Category Archives: Malaria in Pregnancy

Malaria News Today 2020-10-02/03

Recent news and abstracts include mosquito control using solar disruption of of larval habitats and plants that repel the insects around homes. The challenges of malaria related anemia in pregnancy is discussed. Malaria cases increase in Mali and Mozambique, but in the latter, deaths actually decrease. Malaria parasites have ways of making people more attractive to mosquito bites. Finally covid-19 has not disrupted malaria work as much as anticipated. Read more at the links in the sections below.

Improved Mosquito Control with Solar Power Machine that Causes Ripple Effect

Kristina Panos writes that mosquito haters of the world, rejoice! A few years ago we told you about the first version of this solar-powered mosquito repellent that works by disturbing the surface of standing water. Since then, the project has received worldwide attention, and [Pranav] is back with Solar Scare Mosquito version 2.0 in time for the the 2020 Hackaday Prize.

The idea’s still the same as before: let mosquitoes lay their eggs in the standing waters of tanks and swamps, then disturb the water with vibrations so the larvae on the surface can’t breathe. As smart as this simple idea is, version 2.0 is even smarter. It has a microphone that listens to the wing-beat frequencies of mosquitoes that like to hang around places like that. Inside there’s an Arduino MKR GSM to run the ripple-generating air pump, detect water from the sensor, and gather data from the microphone.

With a network of these devices all reporting data, [Pranav] envisions an early warning system for mosquito-borne epidemics that works by alerting the locals through their phones. Solar Scare Mosquito has come a long way since 2014.

Malaria cases spike in northern Mali

Malaria cases in northern Mali have spiked, according to medical workers, claiming 23 lives in the often lawless desert region last week alone. Mali’s ministry of health said this week that 59 people have died of malaria in the north since the start of the year, almost double the number of deaths over the same period last year.

Already struggling to curb coronavirus, the poor Sahel country is also fighting a brutal jihadist insurgency active in the north and centre of the country.

A powerful attractant: Malaria parasites lure blood-sucking mosquitoes

The malaria parasite’s gametocyte-stage has been demonstrated in the field to heavily manipulate the blood-seeking behaviour of vector mosquitoes through increasing the appeal of biting an infected host.

Plasmodium parasites, the causative agents of Malaria in humans and animals, are well known for manipulating both their human and mosquito hosts as a way of maximising the probability of interactions between them, thereby increasing the chance malaria parasites are transmitted from host to host. One way in which these devious parasites have been shown to increase the probability of host interaction is during their transmissible (gametocyte) stage.

This is achieved by inducing host red blood cells to produce volatile compounds that attract malarial vector species, such as mosquitos in the Anopheles family. The increase in production of volatile compounds, such as certain aldehydes and terpenes, by host red blood cells was shown back in 2017 to be specifically induced by a gametocyte-produced molecule called (E)-4-hydroxy-3-methyl-but-2-enyl pyrophosphate, also known as HMBPP.

Malaria campaigns fight off Covid disruptions to deliver programmes

Almost all planned work against the disease has gone ahead this year, delivering nets, drugs and the world’s first malaria vaccine. More than 90% of anti-malaria campaigns planned this year across four continents are on track, despite disruptions caused by the coronavirus pandemic, according to new research.

The delivery of insecticide-treated nets and provision of antimalarial medicines in the majority of malaria-affected countries across Africa, Asia and the Americas were still going ahead, a high-level meeting organised by the RBM Partnership to End Malaria heard on Thursday.

Malaria associated with increased prevalence of anemia during pregnancy

Ken Downey Jr. and colleagues conducted a study in seven sub-Saharan African countries demonstrated an association between malaria and an increased prevalence of anemia among pregnant women, according to findings published in BMC Pregnancy and Childbirth.

“Pregnant women in sub-Saharan Africa suffer a double burden of malaria and HIV infections, and these infections interact with each other to cause anemia,” Ssentongo told Healio. “If not treated, the risk of the mother and the unborn baby dying is high. Multipronged strategies to prevent and treat malaria in HIV pregnant women are critical to ensure the survival of the mothers and their unborn babies.”Paddy Ssentongo, MD, MPH, a research assistant professor at Penn State University,

Mozambique: Malaria Cases Increase, Malaria Death Toll Declines

From January to August, 442 people in Mozambique are known to have died from malaria, according to Health Minister Armindo Tiago. Speaking at the launch of a National Home Spraying Campaign, Tiago said the malaria death toll, in the first eight months of the year, was significantly lower than that recorded in the same period in 2019, when 562 people died of the disease.

But although fewer people are dying of malaria, the number of malaria cases has actually increased – from 7.86 million cases in January-August 2019 to 8.36 million in the same months this year. The number of cases rose by 6.4 per cent, but the number of deaths fell by 21.4 per cent. Thus there is the drive to persuade families to change their behaviour.

The Plants That Keep Mosquitoes Away

Protect outdoor areas from mosquitoes and bugs to enjoy evenings outside. Including the following plants in a home garden can provide homeowners with some important weapons in the war against mosquitoes.

1. Citronella Plants: You may already be familiar with citronella plants, as they are known for emitting a strong smell that mosquitoes find objectionable. This group of plants contain citronellal, the active ingredient commonly found in mosquito repellents like citronella patio candles or sprays.

