10 research outputs found
Comparative population structure of <i>Plasmodium malariae</i> and <i>Plasmodium falciparum</i> under different transmission settings in Malawi
No full text<b>Background:</b> Described here is the first population genetic study of Plasmodium malariae, the causative agent of quartan malaria. Although not as deadly as Plasmodium falciparum, P. malariae is more common than previously thought, and is frequently in sympatry and co-infection with P. falciparum, making its study increasingly important. This study compares the population parameters of the two species in two districts of Malawi with different malaria transmission patterns - one seasonal, one perennial - to explore the effects of transmission on population structures.
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<b>Methods:</b> Six species-specific microsatellite markers were used to analyse 257 P. malariae samples and 257 P. falciparum samples matched for age, gender and village of residence. Allele sizes were scored to within 2 bp for each locus and haplotypes were constructed from dominant alleles in multiple infections. Analysis of multiplicity of infection (MOI), population differentiation, clustering of haplotypes and linkage disequilibrium was performed for both species. Regression analyses were used to determine association of MOI measurements with clinical malaria parameters.
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<b>Results:</b> Multiple-genotype infections within each species were common in both districts, accounting for 86.0% of P. falciparum and 73.2% of P. malariae infections and did not differ significantly with transmission setting. Mean MOI of P. falciparum was increased under perennial transmission compared with seasonal (3.14 vs 2.59, p = 0.008) and was greater in children compared with adults. In contrast, P. malariae mean MOI was similar between transmission settings (2.12 vs 2.11) and there was no difference between children and adults. Population differentiation showed no significant differences between villages or districts for either species. There was no evidence of geographical clustering of haplotypes. Linkage disequilibrium amongst loci was found only for P. falciparum samples from the seasonal transmission setting.
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<b>Conclusions:</b> The extent of similarity between P. falciparum and P. malariae population structure described by the high level of multiple infection, the lack of significant population differentiation or haplotype clustering and lack of linkage disequilibrium is surprising given the differences in the biological features of these species that suggest a reduced potential for out-crossing and transmission in P. malariae. The absence of a rise in P. malariae MOI with increased transmission or a reduction in MOI with age could be explained by differences in the duration of infection or degree of immunity compared to P. falciparum
Effect of transmission setting and mixed species infections on clinical measures of malaria in Malawi
No full text<p>Background: In malaria endemic regions people are commonly infected with multiple species of malaria parasites but the clinical impact of these Plasmodium co-infections is unclear. Differences in transmission seasonality and transmission intensity between endemic regions have been suggested as important factors in determining the effect of multiple species co-infections.</p>
<p>Principal Findings: In order to investigate the impact of multiple-species infections on clinical measures of malaria we carried out a cross-sectional community survey in Malawi, in 2002. We collected clinical and parasitological data from 2918 participants aged >6 months, and applied a questionnaire to measure malaria morbidity. We examined the effect of transmission seasonality and intensity on fever, history of fever, haemoglobin concentration ([Hb]) and parasite density, by comparing three regions: perennial transmission (PT), high intensity seasonal transmission (HIST) and low intensity seasonal transmission (LIST). These regions were defined using multi-level modelling of PCR prevalence data and spatial and geo-climatic measures. The three Plasmodium species (P. falciparum, P. malariae and P. ovale) were randomly distributed amongst all children but not adults in the LIST and PT regions. Mean parasite density in children was lower in the HIST compared with the other two regions. Mixed species infections had lower mean parasite density compared with single species infections in the PT region. Fever rates were similar between transmission regions and were unaffected by mixed species infections. A history of fever was associated with single species infections but only in the HIST region. Reduced mean [Hb] and increased anaemia was associated with perennial transmission compared to seasonal transmission. Children with mixed species infections had higher [Hb] in the HIST region.</p>
<p>Conclusions: Our study suggests that the interaction of Plasmodium co-infecting species can have protective effects against some clinical outcomes of malaria but that this is dependent on the seasonality and intensity of malaria transmission.</p>
Fever and its treatment among the more and less poor in Sub-Saharan Africa
No full textThe author empirically explores the relationship between household poverty and the incidence and treatment of fever--as an indicator of malaria--among children in Sub-Saharan Africa. He uses household Demographic and Health Survey data collected in the 1990s from 22 countriesin which malaria is prevalent. The analysis reveals a positive, but weak, association between reported fever and poverty. The geographic association becomes insignificant, however, after controlling for the mother's education. There is some evidence that higher levels of wealth in other households in the cluster in which the household lives are associated with lower levels of reported fever in Eastern and Southern Africa. Poverty and the type of care sought for an episode of fever are significantly associated: wealthier households are substantially more likely to seek care in the modern health sector. In Central and Western Africa those from richer households are more likely to seek care from all types of sources: government hospitals, lower-level public facilities such as health clinics, as well as private sources. In Eastern and Southern Africa the rich are primarily more likely to seek care from private facilities. In both regions there is substantial use of private facilities--use that increases with wealth. Like the incidence of fever, treatment-seeking behavior is strongly associated with the level of wealth in the cluster in which the child lives.Disease Control&Prevention,Health Systems Development&Reform,Public Health Promotion,Health Monitoring&Evaluation,Early Child and Children's Health,Health Monitoring&Evaluation,Poverty Assessment,Communicable Diseases,Statistical&Mathematical Sciences,Health Indicators
Insecticide‐treated bednet use, anaemia, and malaria parasitaemia in Blantyre District, Malawi
No full textAssociations between Peripheral Plasmodium falciparum Malaria Parasitemia, Human Immunodeficiency Virus, and Concurrent Helminthic Infection among Pregnant Women in Malawi
No full textAzithromycin-chloroquine and the intermittent preventive treatment of malaria in pregnancy.
