Changing malaria epidemiology in four urban settings in sub-Saharan Africa

Background An estimated 200 million persons in sub-Saharan Africa (SSA) live currently in urban centres in malaria endemic areas. The epidemiology and control of urban malaria poses a number of specific challenges in comparison to rural areas, most notably the heterogeneous spatial distribution of transmission and the low state of immunity in the population. Interestingly, much less is currently known about malaria in urban settings than in rural areas. As a result there is an essential need for more information on disease burden, distribution and control strategies. In this multi-country study we undertook to study systematically key malariological features in four large SSA cities: Abidjan (Côte d’Ivoire), Ouagadougou (Burkina Faso), Cotonou (Benin) and Dar es Salaam (United Republic of Tanzania). Objectives The general objective of this series of case studies was to further our understanding of malaria transmission and epidemiology in the urban environment in SSA, in view of developing and implementing effective control measures. Study methodology The basic study design of RUMA in each site included six components: 1) An extensive literature review and contacts with national malaria experts, 2) The collection of routine health statistics, disaggregated by sex, age and residence, 3) The mapping of health facilities and the identification of the main breeding sites on the basis of existing maps, 4) School parasitaemia surveys (200 school children aged 5-10 years in 3-4 schools, 5) Health facility-based fever surveys (200 fever cases and 200 non-fever controls in 3-4 facilities) and 6) A systematic description of the health care delivery system. For components 4 and 5 we categorized each city into 3-4 areas (centre, intermediate, periphery and rural areas), and randomly chose one clinic and one nearby school from each area. All work was completed within six to ten weeks on-site. The main emphasis was put on describing the burden of malaria (components 1, 2, 4), transmission patterns (components 1, 2, 3, 4) and the diagnosis of malaria in urban settings (component 5, 6). Finally, key risk factors for infection were explored (components 4 and 5). Key results Abidjan: The field work was carried out in August-September 2002 during the rainy season. According to national statistics, approximately 240,000 malaria cases were reported by health facilities in Abidjan in 2001 (40.2% of all consultations). The peak malaria incidence was in July-September. In the health facilities of the Yopougon commune, the malaria infection rates in presenting fever cases were 22.1% (under 1 year-old), 42.8% (1-5 years-old), 42.0% (6-15 years-old) and 26.8% (over 15 years-old), while those in the control group were 13.0%, 26.7%, 21.8% and 14.6%. Malaria prevalence in health facilities was homogenous in the different areas of Yopougon. The malaria-attributable fractions (MAFs) among presenting fever cases were 0.12, 0.22, 0.27 and 0.13 for the age groups listed above, suggesting that malaria played only a low to moderate role in fever episodes during the rainy season. Among all patients, 10.1% used a mosquito net (treated or not) the night before the survey and this was protective (OR=0.52, 95% CI 0.29-0.97). Travel to rural areas within the last three months was frequent (31% of all respondents) and associated with a malaria infection (OR=1.75, 95% CI 1.25-2.45). The health facility and breeding site mapping, as well as the school surveys could not be carried out because of political troubles. Ouagadougou: The field work was carried out in November-December 2002 at the start of cold and dry season. Seasonal variations in reported clinical malaria cases were marked. The highest incidence rate was reported from July to September and incidence rates went down in October-December until a low point during the dry season, from January to March. In 2001, there were 203,466 simple malaria cases (29.3-41.4% of consultations) and 19 deaths reported among 596,365 consultations in all public health facilities. A further 20,071 complicated malaria cases were reported. The malaria infection rates in presenting fever cases were 12.1% (under 1 year-old), 25.9% (1-5 years-old), 37.1% (6-15 years-old) and 18.0% (over 15 years-old), while those in the control group were 14.3%, 14.4%, 34.5% and 19.8%. The MAFs among presenting fever cases were 0.00, 0.13, 0.04 and 0.00 for the age groups cited above, suggesting that malaria played only a small role in fever episodes at the start of cold and dry season. The school parasitaemia prevalence was rather high (overall: 48.3%) and there was heterogeneity between the 3 surveyed schools (31.6%, 37.6%, 73.1%). The mapping of Anopheles sp. breeding sites correlated with this gradient of endemicity between the urban centre and the periphery of Ouagadougou. We found a link between malaria infections and urban agriculture activities and the availability of water supply. In total 42.0% of patients used a mosquito net the night before the survey and this was protective (OR=0.74, 95% CI 0.54-1.00). Travelling to a rural area (8.7% of all respondents) did not increase the infection risk (OR=1.14, 95% CI 0.70-1.90). Cotonou: The field work was carried out in February-March 2003. In 2002, there were 100,257 reported simple malaria cases and 12,195 complicated malaria cases reported for 289,342 consultations in the public health facilities of Cotonou. Between 1996 and 2002, on average 34% of total consultations were attributed to simple malaria and 1-4.2% to complicated malaria cases. There was no clear seasonal pattern. The malaria infection rates in presenting fever cases were 0% (under 1 year-old), 6.8% (1-5 years-old), 0% (6-15 years-old) and 0.9% (over 15 years-old), while those in the control group were 1.4%, 2.8%, 1.3% and 2.0%. The MAFs among presenting fever cases were 0.04 in the 1-5 years-old and 0 in the over 15 years-old. MAFs could not be calculated for the other two age groups. Hence, malaria played only a small role in fever episodes at the end of the rainy season. In the school parasitaemia surveys, a malaria infection was found in 5.2 % of all samples. The prevalence of parasitaemia in the centre, intermediate and periphery areas was 2.6%, 9.0% and 2.5%, respectively. In total 69.2% of patients used a mosquito net the night before the survey (OR=0.61, not significant). Traveling to a rural area (5.8% of all respondents) did not increase the infection risk since none of those who had traveled had parasitaemia. No mapping of health facilities and breeding sites could be carried out. Dar es Salaam: The field work was carried out in June-August 2003. An estimated 1.1 million annual malaria cases were reported in 2000 from a total of 2,200,000 outpatient visits in the health facilities (49% of all consultations). A clear seasonal pattern of clinical malaria was recorded, with high rates from March to June and a low point in July-August. The malaria infection rates in presenting fever cases were 2.0 % (under 1 year-old), 7.0% (1-5 years-old), 7.2 (6-15 years-old) and 4.2 % (over 15 years-old), while those in the control group were 3.4%, 4.5%, 3.6% and 1.9%. The MAFs were very low in all age groups: 0.00, 0.03, 0.04 and 0.02 for the age categories shown above. School surveys in Dar es Salaam during a prolonged dry season in 2003 showed that the prevalence of malaria parasites was low: 0.8%, 1.4%, 2.7% and 3.7% in the centre, intermediate, periphery and rural areas, respectively. Anopheles sp. breeding sites were fairly well distributed within the city. We found a remarkably high coverage rate of mosquito nets in the households (91.8% users) and this seemed to be protective (OR=0.60, 95% CI 0.27-0.93). An increased malaria infection rate was seen in the 11.8% of children who traveled to rural areas within last 3 month (OR=3.62, 95% CI 1.48-8.88). Conclusion RUMA was successfully implemented in 4 selected urban areas within a period of six to ten weeks per site. The financial cost for conducting a RUMA in these four sites ranged from 8,500-13,000 USD. All components were feasible (with the exception of breeding site mapping which clearly exceeded what can be done in such a short time period) and highly informative. The RUMA allowed to describe transmission patterns in the four cities and highlighted the enormous level of over-treatment with antimalarials. The collected information should prove of high value as a basis for further investigations and for planning effective control interventions