2. The Mint Family: Some members of the mint family have the power to repel mosquitoes, or at least take the sting out of their bites. Check Lemon Balm, Peppermint, Basil, Lavender, Sage, and Catnip.

3. Flowers: Believe it or not, ornamental plants can actually do double duty and function as mosquito repellents. Even better, these plants love sun and are drought resistant. Marigolds, and their relative, tarragoncontain pyrethrum, an ingredient found in many insect repellents. Verbena is a lemon-scented, easy-to-grow perennial. Citrosum is also named “the mosquito plant,” and is one of the best plants in the game for repelling mosquitoes.

Malaria News Today 2020-09-26: supporting and strengthening malaria programs

Today’s selection of abstracts and news looks at the role of the media in supporting malaria programs, mass treatment to prevent Imported malaria, problems managing malaria in pregnancy services, malaria research in Mali and health systems strengthening to support malaria control in Guinea. Follow links to read mor details.

GHS calls for media support to eradicate malaria

The media has a role in supporting malaria programs

The Ghana Health Service (GHS) has called on journalists to support the Service to deliver integrated health package through accurate messages towards malaria eradication in the country.“Also, we need your support to set malaria as a national development agenda. This will drive advocacy for political will, increase partnership, availability and accessibility of effective tool for prevention, diagnoses and treatment of malaria in all the vulnerable populations.”

Dr Anthony Adofo Ofosu, the Deputy Director General, GHS, said this at the launch of “Zero malaria starts with me” campaign in Accra.  The launch coincided with a sensitisation programme by the African Media and Malaria Research Network (AMMRN), the National Malaria Control Programme and the Speak Up African Organisation. The Deputy Director General said “It is the belief of the GHS that with effective engagement…we will be able to eradicate malaria from the country in the near future.”

Mass radical treatment of a group of foreign workers to mitigate the risk of re-establishment of malaria in Sri Lanka

Following malaria elimination, Sri Lanka was free from indigenous transmission for six consecutive years, until the first introduced case was reported in December 2018. The source of transmission (index case) was a member of a group of 32 migrant workers from India and the location of transmission was their residence reporting a high prevalence of the primary vector for malaria. Despite extensive vector control the situation was highly susceptible to onward transmission if another of the group developed malaria. Therefore, Mass Radical Treatment (MRT) of the group of workers for Plasmodium vivax malaria was undertaken to mitigate this risk.

The workers were screened for malaria by microscopy and RDT, their haemoglobin level assessed, and tested for Glucose 6 phosphate dehydrogenase deficiency (G6PD) using the Care Start RDT and Brewers test prior to treatment with chloroquine (CQ) 25 mg/kg body weight (over three days) and primaquine (PQ, based on G6PD test results) (0.25 mg/kg/day bodyweight for 14 days) following informed consent. All were monitored for adverse events. None of the foreign workers were parasitaemic at baseline screening.

Mass treatment may be an option in prevention of reintroduction settings for groups of migrants who are likely to be carrying latent malaria infections, and resident in areas of high receptivity. However, in the case of Plasmodium vivax and Plasmodium ovale, a more reliable and affordable point-of-care test for G6PD activity would be required. Most countries which are eliminating malaria now are in the tropical zone and face considerable and similar risks of malaria re-introduction due to massive labour migration between them and neighbouring countries. Regional elimination of malaria should be the focus of global strategy if malaria elimination from countries is to be worthwhile and sustainable.

Managing intermittent preventive treatment of malaria in pregnancy challenges: an ethnographic study of two Ghanaian administrative regions

Malaria in pregnancy (MiP) is an important public health problem across sub-Saharan Africa. The package of measures for its control in Ghana in the last 20 years include regular use of long-lasting insecticide-treated bed nets (LLINs), directly-observed administration (DOT) of intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) and prompt and effective case management of MiP. Unfortunately, Ghana like other sub-Saharan African countries did not achieve the reset Abuja targets of 100% of pregnant women having access to IPTp and 100% using LLINs by 2015.

This ethnographic study explored how healthcare managers dealt with existing MiP policy implementation challenges and the consequences on IPTp-SP uptake and access to maternal healthcare. Healthcare managers addressed frequent stock-outs of malaria programme drugs and supplies from the National Malaria Control Programme and delayed reimbursement from the NHIS, by instituting co-payment, rationing and prescribing drugs for women to buy from private pharmacies.

Some clients did not receive the recommended 5?+?doses of SP, others did not obtain LLINs early and some did not obtain treatment for MiP. Healthcare providers felt frustrated whenever they could not provide comprehensive care to women who could not afford comprehensive maternal and MiP care. For Ghana to achieve her goal of controlling MiP, the Ministry of Health and other supporting institutions need to ensure prompt reimbursement of funds, regular supply of programme drugs and medical supplies to public, faith-based and private health facilities.

Malaria prevention program continuation in Guinea

CRS Guinea is the Principal Recipient (PR) in Malaria prevention program continuation grant by the Global Fund for the new cycle of funding (NFM) (January 2021-December 2023). Community health is a top priority of the Ministry of Health as a primary strategy to increase accessibility and coverage to basic health services. Under the new Global Fund grant, the community health component will be expanded to six districts, in addition to two pilot districts, Kindia and Telimele. CRS will also support coordination with other donors, including World Bank, UNICEF, Gavi, European Union and the Guinea Ministry of Health to implement the national community health strategy in 12 health districts supported by Global Fund malaria project.

