Malabo, Equatorial Guinea
Malabo, Equatorial Guinea

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Rehman A.M.,London School of Hygiene and Tropical Medicine | Schwabe C.,Medical Care Development International | Baltazar G.,Medical Care Development International | Matias A.,Medical Care Development International | And 7 more authors.
PLoS ONE | Year: 2011

Background: Insecticide treated nets (ITN) and indoor residual spraying (IRS) are the two pillars of malaria vector control in Africa, but both interventions are beset by quality and coverage concerns. Data from three control programs were used to investigate the impact of: 1) the physical deterioration of ITNs, and 2) inadequate IRS spray coverage, on their respective protective effectiveness. Methods: Malaria indicator surveys were carried out in 2009 and 2010 in Bioko Island, mainland Equatorial Guinea and Malawi to monitor infection with P.falciparum in children, mosquito net use, net condition and spray status of houses. Nets were classified by their condition. The association between infection and quality and coverage of interventions was investigated. Results: There was reduced odds of infection with P.falciparum in children sleeping under ITNs that were intact (Odds ratio (OR): 0.65, 95% CI: 0.55-0.77 and OR: 0.81, 95% CI: 0.56-1.18 in Equatorial Guinea and in Malawi respectively), but the protective effect became less with increasingly worse condition of the net. There was evidence for a linear trend in infection per category increase in deterioration of nets. In Equatorial Guinea IRS offered protection to those in sprayed and unsprayed houses alike when neighbourhood spray coverage was high (≥80%) compared to those living in areas of low IRS coverage (<20%), regardless of whether the house they lived in was sprayed or not (adjusted OR = 0.54, 95% CI 0.33-0.89). ITNs provided only personal protection, offering no protection to non users. Although similar effects were seen in Malawi, the evidence was much weaker than in Equatorial Guinea. Conclusions: Universal coverage strategies should consider policies for repair and replacement of holed nets and promote the care of nets by their owners. IRS programs should ensure high spray coverage since inadequate coverage gives little or no protection at all. © 2011 Rehman et al.


Prescott W.R.,Hydas World Health | Jordan R.G.,Hydas World Health | Grobusch M.P.,University of Tübingen | Chinchilli V.M.,Penn Medicine | And 6 more authors.
Malaria Journal | Year: 2012

Abstract. Background: Viewing Plasmodium in Romanovsky-stained blood has long been considered the gold standard for diagnosis and a cornerstone in management of the disease. This method however, requires a subjective evaluation by trained, experienced diagnosticians and establishing proficiency of diagnosis is fraught with many challenges. Reported here is an evaluation of a diagnostic system (a device consisting of a microscope, a scanner, and a computer algorithm) that evaluates scanned images of standard Giemsa-stained slides and reports species and parasitaemia. Methods. The device was challenged with two independent tests: a 55 slide, expert slide reading test the composition of which has been published by the World Health Organization (WHO55 test), and a second test in which slides were made from a sample of consenting subjects participating in a malaria incidence survey conducted in Equatorial Guinea (EGMIS test). These subjects blood was tested by malaria RDT as well as having the blood smear diagnosis unequivocally determined by a worldwide panel of a minimum of six reference microscopists. Only slides with unequivocal microscopic diagnoses were used for the device challenge, n=119. Results: On the WHO55 test, the device scored a Level 4 using the WHO published grading scheme. Broken down by more traditional analysis parameters this result was translated to 89% and 70% sensitivity and specificity, respectively. Species were correctly identified in 61% of the slides and the quantification of parasites fell within acceptable range of the validated parasitaemia in 10% of the cases. On the EGMIS test it scored 100% and 94% sensitivity/specificity, with 64% of the species correct and 45% of the parasitaemia within an acceptable range. A pooled analysis of the 174 slides used for both tests resulted in an overall 92% sensitivity and 90% specificity with 61% species and 19% quantifications correct. Conclusions: In its current manifestation, the device performs at a level comparable to that of many human slide readers. Because its use requires minimal additional equipment and it uses standard stained slides as starting material, its widespread adoption may eliminate the current uncertainty about the quality of microscopic diagnoses worldwide. © 2012 Prescott et al.; licensee BioMed Central Ltd.


Pappa V.,Yale University | Reddy M.,Yale University | Overgaard H.J.,Medical Care Development International | Overgaard H.J.,Norwegian University of Life Sciences | And 2 more authors.
American Journal of Tropical Medicine and Hygiene | Year: 2011

We determined the Human Blood Index (HBI) of malaria mosquito vectors in Equatorial Guinea. We used a polymerase chain reaction (PCR)-based methodology to identify blood meal sources in engorged mosquitoes. We observed high HBI values, indicating that these vectors are highly anthropophilic despite intensive intradomicillary application of residual insecticides. Our results suggest that estimating the HBI can be a relatively simple and easy way to evaluate the efficacy of antimalaria interventions where an observed diversion to non-human hosts may successfully contribute to the interruption of malaria transmission. Copyright © 2011 by The American Society of Tropical Medicine and Hygiene.


