Tropical Health Matters

Jean Louis Ndikumana Mangara, Marcel Manariyo, Michée S. Kabera, Yvette Muyirukazi, Jean Modeste Harerimana, Christine Mutaganzwa, Marie Rose Kayirangwa, Noella Umulisa, Aimable Mbituyumuremyi report on Improving insecticide treated net coverage through antenatal care services in Rwanda at the 2022 Annual Meeting of the American Society of Tropical Medicine and Hygiene.

Malaria in pregnancy (MIP) negatively affects pregnancy outcomes, including maternal and neonatal mortality and adverse fetal outcomes such as low birth weight. Therefore, among other malaria prevention interventions, Rwanda embarked to achieve the insecticide treated net (ITN) universal coverage through the ITN mass distribution to households and routine distribution to the most vulnerable groups including under five children and pregnant women.

In the period of Jan 2020 to Dec 2021, the program improved ITN distribution and the information, education and communication on challenges related to malaria behavior during ANC visits and conducted capacity building of health care providers on malaria diagnostic and case management training, integrated malaria supportive supervision, monthly data review and validation meetings at health facilities and monitoring of use of ITN program at health facility level.

A quarterly review of data from national Health Management Information System (HMIS) on ITN distributed during ANC services and changes in MIP incidence was done in the period of January 2020 to December 2021. The results show an increase from 49% (z-score (-0.8)) (Jan-Mar 2020) to 74% (z-score 0.5) (Oct-Dec 2021) coverage in the distribution of ITN among pregnant women during ANC visits.

There was a decrease in malaria incidence from 65 (z-score (2)) to 17 (z-score (-1)) cases among pregnant visiting ANC services, and a decrease from 88 to 73 malaria cases in all (567,198) pregnant women for10,000 confirmed malaria case during the January-March 2020 to October-December 2021. There has been a moderate negative correlation between the proportion of pregnant women receiving ITN in ANC services and the proportion of malaria cases in pregnancy every quarter r(9) = -0.655, P (value)=0.056.

Although malaria cases among pregnant women have declined and the distribution of ITN in ANC services increased over the studied period, there is a need to strategize innovation to reach the remaining pregnant women.

Marwa Ramadan of the Alexandria Faculty of Medicine, Alexandria, Egypt and William Brieger of the Johns Hopkins Bloomberg School of Public Health are presenting this information at the Annual Meeting of the American Society of Tropical Medicine and Hygiene in Seattle.

Studies have highlighted the potential impact of conflict and displacement on malaria prevention and mitigation efforts, but few investigated the effect of subnational conflict intensity on access and utilization of mosquito nets in fragile countries.

This study bridges the gap by applying a conflict intensity lens to the analysis of access and utilization of Insecticide Treated Nets (ITN) in two conflict-affected fragile states (Nigeria and Democratic Republic of Congo (DRC)), where at least 45 % of global malaria deaths occur.

We used the Demographic health survey (DHS) and the Uppsala Conflict Data Program for information on access and utilization of nets and conflict events respectively. Access was defined as the percentage of population with at least one ITN per 2 household members, while utilization was defined as the percentage of population who slept under an ITN the night before the survey in households with at least 1 ITN.

To define conflict intensity, we linked household clusters to conflict events within a 50 km distance using ArcGIS. Conflict intensity was then categorized into medium or high intensity conflict and no or low intensity conflict using a cut-off of 2 or more deaths per 100, 000 population per cluster. Access and utilization of ITNs was compared by conflict intensity at the household cluster level.

Analysis of data from 281,689 individuals living in 58,183 households revealed that 42.8% (CI: 42.3 – 43.3%) and 39.9% (CI: 39.5 – 40.1%) of members living in neighborhoods with medium and high intensity conflict in DRC and Nigeria respectively had access to ITNS compared to 47.9% (CI: 47.6 – 48.1%) and 51.0% (CI: 50.8 – 51.2%) in no or low intensity conflict.

Similarly, 65.1% (CI: 64.3 – 65.9%) and 62.8% (CI: 62.3 – 63.3%) of those living in medium or high intensity conflict in DRC and Nigeria respectively utilized ITNS compared to 69.2 % (CI: 68.8 %-69.6 %) and 65.7% (CI: 65.4-66.0%) in no or low intensity conflict.

National malaria control programs must consider that access and utilization of ITNS are statistically significantly lower in neighborhoods with medium or high intensity conflict and target supporting interventions accordingly.