The United States and Mali Celebrate 60 Years of Friendship and Partnership

Thirty years ago, our National Institutes of Health created a Malaria Research and Training Center, which is now a component of the International Center for Excellence in Research in Mali. Until today, it serves as a reference center with over 700 Malian scientists and support staff who work on malaria and other infectious diseases. Together, we have dropped malaria prevalence rates in Mali by an astounding 60 percent since 2012.

 

Malaria News Today 2020-09-18/19

Several reports and studies aim to help understand the malaria parasite and the human behavior surrounding its control. Cultural perceptions in Benin influence treatment seeking. Tracking cases in India aid in elimination efforts. The contrasts between in vivo and in vitro studies are examined. The factors associated with anemia among children and women in Ghana are traced to malaria and other factors. Finally both human and mosquito immunity are discussed. Click the links in each section to read details.

Demonstration of indigenous malaria elimination through Track-Test-Treat-Track (T4) strategy in a Malaria Elimination Demonstration Project in Mandla, Madhya Pradesh

Using the current intervention and prevention tools along with optimum utilization of human resources,This project has revealed about 91% reduction of indigenous cases of malaria during the period from June 2017 to May 2020, through case management and vector control strategies. A total 357,143 febrile cases were screened, out of which 0.19% were found positive.

The reduction was similar in the three high prevalence blocks of the district. These results reveal that malaria elimination is achievable in India within a stipulated time frame. The reduction of malaria at the community level was further validated when zero malaria cases were diagnosed during hospital and community-based studies in Mandla. Prompt detection and treatment of imported/migratory cases may have prevented outbreaks in the district. This project has demonstrated that field programmes backed by adequate technical, management, operational, and financial controls with robust monitoring are needed for achieving malaria elimination.needed for achieving malaria elimination.

Risk factors for anaemia among Ghanaian women and children vary by population group and climate zone

Anaemia has serious effects on human health and has multifactorial aetiologies. This study aimed to determine putative risk factors for anaemia in children 6-59 months and 15- to 49-year-old non-pregnant women living in Ghana. Data from a nationally representative cross-sectional survey were analysed for associations between anaemia and various anaemia risk factors. National and stratum-specific multivariable regressions were constructed separately for children and women to calculate the adjusted prevalence ratio (aPR) for anaemia of variables found to be statistically significantly associated with anaemia in bivariate analysis. Nationally, the aPR for anaemia was greater in children with iron deficiency (ID; aPR 2.20; 95% confidence interval [CI]: 1.88, 2.59), malaria parasitaemia (aPR 1.96; 95% CI: 1.65, 2.32), inflammation (aPR 1.26; 95% CI: 1.08, 1.46), vitamin A deficiency (VAD; aPR 1.38; 95% CI: 1.19, 1.60) and stunting (aPR 1.26; 95% CI: 1.09, 1.46).

In women, ID (aPR 4.33; 95% CI: 3.42, 5.49), VAD (aPR 1.61; 95% CI: 1.24, 2.09) and inflammation (aPR 1.59; 95% CI: 1.20, 2.11) were associated with anaemia, whereas overweight and obese women had lower prevalence of anaemia (aPR 0.74; 95% CI: 0.56, 0.97). ID was associated with child anaemia in the Northern and Middle belts, but not in the Southern Belt; conversely, inflammation was associated with anaemia in both children and women in the Southern and Middle belts, but not in the Northern Belt. Anaemia control programmes should be region specific and aim at the prevention of ID, malaria and other drivers of inflammation as they are the main predictors of anaemia in Ghanaian children and women.

From Circulation to Cultivation: Plasmodium In Vivo versus In Vitro

Research on Plasmodium parasites has driven breakthroughs in reducing malaria morbidity and mortality. Standard in vitro culture environments differ dramatically from in vivo conditions in nutrient levels, hematocrit, and rheology and have lower variability in gas levels and temperature.

Nutritional and physical differences lead to pronounced, and often rapid, changes in phenomenon, important for understanding virulence in Plasmodium. Parasite drug sensitivity may be altered due to culture adaptation selection, supraphysiological metabolite concentrations, and in vitro media formulations. Parasites propagated in vitro, versus in vivo, show altered transcriptomic and genomic patterns related to virulence factors, metabolism, gametocytogenesis, and more.

Direct-from-host methodologies avoid the impacts of in vitro culture adaptation but limit the types of assessments that can be performed as many experiments either require equipment not readily available in endemic settings or necessitate long-term manipulation….

Between traditional remedies and pharmaceutical drugs: prevention and treatment of “Palu” in households in Benin, West Africa

In Benin, malaria clinical cases, including the larger popular entity called “Palu” are evoked when people get fever. “Palu” is often self-diagnosed and self-medicated at home. This study aimed to describe the use of herbal medicine, and/or pharmaceutical medicines for prevention and treatment of malaria at home and the factors associated with this usage.

Methods. A cross-sectional survey was conducted in Benin in an urban and in a rural area in 2016. Around 600 households in each place were selected by using a random sampling of houses GPS coordinates of the families. The association between socio demographic characteristics and the use of herbal medicine was tested by using logistic regression models.