No full textIn the high malaria-transmission settings of sub-Saharan Africa, malaria in pregnancy is an important cause of maternal, perinatal and neonatal morbidity. Intermittent preventive treatment of malaria in pregnancy (IPTp) with sulphadoxine-pyrimethamine (SP) reduces the incidence of low birth-weight, pre-term delivery, intrauterine growth-retardation and maternal anaemia. However, the public health benefits of IPTp are declining due to SP resistance. The combination of azithromycin and chloroquine is a potential alternative to SP for IPTp. This review summarizes key in vitro and in vivo evidence of azithromycin and chloroquine activity against Plasmodium falciparum and Plasmodium vivax, as well as the anticipated secondary benefits that may result from their combined use in IPTp, including the cure and prevention of many sexually transmitted diseases. Drug costs and the necessity for external financing are discussed along with a range of issues related to drug resistance and surveillance. Several scientific and programmatic questions of interest to policymakers and programme managers are also presented that would need to be addressed before azithromycin-chloroquine could be adopted for use in IPTp
Malaria Control Dynamics in Rural Tanzania: Evaluation\ud of implementation of Artemisinin based Anti-malarial\ud Combination Therapy
No full textMalaria is the most important parasitic disease caused by protozoans of the genus plasmodia that are transmitted by female anophelene mosquitoes. Plasmodium falciparum is the most important species owing to its distribution, virulence and pathogenicity. World-wide some 500 million infections, 200-300 million episodes and about 1 million malaria-related deaths occur every year amounting to a burden of some 45 million DALYs (Disability Adjusted Life Years) [1]. At least 80% of this intolerable burden is concentrated in Sub-Saharan Africa with young children bearing the biggest share. In Tanzania, malaria accounts for not less than 30% of the country’s burden of disease [2]. Malaria can be cured if it is diagnosed and treated rapidly with effective drugs. Delay in diagnosis and treatment leads to the progression of disease and eventually death. Chloroquine and salfudoxine-pyremethamine (SP) had for a long time been the first-line treatment of choice for most endemic African countries but these drugs are no longer effective for treating patients in many parts owing to the development of resistance [3]. Artemisinin based Combination Therapy (ACT) is now widely recommended as the first-line treatment of choice owing to its efficacy, safety profile and the fact that no resistance has, so far, been described. Regarding prevention of malaria infections, Insecticide Treated Nets (ITNs) play the key role, while Indoor Residual Spraying (IRS) and elimination of mosquito breeding sites using larvicides are additional tools for integrated malaria control that can be applied dependant on local conditions. As a reaction to the growing resistance of malaria parasites to Chloroquine and SP, and when ACTs were being considered for first-line treatment, the Interdisciplinary Monitoring Project for Anti-malarial Combination Therapy for Tanzania (IMPACT-Tz) was designed to evaluate the effectiveness of ACT introduction and application in the Rufiji, Kilombero and Ulanga districts within the Coast and Morogoro Regions of Southern Tanzania. The present thesis was undertaken within the frame of IMPACT-Tz from 2001- 2006 with the following aims: (i) Describing patients’ adherence to ACT (ii) Following the dynamics of parasite prevalence during ACT promotion and use (iii) Analyzing the project’s impact on health facility use, and ITN coverage and its concomitant delivery strategies within the study areas of IMPACT-Tz . The present studies were based on the demographic surveillance systems which have been well established within the studied districts for many years. We conducted the study assessments using questionnaires to members of sampled households, key informant interviews and analyzed blood specimens that we concurrently collected during the interviews. Follow up visits to the homes of patients who had been treated with ACT at health facilities was the main method that we used to analyze patients’ adherence. Patients’ adherence to ACT showed very promising results with 75% reaching complete adherence as established by self-reporting and tablet counts. These results were substantially better than reported elsewhere and compared favorably with former intervention studies to optimize adherence to chloroquine. ITN coverage continuously increased through mixed delivery strategies involving free distribution during an immunization campaign combined with social marketing and a voucher system. All delivery mechanisms, especially sale of nets at full market price, tended to under-serve the poorest. Voucher-subsidized and freely distributed nets did not appear to create inequalities. In 2005, overall net use reached 62.7% and that among infants 87.2%. Thirty percent of all nets had been treated six months prior to the interview. The parasite prevalence declined over the study period and was clearly related to the interventions. In 2001, parasite prevalence was 26% in the general population of Rufiji and 18% in Ifakara. Following the deployment of ACT in 2003, there was a sharp decline of malaria prevalence from 29% in 2002 to 19% in 2004 in Rufiji. It remained the same in 2005 and decreased to 15% in 2006. The respective estimates for Ifakara were 22% in 2002, 25% in 2004, 11% in 2005 and 14% in 2006. The prevalence of anaemia (Hb<8g/dl) measured from 2004 to 2006 showed a drop from 23% in 2004 to 16% in 2005 and 2006 in Rufiji. Respective values for Ifakara were 12%, 18% and 10%. Use of any nets increased from 18% in 2001 to 63% in 2006 in Rufiji and from 69% to 86% in Ifakara. Treatment-seeking also changed with the introduction of AC. Starting with 31- 35% of febrile episodes seen at health facility level at the beginning of the study, an increase to up to 45% was observed as a consequence of ACT introduction. Treatment seeking in the comparison district where SP was still used as first-line treatment as stipulated in the national policy, treatment-seeking showed fluctuations but remained basically unchanged. Young children were those most seen with febrile episodes. The least poor showed higher health facility usage than the poorest segments of the population. Our study suggests that ACT first-line therapy is an accepted and feasible approach that can reduce both the burden of disease and transmission when ACT is offered at health facility level. ACT was effective as part of an integrated approach that also entailed the promotion of ITNs. The study further demonstrated that high levels of adherence to ACT can be reached provided treatment is preceded by sufficient health worker training together with innovative information, education and communication. Provision of ACT at health facilities improves the use of health facilities in a broad sense. Achieving and sustaining broad access to ACTs will require other strategies for ACT delivery that include all providers of services and may include home-based management in order to reach all segments of a population and, thus, to achieve equitable access. There are additional other important issues that need to be investigated further such as how ACTs can be effectively made available to all possible health service providers in a given area, also including possible home management strategies to achieve broad and equitable access to rapid diagnosis and treatment. Finally we need to understand to what extent synergies are created when different sets of malaria control interventions are implemented concomitantly and/or sequentially with different time-space dynamics of coverage. Such information is critical for tailoring strategies to different endemic settings and for moving from control towards elimination. References 1. Breman JG, Egan A, Keutsch GT: The intolerable burden of malaria: a new look at the numbers. American Journal of Tropical Medicine and Hygiene 2001, 64 (Supplement 1)(1,2):iv-vii. 2. De Savigny D, Kasale H: New weapons in the war on malaria. 