21. Acta Trop. 2012 Aug;123(2):117-22. doi: 10.1016/j.actatropica.2012.04.010. Epub 2012 Apr 28.

ITN protection, MSP1 antibody levels and malaria episodes in young children of rural Burkina Faso. Kynast-Wolf G, Wakilzadeh W, Coulibaly B, Schnitzler P, Traor C, Becher H, Mller O. Institute of Public Health, Ruprecht-Karls-University Heidelberg, Germany. gisela.kynast-wolf@urz.uni-heidelberg.de Malaria blood-stage vaccines are in an early phase of clinical development with MSP1 being a major antigen candidate. There are limited data on the protective efficacy of antibodies against subunits of MSP1 in the malaria endemic areas of sub-Saharan Africa. This prospective cohort study was nested into a large insecticide-treated mosquito net (ITN) trial during which neonates were individually randomised to ITN protection from birth vs. protection from month six onwards in rural Burkina Faso. A sub sample of 120 children from three villages was followed for 10 months with six measurements of MSP1(42) antibodies (ELISA based on recombinant 42kDa fragment) and daily assessment of malaria episodes. Time to the next malaria episode was determined in relation to MSP1(42) antibody titres. MSP1(42) antibody titres were dependent on age, season, ITN-group, number of previous malaria episodes and parasitaemia. There were no significant differences in time until the next malaria episode in children with low compared to children with high MSP1(42) antibody titres at any point in time (101 vs. 97 days in May, p=0.6; 58 vs. 84 days in September, p=0.3; 144 vs. 161 days in March, p=0.5). The findings of this study support the short-lived nature of the humoral immune response in infants of malaria endemic areas. The study provides no evidence for antibodies against a subunit of MSP1 being protective against new malaria episodes in infants. Copyright 2012 Elsevier B.V. All rights reserved. PMID: 22569564 [PubMed - indexed for MEDLINE]

22. BMC Public Health. 2012 May 22;12:315. doi: 10.1186/1471-2458-12-315.

Examining equity in access to long-lasting insecticide nets and artemisinin-based combination therapy in Anambra State, Nigeria. Mbachu CO, Onwujekwe OE, Uzochukwu BS, Uchegbu E, Oranuba J, Ilika AL. Health Policy Research Group, Department of Pharmacology and Therapeutics, College of Medicine, University of Nigeria, and Department of Community Medicine, University of Nigeria Teaching Hospital, Enugu, Enugu State, Nigeria. chinyere23@yahoo.com BACKGROUND: In order to achieve universal health coverage, the government of Anambra State, southeast Nigeria has distributed free Long-lasting Insecticide treated Nets (LLINs) to the general population and delivered free Artemisinin-based Combination Therapy (ACT) to pregnant women and children less than 5 years. However, the levels of coverage with LLINS and ACTs is not clear, especially coverage of different socio-economic status (SES) population groups. This study was carried out to determine the level of coverage and access to LLINs and ACTs amongst different SES groups. METHODS: A questionnaire was used to collect data from randomly selected households in 19 local government areas of the State. Selected households had a pregnant woman and/or a child less than 5 years. The lot quality assurance sampling (LQAS) methodology was used in sampling. The questionnaire explored the availability and utilization of LLINs and ACTs from 2394 households. An asset-based SES index was used to examine the level of access of LLINS and ACTs to different SES quintiles. RESULTS: It was found that 80.5% of the households had an LLIN and 64.4% of the households stated that they actually used the nets the previous night. The findings showed that 42.3% of pregnant women who had fever within the past month received ACTs, while 37.5% of children<5 years old who had malaria in the past month had received ACTs. There was equity in ownership of nets for the range 1-5 nets per household. No significant SES difference was found in use of ACTs for treatment of malaria in children under five years old and in pregnant women. CONCLUSIONS: The free distribution of LLINs and ACTs increased household coverage of both malaria control interventions and bridged the equity gap in access to

them among the most vulnerable groups. PMCID: PMC3358243 PMID: 22545723 [PubMed - indexed for MEDLINE] 23. AIDS Care. 2012;24(12):1559-64. doi: 10.1080/09540121.2012.674094. Epub 2012 Apr 26. Prevalence and correlates of insecticide-treated bednet use among HIV-1infected adults in Kenya. Nnedu ON, John-Stewart GC, Singa BO, Piper B, Otieno PA, Guidry A, Richardson BA, Walson J. Department of Medicine, Section Infectious Diseases, Tulane University, New Orleans, LA, USA. onnedu1@tulane.edu HIV-1-infected adults are at increased risk for malaria. Insecticidetreated bednets protect individuals from malaria. Little is known about correlates of ownership and use of bednets among HIV-1-infected individuals. We conducted a cross-sectional survey of 388 HIV-1-infected adults recruited from three sites in Kenya (Kilifi, Kisii, and Kisumu) to determine factors associated with ownership and use of optimal bednets. We defined an optimal bednet as an untorn, insecticide-treated bednet. Of 388 participants, 134(34.5%) reported owning an optimal bednet. Of those that owned optimal bednets, most (76.9%) reported using it daily. In a multivariate model, higher socioeconomic status as defined as postsecondary education [OR = 2.8 (95% CI: 1.3-6.4), p = 0.01] and living in a permanent home [OR = 1.7(1.03-2.9), p = 0.04] were significantly associated with optimal bednet ownership. Among individuals who owned bednets, employed individuals were less likely [OR = 0.2(0.04-0.8), p = 0.01] and participants from Kilifi were more likely to use bednets [OR = 2.9 (95% CI 1.04-8.1), p = 0.04] in univariate analysis. Participants from Kilifi had the least education, lowest income, and lowest rate of employment. Our findings suggest that lower socioeconomic status is a barrier to ownership of an optimal bednet. However, consistent use is high once individuals are in possession of an optimal bednet. Increasing access to optimal bednets will lead to high uptake and use.