Rapid urban malaria appraisal (RUMA) I: Epidemiology of urban malaria in Ouagadougou

BACKGROUND: Rapid urbanization in sub-Saharan Africa has a major impact on malaria epidemiology. While much is known about malaria in rural areas in Burkina Faso, the urban situation is less well understood. METHODS: An assessment of urban malaria was carried out in Ouagadougou in November -December, 2002 during which a rapid urban malaria appraisal (RUMA) was applied. RESULTS: The school parasitaemia prevalence was relatively high (48.3%) at the cold and dry season 2002. Routine malaria statistics indicated that seasonality of malaria transmission was marked. In the health facilities, the number of clinical cases diminished quickly at the start of the cold and dry season and the prevalence of parasitaemia detected in febrile and non-febrile cases was 21.1% and 22.0%, respectively. The health facilities were likely to overestimate the malaria incidence and the age-specific fractions of malaria-attributable fevers were low (0–0.13). Peak prevalence tended to occur in older children (aged 6–15 years). Mapping of Anopheles sp. breeding sites indicated a gradient of endemicity between the urban centre and the periphery of Ouagadougou. A remarkable link was found between urban agriculture activities, seasonal availability of water supply and the occurrence of malaria infections in this semi-arid area. The study also demonstrated that the usage of insecticide-treated nets and the education level of family caretakers played a key role in reducing malaria infection rates. CONCLUSION: These findings show that determining local endemicity and the rate of clinical malaria cases are urgently required in order to target control activities and avoid over-treatment with antimalarials. The case management needs to be tailored to the level of the prevailing endemicity