2004. 3. Bloland PB: Making malaria treatment policy in the face of drug resistance. Annals of Tropical Medicine And Parasitology 1999, 93(1):5-23. Zusammenfassung Malaria ist die wichtigste parasitäre Erkrankung, welche durch die Protozoen der Gattung Plasmodia verursacht wird. Die Plasmodien werden durch die weiblichen Moskitos der Gattung Anopheles übertragen. Plasmodium falciparum ist die wichtigste Spezies aufgrund ihrer Verbreitung, Virulenz und Pathogenität. Weltweit gibt es geschätzte 500 Millionen Infizierte, wobei etwa 200-300 Millionen Episoden und 1 Million Tote jedes Jahr durch Malaria verursacht werden, was 45 Millionen DALYs (Disability Adjusted Life Years) entspricht. Mindestens 80% von dieser Krankheitslast konzentriert sich auf Afrika südlich der Sahara und dort wiederum insbesondere auf junge Kinder. In Tansania ist Malaria für nicht weniger als 30% der gesamten nationalen Krankheitslast verantwortlich. Malaria kann geheilt werden, wenn die Krankheit rechtzeitig diagnostiziert und mit wirksamen Medikamenten behandelt wird. Verzögerungen in der Diagnose oder Behandlung können zu einem Fortschreiten der Krankheit und letztlich zum Tod führen. Chloroquine und Salfudoxine-Pyremethamine (SP) waren lange Zeit in den meisten endemischen Ländern in Afrika als Erstbehandlung vorgesehen, sind aber heute aufgrund von zunehmenden Resistenzen vielerorts nicht mehr wirksam. Wegen ihrer Wirksamkeit, ihres Sicherheitsprofils und bisher noch nicht aufgetretenen Resistenzbildungen wird deshalb heutzutage die so genannte Artemisinin-based Combination Therapy (ACT) als Erstbehandlung empfohlen. In Bezug auf die Prävention spielen Insecticide Treated Nets (ITN) eine Schlüsselrolle. Indoor Residual Spraying (IRS) sowie das Eliminieren von Moskitobrutstätten mit Larviziden sind zusätzliche Massnahmen für eine lokal angepasste, integrierte Malariakontrolle. Als Reaktion auf die zunehmende Resistenz der Malaria-Erreger gegenüber Chloroquine und SP wurde der Einsatz von ACT als neue Methode der Erstbehandlung in Betracht gezogen. Um die Wirksamkeit von ACT im Rufiji, Kilombero und Ulanga Distrikt in der Küsten- und der Morogoro-Region im Süden von Tansania zu evaluieren, wurde das Interdisciplinary Monitoring Project for Anti-malarial Combination Therapy for Tanzania (IMPACT-Tz) konzipiert. Die vorliegende Doktorarbeit wurde im Rahmen von IMPACT-Tz zwischen 2001 und 2006 durchgeführt und beabsichtigte innerhalb des IMPACT-Tz Studiengebietes (i) die Befolgung der ACT durch die Patienten zu beschreiben, (ii) die Dynamik der Parasiten-Prävalenz während der ACT Förderung und Anwendung zu beschreiben, (iii) den Einfluss des Projekts auf die Nutzung von Gesundheitseinrichtungen und ITNs unter Berücksichtigung von deren Verfügbarkeit und Belieferungsstrategien zu analysieren. Die Studien stützten sich auf die seit einigen Jahren in den Studiengebieten etablierten Demographic Surveillance Systems (DSS). Zur Durchführung der Studien befragten wir Mitglieder von ausgewählten Haushalten mit Hilfe von Fragebogen, führten Interviews mit Key Informants und analysierten Blutproben, welche gleichzeitig mit den Interviews eingesammelt wurden. Hausbesuche bei Patienten, welche in den Gesundheitseinrichtungen mit ACT behandelt wurden, waren die grundlegende Methode um die Befolgung der Therapie durch die Patienten zu beschreiben. Die Resultate zur Befolgung der ACT-Therapie durch die Patienten waren viel versprechend. Gemessen an den Aussagen der Patienten und dem Auszählen der Tabletten befolgten 75% der Patienten die Therapie vollständig. Diese Resultate waren deutlich besser als anderswo und auch besser als Resultate von früheren Interventionsstudien zur Optimierung der Befolgung von Chloroquine- Behandlungen. Der Deckungsgrad mit ITNs stieg kontinuierlich dank einer gemischten Belieferungsstrategie, welche eine Gratis-Verteilung während Impfkampagnen mit Massnahmen des Social Marketing und einem Gutschein-System kombinierte. Alle Belieferungsmechanismen und insbesondere der Verkauf von ITNs zu Marktpreisen tendierten dazu die Ärmsten unterzuversorgen. Durch Gutscheine subventionierte und gratis verteilte Netze schienen am wenigsten Ungleichheiten zu erzeugen. Gesamthaft erreichte der Anteil von Netzbenutzer im Jahr 2005 62.7% und sogar 87.2% bei Kindern. Dreissig Prozent aller Netze wurde in den letzten sechs Monaten vor dem Interview mit Insektizid behandelt. Die Parasiten-Prävalenz war eindeutig mit den Interventionen verbunden und nahm im Verlauf der Studien ab. 2001 betrug die Prävalenz 26% in der allgemeinen Bevölkerung von Rufiji und 18% in Ifakara. Nach dem Start der ATC-Anwendung 2003 sank die Malaria-Prävalenz in Rufiji von 29% im Jahr 2002 auf 19% im Jahr 2004 deutlich, blieb im Jahr 2005 konstant und sank schliesslich noch einmal auf 15% im Jahr 2006. Dieselben Schätzungen für Ifakara sind 22% 2002, 25% 2004, 11% 2005 und 14% 2006. Die Anaemie- Prävalenz (Hb<8g/dl) in Rufiji sank von 23% 2004 auf 16% 2005 und 2006. Dieselben Werte für Ifakara liegen bei 12%, 18% und 10%. In Rufiji nahm die Anwendung von Moskitonetzen aller Art von 18% im Jahr 2001 auf 63% im Jahr 2006 zu und in Ifakara von 69% auf 86%. Durch die Einführung von ACTs änderte sich auch das so genannte Treatment- Seeking. Als Konsequenz der Einführung von ACTs stieg der Anteil Fieberepisoden, welche auch zu den Gesundheitseinrichtungen gelangten, von 31-35% auf 45% im Verlauf der Studien. Treatment-Seeking in einem Vergleichsdistrikt, wo gemäss der nationalen Strategie immer noch SP als Erstbehandlung verwendet wurde, zeigte zwar Fluktuationen, blieb aber im Wesentlichen unverändert. Im Zusammenhang mit Fieberepisoden wurden am häufigsten junge Kinder festgestellt. Die reichsten Bevölkerungssegmente benützten die Gesundheitseinrichtungen häufiger als die ärmsten. Unsere Studien zeigen, dass ACT als Erstbehandlung in Gesundheitseinrichtungen ein akzeptierter und realisierbarer Ansatz ist, der sowohl die Krankheitslast als auch die Krankheitsübertragung einschränken kann. ACT war wirksam als ein Teil eines integrierten Ansatzes, der auch die Förderung von ITNs beinhaltete. Die Studien zeigen auch, dass