Trends in outpatient malaria cases, following Mass Long Lasting Insecticidal Nets (LLIN) distribution in epidemic prone and endemic areas of Kenya

Background: There were over 6 million case of malaria reported in Kenya in 2015 and it remains a major public health priority despite significant investments in interventions to control and prevent infections in high risk areas.Objectives: To analyse trends from 2011-2015, and report i) outpatient department (OPD) malaria case prevalence, ii) the proportion of confirmed malaria cases of all OPD cases stratified by age category, and iii) the proportion of the population potentially protected by long-lasting insecticidal nets (LLINs), following mass distribution of LLINs in malaria epidemic prone and endemic areas.Design: A retrospective study.Setting: Kenya’s Coast endemic, Lake endemic and Highland epidemic zones.Subjects: All outpatient malaria cases reported in the District Health Information System.Results: The proportion of people who received mass LLINs ranged from 80-95% in epidemic prone and endemic areas of Kenya. The coastal endemic zone had the lowest number of reported malaria cases at almost 840,000 in 2011, compared with the lake endemic zone which reported 4.3 million total cases. Confirmed malaria cases of all the OPD morbidity increased by 1%, 20% and 4% in the Highland epidemic prone, the Lake and Coast endemic region in 2011 to 2015, respectively. There was a trend towards fewer cases across all three high risk regions from 2012-2013, but this reversed with increasing cases being reported in 2014-2015.Conclusion: Despite a high LLIN coverage malaria cases increased over time. There is need for patient-level studies to assess if LLINs are being used appropriately and to look towards other complimentary malaria prevention strategies

Intermittent preventive treatment and bed nets uptake among pregnant women in Kenya

Background: Malaria in pregnancy is a preventable disease which results in poor pregnancy outcomes. The use of intermittent preventive treatment in pregnancy (IPTp) and long-lasting insecticide treated nets (LLINs) have been shown to reduce maternal malaria episodes.Objectives: To describe i) The proportion receiving first and second dose (IPTp1 and 2) in malaria endemic zones, ii) proportion receiving IPTp 1 and 2 stratified by coast and lake endemic zones iii) proportion receiving LLINs, stratified by coastal and lake endemic zones.Design: A retrospective descriptive study.Setting: Lake and Coast region malaria endemic zones.Subjects: Pregnant women.Results: IPTp2 dose during an ANC revisit fell by 29% between 2012 and 2015, with 76% receiving an IPTp2 in 2012 and only 47% receiving it in 2015. More pregnant women in Coastal endemic areas received IPTp2 compared to Lake, with 88% versus 73% in 2012, and 53% versus 44% in 2015, respectively.There was steady increase in bed net usage from 69% and 54% in 2012 to 96% and 95% in 2015 for lake and coast endemic zones respectively. The uptake of LLINs was 15% higher in the lake region compared to the coastal endemic region in 2012 and significantly declined over the five years to 6%, 7% and 1% in 2013, 2014 and 2015, respectively.Conclusion: Our study found that there has been a significant decline from 2012 through 2015, in the number of pregnant women in Kenya receiving recommended malaria prophylaxis in the regions of highest malaria burden. However, the coverage of LLIN has consistently improved over the same period

Trends of reported outpatient malaria cases to assess the Test, Treat and Track (T3) policy in Kenya

Background: Kenya reports over six million malaria cases annually. In 2012 the country adopted the Test, Treat and Track (T3) policy to ensure that all suspected malaria cases are tested, confirmed cases are treated with quality-assured drugs and timely accurate malaria surveillance are in place to guide policy and practice.Objective: To describe the trends of confirmed outpatient malaria cases and the consumption of artemisinin-based combination therapy (ACT) in the government health facilities in Kenya following the roll out of the T3 initiative.Design: A retrospective review study.Setting: All government health facilities in the 47 counties.Subjects: Secondary data on all outpatient malaria cases and ACT consumed as reported in the District Helth Information Software (DHIS).Results: Total malaria cases decreased from 8.5 to 6.8million cases in 2012 and 2015, respectively. Confirmed malaria cases increased from 1.97 (23%) to 4.9 (72%) million cases. The greatest decrease in total malaria cases and the greatest rise in confirmation of suspected cases occurred in the lower level health facilities. More confirmation of suspected cases occurred in the malaria endemic regions compared to other epidemiological zones. Excess ACT consumption reduced by 46% to reach 27% in 2015.Conclusion: Though there was increased confirmation of suspected malaria, still onethird of the outpatients were treated clinically in 2015. About one-third of ACTs were also used in excess in 2015. There is need for enhanced efforts to adhere to the T3 policy and malaria elimination guidelines