Rapid Urban Malaria Appraisal (RUMA) IV: Epidemiology of urban malaria in Cotonou (Benin)

BACKGROUND: An estimated 40 % of the population in Benin lives in urban areas. The purpose of the study was to estimate malaria endemicity and the fraction of malaria-attributable fevers in health facilities in Cotonou. METHODS: A health care system evaluation and a series of school parasitaemia surveys and health facility-based surveys were carried out during the dry season in of 2003, applying standard Rapid Urban Malaria Appraisal (RUMA) methodology. This study was part of a multi-site assessment supported by the Roll Back Malaria Partnership. RESULTS: The field work was carried out in February-March 2003. In 2002 and out of 289,342 consultations in the public health facilities of Cotonou there were 100,257 reported simple malaria cases (34.6%) and 12,195 complicated malaria cases (4.2%). In the school parasitaemia surveys, a malaria infection was found in 5.2 % of all samples. The prevalence rates of parasitaemia in the centre, intermediate and periphery zones were 2.6%, 9.0% and 2.5%, respectively. In the health facility surveys the malaria infection rates in presenting fever cases were 0% (under one year old), 6.8% (one to five years old), 0% (> five to 15 years old) and 0.9% (over 15 years old), while these rates in the control group were 1.4%, 2.8%, 1.3% and 2.0%. The malaria-attributable fractions among presenting fever cases were 0.04 in the one to five years old and zero in the three other age groups. Hence, malaria played only a small role in fever episodes at the end of the dry season. In total, 69.2% of patients used a mosquito net the night before the survey and 35.1% used an insecticide-treated net, which was shown to be protective for an infection (OR = 0.23, 95% CI 0.07–0.78). Travelling to a rural area (5.8% of all respondents) did not increase the infection risk. CONCLUSION: The homogenously low malaria prevalence might be associated with urban transformation and/or a high bednet usage. Over-diagnosis of malaria and over-treatment with antimalarials was found to be a serious problem

Rapid Urban Malaria Appraisal (RUMA) III: epidemiology of urban malaria in the municipality of Yopougon (Abidjan)

BACKGROUND: Currently, there is a significant lack of knowledge concerning urban malaria patterns in general and in Abidjan in particular. The prevalence of malaria, its distribution in the city and the fractions of fevers attributable to malaria in the health facilities have not been previously investigated. METHODS: A health facility-based survey and health care system evaluation was carried out in a peripheral municipality of Abidjan (Yopougon) during the rainy season of 2002, applying a standardized Rapid Urban Malaria Appraisal (RUMA) methodology. RESULTS: According to national statistics, approximately 240,000 malaria cases (both clinical cases and laboratory confirmed cases) were reported by health facilities in the whole of Abidjan in 2001. They accounted for 40% of all consultations. In the health facilities of the Yopougon municipality, the malaria infection rates in fever cases for different age groups were 22.1% (under one year-olds), 42.8% (one to five years-olds), 42.0% (> five to 15 years-olds) and 26.8% (over 15 years-olds), while those in the control group were 13.0%. 26.7%, 21.8% and 14.6%, respectively. The fractions of malaria-attributable fever were 0.12, 0.22, 0.27 and 0.13 in the same age groups. Parasitaemia was homogenously detected in different areas of Yopougon. Among all children, 10.1% used a mosquito net (treated or not) the night before the survey and this was protective (OR = 0.52, 95% CI 0.29–0.97). Travel to rural areas within the last three months was frequent (31% of all respondents) and associated with a malaria infection (OR = 1.75, 95% CI 1.25–2.45). CONCLUSION: Rapid urbanization has changed malaria epidemiology in Abidjan and endemicity was found to be moderate in Yopougon. Routine health statistics are not fully reliable to assess the burden of disease, and the low level of the fractions of malaria-attributable fevers indicated substantial over-treatment of malaria