Overgaard H.J.,Norwegian University of Life Sciences | Reddy V.P.,Texas A&M University | Abaga S.,Ministry of Health | Matias A.,Medical Care Development International | And 6 more authors.
Parasites and Vectors | Year: 2012

Background: Malaria is endemic with year-round transmission on Bioko Island. The Bioko Island Malaria Control Project (BIMCP) started in 2004 with the aim to reduce malaria transmission and to ultimately eliminate malaria. While the project has been successful in reducing overall malaria morbidity and mortality, foci of high malaria transmission still persist on the island. Results from the 2009 entomological collections are reported here. Methods. Human landing collections (HLC) and light trap collections (LTC) were carried out on Bioko Island, Equatorial Guinea in 2009. The HLCs were performed in three locations every second month and LTCs were carried out in 10 locations every second week. Molecular analyses were performed to identify species, detect sporozoites, and identify potential insecticide resistance alleles. Results: The entomological inoculation rates (EIR) on Bioko Island ranged from 163 to 840, with the outdoor EIRs reaching > 900 infective mosquito bites per year. All three human landing collection sites on Bioko Island had an annual EIR exceeding the calculated African average of 121 infective bites per year. The highest recorded EIRs were in Punta Europa in northwestern Bioko Island with human biting rates of 92 and 66 mosquito landings per person per night, outdoors and indoors, respectively. Overall, the propensity for mosquito biting on the island was significantly higher outdoors than indoors (p < 0.001). Both Anopheles gambiae s.s. and An. melas were responsible for malaria transmission on the island, but with different geographical distribution patterns. Sporozoite rates were the highest in An. gambiae s.s. populations ranging from 3.1% in Punta Europa and 5.7% in Riaba in the southeast. Only the L1014F (kdr-west) insecticide resistance mutation was detected on the island with frequencies ranging from 22-88% in An. gambiae s.s. No insecticide resistance alleles were detected in the An. melas populations. Conclusions: In spite of five years of extensive malaria control and a generalized reduction in the force of transmission, parasite prevalence and child mortality, foci of very high transmission persist on Bioko Island, particularly in the northwestern Punta Europa area. This area is favorable for anopheline mosquito breeding; human biting rates are high, and the EIRs are among the highest ever recorded. Both vector species collected in the study have a propensity to bite outdoors more frequently than indoors. Despite current vector control efforts mosquito densities remain high in such foci of high malaria transmission. To further reduce transmission, indoor residual spraying (IRS) needs to be supplemented with additional vector control interventions. © 2012 Overgaard et al.; licensee BioMed Central Ltd.


Bradley J.,London School of Hygiene and Tropical Medicine | Matias A.,Medical Care Development International | Schwabe C.,Medical Care Development International | Vargas D.,Medical Care Development International | And 3 more authors.
Malaria Journal | Year: 2012

Background: Malaria is endemic on Bioko Island, Equatorial Guinea, with year-round transmission. In 2004 an intensive malaria control strategy primarily based on indoor residual spraying (IRS) was launched. The limited residual life of IRS poses particular challenges in a setting with year-round transmission, such as Bioko. Recent reports of outdoor biting by Anopheles gambiae are an additional cause for concern. In this study, the effect of the short residual life of bendiocarb insecticide and of children spending time outdoors at night, on malaria infection prevalence was examined. Methods: Data from the 2011 annual malaria indicator survey and from standard WHO cone bioassays were used to examine the relationship between time since IRS, mosquito mortality and prevalence of infection in children. How often children spend time outside at night and the association of this behaviour with malaria infection were also examined. Results: Prevalence of malaria infection in two to 14 year-olds in 2011 was 18.4%, 21.0% and 28.1% in communities with median time since IRS of three, four and five months respectively. After adjusting for confounders, each extra month since IRS corresponded to an odds ratio (OR) of 1.44 (95% CI 1.151.81) for infection prevalence in two to 14 year-olds. Mosquito mortality was 100%, 96%, 81% and 78%, at month 2, 3, 4 and 5 respectively after spraying. Only 4.1% of children spent time outside the night before the survey between the hours of 22.00 and 06.00 and those who did were not at a higher risk of infection (OR 0.87, 95% CI 0.501.54). Sleeping under a mosquito net provided additive protection (OR 0.68, 95% CI 0.540.86). Conclusions: The results demonstrate the epidemiological impact of reduced mosquito mortality with time since IRS. The study underscores that in settings of year-round transmission there is a compelling need for longer-lasting IRS insecticides, but that in the interim, high coverage of long-lasting insecticidal nets (LLINs) may ameliorate the loss of effect of current shorter-lasting IRS insecticides. Moreover, continued use of IRS and LLINs for indoororiented vector control is warranted given that there is no evidence that spending time outdoors at night increases infection prevalence in children. © 2012 Bradley et al.; licensee BioMed Central Ltd.