The Demographic and Health Survey Program has released final and summary reports for both DHS and Malaria Indicator Surveys (MIS) for 2021 from several malaria endemic African countries. Below is a brief summary of some of the findings from Madagascar, Nigeria, Burkina Faso, Mali, Côte d’Ivoire, and Senegal. Click the link on each country to download a copy for yourself.

The proportion of the population who slept under an insecticide treated bednet the night before the survey varied. In Madagascar it was 49%, While in Nigeria it was 59%. Mali achieved the highest coverage at 73%, while Burkina Faso had the lowest previous night coverage at 41%.

Senegal showed a worrying decrease from 63% in 2016 to 46% in 2021. Côte d’Ivoire did not report total household use, but indicated that 72% of homes had at least one net, with 58% of children below 5 years of age and 64% of pregnant women sleeping under them.

At least three doses of sulfadoxine-pyremethamine is recommended for Intermittent preventive treatment of malaria in pregnant women. The national average was 38% for at least 3 doses in Senegal, although ironically 92% had been reached with the first dose. In Mali only 35% received at least a third dose. Burkina Faso started out with 92% for the first dose, but reached 57% with three or more. Côte d’Ivoire started with 80% receiving their first dose and concluded with only 35% receiving a third. Both Madagascar and Nigeria had the lowest 3-dose coverage at 31%.

Malaria testing and treatment using rapid diagnostic tests and artemisinin-based combination therapy (ACT) was reported. Nigeria demonstrates the challenges of following guidelines. Although 63% of children under 5 years of age were reported to have had a fever in the two weeks preceding the survey, only 24% of those received a diagnostic test. The summary results report that 74% of those with fever “who took any anti-malaria medicine” used the recommended ACT. The implication is that many received medicine without confirmatory testing such that some may have gotten ACT who needed another medicine and some who actually had malaria may have missed the correct treatment.

A similar low level of testing was seen in Senegal (22%), Mali (23%), and Madagascar (20%). Côte d’Ivoire reported 38% of febrile children having been tested. Burkina Faso performed better for testing with 65%.

These brief findings indicate that implementation of Malaria interventions are far from ideal. We know that some of the blame can be placed on health service disruptions due to demands of COVID-19 activities by health ministries and partners. Still, with 8 years remaining until 2030, Reinvigorated efforts are needed in all endemic countries if these six examples are indicative of the challenges we face.

Save the Children designs programs to protect children and families from malaria. An important aspect of the design process is learning about the factors that influence community members’ behaviors related to the prevention of the disease. Here we learn about behavioral factors that must be considered to design effective programs. This information is being presented at the 2021 American Society of Tropical Medicine and Hygiene Annual Meeting. See Author List below.

Understanding the drivers of malaria-related behavior helps national malaria control programs and implementing partners to plan national malaria strategies and to tailor interventions accordingly. This study examined the factors affecting adoption of malaria behaviors and those that drive or inhibit them among populations at high risk of malaria in Cote d’Ivoire.

This study was a multi-method, qualitative study with an exploratory approach using focus group discussions (FGDs), in-depth interviews (IDIs) and life stories. The study was conducted in 12 health districts across 10 health regions of Cote d’Ivoire in both urban and rural areas. FGDs and life stories were conducted with pregnant women and mothers of children under 5 and men (heads of household). IDIs were conducted with a number of stakeholders including: departmental district directors; midwives, nurses, community health workers, leaders of women’s groups, community leaders, and the local media.

The findings from this study show that incorrect knowledge about LLINs, LLIN dislike and discomfort, housing structure and size, sleeping arrangements for children under 5, and lack of LLIN recycling strategies were among the root causes for incorrect, non-use and/or inconsistent use of LLINs. In terms of ANC attendance, the main reported barriers were influence of their beliefs and norms, cost, perceived poor services provided, bad experiences from gynecological examinations, and the distance of health facilities in rural areas. Additionally, the lack of information on the benefits of SP for prevention of malaria in pregnancy and the use of traditional medicine were the main barriers for SP in pregnancy. Cost, poor services by health care providers and stock outs were the main barriers to diagnosis and treatment for children U5.  The main factor that influenced the adoption of preventive measures was free LLIN distribution through ANC viists and mass distribution campaigns.

Findings from this study are useful to inform the revision of the Social Behavior Change Communication Strategy in Cote d’Ivoire. Additionally, they can inform key messaging and the design of interventions in a context where malaria is the main cause of morbidity and mortality and children under 5 and pregnant women are the most affected.