PMID: 22533793

[PubMed - indexed for MEDLINE]

24. Malar J. 2012 Apr 25;11:127. doi: 10.1186/1475-2875-11-127. Assessment of the effect of insecticide-treated nets and indoor residual spraying for malaria control in three rural kebeles of Adami Tulu District, South Central Ethiopia. Bekele D, Belyhun Y, Petros B, Deressa W. Natural and Computational Sciences, Biology Department, Debre Markos University, Debre Markos, Ethiopia. BACKGROUND: In the Adami Tulu District, indoor residual spraying (IRS) and insecticide-treated nets (ITNs) has been the main tool used to control malaria. The purpose of this study was to assess the effect of IRS and ITNs control strategies in Aneno Shisho kebele (lowest administrative unit of Ethiopia) compared with Kamo Gerbi (supplied ITN only) and Jela Aluto (no IRS and ITNs), with regards to the prevalence of malaria and mosquito density. METHODS: Cross-sectional surveys were conducted after heavy rains (October/November, 2006) and during the sporadic rains (April, 2007) in the three kebeles of Adami Tulu District. Malaria infection was measured by means of thick and thin film. Monthly collection of adult mosquitoes from OctoberDecember 2006 and April-May 2007 and sporozoite enzyme-linked immunosorbent assay (ELISA) on the collected mosquitoes were detected. Data related to the knowledge of mode of malaria transmission and its control measures were collected. Data collected on parasitological and knowledge, attitude and practice (KAP) surveys were managed and analysed using a statistical computer program SPSS version 13.0. A Pvalue <0.05 was considered to be statistically significant. RESULTS: The overall prevalence of malaria was 8.6% in Jela Aluto, 4.4% in Kamo Gerbi and 1.3% in Aneno Shisho in the two season surveys. The vector, Anopheles gambiae s.l., Anopheles pharoensis and Anopheles coustani were recorded. However, sporozoite ELISA on mosquito collections detected no infection. The difference in overall malaria prevalence and mosquito density between the three kebeles was significant (P<0.05).

CONCLUSIONS: The present study has provided some evidence for the success of ITNs/IRS combined malaria control measures in Aneno Shisho kebele in Adami Tulu District. Therefore, the combined ITNs/IRS malaria control measures must be expanded to cover all kebeles in the District of Ethiopia. PMCID: PMC3407491 PMID: 22533789 [PubMed - indexed for MEDLINE] 25. Trop Med Int Health. 2012 Jun;17(6):733-41. doi: 10.1111/j.1365-3156.2012.02990.x. Epub 2012 Apr 23. Long-term effects of malaria prevention with insecticide-treated mosquito nets on morbidity and mortality in African children: randomised controlled trial. Louis VR, Bals J, Tiendrebogo J, Bountogo M, Ramroth H, De Allegri M, Traor C, Beiersmann C, Coulibaly B, Y M, Jahn A, Becher H, Mller O. Institute of Public Health, Ruprecht-Karls-University, Heidelberg, Germany. OBJECTIVE: The objective is to investigate the effect of malaria control with insecticide-treated mosquito nets (ITNs) regarding possible higher mortality in children protected during early infancy, due to interference with immunity development, and to assess long-term effects on malaria prevalence and morbidity. METHODS: Between 2000 and 2002, a birth cohort was enrolled in 41 villages of a malaria holoendemic area in north-western Burkina Faso. All neonates (n = 3387) were individually randomised to ITN protection from birth (group A) vs. ITN protection from age 6 months (group B). Primary outcome was all-cause mortality. In 2009, a survey took place in six sentinel villages, and in 2010, a census was conducted in all study villages. RESULTS: After a median follow-up time of 8.3 years, 443/3387 (13.1%) children had migrated out of the area and 484/2944 (16.4%) had died, mostly at home. Long-term compliance with ITN protection was good. There were no differences in mortality between study groups (248 deaths in group A, 236 deaths in group B; rate ratio 1.05, 95% CI: 0.889-1.237, P = 0.574). The survey conducted briefly after the rainy season in 2009 showed that more than 80% of study children

carried asexual malaria parasites and up to 20% had clinical malaria. CONCLUSION: Insecticide-treated mosquito net protection in early infancy is not a risk factor for mortality. Individual ITN protection does not sufficiently reduce malaria prevalence in high-transmission areas. Achieving universal ITN coverage remains a major challenge for malaria prevention in Africa. 2012 Blackwell Publishing Ltd. PMID: 22519853 [PubMed - indexed for MEDLINE]

