Improved equity in measles vaccination from integrating insecticide‐treated bednets in a vaccination campaign,Madagascar

Objective To evaluate the effect of integrating ITN distribution on measles vaccination campaign coverage in Madagascar. Methods Nationwide cross‐sectional survey to estimate measles vaccination coverage, nationally, and in districts with and without ITN integration. To evaluate the effect of ITN integration, propensity score matching was used to create comparable samples in ITN and non‐ITN districts. Relative risks (RR) and 95% confidence intervals (CI) were estimated via log‐binomial models. Equity ratios, defined as the coverage ratio between the lowest and highest household wealth quintile (Q), were used to assess equity in measles vaccination coverage. Results National measles vaccination coverage during the campaign was 66.9% (95% CI 63.0–70.7). Among the propensity score subset, vaccination campaign coverage was higher in ITN districts (70.8%) than non‐ITN districts (59.1%) (RR = 1.3, 95% CI 1.1–1.6). Among children in the poorest wealth quintile, vaccination coverage was higher in ITN than in non‐ITN districts (Q1; RR = 2.4, 95% CI 1.2–4.8) and equity for measles vaccination was greater in ITN districts (equity ratio = 1.0, 95% CI 0.8–1.3) than in non‐ITN districts (equity ratio = 0.4, 95% CI 0.2–0.8). Conclusion Integration of ITN distribution with a vaccination campaign might improve measles vaccination coverage among the poor, thus providing protection for the most vulnerable and difficult to reach children.     

Plasmodium infection,anaemia and mosquito net use among school children across different settings in Kenya

Objective To investigate risk factors, including reported net use, for Plasmodium infection and anaemia among school children and to explore variations in effects across different malaria ecologies occurring in Kenya. Methods This study analysed data for 49 975 school children in 480 schools surveyed during a national school malaria survey, 2008–2010. Mixed effects logistic regression was used to investigate factors associated with Plasmodium infection and anaemia within different malaria transmission zones. Results Insecticide‐treated net (ITN) use was associated with reduction in the odds of Plasmodium infection in coastal and western highlands epidemic zones and among boys in the lakeside high transmission zone. Other risk factors for Plasmodium infection and for anaemia also varied by zone. Plasmodium infection was negatively associated with increasing socio‐economic status in all transmission settings, except in the semi‐arid north‐east zone. Plasmodium infection was a risk factor for anaemia in lakeside high transmission, western highlands epidemic and central low‐risk zones, whereas ITN use was only associated with lower levels of anaemia in coastal and central zones and among boys in the lakeside high transmission zone. Conclusions The risk factors for Plasmodium infection and anaemia, including the protective associations with ITN use, vary according to malaria transmission settings in Kenya, and future efforts to control malaria and anaemia should take into account such heterogeneities among school children.     

Personal protection by long‐lasting insecticidal hammocks against the bites of forest malaria vectors

Objective In Southeast Asia, malaria vectors bite outside the houses before bedtime, and forest dwellers rarely use insecticide‐treated nets (ITNs). Thus, we tested the protection of long‐lasting insecticidal hammocks (LLIH) using Olyset? technology against exophagic vectors in two forest villages of Cambodia. Methods In each village, we conducted two entomological surveys (middle and end of the rainy season), each lasting 10 consecutive nights. These comprised human landing collections during the whole night by people sitting outside in the hammocks. Five households were selected per village, and for each household, two fixed positions were allocated: one for the control and one for the treated hammock. Results In total, 6449 mosquitoes were collected from control hammocks compared to 4481 in treated hammocks. Personal protection conferred by the hammocks was 46% (CI 95%: 35–55%) against the bites of Anopheles minimus. A significant reduction of An. dirus bites (46% CI 95%: 25–62%) was only observed at the end of the rainy season. An. maculatus and culicines bites were only reduced in one of the two study sites. Conclusion Even if this LLIH is not inducing full protection against the bites of malaria vectors, it could prove effective in protecting forest workers and villagers before sleeping time. LLIH can be an additional and valuable tool in eliminating artemisinin‐resistant malaria in the region.     