Results. In Cotonou (urban), 43.64% of households reported using herbal or pharmaceutical medicine to prevent “Palu”, while they were 53.1% in Lobogo (rural). To treat “Palu” in Cotonou, 5.34% of households reported using herbal medicine exclusively, 33.70% pharmaceutical medicine exclusively and 60.96% reported using both. In Lobogo, 4% reported using herbal medicine exclusively, 6.78% pharmaceutical medicine exclusively and 89.22% reported using both. In Cotonou, the factors “age of respondent”, “participation to a traditional form of savings” and “low socioeconomic level of the household” were associated with the use of herbal medicine.

Conclusions. This study shows the strong use of herbal medicine to prevent “Palu” or even treat it, and in this case it is mostly associated with the use of pharmaceutical medicine. It also highlights the fact that malaria control and care seeking behaviour with herbal medicine remain closely linked to household low-income status but also to cultural behaviour. The interest of this study is mostly educational, with regards to community practices concerning “Palu”, and to the design of adapted behaviour change communication strategies. Finally, there is a need to take into account the traditional habits of populations in malaria control and define a rational and risk-free use of herbal medicine as WHO-recommended.

Malaria parasite fools body with protein to dodge immune system

By SHIGEKO SEGAWA: OSAKA- The parasite responsible for malaria generates a look-alike of a human protein to suppress the workings of the immune system, leaving humans “defenseless” against infection, according to Japanese and British researchers.
A team comprised mainly of researchers from Osaka University and the University of Oxford said they hope the finding will help lead to new therapies for the mosquito-borne tropical disease.

As plasmodium is resistant to the immune system, the body’s self-defense system, humans can become infected repeatedly. Three years ago, the researchers realized that when plasmodium infects human red blood cells, it generates proteins called RIFINs, which send out signals for suppressing immunity. During the latest study, the researchers analyzed the structure of RIFIN in detail and found it closely resembles part of the structure of a specific human protein, which is involved in the mechanism for preventing the immune system from staging an attack on the body by mistake.

That protein combines with a molecule that suppresses the workings of the immune system. The scientists found the RIFIN that closely imitates the human protein in shape also combines with the same molecule and dodges attacks of the immune system. “We hope our findings will help develop vaccines and therapeutic drugs for malaria,” said Hisashi Arase, a professor of immunology with Osaka University, who is part of the research team. The research results were published in Nature, the British scientific journal.

Why Do Insect Vectors Not Get Ill from the Microbes They Transmit?

Some Evidence from Malaria-carrying Mosquitos by Kevin Noonan. The conservation of diverse and molecularly well-defined hemocyte types between distantly related mosquito genera and the apparent absence of megacytes in our Ae. aegypti mosquito dataset raise questions as to how the immune systems of these mosquito species have evolved to limit their capacity to transmit parasites and arboviruses to humans. This knowledge will ultimately underpin immunological strategies aimed at interrupting disease transmission by rendering mosquitoes resistant to such pathogens.

The conservation of diverse and molecularly well-defined hemocyte types between distantly related mosquito genera and the apparent absence of megacytes in our Ae. aegypti mosquito dataset raise questions as to how the immune systems of these mosquito species have evolved to limit their capacity to transmit parasites and arboviruses to humans. This knowledge will ultimately underpin immunological strategies aimed at interrupting disease transmission by rendering mosquitoes resistant to such pathogens.

Malaria News Today 2020-09-08

Today we share news and abstracts concerning detecting malaria in pregnancy, news about the opening remarks from the WHO Director General at a special malaria and COVID-19 webinar, resumption of NTD activities after COVID-19 restrictions reduced, and mapping of Ebola carrying bats whose territory overlaps malaria in Africa. Click on the links to read more.

Prevalence and clinical impact of malaria infections detected with a highly sensitive HRP2 rapid diagnostic test in Beninese pregnant women

While sub-microscopic malarial infections are frequent and potentially deleterious during pregnancy, routine molecular detection is still not feasible. This study aimed to assess the performance of a Histidine Rich Protein 2 (HRP2)-based ultrasensitive rapid diagnostic test (uRDT, Alere Malaria Ag Pf) for the detection of infections of low parasite density in pregnant women.

This study demonstrates the higher performance of uRDT, as compared to cRDTs, to detect low parasite density P. falciparum infections during pregnancy, particularly in the 1st trimester. uRDT allowed the detection of infections associated with maternal anaemia.

The distribution range of Ebola virus carriers in Africa may be larger than previously assumed

Since Ebola overlaps both symptomatically and geographically with malaria in Africa, it is “Worrying that science has hitherto underestimated the range of Ebola-transmitting bat and fruit bat species. In this case, the models would provide a more realistic picture,” explains Dr. Lisa Koch

Based on ecological niche modeling, his team was able to show that the respective bat and fruit bat species are able to thrive in West and East Africa, including large parts of Central Africa. A wide belt of potential habitats extends from Guinea, Sierra Leone, and Liberia in the west across the Central African Republic, the Republic of the Congo and the Democratic Republic of the Congo to Sudan and Uganda in the East. A few of the studied bats and fruit bats may even occur in the eastern part of South Africa.