eine gute Befolgung der ACT erreicht werden kann, wenn den Behandlungen ein ausreichendes Training des Gesundheitspersonals und innovative Informations-, Aufklärungs- und Kommunikationsmassnahmen vorangehen. Die Bereitstellung von ACT in Gesundheitseinrichtungen verbessert die Nutzung dieser Einrichtungen in vielerlei Hinsicht. Zur Erreichung und Gewährleistung eines breiten Zugangs zu ACTs sind aber auch andere Abgabestrategien nötig, welche alle Anbieter von Gesundheitsleistungen mit einschliessen und für die bessere Erreichbarkeit und Zugangsgerechtigkeit auch heimbasierte Behandlungen zulassen. Dementsprechend gibt es wichtige Probleme, welche weitere Forschungsanstrengungen benötigen. Wie zum Beispiel können ACTs wirksam und unter Berücksichtigung sowohl aller Anbieter von Gesundheitsleistungen in einem bestimmten Gebiet als auch aller Möglichkeiten der heimbasierten Behandlung zur Verfügung gestellt werden, so dass ein möglichst breiter und gerechter Zugang zu schnellen Diagnosen und Behandlungen erreicht werden kann? Zudem sollten wir Synergien, welche entstehen, wenn verschiedene Malariakontrollinterventionen begleitend und/oder einander nachfolgend in unterschiedlichen Zeit-Raum-Dynamiken der Abdeckung implementiert werden, besser verstehen. Diese Informationen sind entscheidend um massgeschneiderte Strategien für verschiedene endemische Situationen zu entwerfen und um einen Schritt von der Malariakontrolle hin zur Malariaelimination zu machen. MUHTASARI Ugonjwa wa malaria huambukizwa na vimelea vya aina ya P.Falciparum. Vimelea hivi huenezwa na mbu wa kike wa aina ya anophelene. Vimelea hivi vya P.Falciparum vina usumbufu wa kipekee kwa vile vipo maeneo mengi na vinazaliana haraka haraka na kuzaa ugonjwa mbaya. Kila mwaka wata wapatao millioni 500 humbukizwa vimelea ambapo wagonjwa baina ya millioni 200 mpaka 300 huugua ugonjwa wa malaria na kiasi ya wagonjwa millioni moja hufa kote duniani. Jumla ya maisha ya binadamu inayopotea kutokana na vifo na kuugua ugonjwa huu inakadiriwa kufikia miaka millioni 45. Kiasi ya asilimia thamanini ya hasara hii hupatikana katika bara la Africa na wanaoathirika zaidi ni watoto wadogo wadogo. Nchini Tanzania kiasi ya asilimia thelathini ya hasara iletwayo na magonjwa husababishwa na malaria. Ugonjwa wa malaria unaweza kutambulika na kutibika kwa haraka kwa dawa imara. Ugonjwa huu hugeuka kuwa hatari sana na kusababisha vifo vingi ikiwa matibabu yake yatacheleweshwa. Dawa za Chloroquine na salfadoxinepyremethamine (SP) ambazo kwa muda mrefu zilikuwa zinatumika kutibia ugonjwa huu katika nchi za Africa zenye kuambukizwa zaidi, sasa hivi hazifanyi tena kazi kwa sababu ya usugu wa vimelea. Dawa za mseto zenye mchanganyiko wa artemisinin (ACT) sasa hivi zinapendekezwa zaidi kutokana na kuthibitika uimara na usalama na kwa vile kwa sasa hakuna matokeo ya usugu wa vimelea uliotolewa taarifa. Pamoja na hayo, Ugonjwa wa malaria unakingika kwa kutumia vyandarua vyenye viatilifu (ITN), dawa za kunyunyiza majumbani na kuuwa mayai ya mbu kwa kutumia dawa katika mazalia ya mbu. Katika kipindi ambapo dawa za Chloroquine na SP zilikuwa zinashindwa kwa kasi kubwa kuponesha ugonjwa wa malaria, mradi wa kutathmini dawa mseto za malaria (IMPACT-TZ) ulibuniwa na ulifanya tathmini ya dawa mseto katika wilaya za Rufiji, Kilomber
Malaria control dynamics in rural Tanzania : evaluation of implementation of artemisinin based anti-malarial combination therapy
No full textMalaria is the most important parasitic disease caused by protozoans of the
genus plasmodia that are transmitted by female anophelene mosquitoes.
Plasmodium falciparum is the most important species owing to its distribution,
virulence and pathogenicity. World-wide some 500 million infections, 200-300
million episodes and about 1 million malaria-related deaths occur every year
amounting to a burden of some 45 million DALYs (Disability Adjusted Life Years)
[1]. At least 80% of this intolerable burden is concentrated in Sub-Saharan Africa
with young children bearing the biggest share. In Tanzania, malaria accounts for
not less than 30% of the country’s burden of disease [2].
Malaria can be cured if it is diagnosed and treated rapidly with effective drugs.
Delay in diagnosis and treatment leads to the progression of disease and
eventually death. Chloroquine and salfudoxine-pyremethamine (SP) had for a
long time been the first-line treatment of choice for most endemic African
countries but these drugs are no longer effective for treating patients in many
parts owing to the development of resistance [3]. Artemisinin based Combination
Therapy (ACT) is now widely recommended as the first-line treatment of choice
owing to its efficacy, safety profile and the fact that no resistance has, so far,
been described.
Regarding prevention of malaria infections, Insecticide Treated Nets (ITNs) play
the key role, while Indoor Residual Spraying (IRS) and elimination of mosquito
breeding sites using larvicides are additional tools for integrated malaria control
that can be applied dependant on local conditions.
As a reaction to the growing resistance of malaria parasites to Chloroquine and
SP, and when ACTs were being considered for first-line treatment, the
Interdisciplinary Monitoring Project for Anti-malarial Combination Therapy for
Tanzania (IMPACT-Tz) was designed to evaluate the effectiveness of ACT
introduction and application in the Rufiji, Kilombero and Ulanga districts within the
Coast and Morogoro Regions of Southern Tanzania.
The present thesis was undertaken within the frame of IMPACT-Tz from 2001-
2006 with the following aims:
(i) Describing patients’ adherence to ACT
(ii) Following the dynamics of parasite prevalence during ACT
promotion and use
(iii) Analyzing the project’s impact on health facility use, and ITN
coverage and its concomitant delivery strategies within the study areas of
IMPACT-Tz .
The present studies were based on the demographic surveillance systems which
have been well established within the studied districts for many years. We
conducted the study assessments using questionnaires to members of sampled
households, key informant interviews and analyzed blood specimens that we
concurrently collected during the interviews. Follow up visits to the homes of
patients who had been treated with ACT at health facilities was the main method
that we used to analyze patients’ adherence.
Patients’ adherence to ACT showed very promising results with 75% reaching
complete adherence as established by self-reporting and tablet counts. These
results were substantially better than reported elsewhere and compared
favorably with former intervention studies to optimize adherence to chloroquine.
ITN coverage continuously increased through mixed delivery strategies involving
free distribution during an immunization campaign combined with social
marketing and a voucher system. All delivery mechanisms, especially sale of
nets at full market price, tended to under-serve the poorest. Voucher-subsidized
and freely distributed nets did not appear to create inequalities. In 2005, overall
net use reached 62.7% and that among infants 87.2%. Thirty percent of all nets
had been treated six months prior to the interview.