AUTHOR LIST:

Jacob Y. Agniman1, Manasse N. Kassi1, Yssouf Ouattara1, Edouard C. Balogoun1, Serge B. Assi2, Philomène A. Beda1, Michel N’da-Ezoa3, Aristide E. Kouadio1, Joel Koffi1, Apollinaire N. Kouadio1, Paul Bouey4, Sara Canavati4, Eric Swedberg4 — 1Save the Children, Abidjan, Côte D’Ivoire, 2Le Programme Nationale de Lutte contre le Paludisme (PNLP), Abidjan, Côte D’Ivoire, 3Socio-Anthropologue de la Santé, Abidjan, Côte D’Ivoire, 4Save the Children, Washington, DC, United States

Save the Children recognizes the importance of strong health systems to deliver malaria interventions. Here they arsharing a wealth of information on these efforts at the 2021 American Society of Tropical Medicine and Hygiene Annual Meeting. Here is an abstract from one of their malaria efforts. See Author List below.

Since 2010, Cote d’Ivoire has made significant progress in the fight against malaria; however, since 2016 progress has stagnated and malaria incidence is steadily increasing. The aims of this study were to assess knowledge, attitudes and practices among heads of households, pregnant women and caretakers of children under 5 years of age (U5) and IPTp-SP compliance.

A mixed-methods study was conducted in rural and urban areas in 20 health districts of Cote d’Ivoire. A total of 1,812 households composed of 8,813 members were surveyed using a structured questionnaire. Qualitative data were gathered through twenty focus group discussions. Data triangulation was used during analysis.

Fever was the main malaria symptom reported by heads of households (38.5%) followed by headache (25.5%). Additionally, many FGD participants also reported sadness as a symptom of malaria. The primary cause of malaria was mosquito bites, followed by fatigue, the sun, and salty water, 70.7%, 15.1% and 10.9%, 3.3% respectively. The main prevention methods reported were sleeping under an ITN (60.4%), spraying the house (25.9%), taking medication (5.8%), and using a fan (7.9%). In FGDs, additional means of prevention were discussed including sanitation of the environment, personal hygiene, and stopping alcohol consumption.

The majority of women with at least one child reported having attended at least three ANC visits in their last pregnancy (85.1%). The cost of ANC was a main factor affecting attendance.  Overall, 78.2% of them received SP and of these women, 98.1% said they received it during their ANC visits. However, only 55.4% received 3 doses or more of SP and 76.79% received SP free of charge. The reasons for not taking SP were stock outs, side effects, bitter taste, and preference for injections.

Our study revealed that knowledge of prevention measures (ITNs) and causes of malaria (mosquito bites) were high and in line with the targets of the National BCC Strategy 2021-2025. However, even though the majority of pregnant women would like to take SP, they were blocked by the health system unable to provide them with the drugs and others had to pay for them. These problems within the health system are likely to contribute to the high malaria incidence in Cote d’Ivoire.

AUTHOR LIST

Edouard C. Balogoun1, Manasse Kassi1, Philomène A. Beda1, Jacob Y. Agniman1, Serge B. Assi2, Florence Kadjo-Kouadio3, Michel N’da-Ezoa4, Aristide E. Kouadio1, Joel Koffi1, Apollinaire N. Kouadio1, Paul Bouey5, Sara Canavati5, Eric Swedberg5 — 1Save the Children, Abidjan, Côte D’Ivoire, 2Le Programme Nationale de Lutte contre le Paludisme (PNLP), Abidjan, Côte D’Ivoire, 3Médecin Spécialiste de Santé, Abidjan, Côte D’Ivoire, 4Socio-Anthropologue de la Santé, Abidjan, Côte D’Ivoire, 5Save the Children, Washington, DC, United States

Save the Children addresses various ways to protect children and families from malaria. Here we learn about Mosquito net knowledge, ownership, use, acceptability and preferences among primary caregivers of children under 5 years of age, pregnant women and household heads in Cote d’Ivoire. This information is being presented at the 2021 American Society of Tropical Medicine and Hygiene Annual Meeting. See Author List below.