Bradley J.,London School of Hygiene and Tropical Medicine | Rehman A.M.,London School of Hygiene and Tropical Medicine | Schwabe C.,Medical Care Development International | Vargas D.,Medical Care Development International | And 4 more authors.
PLoS ONE | Year: 2013

Background: Previous studies demonstrated that fewer mosquitoes enter houses which are screened or have closed eaves. There is little evidence about the effect on malaria infection in humans that changes in house construction may have. This study examines the impact of protective housing improvements on malaria infection on Bioko Island. Methodology/Principal Findings: Data from the annual malaria indicator surveys between 2009 and 2012 were used to assess trends in housing characteristics and their effect on RDT confirmed malaria infection in household members. Odds ratios were adjusted for socio-economic status of the household.22726 children between the ages of 2 and 14 years were tested for P. falciparum. Prevalence of infection in those living in houses with open eaves was 23.0% compared to 18.8% for those living in houses with closed eaves (OR = 0.81, 95% CI 0.67-0.98). The prevalence of infection for children in screened houses was 9.1% versus 20.1% for those living in unscreened houses (OR = 0.44, 95% CI 0.27-0.71). The proportion of houses with closed eaves increased from 66.0% in 2009 to 74.3% in 2012 (test for trend p = 0.01). The proportion of screened houses remained unchanged over time at 1.3%. Conclusion/ Significance: As a malaria control intervention, house modification has the advantages that it is not affected by the growing threat of insecticide resistance; it protects all household members equally and at all times while indoors; and it offers protection against a number of vector borne diseases. The study provides evidence in support of efforts to regulate or encourage housing improvements which impede vector access into residences as part of an integrated vector control approach to complement existing measures which have been only partially successful in reducing malaria transmission in some parts of Bioko. © 2013 Bradley et al.


Bradley J.,London School of Hygiene and Tropical Medicine | Monti F.,Medical Care Development International | Rehman A.M.,London School of Hygiene and Tropical Medicine | Schwabe C.,Medical Care Development International | And 5 more authors.
Malaria Journal | Year: 2015

Background: The impact of importation of falciparum malaria from mainland Equatorial Guinea on malaria infection in non-travellers and travellers on Bioko Island was examined. Methods: Malaria indicator surveys were conducted in 2013 and 2014 to assess the association between malaria infection and travel to the mainland. Infection in non-travellers was compared in neighbourhoods of high travel and neighbourhoods of low travel. Boat passengers leaving from and arriving on the island were tested for infection. Results: Children who had travelled to the mainland in the previous eight weeks were at greater risk of infection than those who had not travelled (56 vs 26% in 2013; 42 vs 18% in 2014). Children who had not travelled, living in localities with the highest proportion of travellers, were significantly more likely to be infected compared to those in localities with the smallest proportion of travellers (adjusted odds ratios 7.7 (95% CI 2.3-25) and 5.3 (95% CI 2.5-11) in 2013 and 2014, respectively). Infection in arriving boat passengers was substantially higher than in those departing (70 vs 38%, p = 0.017). Discussion: Malaria importation by travellers poses a serious public health challenge affecting non-travellers as well as travellers. © 2015 Bradley et al.; licensee BioMed Central.


Athrey G.,Texas A&M University | Hodges T.K.,Texas A&M University | Reddy M.R.,Yale University | Overgaard H.J.,Norwegian University of Life Sciences | And 5 more authors.
PLoS Genetics | Year: 2012

Malaria vectors in sub-Saharan Africa have proven themselves very difficult adversaries in the global struggle against malaria. Decades of anti-vector interventions have yielded mixed results-with successful reductions in transmission in some areas and limited impacts in others. These varying successes can be ascribed to a lack of universally effective vector control tools, as well as the development of insecticide resistance in mosquito populations. Understanding the impact of vector control on mosquito populations is crucial for planning new interventions and evaluating existing ones. However, estimates of population size changes in response to control efforts are often inaccurate because of limitations and biases in collection methods. Attempts to evaluate the impact of vector control on mosquito effective population size (Ne) have produced inconclusive results thus far. Therefore, we obtained data for 13-15 microsatellite markers for more than 1,500 mosquitoes representing multiple time points for seven populations of three important vector species-Anopheles gambiae, An. melas, and An. moucheti-in Equatorial Guinea. These populations were exposed to indoor residual spraying or long-lasting insecticidal nets in recent years. For comparison, we also analyzed data from two populations that have no history of organized vector control. We used Approximate Bayesian Computation to reconstruct their demographic history, allowing us to evaluate the impact of these interventions on the effective population size. In six of the seven study populations, vector control had a dramatic impact on the effective population size, reducing Ne between 55%-87%, the exception being a single An. melas population. In contrast, the two negative control populations did not experience a reduction in effective population size. This study is the first to conclusively link anti-vector intervention programs in Africa to sharply reduced effective population sizes of malaria vectors. © 2012 Athrey et al.