26. Glob Health Action. 2012;5:11619. doi: 10.3402/gha.v5i0.11619. Epub 2012 Apr 16. The impact of indoor residual spraying on malaria incidence in East Shoa Zone, Ethiopia. Hamusse SD, Balcha TT, Belachew T. Oromia Regional Health Bureau, Addis Ababa, Ethiopia. rahelgirma16@yahoo.com BACKGROUND: In Ethiopia, nearly 70% of the population resides in areas prone to malaria infection. The objective of this study is to evaluate the impact of indoor residual spraying (IRS) on the incidence of malaria in East Shoa Zone of Ethiopia. METHODS: Data from the registers of malaria cases at Debrezeit Malaria Control Center in East Shoa Zone of Ethiopia were collected and analyzed. Records of 22 villages with no previous rounds of spraying that were entirely covered with IRS using DDT during the peak malaria transmission season of 2001 and 2002 and other 22 adjacent villages with similar malaria incidence but remained unsprayed were used for the analyses. RESULTS: The incidence of malaria in 2011 and 2002 among the sprayed villages was lower than the respective preceding years for both Plasmodium species (incidence rate ratio 0.60; CI 0.35 to 0.95; p < 0.0001). After the focal spray, there was significant reduction in malaria incidence in the villages sprayed. Spraying was associated with a 62% reduction in malaria incidence. CONCLUSIONS: This study demonstrated that IRS with DDT was effective in reducing malaria incidence in highland epidemic-prone areas in the East Shoa Zone of

Ethiopia. A larger scale study should evaluate the effectiveness of DDT in reducing malaria incidence against its environmental impact and alternative strategies for malaria prevention. PMCID: PMC3329214 PMID: 22514514 [PubMed - indexed for MEDLINE] 27. Soc Sci Med. 2012 Jul;75(1):138-47. doi: 10.1016/j.socscimed.2012.02.035. Epub 2012 Mar 28. A perverse 'net' effect? Health insurance and ex-ante moral hazard in Ghana. Yilma Z, van Kempen L, de Hoop T. International Institute of Social Studies, Erasmus University Rotterdam, The Netherlands. zelexyilma@gmail.com Incentive problems in insurance markets are well-established in economic theory. One of these incentive problems is related to reduced prevention efforts following insurance coverage (ex-ante moral hazard). This prediction is yet to be tested empirically with regard to health insurance, as the health domain is often considered relatively immune to perverse incentives, despite its validation in other insurance markets that entail adverse shocks. This paper tests for the presence of ex-ante moral hazard with reference to malaria prevention in Ghana. We investigate whether enrollment in the country's National Health Insurance Scheme (NHIS) negatively affects ownership and use of insecticide-treated bed nets (ITNs). We use a panel of 400 households in the Brong Ahafo region for this purpose and employ a propensity-adjusted household fixed effects model. Our results suggest that ex-ante moral hazard is present, especially when the level of effort and cost required for prevention is high. Implications of perverse incentive effects for the NHIS are briefly outlined. Copyright 2012 Elsevier Ltd. All rights reserved. PMID: 22507951 [PubMed - indexed for MEDLINE]

28. Am J Trop Med Hyg. 2012 Apr;86(4):649-55. doi: 10.4269/ajtmh.2012.110414.

Collapse of Anopheles darlingi populations in Suriname after introduction of insecticide-treated nets (ITNs); malaria down to near elimination level. Hiwat H, Mitro S, Samjhawan A, Sardjoe P, Soekhoe T, Takken W. Laboratory of Entomology, Wageningen University and Research Centre, Wageningen, The Netherlands. helenehiwat@gmail.com A longitudinal study of malaria vectors was carried out in three villages in Suriname between 2006 and 2010. During 13,392 man hours of collections, 3,180 mosquitoes were collected, of which 33.7% were anophelines. Of these, Anopheles darlingi accounted for 88.1%, and An. nuneztovari accounted for 11.1%. The highest mean An. darlingi human biting rate (HBR) observed per survey was 1.43 bites/man per hour outdoor and 1.09 bites/man per hour indoor; 2 An. darlingi of the 683 tested were infected with Plasmodium falciparum. The anopheline HBR decreased to zero after the onset of malaria intervention activities, including insecticide-treated net (ITN) distribution, in 2006. Malaria transmission decreased to pre-elimination levels. It is concluded that the combination of ITN and climatic events has led to the collapse of malaria vector populations in the study sites in the interior of the country. The results are discussed in relation to the stability of malaria transmission in areas with low-density human populations. PMCID: PMC3403763 [Available on 2013/4/1] PMID: 22492150 [PubMed - indexed for MEDLINE] 29. Malar J. 2012 Mar 30;11:99. doi: 10.1186/1475-2875-11-99. The effect of household heads training on long-lasting insecticidetreated bed nets utilization: a cluster randomized controlled trial in Ethiopia. Deribew A, Birhanu Z, Sena L, Dejene T, Reda AA, Sudhakar M, Alemseged F, Tessema F, Zeynudin A, Biadgilign S, Deribe K. Department of Epidemiology, Jimma University, Jimma, Ethiopia. amare_deribew@yahoo.com BACKGROUND: Long-lasting insecticide-treated bed nets (LLITN) have demonstrated

significant impact in reducing malaria-related childhood morbidity and mortality. However, utilization of LLITN by under-five children is not satisfactory in many sub-Saharan African countries due to behavioural barriers. Previous studies had focused on the coverage and ownership of LLITN. The effect of skill-based training for household heads on LLITN utilization had not yet been investigated. A cluster-randomized trial on the effect of training of household heads on the use of LLITN was done in Ethiopia to fill this knowledge gap. METHODS: The study included 22 (11 intervention and 11 control) villages in southwest Ethiopia. The intervention consisted of tailored training of household heads about the proper use of LLITN and community network system. All households in each group received free LLITN. Data were collected at baseline, six and 12 months of the follow up periods. Utilization of LLITN in the control and intervention villages was compared at baseline and follow up periods. RESULTS: A total of 21,673; 14,735 and 13,758 individuals were included at baseline, sixth and twelfth months of the project period. At the baseline survey, 47.9% of individuals in the intervention villages and 68.4% in the control villages reported that they had utilized LLITN the night before the survey. At the six month, 81.0% of individuals in the intervention villages and 79.3% in the control villages had utilized LLITN. The utilization of LLITN in all age groups in the intervention villages was increased by 17.7 percentage point (95% CI 9.7-25.6) at sixth month and by 31.0 percentage point (95% CI 16.9-45.1) at the twelfth month. Among under-five children, the LLITN utilization increased by 31.6 percentage point (95% CI 17.3-45.8) at the sixth month and 38.4 percentage point (95% CI 12.1-64.7) at the twelfth months of the project period. CONCLUSION: Household level skill-based training has demonstrated a marked positive effect in the utilization of LLITN. The effect of the intervention steadily increased overtime. Therefore, distribution of LLITN should be accompanied by a skill-based training of household heads to improve its utilization. TRAIL REGISTRATION: Australian New Zealand Clinical Trials Registry (ACTR number: ACTRN12610000035022). PMCID: PMC3338089 PMID: 22463488 [PubMed - indexed for MEDLINE]