Strengthening vector control measures among populations at higher risk of malaria, such as pregnant women and children under 5 years of age (U5s), is crucial to malaria control. Cote d’Ivoire has set itself a number of targets for malaria control by 2025. These include: at least 90% of the population are aware of national malaria prevention measures and at least 80% of the general population, pregnant women and children U5 sleep under an LLIN. One of the specific aims of this study was to assess mosquito net knowledge, ownership, use, acceptability and preferences of primary caregivers of children U5, pregnant women and household heads.

A mixed-methods study was conducted in rural and urban areas in 20 health districts of Cote d’Ivoire. A total of 1,812 households composed of 8,813 members were surveyed using a structured questionnaire. Only households who had one or more children under five years of age and/or a pregnant woman were included in the study. Qualitative data were gathered through twenty focus group discussions. Data triangulation of the qualitative and quantitative data was used during analysis.

Sixty percent of participants cited mosquito nets as the main malaria preventive measure. The majority of participants (95.6%) received information on the use of mosquito nets and over half of them received it from mass distribution campaign agents (51.1%). Although 79.5% of households owned at least one mosquito net, less than half (46.47%) owned one mosquito net for two people. The majority (98.2%) of participants received a free mosquito net. Nets were reportedly received mainly through mass distribution campaigns (54.99%) and ANC visits (39.0%). Self-reported mosquito net use by the head of households was 53.5%. This was higher for pregnant women and children U5, 76.2% and 83.2% respectively. However, only 53.0% of mosquito nets were suspended over a bed. Reasons for not using a mosquito nets were feeling of suffocation, heat, side effects, and poor condition of the mosquito net.

While mosquito net was reported as the main malaria preventive measure, mosquito net coverage and use remains below national targets. In addition, there was a noted gap between coverage and net use, potentially undermining the effectiveness of net-related interventions that could impact malaria control efforts in Cote d’Ivoire. The design, material, and condition of nets are important factors for user preferences that appear to drive net use.

AUTHOR LIST:

Edouard C. Balogoun1, Manasse N. Kassi1, Philomène A. Beda1, Serge B. Assi2, Jacob Y. Agniman1, Florence Kadjo-Kouadio3, Michel N’da-Ezoa4, Aristide E. Kouadio1, Joel Koffi1, Apollinaire N. Kouadio1, Paul Bouey5, Sara Canavati5, Eric Swedberg5 — 1Save the Children, Abidjan, Côte D’Ivoire, 2Le Programme Nationale de Lutte contre le Paludisme (PNLP), Abidjan, Côte D’Ivoire, 3Médecin spécialiste de Santé, Abidjan, Côte D’Ivoire, 4Socio-Anthropologue de la Santé, Abidjan, Côte D’Ivoire, 5Save the Children, Washington, DC, United States

In 2001 the first Africa Malaria Day (AMD) was observed. The opportunity to mark progress and exhort increased efforts for the continent continued through 2007. Then in 2008, the concept of World Malaria Day (WMD) took over, though it could not be denied that the bulk of malaria morbidity, mortality and intervention still was focused on African countries. Other countries have made progress such as the recent certification of malaria elimination in Argentina and El Salvador, but twenty years after the first AMD/WMD, Africa is still leading the way for creative, sustained intervention against the disease, despite threats to resources from economic downturns and new pandemic diseases.

Below we go straight to Africa to share activities and observances of WMD 2021 from Jhpiego’s African Malaria Technical Officers. After reading through, please watch “Jhpiego Leaves No One Behind | World Malaria Day, 2021″ on YouTube.

“Saramed” from Guinea reports that Guinea, like other countries in the world, celebrates World Malaria Day under the theme: ” Zero Malaria, Draw a Line on Malaria “. We are currently conducting the following activities:

• Lectures and debates on malaria in medical faculties and health schools;
• Animation of debate programs on malaria in public and private radios and televisions of the country,
• Advocacy and sensitization of religious and other influential people
• Carrying out a package of activities (administration of IPT to pregnant women who have missed their ANC appointment, community distribution of LLINs, screening and treatment of confirmed cases, awareness raising on malaria) in high incidence localities.

These activities is in line with the WHO approach of “high burden, high impact”.

Noella Umulisa reports that the WMD celebration took place in Eastern Province, in Bugesera district in the Mareba sector. Due to COVID-19 pandemic ,only 100 persons were invited to the event.This year’s the national theme is “Zero Malaria starts with me”.

