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Impact of malaria control on childhood anaemia in Africa -- a quantitative review.

OBJECTIVE: To review the impact of malaria control on haemoglobin (Hb) distributions and anaemia prevalences in children under 5 in malaria-endemic Africa. METHODS: Literature review of community-based studies of insecticide-treated bednets, antimalarial chemoprophylaxis and insecticide residual spraying that reported the impact on childhood anaemia. Anaemia outcomes were standardized by conversion of packed cell volumes into Hb values assuming a fixed threefold difference, and by estimation of anaemia prevalences from mean Hb values by applying normal distributions. Determinants of impact were assessed in multivariate analysis. RESULTS: Across 29 studies, malaria control increased Hb among children by, on average, 0.76 g/dl [95% confidence interval (CI): 0.61-0.91], from a mean baseline level of 10.5 g/dl, after a mean of 1-2 years of intervention. This response corresponded to a relative risk for Hb < 11 g/dl of 0.73 (95% CI: 0.64-0.81) and for Hb < 8 g/dl of 0.40 (95% CI: 0.25-0.55). The anaemia response was positively correlated with the impact on parasitaemia (P = 0.005, P = 0.008 and P = 0.01 for the three outcome measures), but no relationship with the type or duration of malaria intervention was apparent. Impact on the prevalence of Hb < 11 g/dl was larger in sites with a higher baseline parasite prevalence. Although no age pattern in impact was apparent across the studies, some individual trials found larger impacts on anaemia in children aged 6-35 months than in older children. CONCLUSION: In malaria-endemic Africa, malaria control reduces childhood anaemia. Childhood anaemia may be a useful indicator of the burden of malaria and of the progress in malaria control.

Africa↗

Malaria control through municipalities in the Philippines: struggling with the mandate of decentralized health programme management.

This is a study on the management of the decentralized malaria control programme in Maharlika, Lipunan, a municipality in rural Philippines. The theoretical assumption is that the malaria control programme must be viewed as a system and that success of reform in malaria control depends upon the understanding of management issues by municipal officials. Through interviews, and documents and archival reviews, a framework for describing the dynamics of municipal management of the malaria control programme was developed. The overall finding was that the administrative management system was not functioning optimally: (a) planning and budgeting systems are not helpful; (b) malaria data do not inform planning; and (c) local financial resources are not utilized for malaria control. The underlying causes were: the absence of a clear statement from national offices regarding decentralization of health services, and the management processes, as stipulated in the Local Government Code, were not responsive to the needs of the municipality.

Communicable Disease Control↗

[Tactics and strategy of malaria control].

Tactics and strategy of malaria control. Both from the qualitative and quantitative point of view malaria can be regarded as one of the most serious medical problems of developing countries. In spite of decades of endeavours by the endemic countries and the World Health Organization using various tactics and strategies malaria prevalence and incidence could not be decreased essentially in tropical developing countries. The author analyses the reasons for this failure and gives realistic recommendations for lowering malaria morbidity and mortality taking into consideration the socio-economic conditions prevailing in the Third World.

Animals↗

Cost of malaria control in China: Henan's consolidation programme from community and government perspectives.

OBJECTIVE: To assist with strategic planning for the eradication of malaria in Henan Province, China, which reached the consolidation phase of malaria control in 1992, when only 318 malaria cases were reported. METHODS: We conducted a prospective two-year study of the costs for Henan's malaria control programme. We used a cost model that could also be applied to other malaria programmes in mainland China, and analysed the cost of the three components of Henan's malaria programme: suspected malaria case management, vector surveillance, and population blood surveys. Primary cost data were collected from the government, and data on suspected malaria patients were collected in two malaria counties (population 2 093 100). We enlisted the help of 260 village doctors in six townships or former communes (population 247 762), and studied all 12 325 reported cases of suspected malaria in their catchment areas in 1994 and 1995. FINDINGS: The average annual government investment in malaria control was estimated to be US$ 111 516 (case-management 59%; active blood surveys 25%; vector surveillance 12%; and contingencies and special projects 4%). The average cost (direct and indirect) for patients seeking treatment for suspected malaria was US$ 3.48, equivalent to 10 days' income for rural residents. Each suspected malaria case cost the government an average of US$ 0.78. CONCLUSION: Further cuts in government funding will increase future costs when epidemic malaria returns; investment in malaria control should therefore continue at least at current levels of US$ 0.03 per person at risk.

Animals↗

Keys to success for a school-based malaria control program in primary schools in Thailand.