30. BMC Pregnancy Childbirth. 2012 Mar 29;12:21. doi: 10.1186/1471-239312-21. Utilization of insecticide treated nets during pregnancy among postpartum women in Ibadan, Nigeria: a cross-sectional study. Aluko JO, Oluwatosin AO. Nurse/Midwife/Public Health Nurse Tutors Programme, University College Hospital, Orita-mefa, Ibadan, Nigeria. joelforfavour@yahoo.com BACKGROUND: Pregnant women are susceptible to symptomatic malaria due to invasion of the placenta by plasmodium. Malaria increases the risk of adverse pregnancy outcomes for mothers, the foetuses and newborns. The effective use of Insecticide Treated Nets (ITNs) would be of benefit to these vulnerable women. Previous studies have focused on prenatal-women but this study sought to explore the actual trend of utilization of the proven strategy across all the pregnancy stages among postpartum women in Ibadan. METHODS: This cross-sectional survey utilized a validated structured questionnaire for data collection. A calculated sample of 335 postpartum women was proportionately recruited from three fee-paying facilities within Ibadan, Nigeria using a simple random sampling technique. These hospitals have high client flow for maternity cases and are known for provision of care under traditional ANC model. The data collected were analyzed using descriptive and inferential statistics by means of Statistical Package of Social Sciences (SPSS) version 15. The level of significance was set at = 0.05. RESULTS: The women's age ranged between 18 and 47 years, mean age was 29.4 0.8 years. Various irregularities marked the traditional model of ANC provided at the settings and no exposure to preconception care. Also, 276 (82.4%) had heard of ITNs. Antenatal clinics formed the major source of information. Low utilization and compliance rates were observed. One hundred and twenty-seven (37.9%) of the women had high knowledge of Malaria in Pregnancy (MIP) but only 70 (20.9%) demonstrated positive attitude towards the use of ITNs. Participants' educational status, family types, employment and residential areas significantly influenced ITNs utilization.

CONCLUSIONS: The women knew and learned about ITNs from ANC visits. Majority of the women did not own ITNs because of lack of access to free distribution. The existing traditional model of ANC was marked by irregularities and none of the women was exposed to preconception care. In addition, negative attitude in spite of increased knowledge of MIP was observed among the women. Therefore, evaluation of free distribution of ITNs is recommended. Integration of focused ANC and preconception care are advocated to promote early access to health information. PMCID: PMC3352125 PMID: 22458645 [PubMed - indexed for MEDLINE] 31. Malar J. 2012 Mar 28;11:94. doi: 10.1186/1475-2875-11-94. Lives saved from malaria prevention in Africa--evidence to sustain costeffective gains. Korenromp EL. Global Fund to Fight AIDS, Tuberculosis and Malaria, Vernier, Geneva CH1214, Switzerland. eline.korenromp@theglobalfund.org Lives saved have become a standard metric to express health benefits across interventions and diseases. Recent estimates of malaria-attributable under-five deaths prevented using the Lives Saved tool (LiST), extrapolating effectiveness estimates from community-randomized trials of scale-up of insecticidetreated nets (ITNs) in the 1990s, confirm the substantial impact and good cost-effectiveness that ITNs have achieved in high-endemic sub-Saharan Africa. An even higher cost-effectiveness would likely have been found if the modelling had included the additional indirect mortality impact of ITNs on preventing deaths from other common child illnesses, to which malaria contributes as a risk factor. As conventional ITNs are being replaced by long-lasting insecticidal nets and scale-up is expanded to target universal coverage for full, all-age populations at risk, enhanced transmission reduction may--above certain thresholds-enhance the mortality impact beyond that observed in the trials of the 1990s. On the

other hand, lives saved by ITNs might fall if improved malaria case management with artemisinin-based combination therapy averts the deaths that ITNs would otherwise prevent.Validation and updating of LiST's simple assumption of a universal, fixed coverage-to-mortality-reduction ratio will require enhanced national programme and impact monitoring and evaluation. Key indicators for time trend analysis include malaria-related mortality from population-based surveys and vital registration, vector control and treatment coverage from surveys, and parasitologically-confirmed malaria cases and deaths recorded in health facilities. Indispensable is triangulation with dynamic transmission models, fitted to long-term trend data on vector, parasite and human populations over successive phases of malaria control and elimination.Sound, locally optimized budget allocation including on monitoring and evaluation priorities will benefit much if policy makers and programme planners use planning tools such as LiST even when predictions are less certain than often understood. The ultimate success of LiST for supporting malaria prevention may be to prove its linear predictions less and less relevant. PMCID: PMC3373378 PMID: 22455309 [PubMed - indexed for MEDLINE] 32. PLoS One. 2012;7(3):e31481. doi: 10.1371/journal.pone.0031481. Epub 2012 Mar 16. Species shifts in the Anopheles gambiae complex: do LLINs successfully control Anopheles arabiensis? Kitau J, Oxborough RM, Tungu PK, Matowo J, Malima RC, Magesa SM, Bruce J, Mosha FW, Rowland MW. Kilimanjaro Christian Medical College, Tumaini University, Moshi, Tanzania. jvnkit@gmail.com INTRODUCTION: High coverage of conventional and long-lasting insecticide treated nets (ITNs and LLINs) in parts of E Africa are associated with reductions in local malaria burdens. Shifts in malaria vector species ratio have coincided with