WHO Director-General’s Opening Remarks At the Webinar – Responding to the Double Challenge of Malaria and Covid-19

The WHO Director General is encouraged by efforts to maintain malaria services despite the COVID-19 outbreak, but says, “I would like to recognize and applaud all these efforts, and to thank all of you who have worked so hard to preserve and maintain those services to the greatest degree possible. However, despite these actions, it breaks my heart to report that we still expect to see an increase in cases and deaths from malaria.

“In a recent WHO survey of 105 countries, 46% of countries reported disruptions in malaria diagnosis and treatment. These disruptions threaten to set us back even further in realizing our shared vision for a malaria-free world.”

NTD Disease treatments restart in Africa as COVID-19 restrictions ease

It is not just malaria services that have been disrupted by COVID-19 responses. Treatment programmes that will reach millions of Africans at risk from debilitating neglected tropical diseases (NTDs) have restarted in a significant step towards COVID-19 recovery. Around one million people in Jigawa state, Nigeria have received antibiotics to treat the blinding eye disease trachoma and stop it from spreading.

Nigeria is the first country that Sightsavers and partners has supported to resume work on NTDs, which can have a devastating impact on some of the poorest communities in the world, with other African countries due to follow soon. In April, the threat of COVID-19 led the World Health Organization to recommend suspending mass treatment campaigns, which treat and prevent these diseases, but it has since provided guidance on restarting activities safely.

Malaria News Today 2020-09-03

Various updates were found in newsletters and journal abstracts online today. These looked at mosquitoes – what attracts them to people, how ookinetes move in the midgut, and how perlite from volcanic rock may be a barrier repellent. Nigeria reports that there is no ACT resistance – so far.  And malaria partners join to coordinate actions in Uganda.  Click on links to read details.

Nigeria yet to detect resistance of malaria parasite to ACTs, says ministe

Contrary to reports that Africa has for the first time identified resistance strain of the malaria parasite to the drug of choice, Artemisinin Combination Therapy (ACT), the Minister of Health, Dr. Osagie Emmanuel Ehanire, on Monday said a study conducted in three states of the country showed there is no such phenomenon in Nigeria.  “However, we are still monitoring the situation. We insist that people should conduct a malaria test before using the drug of choice. This we hope will help prevent any kind of resistance of the malaria parasite to ACTs.”

Ministry of Health launches the Malaria Free Uganda Fund

Health Minister Dr Jane Ruth Aceng told journalists in Kampala today that the idea of having this new board was reached after realizing that different entities have been conducting the same malaria control related work. She said that the ministry resolved that mainstreaming responsibility will remove financial and operational bottlenecks that deter them from achieving set targets for elimination of the disease. The fund with a board of 11 members is chaired by Kenneth Wycliffe Mugisha of the Rotarian Malaria Partners-Uganda.

Volcanic Rock Yields a New Kind of Insecticide for Mosquitoes

Insecticide resistance to pesticides has become widespread in mosquito populations, making insecticides less effective over time. Therefore, there is an urgent need for insecticides with alternative modes of action. tested a material derived from volcanic rock, perlite, as a potential non-chemical insecticide against Anopheles gambiae, one of the primary mosquitoes that spreads malaria in Africa. In their new report published in August in the Journal of Medical Entomology, they show that perlite has encouraging potential as a mechanical insecticide. Perlite is believed to act by causing dehydration in the mosquitoes. read more…

Mosquitoes love pregnant, beer-drinking exercisers with Type O blood

Mosquitoes spread Zika, West Nile, Chikungunya, Dengue, and Malaria, resulting in 700 million illnesses a year and a million deaths. Even if you don’t get sick from a mosquito bite, the blood thinner they pump into your flesh before draining your blood causes swelling and itching. This article in Smithsonian Magazine lists the factors that make some people more tempting targets than others to mosquito bites. They include:

  • Blood type: “One study found that in a controlled setting, mosquitoes landed on people with Type O blood nearly twice as often as those with Type A.”
  • Carbon Dioxide: “people who simply exhale more of the gas over time—generally, larger people—have been shown to attract more mosquitoes than others.”
  • Exercise: “mosquitoes find victims at closer range by smelling the lactic acid, uric acid, ammonia and other substances expelled via their sweat”
  • Skin bacteria: “scientists found that having large amounts of a few types of bacteria made skin more appealing to mosquitoes”
  • Beer: “Just a single 12-ounce bottle of beer can make you more attractive to the insects”
  • Pregnancy: “pregnant people exhale about 21 percent more carbon dioxide and are on average about 1.26 degrees Fahrenheit warmer than others”
  • Clothing color: “wearing colors that stand out (black, dark blue or red) may make you easier to find”
  • Genetics: “underlying genetic factors are estimated to account for 85 percent of the variability between people in their attractiveness to mosquitoes”

Live In Vivo Imaging of Plasmodium Invasion of the Mosquito Midgut

Malaria is one of the most devastating parasitic diseases in humans and is transmitted by anopheline mosquitoes. The mosquito midgut is a critical barrier that Plasmodium parasites must overcome to complete their developmental cycle and be transmitted to a new host. Here, we developed a new strategy to visualize Plasmodium ookinetes as they traverse the mosquito midgut and to follow the response of damaged epithelial cells by imaging live mosquitoes. Understanding the spatial and temporal aspects of these interactions is critical when developing novel strategies to disrupt disease transmission.