The Gates Malaria Partnership: a consortium approach to malaria research and capacity development

Recently, there has been a major increase in financial support for malaria control. Most of these funds have, appropriately, been spent on the tools needed for effective prevention and treatment of malaria such as insecticide‐treated bed nets, indoor residual spraying and artemisinin combination therapy. There has been less investment in the training of the scientists from malaria‐endemic countries needed to support these large and increasingly complex malaria control programmes, especially in Africa. In 2000, with support from the Bill & Melinda Gates Foundation, the Gates Malaria Partnership was established to support postgraduate training of African scientists wishing to pursue a career in malaria research. The programme had three research capacity development components: a PhD fellowship programme, a postdoctoral fellowship programme and a laboratory infrastructure programme. During an 8‐year period, 36 African PhD students and six postdoctoral fellows were supported, and two research laboratories were built in Tanzania. Some of the lessons learnt during this project – such as the need to improve PhD supervision in African universities and to provide better support for postdoctoral fellows – are now being applied to a successor malaria research capacity development programme, the Malaria Capacity Development Consortium, and may be of interest to other groups involved in improving postgraduate training in health sciences in African universities.     

Susceptibility status of malaria vectors to insecticides commonly used for malaria control in Tanzania

Objective The aim of the study was to monitor the insecticide susceptibility status of malaria vectors in 12 sentinel districts of Tanzania. Methods WHO standard methods were used to detect knock‐down and mortality in the wild female Anopheles mosquitoes collected in sentinel districts. The WHO diagnostic doses of 0.05% deltamethrin, 0.05% lambdacyhalothrin, 0.75% permethrin and 4% DDT were used. Results The major malaria vectors in Tanzania, Anopheles gambiae s.l., were susceptible (mortality rate of 98–100%) to permethrin, deltamethrin, lambdacyhalothrin and DDT in most of the surveyed sites. However, some sites recorded marginal susceptibility (mortality rate of 80–97%); Ilala showed resistance to DDT (mortality rate of 65% [95% CI, 54–74]), and Moshi showed resistance to lambdacyhalothrin (mortality rate of 73% [95% CI, 69–76]) and permethrin (mortality rate of 77% [95% CI, 73–80]). Conclusions The sustained susceptibility of malaria vectors to pyrethroid in Tanzania is encouraging for successful malaria control with Insecticide‐treated nets and IRS. However, the emergency of focal points with insecticide resistance is alarming. Continued monitoring is essential to ensure early containment of resistance, particularly in areas that recorded resistance or marginal susceptibility and those with heavy agricultural and public health use of insecticides.     

Spatial synchrony of malaria outbreaks in a highland region of Ethiopia

To understand the drivers and consequences of malaria in epidemic‐prone regions, it is important to know whether epidemics emerge independently in different areas as a consequence of local contingencies, or whether they are synchronised across larger regions as a result of climatic fluctuations and other broad‐scale drivers. To address this question, we collected historical malaria surveillance data for the Amhara region of Ethiopia and analysed them to assess the consistency of various indicators of malaria risk and determine the dominant spatial and temporal patterns of malaria within the region. We collected data from a total of 49 districts from 1999–2010. Data availability was better for more recent years and more data were available for clinically diagnosed outpatient malaria cases than confirmed malaria cases. Temporal patterns of outpatient malaria case counts were correlated with the proportion of outpatients diagnosed with malaria and confirmed malaria case counts. The proportion of outpatients diagnosed with malaria was spatially clustered, and these cluster locations were generally consistent from year to year. Outpatient malaria cases exhibited spatial synchrony at distances up to 300 km, supporting the hypothesis that regional climatic variability is an important driver of epidemics. Our results suggest that decomposing malaria risk into separate spatial and temporal components may be an effective strategy for modelling and forecasting malaria risk across large areas. They also emphasise both the value and limitations of working with historical surveillance datasets and highlight the importance of enhancing existing surveillance efforts.     