the scale-up suggesting that some species are being controlled by ITNs/LLINs better than others. METHODS: Between 2005-2006 six experimental hut trials of ITNs and LLINs were conducted in parallel at two field stations in northeastern Tanzania; the first station was in Lower Moshi Rice Irrigation Zone, an area where An. arabiensis predominates, and the second was in coastal Muheza, where An. gambiae and An. funestus predominate. Five pyrethroids and one carbamate insecticide were evaluated on nets in terms of insecticide-induced mortality, bloodfeeding inhibition and exiting rates. RESULTS: In the experimental hut trials mortality of An. arabiensis was consistently lower than that of An. gambiae and An. funestus. The mortality rates in trials with pyrethroid-treated nets ranged from 25-52% for An. arabiensis, 63-88% for An. gambiae s.s. and 53-78% for An. funestus. All pyrethroidtreated nets provided considerable protection for the occupants, despite being deliberately holed, with blood-feeding inhibition (percentage reduction in biting rates) being consistent between species. Veranda exiting rates did not differ between species. Percentage mortality of mosquitoes tested in cone bioassays on netting was similar for An. gambiae and An. arabiensis. CONCLUSIONS: LLINs and ITNs treated with pyrethroids were more effective at killing An. gambiae and An. funestus than An. arabiensis. This could be a major contributing factor to the species shifts observed in East Africa following scale up of LLINs. With continued expansion of LLIN coverage in Africa An. arabiensis is likely to remain responsible for residual malaria transmission, and species shifts might be reported over larger areas. Supplementary control measures to LLINs may be necessary to control this vector species. PMCID: PMC3306310 PMID: 22438864 [PubMed - indexed for MEDLINE] 33. Med Mal Infect. 2012 Mar;42(3):114-8. doi: 10.1016/j.medmal.2012.01.010. Epub 2012 Mar 7. Assessment of microbial larvicide spraying with Bacillus thuringiensis israelensis, for the prevention of malaria. Kinde-Gazard D, Baglo T.

Facult des Sciences de la Sant de l'Universit d'Abomey-Calavi 03, BP 1428 Cotonou, Benin. kindegazard@yahoo.fr OBJECTIVES: The aim of this study was to assess the contribution of microbial larvicide spraying, Bacillus thuringiensis israelensis, as prevention strategy against malaria. METHODS: An experimental study consisted in spraying B. thuringiensis israelensis in a district during 1 year has been conducted. Another district (control) was not sprayed. Eight hundred and two children were evaluated, thick drop and swab examination was performed for those presenting with fever. The larval density was calculated in their habitats as well as larvicide remanence. Capture of mosquitoes with human bait allowed determining human exposure to bites at night, and identifying anopheles after dissection. RESULTS: The incidence of pediatric malaria was 13.8% in the sprayed district and 31.4% in the control district. The parasitic load ranged from 2000 to 42,000 parasites/L in the sprayed district and 2000 to 576,000 parasites/L in the control district. Plasmodium falciparum was the most frequent (97.8%) plasmodial species. In the control district, at least 20 larvae by liter of water were counted; anopheles larvae were found in 11 larval habitats out of 15 (73.33%). The human exposure to anopheles bites at night was 14.25 in the sprayed district and 33.13 in the control district. The remanence of B. thuringiensis israelensis was estimated at 9 days in the sprayed district. CONCLUSION: The larvicide B. thuringiensis israelensis may be used in vector control strategy for the prevention of malaria. Copyright 2012 Elsevier Masson SAS. All rights reserved. PMID: 22405513 [PubMed - indexed for MEDLINE]

34. PLoS One. 2012;7(2):e31409. doi: 10.1371/journal.pone.0031409. Epub 2012 Feb 20. High prevalence of malaria in Zambezia, Mozambique: the protective effect of IRS versus increased risks due to pig-keeping and house construction. Temu EA, Coleman M, Abilio AP, Kleinschmidt I. London School of Hygiene and Tropical Medicine, London, United Kingdom.