The parasite prevalence declined over the study period and was clearly related to
the interventions. In 2001, parasite prevalence was 26% in the general
population of Rufiji and 18% in Ifakara. Following the deployment of ACT in 2003,
there was a sharp decline of malaria prevalence from 29% in 2002 to 19% in
2004 in Rufiji. It remained the same in 2005 and decreased to 15% in 2006. The
respective estimates for Ifakara were 22% in 2002, 25% in 2004, 11% in 2005
and 14% in 2006. The prevalence of anaemia (Hb<8g/dl) measured from 2004 to
2006 showed a drop from 23% in 2004 to 16% in 2005 and 2006 in Rufiji.
Respective values for Ifakara were 12%, 18% and 10%. Use of any nets
increased from 18% in 2001 to 63% in 2006 in Rufiji and from 69% to 86% in
Ifakara.
Treatment-seeking also changed with the introduction of AC. Starting with 31-
35% of febrile episodes seen at health facility level at the beginning of the study,
an increase to up to 45% was observed as a consequence of ACT introduction.
Treatment seeking in the comparison district where SP was still used as first-line
treatment as stipulated in the national policy, treatment-seeking showed
fluctuations but remained basically unchanged. Young children were those most
seen with febrile episodes. The least poor showed higher health facility usage
than the poorest segments of the population.
Our study suggests that ACT first-line therapy is an accepted and feasible
approach that can reduce both the burden of disease and transmission when
ACT is offered at health facility level. ACT was effective as part of an integrated
approach that also entailed the promotion of ITNs. The study further
demonstrated that high levels of adherence to ACT can be reached provided
treatment is preceded by sufficient health worker training together with innovative
information, education and communication. Provision of ACT at health facilities
improves the use of health facilities in a broad sense. Achieving and sustaining
broad access to ACTs will require other strategies for ACT delivery that include
all providers of services and may include home-based management in order to
reach all segments of a population and, thus, to achieve equitable access.
There are additional other important issues that need to be investigated further
such as how ACTs can be effectively made available to all possible health
service providers in a given area, also including possible home management
strategies to achieve broad and equitable access to rapid diagnosis and
treatment. Finally we need to understand to what extent synergies are created
when different sets of malaria control interventions are implemented
concomitantly and/or sequentially with different time-space dynamics of coverage.
Such information is critical for tailoring strategies to different endemic settings
and for moving from control towards elimination.
References
1. Breman JG, Egan A, Keutsch GT: The intolerable burden of malaria: a
new look at the numbers. American Journal of Tropical Medicine and
Hygiene 2001, 64 (Supplement 1)(1,2):iv-vii.
2. De Savigny D, Kasale H: New weapons in the war on malaria. 2004.
3. Bloland PB: Making malaria treatment policy in the face of drug resistance.
Annals of Tropical Medicine And Parasitology 1999, 93(1):5-23.
Zusammenfassung
Malaria ist die wichtigste parasitäre Erkrankung, welche durch die Protozoen der
Gattung Plasmodia verursacht wird. Die Plasmodien werden durch die weiblichen
Moskitos der Gattung Anopheles übertragen. Plasmodium falciparum ist die
wichtigste Spezies aufgrund ihrer Verbreitung, Virulenz und Pathogenität.
Weltweit gibt es geschätzte 500 Millionen Infizierte, wobei etwa 200-300
Millionen Episoden und 1 Million Tote jedes Jahr durch Malaria verursacht
werden, was 45 Millionen DALYs (Disability Adjusted Life Years) entspricht.
Mindestens 80% von dieser Krankheitslast konzentriert sich auf Afrika südlich der
Sahara und dort wiederum insbesondere auf junge Kinder. In Tansania ist
Malaria für nicht weniger als 30% der gesamten nationalen Krankheitslast
verantwortlich.
Malaria kann geheilt werden, wenn die Krankheit rechtzeitig diagnostiziert und
mit wirksamen Medikamenten behandelt wird. Verzögerungen in der Diagnose
oder Behandlung können zu einem Fortschreiten der Krankheit und letztlich zum
Tod führen. Chloroquine und Salfudoxine-Pyremethamine (SP) waren lange Zeit
in den meisten endemischen Ländern in Afrika als Erstbehandlung vorgesehen,
sind aber heute aufgrund von zunehmenden Resistenzen vielerorts nicht mehr
wirksam. Wegen ihrer Wirksamkeit, ihres Sicherheitsprofils und bisher noch nicht
aufgetretenen Resistenzbildungen wird deshalb heutzutage die so genannte
Artemisinin-based Combination Therapy (ACT) als Erstbehandlung empfohlen. In
Bezug auf die Prävention spielen Insecticide Treated Nets (ITN) eine
Schlüsselrolle. Indoor Residual Spraying (IRS) sowie das Eliminieren von
Moskitobrutstätten mit Larviziden sind zusätzliche Massnahmen für eine lokal
angepasste, integrierte Malariakontrolle.
Als Reaktion auf die zunehmende Resistenz der Malaria-Erreger gegenüber
Chloroquine und SP wurde der Einsatz von ACT als neue Methode der
Erstbehandlung in Betracht gezogen. Um die Wirksamkeit von ACT im Rufiji,
Kilombero und Ulanga Distrikt in der Küsten- und der Morogoro-Region im Süden
von Tansania zu evaluieren, wurde das Interdisciplinary Monitoring Project for
Anti-malarial Combination Therapy for Tanzania (IMPACT-Tz) konzipiert.
Die vorliegende Doktorarbeit wurde im Rahmen von IMPACT-Tz zwischen 2001
und 2006 durchgeführt und beabsichtigte innerhalb des IMPACT-Tz
Studiengebietes (i) die Befolgung der ACT durch die Patienten zu beschreiben, (ii)
die Dynamik der Parasiten-Prävalenz während der ACT Förderung und
Anwendung zu beschreiben, (iii) den Einfluss des Projekts auf die Nutzung von
Gesundheitseinrichtungen und ITNs unter Berücksichtigung von deren
Verfügbarkeit und Belieferungsstrategien zu analysieren. Die Studien stützten
sich auf die seit einigen Jahren in den Studiengebieten etablierten Demographic
Surveillance Systems (DSS). Zur Durchführung der Studien befragten wir
Mitglieder von ausgewählten Haushalten mit Hilfe von Fragebogen, führten
Interviews mit Key Informants und analysierten Blutproben, welche gleichzeitig
mit den Interviews eingesammelt wurden. Hausbesuche bei Patienten, welche in
den Gesundheitseinrichtungen mit ACT behandelt wurden, waren die
grundlegende Methode um die Befolgung der Therapie durch die Patienten zu
beschreiben.
Die Resultate zur Befolgung der ACT-Therapie durch die Patienten waren viel
versprechend. Gemessen an den Aussagen der Patienten und dem Auszählen
der Tabletten befolgten 75% der Patienten die Therapie vollständig. Diese
Resultate waren deutlich besser als anderswo und auch besser als Resultate von
früheren Interventionsstudien zur Optimierung der Befolgung von Chloroquine-
Behandlungen.