Preventing Malaria in Mozambique: the 2018 Malaria Indicator Survey Summarized

The Demographic and Health Survey Program has recently released the 2018 Malaria Indicator Survey for Mozambique. Below is a summary of some of the key findings. These focus on access and use of insecticide-treated nets, intermittent preventive treatment in pregnancy and case management

While “82% of Mozambican households have at least one ITN, and half have at least one ITN for each two people,” these achievements do not reach universal coverage targets. That said, the ownership of at least one net by a household did increase from 51% in 2011 to the recent 82%. Likewise 23% of households met the universal coverage target of one net per two people in a household in 2011 compared to 51% in 2018. The pace of progress may appear good, but this must be seen in light of lack of growth in donor funding and greater calls for countries to assume more financial responsibility for disease control.

Of interest is the fact that net ownership is spread somewhat evenly over the economic class quintiles. Ideally we would want to see better ownership figures for the lower quintiles.

Households obtained their nets from three major sources. “Most ITNs (87%) were obtained in mass distribution campaigns, 4% in prenatal consultations (PNC) and 6% are purchased in stores or markets.” While the proportion getting their nets through PNC may roughly reflect the proportion of the population who are pregnant at a given time, the survey is not specifically a snapshot of this population in real time. Thus, one could question whether distribution of ITNs through routine health services is fully functioning.

Since it was noted that only half of households have the ideal number of ITNs to reach universal coverage of their members, it is not surprising that only, “69% of the population of households’ family members have access to an ITN. This means that 7 in every 10 people could sleep under an ITN if each ITN in a household were used by a maximum of two people.” On the positive side, this represents an approximate doubling of use of ITNs since 2011.

The survey further notes that those segments of the population traditionally viewed as “vulnerable” fared a bit better: “73% of children under 5 years and 76% of pregnant women slept under an ITN the night before investigation.” This too, represents a doubling from 2011. There is also geographical variation where it appears that the more rural provinces have higher rates of use.

It would appear that IRS is not a major component of malaria control. Household coverage with indoor residual spray “decreased from 19% in 2011 to 11% in 2015, and then increased to 16% in 2018.” Urban coverage (23%) of IRS in the twelve months prior to the survey is twice as high as the percentage in rural areas (12%).

Although still not meeting targets, Mozambique has seen major progress in providing IPTp for pregnant women. Over the period from 2011 to 2018 the proportion of pregnant women receiving even one dose rose from 37% to 85%. Since WHO has set targets for at least 3 monthly doses from the 13th week of pregnancy, Mozambique’s coverage of the third dose increased from 10% to 41% with wide variation among provinces.

UNICEF shared data from 2015 to show that 51% of pregnant women in Mozambique attended 4 PNC/ANC visits, implying that there are missed opportunities for achieving at least 3 doses of IPTp. Also, since more women are now getting the first dose of IPTp, hopefully more can also get an ITN at PNC.

These national surveys (MIS, DHS) are invaluable for assessing progress and planning what interventions need to be strengthened where and among whom. They also show that progress is slow, reinforcing global concerns that malaria elimination will still be a challenge by 2050.

Improved Uptake of Malaria in Pregnancy Indicators: A Case from USAID Boresha Afya Project, Lake & Western Zone, Tanzania

Zipporah Wandia,* Jasmine Chadewa, Agnes Kosia, Goodluck Tesha, Lusekelo Njoge, Zahra Mkomwa, Dunstan Bishanga, Rita Noronha, Bayoum Awadhi, Gaudiosa Tibaijuka, Chonge Kitojo, Erik Reaves, and Abdallah Lusasi presented a poster entitled “Improved Uptake of Malaria in Pregnancy Indicators: A Case from USAID Boresha Afya project, Lake & Western Zone, Tanzania” at the 68th Annual meeting of the American Society of Tropical Medicine and Hygiene. Their findings are seen below.

Magnitude of Malaria in Pregnancy: Malaria in pregnancy (MiP) has been recognized as a major public health concern. It is contributing to poor maternal and newborn health outcomes. In Sub-Saharan Africa, up to 20% of stillbirths are attributable to MiP and contributes to an estimated 10,000 maternal deaths and 100,000 infant deaths each year (Desai M. ter Kuile et al 2018).

Tanzania implements a three-pronged approach to prevent the adverse effect associated with MiP as recommended by WHO including 1)Intermittent preventive treatment of malaria in pregnancy (IPTp) with sulfadoxine-pyrimethamine, 2) Use of long-lasting insecticide-treated bed nets (LLINs), and 3) Strengthened Case management with Prompt diagnosis and treatment.

USAID Boresha Afya Lake and Western Zone Project supports Ministry of Health through the National Malaria Control Program to implements its strategies targeted to improve MiP in seven project supported regions. The Project uses the malaria data dashboard to identify facilities with gaps through:

  • Malaria Service Data Quality Improvement (MSDQI)
  • Supportive supervision
  • On job training and mentorship to capacitate health care providers to provide quality MiP services to improve indicators performanc

Results: USAID Boresha Afya Project in collaboration with the National Malaria Control Program(NMCP) and involvement regional and council health management teams improved uptake of IPTp and MiP indicators in seven regions supported by the project
Improved documentation in Health Management Information System Book 6  and the Antenatal care (ANC) register used in Tanzania’s health facilities. Quarterly follow-up and mentorship for health care workers at ANC were completed between 2016–2018 in 1817 (100%) health facilities.