BACKGROUND: African countries are scaling up malaria interventions, especially insecticide treated nets (ITN) and indoor residual spraying (IRS), for which ambitious coverage targets have been set. In spite of these efforts infection prevalence remains high in many parts of the continent. This study investigated risk factors for malaria infection in children using three malaria indicator surveys from Zambezia province, Mozambique. The impact of IRS and ITNs, the effects of keeping farm animals and of the construction material of roofs of houses and other potential risk factors associated with malaria infection in children were assessed. METHODS: Cross-sectional community-based surveys were conducted in October of 2006, 2007 and 2008. A total of 8338 children (ages 1-15 years) from 2748 households were included in the study. All children were screened for malaria by rapid diagnostic tests. Caregiver interviews were used to assess household demographic and wealth characteristics and ITN and IRS coverage. Associations between malaria infection, vector control interventions and potential risk factors were assessed. RESULTS: Overall, the prevalence of malaria infection was 47.8% (95%CI: 38.7%-57.1%) in children 1-15 years of age, less than a quarter of children (23.1%, 95%CI: 19.1%-27.6%) were sleeping under ITN and almost two thirds were living in IRS treated houses (coverage 65.4%, 95%CI: 51.5%-77.0%). Protective factors that were independently associated with malaria infection were: sleeping in an IRS house without sleeping under ITN (Odds Ratio (OR)=0.6; 95%CI: 0.4-0.9); additional protection due to sleeping under ITN in an IRS treated house (OR=0.5; 95%CI: 0.3-0.7) versus sleeping in an unsprayed house without a ITN; and parental education (primary/secondary: OR=0.6; 95%CI: 0.5-0.7) versus parents with no education. Increased risk of infection was associated with: current fever (OR=1.2; 95%CI: 1.0-1.5) versus no fever; pig keeping (OR=3.2; 95%CI: 2.1-4.9) versus not keeping pigs; living in houses with a grass roof (OR=1.7; 95%CI: 1.3-2.4) versus other roofing materials and bigger household size (8-15 people: OR=1.6; 95%CI: 1.3-2.1) versus small households (1-4 persons).

CONCLUSION: Malaria infection among children under 15 years of age in Zambezia remained high but conventional malaria vector control methods, in particular IRS, provided effective means of protection. Household ownership of farm animals, particularly pigs, and living in houses with a grass roof were independently associated with increased risk of infection, even after allowing for household wealth. To reduce the burden of malaria, national control programs need to ensure high coverage of effective IRS and promote the use of ITNs, particularly in households with elevated risks of infection, such as those keeping farm animals, and those with grass roofs. PMCID: PMC3282725 PMID: 22363640 [PubMed - indexed for MEDLINE] 35. Cochrane Database Syst Rev. 2012 Feb 15;2:CD003756. doi: 10.1002/14651858.CD003756.pub4. Intermittent preventive treatment for malaria in children living in areas with seasonal transmission. Meremikwu MM, Donegan S, Sinclair D, Esu E, Oringanje C. Department of Paediatrics, University of Calabar Teaching Hospital, Calabar, Nigeria. mmeremiku@yahoo.co.uk. Update of Cochrane Database Syst Rev. 2008;(2):CD003756. BACKGROUND: In malaria endemic areas, pre-school children are at high risk of severe and repeated malaria illness. One possible public health strategy, known as Intermittent Preventive Treatment in children (IPTc), is to treat all children for malaria at regular intervals during the transmission season, regardless of whether they are infected or not. OBJECTIVES: To evaluate the effects of IPTc to prevent malaria in preschool children living in endemic areas with seasonal malaria transmission. SEARCH METHODS: We searched the Cochrane Infectious Diseases Group Specialized Register (July 2011), CENTRAL (The Cochrane Library 2011, Issue 6), MEDLINE (1966 to July 2011), EMBASE (1974 to July 2011), LILACS (1982 to July 2011), mRCT (July

2011), and reference lists of identified trials. We also contacted researchers working in the field for unpublished and ongoing trials. SELECTION CRITERIA: Individually randomized and cluster-randomized controlled trials of full therapeutic dose of antimalarial or antimalarial drug combinations given at regular intervals compared with placebo or no preventive treatment in children aged six years or less living in an area with seasonal malaria transmission. DATA COLLECTION AND ANALYSIS: Two authors independently assessed eligibility, extracted data and assessed the risk of bias in the trials. Data were meta-analysed and measures of effects (ie rate ratio, risk ratio and mean difference) are presented with 95% confidence intervals (CIs). The quality of evidence was assessed using the GRADE methods. MAIN RESULTS: Seven trials (12,589 participants), including one cluster-randomized trial, met the inclusion criteria. All were conducted in West Africa, and six of seven trials were restricted to children aged less than 5 years.IPTc prevents approximately three quarters of all clinical malaria episodes (rate ratio 0.26; 95% CI 0.17 to 0.38; 9321 participants, six trials, high quality evidence), and a similar proportion of severe malaria episodes (rate ratio 0.27, 95% CI 0.10 to 0.76; 5964 participants, two trials, high quality evidence). These effects remain present even where insecticide treated net (ITN) usage is high (two trials, 5964 participants, high quality evidence).IPTc probably produces a small reduction in all-cause mortality consistent with the effect on severe malaria, but the trials were underpowered to reach statistical significance (risk ratio 0.66, 95% CI 0.31 to 1.39, moderate quality evidence).The effect on anaemia varied between studies, but the risk of moderately severe anaemia is probably lower with IPTc (risk ratio 0.71, 95% CI 0.52 to 0.98; 8805 participants, five trials, moderate quality evidence).Serious drug-related adverse events, if they occur, are probably rare, with none reported in the six trials (9533 participants, six trials, moderate quality evidence). Amodiaquine plus sulphadoxine-pyrimethamine is the most studied drug combination for seasonal chemoprevention. Although effective, it causes increased vomiting in this age-group (risk ratio 2.78, 95% CI 2.31 to 3.35; two trials, 3544 participants, high quality evidence).When antimalarial IPTc was stopped, no rebound increase in malaria was observed in the three trials which continued

follow-up for one season after IPTc. AUTHORS' CONCLUSIONS: In areas with seasonal malaria transmission, giving antimalarial drugs to preschool children (age < 6 years) as IPTc during the malaria transmission season markedly reduces episodes of clinical malaria, including severe malaria. This benefit occurs even in areas where insecticide treated net usage is high. PMID: 22336792 [PubMed - indexed for MEDLINE]

