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Kunene S.,National Malaria Control Programme | Phillips A.A.,University of California at San Francisco | Gosling R.D.,University of California at San Francisco | Kandula D.,University of California at San Francisco | Novotny J.M.,University of California at San Francisco
Malaria Journal | Year: 2011

Swaziland is working to be the first country in mainland sub-Saharan Africa to eliminate malaria. The highest level of Swaziland's government recently approved a national elimination policy, which endorses Swaziland's robust national elimination strategic plan. This commentary outlines Swaziland's progress towards elimination as well as the challenges that remain, primarily around securing long-term financial resources and managing imported cases from neighbouring countries. © 2011Kunene et al; licensee BioMed Central Ltd.

Galappaththy G.N.,National Malaria Control Programme
The Cochrane database of systematic reviews | Year: 2013

Plasmodium vivax infections are an important contributor to the malaria burden worldwide. The World Health Organization recommends a 14-day course of primaquine (0.25 mg/kg/day, giving an adult dose of 15 mg/day) to eradicate the liver stage of the parasite and prevent relapse of the disease. Many people find a 14-day primaquine regimen difficult to complete, and there is a potential risk of haemolytic anaemia in people with glucose-6-phosphate-dehydrogenase enzyme (G6PD) deficiency. This review evaluates primaquine in P. vivax, particularly alternatives to the standard 14-day course. To compare alternative primaquine regimens to the recommended 14-day regimen for preventing relapses (radical cure) in people with P. vivax malaria treated for blood stage infection with chloroquine. We also summarize trials comparing primaquine to no primaquine that led to the recommendation for the 14-day regimen. We searched the Cochrane Infectious Diseases Group's Specialized Register, CENTRAL (The Cochrane Library), MEDLINE, EMBASE and LILACS up to 8 October 2013. We checked conference proceedings, trial registries and reference lists and contacted researchers and pharmaceutical companies for eligible studies. Randomized controlled trials (RCTs) and quasi-RCTs comparing various primaquine dosing regimens with the standard primaquine regimen (15 mg/day for 14 days), or with no primaquine, in people with vivax malaria treated for blood stage infection with chloroquine. We independently assessed trial eligibility, trial quality, and extracted data. We calculated risk ratios (RR) with 95% confidence intervals (CI) for dichotomous data, and used the random-effects model in meta-analyses if there was significant heterogeneity. We assessed the overall quality of the evidence using the GRADE approach. We included 15 trials (two cluster-RCTs) of 4377 adult and child participants. Most trials excluded people with G6PD deficiency. Trials compared various regimens of primaquine with the standard primaquine regimen, or with placebo or no treatment. All trials treated blood stage infection with chloroquine. Alternative primaquine regimens compared to 14-day primaquineRelapse rates were higher over six months with the five-day primaquine regimen than the standard 14-day regimen (RR 10.05, 95% CI 2.82 to 35.86; two trials, 186 participants, moderate quality evidence). Similarly, relapse over six months was higher with three days of primaquine than the standard 14-day regimen (RR 3.18, 95% CI 2.1 to 4.81; two trials, 262 participants, moderate quality evidence; six months follow-up); and with primaquine for seven days followed up over two months, compared to 14-day primaquine (RR 2.24, 95% CI 1.24 to 4.03; one trial, 126 participants, low quality evidence).Relapse with once-weekly supervised primaquine for eight weeks was little different over nine months follow-up compared to 14-day self-administered primaquine in one small study (RR 2.97, 95% CI 0.34 to 25.87; one trial, 129 participants, very low quality evidence). Primaquine regimens compared to no primaquineThe number of people that relapsed was similar between people given five days of primaquine or given placebo or no primaquine (four trials, 2213 participants, high quality evidence; follow-up six to 15 months); but lower with 14 days of primaquine (RR 0.6; 95% CI 0.48 to 0.75; ten trials, 1740 participants, high quality evidence; follow-up seven weeks to 15 months).No serious adverse events were reported. Treatment-limiting adverse events were rare and non-serious adverse events were mild and transient. Trial authors reported that people tolerated the drugs.We did not find trials comparing higher dose primaquine regimens (0.5 mg/kg/day or more) for five days or more with the 14-day regimen. The analysis confirms the current World Health Organization recommendation for 14-day primaquine (15 mg/day) to prevent relapse of vivax malaria. Shorter primaquine regimens at the same daily dose are associated with higher relapse rates. The comparative effects with weekly primaquine are promising, but require further trials to establish equivalence or non-inferiority compared to the 14-day regimen in high malaria transmission settings.

Mbacham W.F.,University of Yaounde I | Mangham-Jefferies L.,London School of Hygiene and Tropical Medicine | Cundill B.,London School of Hygiene and Tropical Medicine | Achonduh O.A.,University of Yaounde I | And 10 more authors.
The Lancet Global Health | Year: 2014