Key activities during the event included …

• Visit of breeding sites under sentinel surveillance
• Visit of indoor residual spraying (IRS) sites
• Launching of the Awareness of the population using drones on the ongoing IRS campaign in this time of COVID-19
• Song by CHWs
• Certificate to Integrated Vector Management (IVM) Training of Trainers who will train others up to village level
• Speech of the Director General ,the guest of honor.

From Burkina Faso, Yousseff Sawadogo and Moumouni Bonkoungou shared photos of the celebration that featured a giant Insecticide-Treated  Net, a speech by the US Ambassador, a malaria song composed by a nurse, an official speech by the President of the National Assembly, and national recognition given to one of the current Jhpiego staff members, Thiery Ouedraogo, who at one time also served as director of the national malaria control program. He was decorated by the country’s authorities as a knight of the order of merit.

Bright Orgi from Jhpiego’s TiPToP malaria in pregnancy project in Nigeria ?? shared photos from a series of compound meetings in the community to mark WMD 2021. The meetings focused on malaria prevention and treatment. Provided opportunities to rural communities to ask questions on malaria issues. Here we can see that observance of WMD must be taken to the people who actually suffer from malaria and need to be actively involved in its solution. Deo Cibinda from the Democratic Republic of the Congo share photos of a national celebration, seen to the left.

Finally, As Kristen Vibbert noted, “These are such amazing World Malaria Day stories. I’m so heartened to see all of these great country efforts to remind everyone of how the fight against malaria must continue despite the Covid-19 pandemic.”  Charles Wanga tweeted, “We know how to defeat #malaria. But that’s not enough. We must do more to save pregnant women and children from the deadly scourge. This #WorldMalariaDay and everyday, because@Jhpiego leaves no one behind in our fight to #EndMalaria for good in Africa, and everywhere”

Courtney Emerson and co-workers address the issues of Intermittent Preventive Treatment of Malaria with Sulfadoxine Pyrimethamine and Provision of Insecticide Treated Nets in Geita, Tanzania: Provider Communication and Opportunities at the virtual 69^th Annual Meeting of American Society of Tropical Medicine and Hygiene. See their findings below.

Intermittent preventive treatment of malaria in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is a life-saving intervention to reduce morbidity and mortality among pregnant women and their infants. Additionally, provision and use of insecticide treated nets (ITNs) to prevent malaria is critical to improving pregnancy outcomes.

To assess implementation of malaria in pregnancy services and related health communications, we surveyed 1111 women who had delivered a live born infant in the preceding 12 months (recently pregnant women), as well as 1194 adults from randomly selected households without a recently pregnant woman in Geita Region, Tanzania in 2019. Most (88.2%) recently pregnant women reported receiving any IPTp dose; 45.5% received 3 doses. 72.3% of women received their first dose in the second trimester, as recommended by national guidelines, but only 14.4% received IPTp in the 4th month; 20.3% of women did not receive IPTp until third trimester.

There was a significant difference between ITN ownership and use among households (HH) with and without a recent pregnancy: ownership of at least one net was 95.2% vs 87.9%, respectively (p<0.0001), and use was 90% vs 77.8%, respectively (p<.0001). Despite this, few HHs had enough ITNs to cover all residents; on average, HHs had 1 ITN for every 3 rather than every 2 people, as recommended. Notably, only 21.2% and 26.2% of HH with and without a recent pregnancy had sufficient ITNS (p=0.005), despite 87.3% of recently pregnant women receiving an ITN during their last pregnancy.

Of recently pregnant women, 87% received advice on preventing malaria from a health worker. Of these, 82.7% were advised to sleep under an ITN, but only 66.4% were advised to take SP, and 52.1% to attend ANC regularly. Although uptake of any IPTp was high, there are critical messages that need to be more consistently communicated to pregnant women by ANC providers including the importance of attending ANC regularly during pregnancy. To improve outcomes among pregnant women, additional net distribution may be warranted due to the unexpectedly low access.