Garcia-Basteiro A.L.,University of Barcelona | Schwabe C.,Medical Care Development International | Aragon C.,Medical Care Development International | Baltazar G.,Medical Care Development International | And 4 more authors.
Malaria Journal | Year: 2011

Background: As part of comprehensive malaria control strategies, the Bioko Island Malaria Control Project (BIMCP) distributed 110,000 long-lasting insecticide-treated nets (LLIN) in late 2007 with the aim of providing one net for each sleeping area. Despite attaining initially very high levels of net coverage and net use, many children under five years of age did not sleep under a net by 2009, according to annual malaria indicator surveys. The aim of this study was to assess the determinants of bed net use in children under five and bed net ownership of the households in which they live. Methods. Using data from annual cross-sectional household surveys of 2008 and 2009, we investigated factors associated with sleeping under a mosquito net the night prior to the survey, and a households owning at least one net, in all households which had at least one child under five years. Amongst others, caregiver's knowledge of malaria and household characteristics including a socio-economic score (SES), based on ownership of household assets, were analysed for their effect on net ownership and use. Results: There was a decline of around 32% in the proportion of households that owned at least one net between 2008 and 2009. Higher household bed net ownership was associated with knowing how malaria was prevented and transmitted, having the house sprayed in the previous 12 months, having fewer children under five in the household, and children being sick at some point in the previous 14 days. Higher bed net use in children < 5 was associated with being sick at some point in the last 14 days prior to the survey, living in an urban area, more years of education of the head of the household, household ownership of at least one ITN (as opposed to an untreated net) and the year in which the survey took place. Conclusions: The big fall in bed net use from 2008 to 2009 was attributable to the striking decline in ownership. Although ownership was similar in rural and urban areas, rural households were less likely to protect their children with bed nets. Knowledge about malaria was an important determinant of bed net ownership. Further research is needed to elucidate the decline in bed net ownership between 2008 and 2009. © 2011 García-Basteiro et al; licensee BioMed Central Ltd.


Overgaard H.J.,Norwegian University of Life Sciences | Overgaard H.J.,Ministry of Health and Social Welfare | Saebo S.,Norwegian University of Life Sciences | Reddy M.R.,Yale University | And 4 more authors.
Malaria Journal | Year: 2012

Background: The human biting rate (HBR), an important parameter for assessing malaria transmission and evaluating vector control interventions, is commonly estimated by human landing collections (HLC). Although intense efforts have been made to find alternative non-exposure mosquito collection methods, HLC remains the standard for providing reliable and consistent HBRs. The aim of this study was to assess the relationship between human landing and light trap collections (LTC), in an attempt to estimate operationally feasible conversion factors between the two. The study was conducted as part of the operational research component of the Bioko Island Malaria Control Project (BIMCP), Equatorial Guinea. Methods. Malaria mosquitoes were collected indoors and outdoors by HLCs and LTCs in three villages on Bioko Island, Equatorial Guinea during five bimonthly collections in 2009. Indoor light traps were suspended adjacent to occupied long-lasting, insecticide-treated bed nets. Outdoor light traps were placed close to the outer wall under the roof of the collection house. Collected specimens were subjected to DNA extraction and diagnostic PCR to identify species within the Anopheles gambiae complex. Data were analysed by simple regression of log-transformed values and by Bayesian regression analysis. Results: There was a poor correlation between the two collection methods. Results varied by location, venue, month, house, but also by the statistical method used. The more robust Bayesian analyses indicated non-linear relationships and relative sampling efficiencies being density dependent for the indoor collections, implying that straight-forward and simple conversion factors could not be calculated for any of the locations. Outdoor LTC:HLC relationships were weak, but could be estimated at 0.10 and 0.07 for each of two locations. Conclusions: Light trap collections in combination with bed nets are not recommended as a reliable method to assess human biting rates on Bioko Island. Different statistical analyses methods give variable and inconsistent results. Substantial variation in collection methods prevents the determination of reliable and operationally feasible conversion factors for both indoor and outdoor data. Until improved mosquito collection methods are developed that can provide reliable and unbiased HBR estimates, HLCs should continue to serve as the reference method for HBR estimation. © 2012 Overgaard et al; licensee BioMed Central Ltd.

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