Der Deckungsgrad mit ITNs stieg kontinuierlich dank einer gemischten
Belieferungsstrategie, welche eine Gratis-Verteilung während Impfkampagnen
mit Massnahmen des Social Marketing und einem Gutschein-System kombinierte.
Alle Belieferungsmechanismen und insbesondere der Verkauf von ITNs zu
Marktpreisen tendierten dazu die Ärmsten unterzuversorgen. Durch Gutscheine
subventionierte und gratis verteilte Netze schienen am wenigsten Ungleichheiten
zu erzeugen. Gesamthaft erreichte der Anteil von Netzbenutzer im Jahr 2005
62.7% und sogar 87.2% bei Kindern. Dreissig Prozent aller Netze wurde in den
letzten sechs Monaten vor dem Interview mit Insektizid behandelt.
Die Parasiten-Prävalenz war eindeutig mit den Interventionen verbunden und
nahm im Verlauf der Studien ab. 2001 betrug die Prävalenz 26% in der
allgemeinen Bevölkerung von Rufiji und 18% in Ifakara. Nach dem Start der
ATC-Anwendung 2003 sank die Malaria-Prävalenz in Rufiji von 29% im Jahr
2002 auf 19% im Jahr 2004 deutlich, blieb im Jahr 2005 konstant und sank
schliesslich noch einmal auf 15% im Jahr 2006. Dieselben Schätzungen für
Ifakara sind 22% 2002, 25% 2004, 11% 2005 und 14% 2006. Die Anaemie-
Prävalenz (Hb<8g/dl) in Rufiji sank von 23% 2004 auf 16% 2005 und 2006.
Dieselben Werte für Ifakara liegen bei 12%, 18% und 10%. In Rufiji nahm die
Anwendung von Moskitonetzen aller Art von 18% im Jahr 2001 auf 63% im Jahr
2006 zu und in Ifakara von 69% auf 86%.
Durch die Einführung von ACTs änderte sich auch das so genannte Treatment-
Seeking. Als Konsequenz der Einführung von ACTs stieg der Anteil
Fieberepisoden, welche auch zu den Gesundheitseinrichtungen gelangten, von
31-35% auf 45% im Verlauf der Studien. Treatment-Seeking in einem
Vergleichsdistrikt, wo gemäss der nationalen Strategie immer noch SP als
Erstbehandlung verwendet wurde, zeigte zwar Fluktuationen, blieb aber im
Wesentlichen unverändert. Im Zusammenhang mit Fieberepisoden wurden am
häufigsten junge Kinder festgestellt. Die reichsten Bevölkerungssegmente
benützten die Gesundheitseinrichtungen häufiger als die ärmsten.
Unsere Studien zeigen, dass ACT als Erstbehandlung in
Gesundheitseinrichtungen ein akzeptierter und realisierbarer Ansatz ist, der
sowohl die Krankheitslast als auch die Krankheitsübertragung einschränken kann.
ACT war wirksam als ein Teil eines integrierten Ansatzes, der auch die
Förderung von ITNs beinhaltete. Die Studien zeigen auch, dass eine gute
Befolgung der ACT erreicht werden kann, wenn den Behandlungen ein
ausreichendes Training des Gesundheitspersonals und innovative Informations-,
Aufklärungs- und Kommunikationsmassnahmen vorangehen. Die Bereitstellung
von ACT in Gesundheitseinrichtungen verbessert die Nutzung dieser
Einrichtungen in vielerlei Hinsicht. Zur Erreichung und Gewährleistung eines
breiten Zugangs zu ACTs sind aber auch andere Abgabestrategien nötig, welche
alle Anbieter von Gesundheitsleistungen mit einschliessen und für die bessere
Erreichbarkeit und Zugangsgerechtigkeit auch heimbasierte Behandlungen
zulassen.
Dementsprechend gibt es wichtige Probleme, welche weitere
Forschungsanstrengungen benötigen. Wie zum Beispiel können ACTs wirksam
und unter Berücksichtigung sowohl aller Anbieter von Gesundheitsleistungen in
einem bestimmten Gebiet als auch aller Möglichkeiten der heimbasierten
Behandlung zur Verfügung gestellt werden, so dass ein möglichst breiter und
gerechter Zugang zu schnellen Diagnosen und Behandlungen erreicht werden
kann? Zudem sollten wir Synergien, welche entstehen, wenn verschiedene
Malariakontrollinterventionen begleitend und/oder einander nachfolgend in
unterschiedlichen Zeit-Raum-Dynamiken der Abdeckung implementiert werden,
besser verstehen. Diese Informationen sind entscheidend um
massgeschneiderte Strategien für verschiedene endemische Situationen zu
entwerfen und um einen Schritt von der Malariakontrolle hin zur Malariaelimination zu machen.
MUHTASARI
Ugonjwa wa malaria huambukizwa na vimelea vya aina ya P.Falciparum.
Vimelea hivi huenezwa na mbu wa kike wa aina ya anophelene. Vimelea hivi vya
P.Falciparum vina usumbufu wa kipekee kwa vile vipo maeneo mengi na
vinazaliana haraka haraka na kuzaa ugonjwa mbaya. Kila mwaka wata wapatao
millioni 500 humbukizwa vimelea ambapo wagonjwa baina ya millioni 200 mpaka
300 huugua ugonjwa wa malaria na kiasi ya wagonjwa millioni moja hufa kote
duniani. Jumla ya maisha ya binadamu inayopotea kutokana na vifo na kuugua
ugonjwa huu inakadiriwa kufikia miaka millioni 45. Kiasi ya asilimia thamanini ya
hasara hii hupatikana katika bara la Africa na wanaoathirika zaidi ni watoto
wadogo wadogo. Nchini Tanzania kiasi ya asilimia thelathini ya hasara iletwayo
na magonjwa husababishwa na malaria.
Ugonjwa wa malaria unaweza kutambulika na kutibika kwa haraka kwa dawa
imara. Ugonjwa huu hugeuka kuwa hatari sana na kusababisha vifo vingi ikiwa
matibabu yake yatacheleweshwa. Dawa za Chloroquine na salfadoxinepyremethamine
(SP) ambazo kwa muda mrefu zilikuwa zinatumika kutibia
ugonjwa huu katika nchi za Africa zenye kuambukizwa zaidi, sasa hivi hazifanyi
tena kazi kwa sababu ya usugu wa vimelea. Dawa za mseto zenye
mchanganyiko wa artemisinin (ACT) sasa hivi zinapendekezwa zaidi kutokana na
kuthibitika uimara na usalama na kwa vile kwa sasa hakuna matokeo ya usugu
wa vimelea uliotolewa taarifa. Pamoja na hayo, Ugonjwa wa malaria unakingika
kwa kutumia vyandarua vyenye viatilifu (ITN), dawa za kunyunyiza majumbani na
kuuwa mayai ya mbu kwa kutumia dawa katika mazalia ya mbu.