Authors and Affiliations

Courtney Nicole Emerson(1), Ryan Lash(1), Ruth Lemwayi(2), Melkior Assenga(2), Alen Kinyina(2), Annette Almeida(2), Samwel L. Nhiga(3), Lia Florey(4), Chonge Kitojo(5), Erik Reaves(6), Miriam Kombe(5), Peter Winch(7), Stephanie Suhowatsky(7), Mary Drake(2), Julie Gutman(1) 1.US Centers for Disease Control and Prevention, Atlanta, GA, United States, 2.Jhpiego, Dar es Salaam, United Republic of Tanzania, 3.National Malaria Control Program, Tanzania, Dar es Salaam, United Republic of Tanzania, 4.US Agency for International Development (USAID), Washington DC, DC, United States, 5.US Agency for International Development (USAID), Dar es Salaam, United Republic of Tanzania, 6.US Centers for Disease Control and Prevention, Dar es Salaam, United Republic of Tanzania, 7.Jhpiego, Baltimore, MD, United States

This year the 69^th Annual Meeting of American Society of Tropical Medicine and Hygiene is virtual.  Catherine Dentinger and colleagues (see authors below) gathered information to guide partner planning to combat malaria in pregnancy in Madagascar. Here are their findings.

Malaria in pregnancy (MIP) increases the risk of poor maternal and infant outcomes; to prevent this, the World Health Organization (WHO) recommends insecticide-treated net (ITN) use, intermittent preventive treatment during pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP), and prompt case management. In Madagascar, IPTp uptake remains low; 10% of targeted women receive 3 doses.

To determine if additional data are needed to improve MIP activities, we conducted a scoping review to identify barriers to antenatal care (ANC) and IPTp uptake. We searched PubMed, Google Scholar and USAID’s files (Development Experience Catalog) using the terms “Madagascar” and “pregnancy” and “malaria” and collected materials from stakeholders. We included English and French documents from 2010 to 2019 with quantitative or qualitative data regarding malaria during pregnancy.

Documents were reviewed and categorized as MIP background information, care seeking, and facility readiness. Of 69 project reports, surveys and published articles, 15 (22%) met the inclusion criteria; 4 (27%) were categorized as care seeking, 4 (27%) as background, and 7 (47%) as facility readiness.

Eight (53%) articles mentioned SP stock outs, 3 (20%) mentioned poor provider knowledge of IPTp guidelines despite recent training, and 5 (33%) discussed barriers to ANC including distance, wait times, poor service quality, cost, and unfriendly providers. One study found only 30% of targeted health workers received recommended supervision.  A 2015 survey of 52 health facilities revealed limited access to ANC due to financial and geographic barriers; 2018 surveys revealed similar findings. Self-treatment and care-seeking delays were reported even when distance was not a barrier.

Our review revealed well-documented barriers to MIP services that could be mitigated by reducing stock outs, improving access to healthcare by removing fees and providing services closer to women’s homes, and targeted behavior change. These findings can be used to guide coordinated donor and government efforts to address management, financial, and human resource gaps to improve MIP services.

Authors and Affiliations

Catherine Dentinger(1), Natasha Hansen(2), Susan Youll(2), Annett Cotte(1), Mary Lindsay(3), Chiarella Matten(4), Vololoniala Aimee Ravaoarinosy(5). 1.Centers for Disease Control and Prevention, Atlanta, GA, United States, States, 3.US Agency for International Development, Washington, DC, United States, 4.Institut Pasteur de Madagascar, Antananarivo, Madagascar, 5.National Malaria Control Program, Antananarivo, Madagascar 2.US Agency for International  Development, Washington DC, DC, United States

Recent publications in Malaria Journal, The Lancet and eLife tackle several challenges to saving lives and malaria elimination. Problems include low access to bednets for children in Ethiopia, high prevalence of asymptomatic malaria in Ghanaian adults, risk of co-infection with other infectious diseases, and gaps in current interventions to prevent malaria in pregnancy and children. On the hopeful side, new targets for drug therapy are being identified. Read more on each by following the links below.

Long-lasting insecticide-treated bed net ownership, utilization and associated factors among school-age children in Southern Ethiopia

Zerihun Zerdo and colleagues examined net use among children in malaria-prone areas of

Dara Mallo and Uba Debretsehay districts because malaria is one of the major causes of morbidity and mortality among school-age children (SAC) in sub-Saharan Africa. This study was part of a baseline assessment in a cluster-randomized controlled trial.

The ownership of at least one LLIN by households of school-aged children (SAC) was about 19.3% (95% CI 17.7–21.0%) but only 10.3% % (95% CI 7.7–13.7%) of these households had adequate access of bed nets to the household members. Ownership of bed net was lower than universal coverage of at least one bed net for two individuals. It is important to monitor replacement needs and educate mothers with low education level with their SAC on the benefit of consistent utilization of bed nets.