Ownership and use of insecticide-treated nets in Oromia and Amhara regional states of Ethiopia two years after a nationwide campaign

Objective To evaluate the ownership and use of insecticide‐treated nets (ITNs) by the local community 2 years after a free distribution campaign in Ethiopia. Methods This is a population‐based survey using a two‐stage cluster sample design in 115 randomly selected clusters in Oromia and Amhara regional states of Ethiopia, performed in June 2009. Data on the possession and use of ITNs were collected using structured and pre‐tested questionnaires through house‐to‐house visits. Bivariate and multivariate logistic regression analyses were performed to examine the effect of participant’s malaria knowledge, location and ITN characteristics on the use of ITNs. Results A total of 2874 households participated in the study, and 90.6% of the study population was knowledgeable about ITNs. About 49.1% of households reported at least one ITN; 28.4% owned two or more. ITN coverage was significantly lower in Oromia (34.9%) than in Amhara (76.8%, P < 0.001). The average number of ITNs per ITN‐owning household was 1.8. In all surveyed households, only 21.8% of all family members, 29.4% of all children under the age of 5 years and 23.2% of all pregnant women had slept under an ITN the night preceding the survey. Among ITN‐owning households, 63.0% of all children under the age of 5 years and 52.1% of pregnant women had slept under an ITN the night before the survey. Using multivariate analysis, factors significantly associated with ITN use were number of ITNs in the household, number of ITNs hung over the bed in the household, women’s knowledge of ITNs and women’s lack of problem in using ITNs, whereas region, area of residence and ITN status were not. Conclusions Household ITN ownership and use remain below the current Roll Back Malaria targets of universal coverage. A replacement strategy is urgently needed to scale‐up coverage and use of ITNs.     

Research capacity for institutional collaboration in implementation research on diseases of poverty

Objective To assess the capacity for research collaboration and implementation research in strengthening networks and institutions in developing countries. Methods Bibliometric analysis of implementation research on diseases of poverty in developing countries from 2005 to 2010 through systematically searching bibliographic databases. Methods identified publication trends, participating institutions and countries and the cohesion and centrality of networks across diverse thematic clusters. Results Implementation research in this field showed a steadily growing trend of networking, although networks are loose and a few institutions show a high degree of centrality. The thematic clusters with greatest cohesion were for tuberculosis and malaria. Conclusions The capacity to produce implementation research on diseases of poverty is still low, with the prominence of institutions from developed countries. Wide ranges of collaboration and capacity strengthening strategies have been identified which should be put into effect through increased investments.     

Long‐lasting insecticide–treated net usage in eastern Sierra Leone – the success of free distribution

Objective Médecins Sans Frontières (MSF) runs a malaria control project in Bo and Pujehun districts (population 158 000) that includes the mass distribution, routine delivery and demonstration of correct use of free, long‐lasting insecticide–treated nets (LLINs). In 2006/2007, around 65 000 LLINs were distributed. The aim of this follow‐up study was to measure LLIN usage and ownership in the project area. Methods Heads of 900 randomly selected households in 30 clusters were interviewed, using a standardized questionnaire, about household use of LLINs. The condition of any LLIN was physically assessed. Results Of the 900 households reported, 83.4% owning at least one LLIN. Of the 16.6% without an LLIN, 91.9% had not participated in the MSF mass distribution. In 94.1% of the households reporting LLINs, the nets were observed hanging correctly over the beds. Of the 1135 hanging LLINs, 75.2% had no holes or 10 or fewer finger‐size holes. The most common source of LLINs was MSF (75.2%). Of the 4997 household members, 67.2% reported sleeping under an LLIN the night before the study, including 76.8% of children under 5 years and 73.0% of pregnant women. Conclusion Our results show that MSF achieved good usage with freely distributed LLINs. It is one of the few areas where results almost achieve the new targets set in 2005 by Roll Back Malaria to have at least 80% of pregnant women and children under 5 years using LLINs by 2010.