Uptake of both IPTp2 and IPTp3 increased steadily as seen in the two graphs. The increase between 2016 and 2019 was from 50% to 80% for IPTp2. IPTp3 increased 0 to 63%. General support to antenatal care where IPTp is given resulted in an increase in those women attending for the first time in their first trimester: 15% to 34% over the same time period.

Testing of pregnant women for malaria rose from 75% to 99%. During the period an average of 10% of women tested positive and were given appropriate malaria treatment.

Lessons Learnt: The improvements in MiP indicators in the Project supported regions is partly attributed to:

  • Commitment among health care workers
  • Mentorship and proper documentation
  • Improved the overall quality of ANC services in the supported regions

*Affiliation: USAID Boresha Afya Project – Jhpiego Tanzania; USAID Boresha Afya Project – Path Tanzania; National Malaria Control Programme-Tanzania Ministry of Health, Community Development, Gender, Elderly and Children, Tanzania; US President’s Malaria Initiative-United States Agency for International Development

This presentation was made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of the USAID Boresha Afya and do not necessarily reflect the views of USAID or the United States government.

Zero Malaria Starts with Universal Coverage: Part 2 Preventive and Curative Treatments

April hosts several important global health days or observances. On World Health Day 2019 WHO stressed that, “Universal health coverage (UHC) is WHO’s number one goal. Key to achieving it is ensuring that everyone can obtain the care they need, when they need it, right in the heart of the community.” Nationwide monitoring through the Demographic and Health Surveys (DHS), the Malaria Indicator Surveys (MIS) and the Multi-Indicator Cluster Surveys (MICS) can document the status of appropriate malaria treatment and intermittent preventive treatment in pregnant women (IPTp).

Definitions of indicators have evolved for treatment-related malaria interventions. When Intermittent Preventive Treatment for pregnant women (IPTp) began in the early 2000s, the recommended dosing was twice during pregnancy after the first trimester one month apart in high and/or stable transmission areas. Due to lessening efficacy of sulfadoxine-pyrimethamine (SP), the dosage recommendation has changed to at least three times, still a month apart from the beginning of the second trimester.

This updated policy was broadcast widely between 2012 and 2013, but it took countries some time to build capacity and scale up for the expanded coverage goals. UNICEF Data5 again show that between 2014 and 2017 coverage was far below either 80% of pregnant women, let alone reaching them universally (Figure 2). Most countries achieved 30% or less coverage. Zambia at 50% was the highest. Low coverage leaves both pregnant women and the unborn child at risk for anemia and death in the former and low birth weight, still birth or miscarriage for the latter. The World Malaria Report of 2018 estimates that three doses of IPTp were received by only 22% of pregnant women in the target countries in 2017.

The concept of IPT was investigated for infants and children during by a consortium of researchers in several African Countries. It was found that IPTi with SP could have a positive effect on preventing malaria. To operationalize this concept, the World Health Organization developed what is known as Seasonal Malaria Chemoprevention (SMC) that would be delivered in the Sahel region of West Africa where malaria transmission itself is seasonal and where there are some countries with very low transmission with implications for malaria elimination.

The SMC delivery process was not linked to immunization but provided by community health workers and volunteers. SP and Amodiaquine (SP-AQ) were used in combination and provided monthly, three or four times during the rainy/high transmission season. Coverage was targeted at children below school age. It is only recently that SMC has been scaled up to reach all eligible countries or states and regions within designated countries.

WHO states that SMC focuses on, “children aged 3–59 months (and) reduces the incidence of clinical attacks and severe malaria by about 75%.” In some countries the coverage is extended to primary school aged children, making comparisons and calculations of coverage (universal por otherwise) challenging.

The World Malaria Report of 2018 notes that, “In 2017, 15.7 million children in 12 countries in Africa’s Sahel subregion were protected through seasonal malaria chemoprevention (SMC) programs. However, about 13.6 million children who could have benefited from this intervention were not covered, mainly due to a lack of funding.” This implies that 54% of eligible children were reached.  Coverage of SMC can refer to receiving any of the doses or as having received all the monthly doses offered by a nation’s malaria control program. Specifically, the World Malaria Report 2018 drew on surveys in 7 countries that provided 4 monthly doses to determine that 53% of children received all doses.

Determining coverage for malaria treatment for sick people is not as straightforward as finding out the numbers who slept under an ITN or swallowed IPTp doses, and even those are not simple. As defined, correct treatment first consists of parasitological diagnosis, which at the primary care level could be by microscopy or rapid diagnostic test (RDT). The next issue is treating only those with positive tests. Finally, the treatment must consist of age- or weight-specific doses of an approved artemisinin-based combination therapy (ACT) drug. Very few clinic records or surveys document whether the treatment given is ‘correct’ by these standards.

WHO addresses the need for achieving universal access to malaria diagnostic testing and notes this will not be easy. They provide a successful example of Senegal, where following the introduction of malaria RDTs in 2007, malaria diagnostic testing rates rose rapidly from 4% to 86% (by 2009). Logistics, funding, training and supportive supervision complicate implementation.