Prevalence of and risk factors for Plasmodium spp. co-infection with hepatitis B virus: a systematic review and meta-analysis

Kotepui and Kotepui observed that Plasmodium spp. and hepatitis B virus (HBV) are among the most common infectious diseases in underdeveloped countries. Therefore they examined co-infection in people living in endemic areas of both diseases. The PubMed, Web of Science, and Scopus databases were searched. Observational cross-sectional studies and retrospective studies assessing the prevalence of Plasmodium species and HBV co-infection were examined. and found 22 studies to include in a systematic review and meta-analysis. Overall, the pooled prevalence estimate of Plasmodium spp. and HBV co-infection was 6% (95% CI 4–7%, Cochran’s Q statistic?<?0.001, I2: 95.8%).

No difference in age or gender and risk of Plasmodium spp. and HBV co-infection group was found. The present study revealed the prevalence of Plasmodium spp. and HBV co-infection, which will help in understanding co-infection and designing treatment strategies. Future studies assessing the interaction between Plasmodium spp. and HBV are recommended.

High prevalence of asymptomatic malaria infections in adults, Ashanti Region, Ghana, 2018

Melina Heinemann and co-researchers noted that Ghana is among the high-burden countries for malaria infections and recently reported a notable increase in malaria cases. While asymptomatic parasitaemia is increasingly recognized as a hurdle for malaria elimination, studies on asymptomatic malaria are scarce, and usually focus on children and on non-falciparum species. Therefore asymptomatic adult residents from five villages in the Ashanti Region, Ghana, were screened for Plasmodium species by rapid diagnostic test (RDT) and polymerase chain reaction (PCR) during the rainy season. Samples tested positive were subtyped using species-specific real-time PCR.

Molecular prevalence of asymptomatic Plasmodium infection was 284/391 (73%); only 126 (32%) infections were detected by RDT. While 266 (68%) participants were infected with Plasmodium falciparum, 33 (8%) were infected with Plasmodium malariae and 34 (9%) with P. ovale. The sub-species P. ovale curtisi and P. ovale wallikeri were identified to similar proportions. Non-falciparum infections usually presented as mixed infections with P. falciparum.

Most adult residents in the Ghanaian forest zone are asymptomatic Plasmodium carriers. The high Plasmodium prevalence not detected by RDT in adults highlights that malaria eradication efforts must target all members of the population. Beneath Plasmodium falciparum, screening and treatment must also include infections with P. malariae, P. o. curtisi and P. o. wallikeri.

Scientists shed new light on mechanisms of malaria parasite motility

eLife reports a new insight on the molecular mechanisms that allow malaria parasites to move and spread disease within their hosts has just been published. The first X-ray structures of the molecular complex that allows malaria parasites to spread disease highlight a novel target for antimalarial treatments.

The movement and infectivity of the parasite Plasmodium falciparum, and ultimately its ability to spread malaria among humans, rely on a large molecular complex called the glideosome. The new findings provide a blueprint for the design of future antimalarial treatments that target both the glideosome motor and the elements that regulate it.

New Lancet Series: Malaria in early life

Malaria infections are harmful to both the pregnant mother and the developing fetus. Malaria is associated with a 3–4 times increased risk of miscarriage and a substantially increased risk of stillbirth, and it disproportionately affects children younger than 5 years. Falciparum malaria is responsible for more than 200 000 child deaths per year in Africa and vivax malaria causes excess mortality in children in Asia and Oceania. In a duet of papers, we review 1) the deleterious effects of malaria in pregnancy on the developing fetus and 2) the current strategies for prevention and treatment of malaria in children.

Paper 1 is “Deleterious effects of malaria in pregnancy on the developing fetus: a review on prevention and treatment with antimalarial drugs” by Makoto Saito, Valérie Briand, Aung Myat Min, and Rose McGready. The authors are concerned that one in ten maternal deaths in malaria endemic countries may result from Plasmodium falciparum infection, that malaria is associated with a 3–4 times increased risk of miscarriage and a substantially increased risk of stillbirth. While current treatment and prevention strategies reduce, but do not eliminate, malaria’s damaging effects on pregnancy outcomes. They conclude that there is a need for alternative strategies to prevent malaria in pregnancy.

Paper 2 is “Treatment and prevention of malaria in children” by Elizabeth A Ashley and Jeanne Rini Poespoprodjo. They examine the following interventions: Triple antimalarial combination therapies, the RTS,S/AS01 vaccine, seasonal malaria chemoprevention and preventing relapse in Plasmodium vivax infection with primaquine.