Katika kipindi ambapo dawa za Chloroquine na SP zilikuwa zinashindwa kwa
kasi kubwa kuponesha ugonjwa wa malaria, mradi wa kutathmini dawa mseto za
malaria (IMPACT-TZ) ulibuniwa na ulifanya tathmini ya dawa mseto katika wilaya
za Rufiji, Kilombero na Ulanga zilizopo mikoa ya Pwani na Morogoro nchini
Tanzania.
Kitabu hiki cha uhitimu wangu wa shahada ya udaktari wa falsafa katika fani ya
epidemiology kinatokana na utafiti uliofanywa chini ya muavuli wa mradi wa
IMPACT-Tz kati ya mwaka 2001 mpaka 2006. Madhumuni yake ni (i)kutathmini
jinsi wagonjwa wa malaria waliotibiwa kwa dawa mseto walivykuwa wakitumia
dawa hizo kwa usahihi; (ii) kufuatilia uwepo wa vimelea vya malaria katika kipindi
ambacho dawa mseto zilihamasishwa na kutumika; na (iii) kutafiti athari ya
utekelezaji wa mradi huu kwa matumizi ya vituo vya tiba na pia matumizi ya
vyandarua vyente viatilifu na mikakati mbali mbali ya kuvisambaza katika vijiji
vilivyokuwa kwenye mradi. Tathmini hizi zilifanywa katika vijiji vilivyo kwenye
mpango wa kufuatilia taarifa zinazohusu uhamiaji, uhamaji, vizazi na vifo (DSS
sites) katiak sehemu za Rufiji na Ifaka zilizo chini ya Taasisi ya Utafiti wa afya ya
binadamu ya Ifakara (IHI). Utaratibu huu wa DSS ulishakuwepo kwenye vijiji
hivyo kwa muda mrefu. Tulifanya utafiti huu kwa njia ya mahojiano na wanakaya
wa kaya ambazo zilichaguliwa kwa bahati nasibu na kwa kuhakiki matone ya
damu yaliyokuwa yakichukuliwa wakati wa mahojiano. Katika kuangalia matumizi
ya dawa mseto kwa usahihi, tulikuwa tunawazungukia wagonjwa waliokuwa
walishatibiwa kwa dawa mseto katika vituo vya tiba majumbani mwao na
kuwadodosa jinsi walivyokuwa wametumia dawa hizo.
Jumla ya wagonjwa 253 walifuatiliwa majumbani mwao kuulizwa maswali baada
ya masaa 24 na 48 tokea kwenda kituoni kupata matibabu. Ilionekana kuwa
asilimia 75 ya wagonjwa waliofuatiliwa baada ya masaa 48 walitumia dawa
mseto kiusahihi. Haya yalipimwa kwa kukehasabu idadi ya vidonge vilivyokuwa
vimebaki na taarifa za mgonjwa mwenyewe walipotembelewa majumbani mwao
na kudodoswa na wahojaji. Kwa kweli majibu haya ya wagonjwa kutumia dawa
mseto kiusahihi yalikuwa bora kuliko majibu yaliyokuya yamepatikana huko
nyuma katika tathmini ya dawa za Chloroquine
Matumizi ya vyandarua vyenye viatilifu yalikuwa yanaongezeka kutokana na
vyandaraua hivyo kusambazwa kwa kutumia njia mseto ambazo zilijumuisha
ugawaji wa vyandarua vya bure siku ya chanjo na kwa njia ya soko na hati
punguzo. Njia zote hizo hasa ile ya kuviuza vyandarua dukani haikuwanyanyua
sana watu maskini sana. Vyandarau vilivyotolewa bure na vile vilivyouzwa kwa
hati punguzo havikuonekana kuleta kutokuwepo na usawa. Katika mwaka 2005,
matumizi ya kila aina ya chandarua yalifikia silimia 63 na kwa watoto wachanga
peke yao yalifikia asilimia 87. Asilimia thelathini ya vyandarua vilikuwa
vimewekwa viatilifu kipindi cha miezi 6 kabla ya mahojiano.
Ama katika tathmini ya vimelea vya malaria katika jamii, tuliona kuwa mwaka
2001 uwepo wa vimelea ulikuw asilimia 26 ya watu wote katika DSS upande wa
Rufiji ikilinganishwa na asilimia 18 katika upande wa Ifakara. Uwepo wa vimelea
ulipungua hadi kufikia asilimia 19 mwaka 2004 kwa upande wa Rufiji baada ya
kanzishwa matibabu ya dawa mseto mwaka 2003. Katika mwaka 2002 uwepo
wa vimelea huko ulikuwa 29%. Baadae kiwango hicho cha mwaka 2004 huko
Rufiji kilibaki hivyo kwa mwaka 2005 na kushuka kufikia asilimia 15 mwaka 2006.
Tathmini ya Ifakara ilionesha kuwa uwepo wa vimelea ulikuwa 22% mwaka 2002,
25% katika mwaka 2004, 11% mwaka 2005 na 14% mwaka 2006. Kwa upande
wa upungufu wa damu mwilini , tathmini yetu iliyofanywa mwaka 2004 mpaka
2006 katika upande wa Rufiji ilionesha kuwa upungufu ulipungua kutoka asilimia
23 mwaka 2004 hadi 16% mwaka 2005 na 2006. Upande wa Ifakara hali ilikuwa
12% mwaka 2004, 18% mwaka 2005 na 10% mwaka 2006. Matumizi ya
vyandarua yaliongezeka huko Rufiji kutoka asilimia 18% mwaka 2001 na kufikia
asilimia 63 mwaka 2006. Na huko Ifakara matumizi yalikuwa asilimia 69 mwaka
2001 na kuongezeka kuwa asilimia 86 mwaka 2006.
Katika tathmini yetu ya kujua matumizi ya vituo vya matibabu kwa wale
waliosema waligua homa au malaria wiki mbili kabla ya mahojiano tuligundua
kwamba matumizi ya chanzo hicho yalikuwa 31% na 35% kwa mika ya 2001 na
2002 huko Rufiji. Hii ni miaka kabla ya kuanza kutibu malaria kwa kutumia dawa
mseto katika vituo vya afya sehemu hiyo. Matumizi yaliongezeka kufikia 45%
katika mwaka 2004, mwaka mmoja baada ya kuanza dawa hizo katika vituo vya
afya peke yake. Matumizi hayo yalipungua kidogo na kufikia 41% mwaka 2005.
Yalianguka zaidi mwaka 2006 kwa kufikia 30% tu. Kwa upande wa Ifakara
ambako wagonjwa waliendelea na sera ya serikali kwa nchi nzima ya matibabu
ya dawa isiyo ya mseto ya SP wakati ule , wagonjwa waliopata matibabu yao
kutoka vituo vya Afya yalikuwa 27% kunako mwaka 2001 na 33% katika mwaka
2002. Hali ilishuka na kufikia 29% kunako mwaka 2004 na kuongezeka kufikia
36% katika mwaka 2005 na kutokuwepo na mabadiliko katika mwaka 2006.