School-based malaria control has been recognized as a new approach for the control of this disease in the Greater Mekong Subregion since 2000. We evaluated a school-based malaria control program near the western border of Thailand using a before-after intervention study. The major intervention activities included teacher training with specialized malaria teaching materials and participatory learning methods. The target population was 17 school principals, 111 teachers and 852 schoolchildren of grade 3, 4, and 5 in 17 schools. After the intervention, the teachers taught about malaria more actively than before. The teachers who could design a lesson plan on malaria increased from 30.7% to 47.7% (p=0.015) and the teachers who had taught about malaria increased from 71.9% to 84.3% (p=0.035). As a result of the program, the schoolchildren changed their behavior positively towards malaria prevention with significant difference in 6 of 7 questions. For example, the schoolchildren 'who always took care of mosquito bites' increased from 42.7% to 62.1% (p<0.001) and the schoolchildren 'who always reported their parents or teachers when they had fever' increased from 36.0% to 56.0% (p<0.001). In conclusion, the keys to a successful intervention lie in good teaching materials and a participatory approach utilizing the well-established Thailand's school health system. Beyond Thailand, school-based malaria control could be applied to other Greater Mekong Subregion countries with careful analysis of school health context in each country.

Adult↗

Participation of African social scientists in malaria control: identifying enabling and constraining factors.

OBJECTIVE: To examine the enabling and constraining factors that influence African social scientists involvement in malaria control. METHODS: Convenience and snowball sampling was used to identify participants. Data collection was conducted in two phases: a mailed survey was followed by in-depth phone interviews with selected individuals chosen from the survey. FINDINGS: Most participants did not necessarily seek malaria as a career path. Having a mentor who provided research and training opportunities, and developing strong technical skills in malaria control and grant or proposal writing facilitated career opportunities in malaria. A paucity of jobs and funding and inadequate technical skills in malaria limited the type and number of opportunities available to social scientists in malaria control. CONCLUSION: Understanding the factors that influence job satisfaction, recruitment and retention in malaria control is necessary for better integration of social scientists into malaria control. However, given the wide array of skills that social scientists have and the variety of deadly diseases competing for attention in Sub Saharan Africa, it might be more cost effective to employ social scientists to work broadly on issues common to communicable diseases in general rather than solely on malaria.

Adult↗

A birthweight nomogram for Africa, as a malaria-control indicator.

Low birthweight (LBW) attributable to malaria in pregnancy is a significant risk for millions in Africa. Infants born to primigravidae are at greatest risk and it is proposed that this excess risk can be used as a simple indicator of malaria transmission and exposure in pregnant women in Africa. Birthweight data from different regions in 11 malarious and three non-malarious African countries were investigated. A regression analysis of the excess risk of low birthweight in first pregnancies, compared with later ones, was completed and interpreted in relation to malaria-transmission intensities. The aim was to develop a simple birthweight chart (nomogram) as a tool for monitoring malaria transmission or malaria control in pregnancy. Low-birthweight risk in first pregnancies was associated with levels of malaria-transmission intensity amongst different African countries. The nomogram distinguished longitudinal changes in malaria exposure, related to season and changes in antimalarial-drug policy. Malaria is one of the most important causes of LBW in first pregnancies in Africa. As birthweight and parity are routinely recorded in many delivery centres across Africa, the nomogram provides a simple, available and inexpensive tool for monitoring malaria transmission and exposure in pregnant women and the effectiveness of malaria-control activities for this high-risk group.

Africa↗

Which way for malaria control and epidemiological services?

Historically epidemiological services were intimately linked with malaria control, and both were conceived as an integral part of local public health services. The strategy of malaria eradication between 1956 and 1969 moved malaria activities away from the health services and led to a weakening of epidemiological capacities. The epidemiological requirements of malaria control are now greater than ever. However, the capacity of health services to fulfil these requirements remains seriously weak. Investment in malaria control could provide an important building block for the much-needed strengthening of national public health.

Developing Countries↗

Tents pre-treated with insecticide for malaria control in refugee camps: an entomological evaluation.

BACKGROUND: A refugee shelter that is treated with insecticide during manufacture would be useful for malaria control at the acute stage of an emergency, when logistic problems, poor co-ordination and insecurity limit the options for malaria control. METHODS: Tents made of untreated canvas with deltamethrin-treated polyethylene threads interwoven through the canvas during manufacture, 'pre-treated tents', were tested in Pakistan for their impact on malaria vectors. Fixed-time contact bioassays tested the insecticidal activity of the material over 3 months of outdoor weathering. Unweathered tents were erected under large trap-nets on outdoor platforms and tested using wild-caught, host-seeking mosquitoes and insectary-reared mosquitoes released during the night into the trap-nets. RESULTS: The insecticide-treated tents were effective both in killing mosquitoes and reducing blood-feeding. Mean 24 hour mortality was 25.7% on untreated tents and 50.8% on treated tents (P = 0.001) in wild anophelines and 5.2% on untreated tents and 80.9% on treated tents (P < 0.001) in insectary-reared Anopheles stephensi. Blood-feeding of wild anophelines was reduced from 46% in the presence of an untreated tent to 9.2% (P < 0.001) in the presence of treated tents and from 51.1% to 22.2% (P < 0.001) for insectary-reared An. stephensi. In contact bioassays on tents weathered for three months there was 91.3% mortality after 10-minute exposure and a 24 h holding period and 83.0% mortality after 3-minute exposure and a 24 h holding period. CONCLUSION: The results demonstrate the potential of these pre-treated canvas-polyethylene tents for malaria control. Further information on the persistence of the insecticide over an extended period of weathering should be gathered. Because the epidemiological evidence for the effectiveness of pyrethroid-treated tents for malaria control already exists, this technology could be readily adopted as an option for malaria control in refugee camps, provided the insecticidal effect is shown to be sufficiently persistent.