The malaria testing and treatment landscape in Kenya: results from a nationally representative survey among the public and private sector in 2016

Abstract Background Since 2004, Kenya’s national malaria treatment guidelines have stipulated artemisinin-based combination therapy (ACT) as first-line treatment for uncomplicated malaria, and since 2014, confirmatory diagnosis of malaria in all cases before treatment has been recommended. A number of strategies to support national guidelines have been implemented in the public and private sectors in recent years. A nationally-representative malaria outlet survey, implemented across four epidemiological zones, was conducted between June and August 2016 to provide practical evidence to inform strategies and policies in Kenya towards achieving national malaria control goals. Results A total of 17,852 outlets were screened and 2271 outlets were eligible and interviewed. 78.3% of all screened public health facilities stocked both malaria diagnostic testing and quality-assured ACT (QAACT). Sulfadoxine–pyrimethamine (SP) for intermittent preventive treatment in pregnancy was available in 70% of public health facilities in endemic areas where it is recommended for treatment. SP was rarely found in the public sector outside of the endemic areas (< 0.5%). The anti-malaria stocking private sector had lower levels of QAACT (46.7%) and malaria blood testing (20.8%) availability but accounted for majority of anti-malarial distribution (70.6% of the national market share). More than 40% of anti-malarials were distributed by unregistered pharmacies (37.3%) and general retailers (7.1%). QAACT accounted for 58.2% of the total anti-malarial market share, while market share for non-QAACT was 15.8% and for SP, 24.8%. In endemic areas, 74.9% of anti-malarials distributed were QAACT. Elsewhere, QAACT market share was 49.4% in the endemic-prone areas, 33.2% in seasonal-transmission areas and 37.9% in low-risk areas. Conclusion Although public sector availability of QAACT and malaria diagnosis is relatively high, there is a gap in availability of both testing and treatment that must be addressed. The private sector in Kenya, where the majority of anti-malarials are distributed, is also critical for achieving universal coverage with appropriate malaria case management. There is need for a renewed commitment and effective strategies to ensure access to affordable QAACT and confirmatory testing in the private sector, and should consider how to address malaria case management among informal providers responsible for a substantial proportion of the anti-malarial market share

Autonomously learning neural networks for clinical decision support

Background Spatial and temporal malaria risk maps are essential tools to monitor the impact of control, evaluate priority areas to reorient intervention approaches and investments in malaria endemic countries. Here, the analysis of 36 years data on Plasmodium falciparum prevalence is used to understand the past and chart a future for malaria control in Kenya by confidently highlighting areas within important policy relevant thresholds to allow either the revision of malaria strategies to those that support pre-elimination or those that require additional control efforts. Methods Plasmodium falciparum parasite prevalence (PfPR) surveys undertaken in Kenya between 1980 and 2015 were assembled. A spatio-temporal geostatistical model was fitted to predict annual malaria risk for children aged 2–10 years (PfPR2–10) at 1 × 1 km spatial resolution from 1990 to 2015. Changing PfPR2–10 was compared against plausible explanatory variables. The fitted model was used to categorize areas with varying degrees of prediction probability for two important policy thresholds PfPR2–10 &lt; 1% (non-exceedance probability) or ≥ 30% (exceedance probability). Results 5020 surveys at 3701 communities were assembled. Nationally, there was an 88% reduction in the mean modelled PfPR2–10 from 21.2% (ICR: 13.8–32.1%) in 1990 to 2.6% (ICR: 1.8–3.9%) in 2015. The most significant decline began in 2003. Declining prevalence was not equal across the country and did not directly coincide with scaled vector control coverage or changing therapeutics. Over the period 2013–2015, of Kenya’s 47 counties, 23 had an average PfPR2–10 of &lt; 1%; four counties remained ≥ 30%. Using a metric of 80% probability, 8.5% of Kenya’s 2015 population live in areas with PfPR2–10 ≥ 30%; while 61% live in areas where PfPR2–10 is &lt; 1%. Conclusions Kenya has made substantial progress in reducing the prevalence of malaria over the last 26 years. Areas today confidently and consistently with &lt; 1% prevalence require a revised approach to control and a possible consideration of strategies that support pre-elimination. Conversely, there remains several intractable areas where current levels and approaches to control might be inadequate. The modelling approaches presented here allow the Ministry of Health opportunities to consider data-driven model certainty in defining their future spatial targeting of resources