UNICEF Data report that performance of malaria diagnostics in febrile children in surveys between 2014-17 was approximately 30% on average for countries with national surveys within that time frame (Figure 3). Only 4 countries achieved 50% or better. Most surveys then go on to report the number of febrile children who received ACTs, but do not necessary indicate how many who were correctly diagnoses were given ACTs vs those who received ACT but did not receive a test or tested negative.

The Nigeria 2015 Malaria Indicator Survey Illustrates this dilemma. Among 2600 children who reported having a fever in the two weeks preceding the survey, 66.1% sought advice (or care). Overall, 12.6% of febrile children received a diagnostic test as defined in the question as to whether the child was stuck on the finger or heel to obtain blood. Among the febrile children 37.6% reportedly were given some type of antimalarial drug. Overall 15.5% of febrile children were given an ACT. Even if ACTs were given only to tested children, not all tests would have been positive.

The overall implication of measuring treatment without a link to testing is that if more children receive any, let alone the correct drugs, is that evidence for actual presence of disease. We have a long way to go to measure malaria treatment coverage correctly, not to mention achieving universal coverage with appropriate treatment. Different malaria treatment-related interventions with different steps and different target groups in different regions of Africa and the World make defining, no less achieving UHC, a huge challenge.

Scaling up Malaria in Pregnancy Prevention at the Community Level

Community meeting to introduce community based IPTp

Elaine Roman and Kristin Vibbert of the Jhpiego malaria team describe below an important community-based intervention to prevent malaria in pregnancy. Follow their links to learn more.

The World Health Organization (WHO) 2018 World Malaria Report revealed that of 33 countries where intermittent preventive treatment (with sulfadoxine-

Quality Assured SP Packets

pyrimethamine/SP) is recommended for pregnant women, only 22% of eligible pregnant women received three doses of intermittent preventive treatment during pregnancy (IPTp3) with SP in 2017 (). Therefore, it is crucial that innovative interventions to scale up the provision of IPTp are needed to protect lives of mothers, fetuses and newborns.

The Transforming Intermittent Preventive Treatment for Optimal Pregnancy (TIPTOP), a five-year project, is one such innovative effort that aims to contribute to reduced maternal and neonatal mortality in four countries: DRC, Madagascar, Mozambique, and Nigeria by expanding access to quality-assured (QA) SP.

TIPTOP Infographic

The TIPTOP project is implementing a community-based approach to expand coverage of IPTp3 to a minimum of 50% in project areas, helping to reach the hardest-to-reach pregnant women and to ensure there are no missed opportunities for pregnant women to receive QA SP. Through rigorous research and routine monitoring, TIPTOP will generate evidence for WHO to inform a potential policy decision on global intermittent preventive treatment of malaria in pregnancy.

TIPTOP is also setting the stage for scale up, supporting Ministries of Health to pilot test SP distribution at the community level in settings that will not only yield quality data in real-life program settings but also lend to program learning, including documenting best practices and lessons learned. Further, in coordination with Medicines for Malaria Venture (MMV), TIPTOP is creating demand for and expanding access to QA SP.

Now that procurement, training, supervision, community education, monitoring and evaluation systems are nearly built, full implementation on the ground will be phased in over the next few months.

Tanzania: Slow Progress in Preventing Malaria

The full 2017 Malaria Indicator Survey (MIS) results have been published for Tanzania providing an opportunity to look at the findings in more detail. Several important factors need highlighting since Tanzania is part of a regional block where some countries are activly considering malaria elimination – the E8 countries of the Southern Africa Development Community.

So far Tanzania has come close to achieving a target of 80% of households owning insecticide treated nets (ITNs) with 78% on the mainland and 79% in Zanzibar. A closer look shows that there is still a ways to go to get to universal coverage or at least one net for every two persons in the household. With this indicator 45% of mainland and 42% of Zanzibar households have met the target, meaning that there are unprotected people in a majority of households across the country. This indicator experienced a drop from a 2011 “high” of 56%, a drop to 39% in 2015 and a slight recovery to 45% in 2017.

Even the universal coverage target requires that people actually sleep under the nets. What the MIS report shows is that although 63% of people had access to an ITN, only 52% reported sleeping under one the night before the survey.

Equity remains an issue with 69% of households in the lowest wealth quintile owning at least one net compared to 81% and 83% in the middle and fourth quintiles. Although households in the highest quintile had 78% ownership, this group is more likely to live in better quality housing that prevents the ingress of most mosquitoes. Also residents in urban areas have an edge over rural counterparts in terms of net access.

The report show that 55% of children under 5 years of age and 51% of pregnant women slept under an ITN. This is down from 72% and 75% respectively in 2011.

We learn that 90% of existing nets were obtained through some form of public sector campaign including mass distribution (62%), village coupons redeemable at health centers (15%), and school campaigns (4%). Only 5% were obtained through routine services (ANC, child immunization) indicating that efforts to ‘keep up’ after mass campaigns need to be strengthened. The 10% of nets, whether treated or not, that were obtained in shops and markets cost the owner in the neighborhood of US$5.00.

Uptake of doses of intermittent preventive treatment for malaria in pregnancy has slowly but steadily increased over the past 15 years and stood at 83% for one dose, 56% for two doses and 26% for three in this most recent MIS. With the current target being three or more doses needed for optimal protection, Tanzania still has a far long way to go, especially considering that accessing ITNs through ANC services is also low..