specific differences. We enrolled schoolchildren aged 6-13 years in an open-label, rolling-cohort randomized controlled trial between September 2007 and February 2013 in Kolle, Mali. Annually, schoolchildren received two full-treatment courses of sulfadoxine-pyrimethamine (SP) plus artesunate, or amodiaquine (AQ) plus artesunate, or no malaria treatment as control. We used mixed-effects generalized linear models to estimate differences in treatment outcomes across groups with interaction terms to explore gender-specific differences associated with Plasmodium falciparum infection, hemoglobin, and grade point averages (GPA) based on standardized testing. Overall, 305 students contributed 4,564 observations. Compared with the control, SP plus artesunate and AQ plus artesunate reduced the odds of P. falciparum infection (odds ratio [OR]: 0.33, 95% CI: 0.26-0.43; OR: 0.46, 95% CI: 0.36-0.59). We found strong evidence of increased mean hemoglobin concentrations (g/dL) in the SP plus artesunate group versus control (difference +0.37, 95% CI: 0.13-0.58). Collectively, schoolchildren given AQ plus artesunate had higher mean GPA (difference +0.36, 95% CI: 0.02-0.69) relative to control. Schoolgirls, compared with schoolboys, given SP plus artesunate had greater improvement in GPA (+0.50, 95% CI: -0.02 to 1.02 versus -0.27, 95% CI: -0.71 to 0.16); interaction P = 0.048, respectively. The IPTsc decreases P. falciparum infections in schoolchildren. Treatment regimens that include longer-acting drugs may be more effective at decreasing malaria-related anemia and improving educational outcomes as observed among girls in this setting

Two-Year Scale-Up of Seasonal Malaria Chemoprevention Reduced Malaria Morbidity among Children in the Health District of Koutiala, Mali

International audienceBackground: Previous controlled studies demonstrated seasonal malaria chemoprevention (SMC) reduces malaria morbidity by >80% in children aged 3-59 months. Here, we assessed malaria morbidity after large-scale SMC implementation during a pilot campaign in the health district of Koutiala, Mali.Methods: Starting in August 2012, children received three rounds of SMC with sulfadoxine-pyrimethamine (SP) and amodiaquine (AQ). From July 2013 onward, children received four rounds of SMC. Prevalence of malaria infection, clinical malaria and anemia were assessed during two cross-sectional surveys conducted in August 2012 and June 2014. Investigations involved 20 randomly selected clusters in 2012 against 10 clusters in 2014.Results: Overall, 662 children were included in 2012, and 670 in 2014. Children in 2014 versus those surveyed in 2012 showed reduced proportions of malaria infection (12.4% in 2014 versus 28.7% in 2012 (p = 0.001)), clinical malaria (0.3% versus 4.2%, respectively (p < 0.001)), and anemia (50.1% versus 67.4%, respectively (p = 0.001)). A propensity score approach that accounts for environmental differences showed that SMC conveyed a significant protective effect against malaria infection (IR = 0.01, 95% CI (0.0001; 0.09), clinical malaria (OR = 0.25, 95% CI (0.06; 0.85)), and hemoglobin concentration (β = 1.3, 95% CI (0.69; 1.96)) in 2012 and 2014, respectively.Conclusion: SMC significantly reduced frequency of malaria infection, clinical malaria and anemia two years after SMC scale-up in Koutiala

Prevalence of molecular markers of resistance to sulphadoxine, pyrimethamine and amodiaquine at baseline and post-SMC in the SMC population.

<p>Prevalence of molecular markers of resistance to sulphadoxine, pyrimethamine and amodiaquine at baseline and post-SMC in the SMC population.</p

Demographic, clinical, and laboratory participant characteristics in SMC and non-SMC population.

<p>Demographic, clinical, and laboratory participant characteristics in SMC and non-SMC population.</p

Prevalence of molecular markers of resistance to sulphadoxine, pyrimethamine and amodiaquine at baseline and post intervention period in Non-SMC patient population.

<p>Prevalence of molecular markers of resistance to sulphadoxine, pyrimethamine and amodiaquine at baseline and post intervention period in Non-SMC patient population.</p

Prevalence of molecular markers of resistance to sulphadoxine, pyrimethamine and amodiaquine at post-SMC in the SMC population <i>vs</i>. concurrent Non-SMC patient population.

<p>Prevalence of molecular markers of resistance to sulphadoxine, pyrimethamine and amodiaquine at post-SMC in the SMC population <i>vs</i>. concurrent Non-SMC patient population.</p