Animals↗

The need for health behaviour and socio-economic research in malaria control in Thailand.

Malaria is still a disease of public health importance in Thailand despite the encouraging downward trend in the number of malaria cases during the past ten years. In the last few years there were still nearly a quarter of million malaria cases detected and about 3,000 malaria deaths yearly reported. The social and economic factors seem to play major roles in keeping low persistent transmission of malaria in certain communities especially those residing in and near forested areas, mountains and foothills in the places not far away from Thai-Kampuchea border in East Thailand and Thai-Burmese border in West Thailand. These communities consist of migrants and local native residents living in newly opened lands for agriculture, and some are remote areas where communication and transportation are inaccessible. Preliminary results on these people revealed some interesting social and economic problems and health behaviour of the people in connection with persistent malaria transmission among them. It is suggested that further investigation should be carried out on the social and economic elements in these communities including migratory pattern, their population characteristics and life, social behaviour, health belief and practice, malaria prone behaviour, etc. in association with malaria transmission among them. The results to be obtained may lead to the effective control measures of malaria in future.

Attitude to Health↗

Molecular biological approaches to the study of vectors in relation to malaria control.

To a large extent, control of malaria vectors relies on the elimination of breeding sites and the application of chemical agents. There are increasing problems associated with the use of synthetic insecticides for vector control, including the evolution of resistance, the high cost of developing and registering new insecticides and an awareness of pollution from insecticide residues. These factors have stimulated interest in the application of molecular biology to the study of mosquito vectors of malaria; focussing primarily on two aspects. First, the improvement of existing control measures through the development of simplified DNA probe systems suitable for identification of vectors of malaria. The development of synthetic, non-radioactive DNA probes suitable for the identification of species in the Anopheles gambiae complex is described with the aim of defining a simplified methodology which is suitable for entomologist in the field. The second aspect to be considered is the development of completely novel strategies through the genetic manipulation of insect vectors of malaria in order to alter their ability to transmit the disease. The major requirements for producing transgenic mosquitoes are outlined together with the progress which has been made to date and discussed in relation to the prospects which this type of approach has for the future control of malaria.

Animals↗

Genetic approaches to malaria control: how long the road?

Malaria control schemes based on the yet untested concept of replacing vector populations with mosquitoes of the same species unable to transmit the parasite offer one more means of attacking this important public health problem. Research is underway in several laboratories aimed at defining factors that can act to interrupt the development of the malaria parasite in the mosquito host, the genetic basis for such refractory mechanisms, methods for introducing genes coding for refractory mechanisms into the mosquito genome, and methods for replacing vector populations in the field. The complexities of such an undertaking are many and varied, but the potential impact of a successful replacement strategy on the epidemiology of malaria in the target area could be significant.

Animals↗

A new challenge for malaria control in Brazil: asymptomatic Plasmodium infection--a review.

The evolution of malaria in Brazil, its morbidity, the malaria control programs, and the new challenges for these programs in the light of the emergence of asymptomatic infection in the Amazon region of Brazil were reviewed. At least six Brazilian research groups have demonstrated that asymptomatic infection by Plasmodium is an important impediment to malaria control, among mineral prospectors in Mato Grosso and riverside communities in Rondônia and, in our group, in the middle and upper reaches of the Negro river, in the state of Amazonas. Likewise, other researchers have studied the problem among indigenous communities in the Colombian, Peruvian, and Venezuelan parts of the Amazon basin, adjacent to Brazil. The frequency of positive results from the polymerase chain reaction (PCR) among asymptomatic individuals has ranged from 20.4 to 49.5%, and the presence of Plasmodium in the thick blood smears, from 4.2 to 38.5%. Infection with Anopheles darlingi has also been demonstrated by xenodiagnosis among asymptomatic patients with positive PCR results. If a mean of 25% is taken for the asymptomatic infection caused by Plasmodium sp. in the Amazon region of Brazil, malaria control will be difficult to achieve in that region with the measures currently utilized for such control.