Rapid urban malaria appraisal (RUMA) in sub-Saharan Africa

BACKGROUND: The rapid urban malaria appraisal (RUMA) methodology aims to provide a cost-effective tool to conduct rapid assessments of the malaria situation in urban sub-Saharan Africa and to improve the understanding of urban malaria epidemiology. METHODS: This work was done in Yopougon municipality (Abidjan), Cotonou, Dar es Salaam and Ouagadougou. The study design consists of six components: 1) a literature review, 2) the collection of available health statistics, 3) a risk mapping, 4) school parasitaemia surveys, 5) health facility-based surveys and 6) a brief description of the health care system. These formed the basis of a multi-country evaluation of RUMA's feasibility, consistency and usefulness. RESULTS: A substantial amount of literature (including unpublished theses and statistics) was found at each site, providing a good overview of the malaria situation. School and health facility-based surveys provided an overview of local endemicity and the overall malaria burden in different city areas. This helped to identify important problems for in-depth assessment, especially the extent to which malaria is over-diagnosed in health facilities. Mapping health facilities and breeding sites allowed the visualization of the complex interplay between population characteristics, health services and malaria risk. However, the latter task was very time-consuming and required special expertise. RUMA is inexpensive, costing around 8,500–13,000 USD for a six to ten-week period. CONCLUSION: RUMA was successfully implemented in four urban areas with different endemicity and proved to be a cost-effective first approach to study the features of urban malaria and provide an evidence basis for planning control measures

Global research priorities for interpersonal violence prevention: A modified Delphi study

© 2017, World Health Organization. All rights reserved. Objective To establish global research priorities for interpersonal violence prevention using a systematic approach. Methods Research priorities were identified in a three-round process involving two surveys. In round 1, 95 global experts in violence prevention proposed research questions to be ranked in round 2. Questions were collated and organized according to the four-step public health approach to violence prevention. In round 2, 280 international experts ranked the importance of research in the four steps, and the various substeps, of the public health approach. In round 3, 131 international experts ranked the importance of detailed research questions on the public health step awarded the highest priority in round 2. Findings In round 2, “developing, implementing and evaluating interventions” was the step of the public health approach awarded the highest priority for four of the six types of violence considered (i.e. child maltreatment, intimate partner violence, armed violence and sexual violence) but not for youth violence or elder abuse. In contrast, “scaling up interventions and evaluating their cost-effectiveness” was ranked lowest for all types of violence. In round 3, research into “developing, implementing and evaluating interventions” that addressed parenting or laws to regulate the use of firearms was awarded the highest priority. The key limitations of the study were response and attrition rates among survey respondents. However, these rates were in line with similar priority-setting exercises. Conclusion These findings suggest it is premature to scale up violence prevention interventions. Developing and evaluating smaller-scale interventions should be the funding priority

Survivors of war in the Northern Kosovo (II): baseline clinical and functional assessment and lasting effects on the health of a vulnerable population

<p>Abstract</p> <p>Background</p> <p>This study documents torture and injury experience and investigates emotional well-being of victims of massive violence identified during a household survey in Mitrovicë district in Kosovo. Their physical health indicators such as body mass index (BMI), handgrip strength and standing balance were also measured. A further aim is to suggest approaches for developing and monitoring rehabilitation programmes.</p> <p>Methods</p> <p>A detailed assessment was carried out on 63 male and 62 female victims. Interviews and physical examination provided information about traumatic exposure, injuries, and intensity and frequency of pain. Emotional well-being was assessed using the "WHO-5 Well-Being" score. Height, weight, handgrip strength and standing balance performance were measured.</p> <p>Results</p> <p>Around 50% of victims had experienced at least two types of torture methods and reported at least two injury locations; 70% had moderate or severe pain and 92% reported constant or periodic pain within the previous two weeks. Only 10% of the victims were in paid employment. Nearly 90% of victims had experienced at least four types of emotional disturbances within the previous two weeks, and many had low scores for emotional well-being. This was found to be associated with severe pain, higher exposure to violence and human rights violations and with a low educational level, unemployment and the absence of political or social involvement.</p> <p>Over two thirds of victims were overweight or obese. They showed marked decline in handgrip strength and only 19 victims managed to maintain standing balance. Those who were employed or had a higher education level, who did not take anti-depressant or anxiety drugs and had better emotional well-being or no pain complaints showed better handgrip strength and standing balance.</p> <p>Conclusions</p> <p>The victims reported a high prevalence of severe pain and emotional disturbance. They showed high BMI and a reduced level of physical fitness. Education, employment, political and social participation were associated with emotional well-being. Interventions to promote physical activity and social participation are recommended. The results indicate that the rapid assessment procedure used here offers an adequate tool for collecting data for the monitoring of health interventions among the most vulnerable groups of a population exposed to violence.</p