Katika kuhusisha matumizi haya ya vituo vya afya na rika za watu, watoto chini
ya miaka 5 walikuwa wanatumia vituo hivyo mara nyingi zaidi kuliko wenye umri
zaidi yao kutoka zote za Rufiji na Ifakara. Aidha, wale wenye unafuu wa maisha
walikuwa na fursa zaidi ya kutumia vituo vya matibabu kwa zaidi ya 50% ya wale
waliokuwa wanaishi maisha ya chini zaidi kutoka katika sehemu zot
Malaria control policies and strategies in Ghana: the level of community participation in the intersectoral collaboration
No full textFor more than a century now, malaria has been a major public health problem in Ghana which consequently has been one of the country’s sources of underdevelopment due to economic losses, high rate of morbidity and mortality. Faced with this problem, the last ten years has seen a commitment from the Ghanaian government to address the issue by establishing a policy that would transform the way the disease is prevented and controlled. The transformation of the management of the disease by the use of intersectoral collaboration strategy (ISC) was to ensure the inclusion of the grass root community members who were hitherto excluded from participating in policymaking process of the national malaria control programme (NMCP) activities. The idea was that by allowing the communities to participate, members would be empowered to have ownership of programme activities, could accept the challenges associated with the control of the disease, and above all contribute more effectively to the success of the policy goal of minimising the persistence of malaria in Ghana.However, over ten years now, no systematic study has been done to access the extent to which this policy goal has been rhetoric or a reality. This thesis therefore seeks to examine this vision by investigating the extent to which the community members are allowed by the health authorities to participate in this policy strategy. Drawing on the case studies in the rural and urban districts in Ghana, the practical reality of the degree of community participation in ISC has been explored. In addition, the roles played by the community members in malaria control programme activities were examined with the aim of understanding the importance of communities in malaria control efforts. Finally, the barriers to participation as well as the extent of the institutional involvement in ISC and its possibility to facilitate community participation have also been examined.Overall, the evidence from the study findings demonstrated that the established strategy of ISC has not significantly promoted community participation in the NMCP activities. While the communities were consulted on malaria issues, they were often excluded from the final decision-making on issues that needed to be acted upon. Consequently, the communities have no guarantee that their views will be considered during the final deliberation in which they have little or no part to play. In spite of this, the study found that through various ways, the community members had been playing a number of significant roles in the control activities. These roles included: supporting health staff in their outreach services, contributing in managing the environment, providing assistance in the monitoring and evaluation of malaria programmes and finally assisting victims to cope with the disease. The findings also indicated that without a number of barriers, certain existing contextual factors (e.g. good level of horizontal integration and political structures and social-cultural institutions) potentially could have contributed to the community participation. From the views of health officials, these barriers were the powers of central bureaucratic structures and lack of resources whilst the community members perceived poverty, lack of support from the local health authorities, the precarious nature of their livelihood and traditional culture as those factors that have undermined participation. These barriers were structural and as such tackling any one barrier in isolation was not likely to solve the malaria problem. Besides, no one government sector, on its own, through participation, could make it possible for the community members to have a full ownership of the control programme activities as well as develop a culture of malaria prevention and control.Thus in the context of the study sites, the study concluded that although there is no evidence to suggest that ISC has enhanced full community participation, the strategy should be commended. In reality, the finding indicated that through ISC strategy many sectors including the community have become more aware of malaria problem and communicate more to solve the problem together. In the light of this, the study finds joint action in the form of ISC across many government sectors as a potential solution if these barriers are to be dealt with in a more strategic way rather than a piecemeal manner.In conclusion, it has been argued that with such a complex problem like malaria, ISC with community participation in policy making process is both a necessary and sufficient condition in reducing malaria persistence in the study sites. The health sector must work collaboratively with other related sectors and it is with such collaborative efforts that can change the attitudes of the community members. Changes in behavioural attitudes are paramount if communities’ activities that affect the environment and promote breeding of mosquitoes are to be minimised. Thus with ISC strategy, what is further needed are: proper control planning that will ensure better coordination amongst sectors, adequate resources and behavioural change by the community members themselves. Each of these factors, I believe should not work in isolation, rather must work together otherwise malaria persistence in Ghana will not go away anytime soon
Antimalarial drug resistence and artemisinin based combination therapy : a bio-economic model for elucidating policy choices
No full textAntimalarial drug resistance is a major cause
of
the increasing
burden
due to
P. falciparum
malaria. Artemisinin-based combination therapies
(ACTs)
are now
recognised to
be the ideal
choice for the first-line treatment of uncomplicated
malaria,
in
order to
achieve two
beneficial
outcomes: improvement of treatment efficacy
and
delay in the
development
of
drug
resistance.
However uncertainties remain about the current and
future
benefits,
risks
and costs of
ACTs
and
in particular how these outcomes are
affected
by differences in
malaria epidemiology,
health
care settings, human behaviour and implementation strategies.
This thesis seeks to address these uncertainties
by
creating a comprehensive,
dynamic, bio-
economic model of malaria transmission and
the
spread
of
drug
resistance, which
incorporates
vector factors, human immunity, human behaviour, drug
characteristics
and costs.
Central to
the model is a biological model, developed in
collaboration with
a
mathematician,
which
outputs the proportion of drug resistant
infections
and the
incidence
of
new
and recrudescent
infections. Parasite biomass is also tracked in
order
for
human
"infectiousness" to
be
measured
and fed-back into the model. Sub-models are used
to
calculate
severe malaria,
deaths,
costs
and
cost-effectiveness.
Data were obtained to develop and populate the
model.
This included
a community
drug
usage
survey in Cambodia, which was undertaken
in
order
to
document the
adherence
and
coverage
rates to ACT following the implementation of
locally blister-packaged
ACT.
Coverage
was
found to be extremely low, and the use of artemisinin
derivatives
on their
own
was
widespread.
However, both of these outcomes were
improved
by interventions to increase
coverage,
particularly village malaria volunteers.
Application of the model in a low transmission setting suggests
that
with
a
10-year time-frame,
switching from monotherapy to an ACT is
very
cost-effective
and
results
in
overall
cost savings
in a range of scenarios. High coverage rates
with
an
ACT
are required
to
delay the
spread
of
drug resistance if resistance has already arisen
to
one of the
partner
drugs. Running the
model
with data from Cambodia suggests that even
in
settings
with
low
coverage, the
change
will
be
cost-effective and significant benefits are
gained
from the
implementation
of
the
specific
delivery interventions. Strategies for optimising
the
implementation of
ACTs
are
discussed in light of the findings