Background: The scale-up of malaria rapid diagnostic tests (RDTs) is intended to improve case management of fever and targeting of artemisinin-based combination therapy. Habitual presumptive treatment has hampered these intentions, suggesting a need for strategies to support behaviour change. We aimed to assess the introduction of RDTs when packaged with basic or enhanced clinician training interventions in Cameroon. Methods: We did a three-arm, stratified, cluster-randomised trial at 46 public and mission health facilities at two study sites in Cameroon to compare three approaches to malaria diagnosis. Facilities were randomly assigned by a computer program in a 9:19:19 ratio to current practice with microscopy (widely available, used as a control group); RDTs with a basic (1 day) clinician training intervention; or RDTs with an enhanced (3 days) clinician training intervention. Patients (or their carers) and fieldworkers who administered surveys to obtain outcome data were masked to study group assignment. The primary outcome was the proportion of patients treated in accordance with WHO malaria treatment guidelines, which is a composite indicator of whether patients were tested for malaria and given appropriate treatment consistent with the test result. All analyses were by intention to treat. This study is registered at ClinicalTrials.gov, number NCT01350752. Findings: The study took place between June 7 and Dec 14, 2011. The analysis included 681 patients from nine facilities in the control group, 1632 patients from 18 facilities in the basic-training group, and 1669 from 19 facilities in the enhanced-training group. The proportion of patients treated in accordance with malaria guidelines did not improve with either intervention; the adjusted risk ratio (RR) for basic training compared with control was 1·04 (95% CI 0·53-2·07; p=0·90), and for enhanced training compared with control was 1·17 (0·61-2·25; p=0·62). Inappropriate use of antimalarial drugs after a negative test was reduced from 84% (201/239) in the control group to 52% (413/796) in the basic-training group (unadjusted RR 0·63, 0·28-1·43; p=0·25) and to 31% (232/759) in the enhanced-training group (0·29, 0·11-0·77; p=0·02). Interpretation: Enhanced clinician training, designed to translate knowledge into prescribing practice and improve quality of care, has the potential to halve overtreatment in public and mission health facilities in Cameroon. Basic training is unlikely to be sufficient to support the behaviour change required for the introduction of RDTs. Funding: ACT Consortium (Bill & Melinda Gates Foundation). © 2014 Mbacham et al. Open Access article distributed under the terms of CC BY-NC-SA.

Tusting L.S.,London School of Hygiene and Tropical Medicine | Willey B.,London School of Hygiene and Tropical Medicine | Lucas H.,Institute of Development Studies | Thompson J.,Institute of Development Studies | And 3 more authors.
The Lancet | Year: 2013

Background: Future progress in tackling malaria mortality will probably be hampered by the development of resistance to drugs and insecticides and by the contraction of aid budgets. Historically, control was often achieved without malaria-specific interventions. Our aim was to assess whether socioeconomic development can contribute to malaria control. Methods: We did a systematic review and meta-analysis to assess whether the risk of malaria in children aged 0-15 years is associated with socioeconomic status. We searched Medline, Web of Science, Embase, the Cochrane Database of Systematic Reviews, the Campbell Library, the Centre for Reviews and Dissemination, Health Systems Evidence, and the Evidence for Policy and Practice Information and Co-ordinating Centre evidence library for studies published in English between Jan 1, 1980, and July 12, 2011, that measured socioeconomic status and parasitologically confirmed malaria or clinical malaria in children. Unadjusted and adjusted effect estimates were combined in fixed-effects and random-effects meta-analyses, with a subgroup analysis for different measures of socioeconomic status. We used funnel plots and Egger's linear regression to test for publication bias. Findings: Of 4696 studies reviewed, 20 met the criteria for inclusion in the qualitative analysis, and 15 of these reported the necessary data for inclusion in the meta-analysis. The odds of malaria infection were higher in the poorest children than in the least poor children (unadjusted odds ratio [OR] 1.66, 95% CI 1.35-2.05, p<0.001, I2=68%; adjusted OR 2.06, 1.42-2.97, p<0.001, I2=63%), an effect that was consistent across subgroups. Interpretation: Although we would not recommend discontinuation of existing malaria control efforts, we believe that increased investment in interventions to support socioeconomic development is warranted, since such interventions could prove highly effective and sustainable against malaria in the long term.

Hassan S.E.-D.H.,Emergency and Humanitarian Action Directorate | Okoued S.I.,Communicable Disease Control Directorate | Mudathir M.A.,National Malaria Control Programme | Malik E.M.,Communicable Disease Control Directorate
Malaria Journal | Year: 2010

Background. Early diagnosis and treatment of malaria are necessary components in the control of malaria. The gold standard light microscopy technique has high sensitivity, but is a relatively time-consuming procedure especially during epidemics and in areas of high endemicity. This study attempted to test the sensitivity and specificity of a new diagnostic tool - the Cyscopereg; fluorescence microscope, which is based on the use of Plasmodium nucleic acid-specific fluorescent dyes to facilitate detection of the parasites even in low parasitaemia conditions due to the contrast with the background. Methods. In this study, 293 febrile patients above the age of 18 years attending the malaria treatment centre in Sinnar State (Sudan) were interviewed using a structured questionnaire. Finger-prick blood samples were also collected from the participants to be tested for malaria using the hospital's microscope, the reference laboratory microscope, as well as the Cyscope® microscope. The results of the investigations were then used to calculate the sensitivity, specificity, and positive and negative predictive values of the Cyscope® microscope in reference to gold standard light microscopy. Results. The sensitivity was found to be 98.2% (95% CI: 90.6%-100%); specificity = 98.3% (95% CI: 95.7% - 99.5%); positive predictive value = 93.3% (95% CI: 83.8% - 98.2%); and negative predictive value = 99.6% (95% CI: 97.6% - 100%). Conclusions. In conclusion, the Cyscope ® microscope was found to be sensitive, specific and provide rapid, reliable results in a matter of less than 10 minutes. The Cyscope ® microscope should be considered as a viable, cheaper and time-saving option for malaria diagnosis, especially in areas where Plasmodium falciparum is the predominant parasite. © 2010 Hassan et al; licensee BioMed Central Ltd.

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