Animals↗

Knowledge, attitudes and practices with regard to malaria control in an endemic rural area of Myanmar.

Malaria is a global health problem, in particular, a major health problem within Southeast Asia. This study aimed to investigate malaria control within a rural area of Myanmar, where traditionally non-western medicine is the preferred treatment. Whilst malaria was perceived by the local people to be a major health problem, knowledge about the mode of transmission and correct treatment for malaria was relatively low. Consequently, the practices of the local people to control malaria were often ill-informed or based on cultural and traditional beliefs.

Adolescent↗

Do malaria control interventions reach the poor? A view through the equity lens.

Malaria, more than any other disease of major public health importance in developing countries, disproportionately affects poor people, with 58% of malaria cases occurring in the poorest 20% of the world's population. If malaria control interventions are to achieve their desired impact, they must reach the poorest segments of the populations of developing countries. Unfortunately, a growing body of evidence from benefit-incidence analyses has demonstrated that many public health interventions that were designed to aid the poor are not reaching their intended target. For example, the poorest 20% of people in selected developing countries were as much as 2.5 times less likely to receive basic public health services as the least-poor 20%. In the field of malaria control, a small number of studies have begun to shed light on differences by wealth status of malaria burden and of access to treatment and prevention services. These early studies found no clear difference in fever incidence based on wealth status, but did show significant disparities in both the consequences of malaria and in the use of malaria prevention and treatment services. Further study is needed to elucidate the underlying factors that contribute to these disparities, and to examine possible inequities related to gender, social class, or other factors. To achieve impact and overcome such inequities, malaria control efforts must begin to incorporate approaches relevant to equity in program design, implementation, and monitoring and evaluation.

Delivery of Health Care↗

Malaria control, the cold war, and the postwar reorganization of international assistance.

This article explores the control of rural malaria shortly before and after World War II. During this period rural malaria moved from being an almost impossible problem to control to one which many believed could be eradicated. However, instead of rural development serving as an operational and economic framework for malaria control, as some had advocated before the war, malaria control moved toward independence in the form of a global eradication campaign. Whereas this transition is generally portrayed strictly in terms of the success of DDT, I document how various factors, the Cold War in particular, contributed to the "inevitability" of eradication.

Communicable Disease Control↗

Rebound mortality and the cost-effectiveness of malaria control: potential impact of increased mortality in late childhood following the introduction of insecticide treated nets.

The efficacy and relative cost-effectiveness of insecticide-treated nets (ITNs) for the control of malaria in children under 5 years of age have recently been demonstrated by several large-scale trials. However, it has been suggested that long-term use of ITNs in areas of high transmission could lead to mortality rebound in later childhood, which would reduce the cost-effectiveness of the intervention, and at the extreme could lead to negative overall effects. A model is presented in which the cost and disability adjusted life years (DALYs) per child aged 1-119 months were estimated for a sub-Saharan African population with and without an ITN intervention. The rebound rate, defined as the percentage increase in age-specific all-cause mortality and malaria specific-morbidity, was varied to estimate the threshold at which the intervention was no longer cost-effective. Rebound was considered over two possible age ranges: 5-9 years and 3-6 years. With mortality and morbidity reductions due to ITNs in children aged 1-59 months and rebound in the 5-9 years age class, one could be reasonably certain that the cost per DALY averted is below $150 up to a rebound rate of 39%. Up to an 84% rebound rate it is highly likely that the intervention will be DALY-averting, that is the DALYs averted by the intervetion outweigh DALYs incurred through rebound effects. These thresholds are sensitive to the age range over which reductions and rebound in morbidity and mortality occur. With reductions confined to children aged 1-35 months and rebound in the 3-6 years age class, the cost per DALY is highly likely to fall below $150 only up to a 2.5% rebound rate, and with a rate in excess of 11% one can no longer be reasonably certain that the intervention is DALY-averting. These rates apply to the whole population. If there is no rebound amongst children who did not comply with the intervention, the actual increases in morbidity and mortality required to reach these thresholds amongst compliers would be much higher. The age range over which rebound occurs is a critical determinant of the thresholds at which one can no longer be reasonably certain that ITNs remain cost-effective in the long term. Based on empirical estimates of age-specific malaria mortality in sub-Saharan Africa, it appears unlikely that this threshold rate would be reached if rebound occurs over the 5-9 years age range. By contrast, if rebound occurs over the ages of 3-6 years, the increase in mortality rates required to reach this threshold falls within the observed range of malaria-specific mortality rates for this age group. It is essential that long-term surveillance is included as part of ITN interventions, with particular attention to the age range over which rebound may occur.

Africa South of the Sahara↗