Monitoring health systems readiness and inpatient malaria case-management at Kenyan county hospitals

Background Change of severe malaria treatment policy from quinine to artesunate, a major malaria control advance in Africa, is compromised by scarce data to monitor policy translation into practice. In Kenya, hospital surveys were implemented to monitor health systems readiness and inpatient malaria case-management. Methods All 47 county referral hospitals were surveyed in February and October 2016. Data collection included hospital assessments, interviews with inpatient health workers and retrospective review of patients’ admission files. Analysis included 185 and 182 health workers, and 1162 and 1224 patients admitted with suspected malaria, respectively, in all 47 hospitals. Cluster-adjusted comparisons of the performance indicators with exploratory stratifications were performed. Results Malaria microscopy was universal during both surveys. Artesunate availability increased (63.8–85.1%), while retrospective stock-outs declined (46.8–19.2%). No significant changes were observed in the coverage of artesunate trained (42.2% vs 40.7%) and supervised health workers (8.7% vs 12.8%). The knowledge about treatment policy improved (73.5–85.7%; p = 0.002) while correct artesunate dosing knowledge increased for patients &lt; 20 kg (42.7–64.6%; p &lt; 0.001) and &gt; 20 kg (70.3–80.8%; p = 0.052). Most patients were tested on admission (88.6% vs 92.1%; p = 0.080) while repeated malaria testing was low (5.2% vs 8.1%; p = 0.034). Artesunate treatment for confirmed severe malaria patients significantly increased (69.9–78.7%; p = 0.030). No changes were observed in artemether– lumefantrine treatment for non-severe test positive patients (8.0% vs 8.8%; p = 0.796). Among test negative patients, increased adherence to test results was observed for non-severe (68.6–78.0%; p = 0.063) but not for severe patients (59.1–62.1%; p = 0.673). Overall quality of malaria case-management improved (48.6–56.3%; p = 0.004), both for children (54.1–61.5%; p = 0.019) and adults (43.0–51.0%; p = 0.041), and in both high (51.1–58.1%; p = 0.024) and low malaria risk areas (47.5–56.0%; p = 0.029). Conclusion Most health systems and malaria case-management indicators improved during 2016. Gaps, often specific to different inpatient populations and risk areas, however remain and further programmatic interventions including close monitoring is needed to optimize policy translation.</p

A national health facility survey of malaria infection among febrile patients in Kenya, 2014

Background The use of malaria infection prevalence among febrile patients at clinics has a potential to be a valuable epidemiological surveillance tool. However, routine data are incomplete and not all fevers are tested. This study was designed to screen all fevers for malaria infection in Kenya to explore the epidemiology of fever test positivity rates. Methods Random sampling was used within five malaria epidemiological zones of Kenya (i.e., high lake endemic, moderate coast endemic, highland epidemic, seasonal low transmission and low risk zones). The selected sample was representative of the number of hospitals, health centres and dispensaries within each zone. Fifty patients with fever presenting to each sampled health facility during the short rainy season were screened for malaria infection using a rapid diagnostic test (RDT). Details of age, pregnancy status and basic demographics were recorded for each patient screened. Results 10,557 febrile patients presenting to out-patient clinics at 234 health facilities were screened for malaria infection. 1633 (15.5%) of the patients surveyed were RDT positive for malaria at 124 (53.0%) facilities. Infection prevalence among non-pregnant patients varied between malaria risk zones, ranging from 0.6% in the low risk zone to 41.6% in the high lake endemic zone. Test positivity rates (TPR) by age group reflected the differences in the intensity of transmission between epidemiological zones. In the lake endemic zone, 6% of all infections were among children aged less than 1 year, compared to 3% in the coast endemic, 1% in the highland epidemic zone, less than 1% in the seasonal low transmission zone and 0% in the low risk zone. Test positivity rate was 31% among febrile pregnant women in the high lake endemic zone compared to 9% in the coast endemic and highland epidemic zones, 3.2% in the seasonal low transmission zone and zero in the low risk zone. Conclusion Malaria infection rates among febrile patients, with supporting data on age and pregnancy status presenting to clinics in Kenya can provide invaluable epidemiological data on spatial heterogeneity of malaria and serve as replacements to more expensive community-based infection rates to plan and monitor malaria control