36. J Community Health. 2012 Oct;37(5):1006-14. doi: 10.1007/s10900-0129546-z. Factors associated with utilization of insecticide-treated nets in children seeking health care at a Ugandan hospital: perspective of child caregivers. Nankinga Z, Muliira JK, Kalyango J, Nankabirwa J, Kiwuwa S, Njama-Meya D, Karamagi C. Department of Nursing, School of Health Sciences, Makerere University, P. O. Box 7072, Kampala, Uganda. zknankinga@yahoo.com In Uganda malaria causes more morbidity and mortality than any other disease and children below 5 years contribute the biggest percentage of malaria related mortality. Insecticide treated nets (ITNs) are currently one of the most cost effective option for reducing malaria-related morbidity and mortality, however the factors affecting their utilization in Uganda are still not well understood. This study examined the prevalence and factors associated with ITN utilization among children of age 0-12 years seeking health care from a Ugandan hospital using caregiver's reports. A cross sectional design was used to collect data using a semi-structured questionnaire from 418 participants. Binary logistic regression was employed to determine predictors of ITN utilization. Results show that the prevalence of ITN utilization among children seeking health care was 34.2%. ITN utilization was higher among children of age <5 years [37.0, 95% CI 31.81-42.21] as compared to children aged 5 years [22.9, 95% CI 13.7732.01]. Source of mosquito net (OR = 13.53, 95% CI = 6.47-28.27), formal employment by

head of household (OR = 6.00, 95% CI = 1.95-18.48), sharing a bed with parent (s) (OR = 2.61, 95% CI = 1.21-5.63) and number of children below 12 years in a household (OR = 0.80, 95% CI = 0.65-0.99), were significant predictors of utilization. ITN utilization among children was below the set national target. The predictors identified by this study reveal opportunities that can be taken advantage of by malaria control programs to achieve the desired rates of utilization and subsequently malaria prevention in children. PMID: 22323100 [PubMed - indexed for MEDLINE]

37. BMC Public Health. 2012 Feb 6;12:105. doi: 10.1186/1471-2458-12-105. Determinants of insecticide-treated net ownership and utilization among pregnant women in Nigeria. Ankomah A, Adebayo SB, Arogundade ED, Anyanti J, Nwokolo E, Ladipo O, Meremikwu MM. College of Medical Sciences, University of Calabar, Calabar, Nigeria. BACKGROUND: Malaria during pregnancy is a major public health problem in Nigeria leading to increase in the risk of maternal mortality, low birth weight and infant mortality. This paper is aimed at highlighting key predictors of the ownership of insecticide treated nets (ITNs) and its use among pregnant women in Nigeria. METHODS: A total of 2348 pregnant women were selected by a multi-stage probability sampling technique. Structured interview schedule was used to elicit information on socio-demographic characteristics, ITN ownership, use, knowledge, behaviour and practices. Logistic regression was used to detect predictors of two indicators: ITN ownership, and ITN use in pregnancy among those who owned ITNs. RESULTS: ITN ownership was low; only 28.8% owned ITNs. Key predictors of ITN ownership included women who knew that ITNs prevent malaria (OR = 3.85; p < 0001); and registration at antenatal clinics (OR = 1.34; p = 0.003). The use of ITNs was equally low with only 7.5% of all pregnant women, and 25.7% of all pregnant women who owned ITNs sleeping under a net. The predictors of ITN use in pregnancy among women who owned ITNs (N = 677) identified by logistic regression

were: urban residence (OR = 1.87; p = 0.001); knowledge that ITNs prevent malaria (OR = 2.93; p < 0001) and not holding misconceptions about malaria prevention (OR = 1.56; p = 0.036). Educational level was not significantly related to any of the two outcome variables. Although registration at ANC is significantly associated with ownership of a bednet (perhaps through free ITN distribution) this does not translate to significant use of ITNs. CONCLUSIONS: ITN use lagged well behind ITN ownership. This seems to suggest that the current mass distribution of ITNs at antenatal facilities and community levels may not necessarily lead to use unless it is accompanied by behaviour change interventions that address the community level perceptions, misconceptions and positively position ITN as an effective prevention device to prevent malaria. PMCID: PMC3340311 PMID: 22309768 [PubMed - indexed for MEDLINE] 38. Malar J. 2012 Feb 1;11:32. doi: 10.1186/1475-2875-11-32. Can universal insecticide-treated net campaigns achieve equity in coverage and use? the case of northern Nigeria. Ye Y, Patton E, Kilian A, Dovey S, Eckert E. ICF International, 11785 Beltsville Drive, Suite 300, Calverton, MD 20705, USA. yye2@icfi.com BACKGROUND: Insecticide-treated nets (ITNs) are effective tools for malaria prevention and can significantly reduce severe disease and mortality due to malaria, especially among children under five in endemic areas. However, ITN coverage and use remain low and inequitable among different socioeconomic groups in sub-Saharan Africa, particularly in Nigeria. Several strategies have been proposed to increase coverage and use and reduce inequity in Nigeria, including free distribution campaigns recently conducted by the Nigerian federal government. Using data from the first post-campaign survey, the authors investigated the effect of the mass free distribution campaigns in achieving equity in household ownership and use of ITNs. METHODS: A post-campaign survey was undertaken in November 2009 in northern

Nigeria to assess the effect of the campaigns in addressing equity across different socio-economic groups. The survey included 987 households randomly selected from 60 clusters in Kano state. Using logistic regression and the Lorenz concentration curve and index, the authors assessed equity in ITN coverage and use. RESULTS: ITN ownership coverage increased from 10% before the campaigns to 70%-a more than fivefold increase. The campaigns reduced the ownership coverage gap by 75%, effectively reaching parity among wealth quintiles (Concentration index 0.02, 95% CI (-0.02 ; 0.05) versus 0.21 95%CI (0.08 ; 0.34) before the campaigns). ITN use (individuals reporting having slept under an ITN the night before the survey visit) among individuals from households owning at least one ITN, was 53.1% with no statistically significant difference between the lowest, second, third and fourth wealth quintiles and the highest wealth quintile (lowest: odds ratio (OR) 0.87, 95% confidence interval (CI) (0.67 ; 1.13); second: OR 0.85, 95% CI (0.66 ; 1.24); third: OR 1.10 95% CI (0.86 ; 1.4) and fourth OR 0.91 95% CI (0.72 ; 1.15). CONCLUSION: The campaign had a significant impact by increasing ITN coverage and reducing inequity in ownership and use. Free ITN distribution campaigns should be sustained to increase equitable coverage. These campaigns should be supplemented with other ITN distribution strategies to cover newborns and replace aging nets. PMCID: PMC3312823 PMID: 22297189 [PubMed - indexed for MEDLINE] 39. Trop Med Int Health. 2012 Apr;17(4):430-7. doi: 10.1111/j.13653156.2011.02953.x. Epub 2012 Jan 24. Improved equity in measles vaccination from integrating insecticidetreated bednets in a vaccination campaign, Madagascar. Goodson JL, Kulkarni MA, Vanden Eng JL, Wannemuehler KA, Cotte AH, Desrochers RE, Randriamanalina B, Luman ET. Global Immunization Division, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA. jgoodson@cdc.gov OBJECTIVE: To evaluate the effect of integrating ITN distribution on measles

vaccination campaign coverage in Madagascar. METHODS: Nationwide cross-sectional survey to estimate measles vaccination coverage, nationally, and in districts with and without ITN integration. To evaluate the effect of ITN integration, propensity score matching was used to create comparable samples in ITN and non-ITN districts. Relative risks (RR) and 95% confidence intervals (CI) were estimated via log-binomial models. Equity ratios, defined as the coverage ratio between the lowest and highest household wealth quintile (Q), were used to assess equity in measles vaccination coverage. RESULTS: National measles vaccination coverage during the campaign was 66.9% (95% CI 63.0-70.7). Among the propensity score subset, vaccination campaign coverage was higher in ITN districts (70.8%) than non-ITN districts (59.1%) (RR=1.3, 95% CI 1.1-1.6). Among children in the poorest wealth quintile, vaccination coverage was higher in ITN than in non-ITN districts (Q1; RR=2.4, 95% CI 1.2-4.8) and equity for measles vaccination was greater in ITN districts (equity ratio=1.0, 95% CI 0.8-1.3) than in non-ITN districts (equity ratio=0.4, 95% CI 0.20.8). CONCLUSION: Integration of ITN distribution with a vaccination campaign might improve measles vaccination coverage among the poor, thus providing protection for the most vulnerable and difficult to reach children. 2012 Blackwell Publishing Ltd. PMID: 22273490 [PubMed - indexed for MEDLINE]

40. Malar J. 2012 Jan 13;11:20. doi: 10.1186/1475-2875-11-20. Importance of factors determining the effective lifetime of a mass, longlasting, insecticidal net distribution: a sensitivity analysis. Brit OJ, Hardy D, Smith TA. Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland. olivier.briet@unibas.ch BACKGROUND: Long-lasting insecticidal nets (LLINs) reduce malaria transmission by protecting individuals from infectious bites, and by reducing mosquito survival.

In recent years, millions of LLINs have been distributed across subSaharan Africa (SSA). Over time, LLINs decay physically and chemically and are destroyed, making repeated interventions necessary to prevent a resurgence of malaria. Because its effects on transmission are important (more so than the effects of individual protection), estimates of the lifetime of mass distribution rounds should be based on the effective length of epidemiological protection. METHODS: Simulation models, parameterised using available field data, were used to analyse how the distribution's effective lifetime depends on the transmission setting and on LLIN characteristics. Factors considered were the preintervention transmission level, initial coverage, net attrition, and both physical and chemical decay. An ensemble of 14 stochastic individual-based model variants for malaria in humans was used, combined with a deterministic model for malaria in mosquitoes. RESULTS: The effective lifetime was most sensitive to the preintervention transmission level, with a lifetime of almost 10 years at an entomological inoculation rate of two infectious bites per adult per annum (ibpapa), but of little more than 2 years at 256 ibpapa. The LLIN attrition rate and the insecticide decay rate were the next most important parameters. The lifetime was surprisingly insensitive to physical decay parameters, but this could change as physical integrity gains importance with the emergence and spread of pyrethroid resistance. CONCLUSIONS: The strong dependency of the effective lifetime on the pre-intervention transmission level indicated that the required distribution frequency may vary more with the local entomological situation than with LLIN quality or the characteristics of the distribution system. This highlights the need for malaria monitoring both before and during intervention programmes, particularly since there are likely to be strong variations between years and over short distances. The majority of SSA's population falls into exposure categories where the lifetime is relatively long, but because exposure estimates are highly uncertain, it is necessary to consider subsequent interventions before the end of the expected effective lifetime based on an imprecise transmission

measure. PMCID: PMC3273435 PMID: 22244509 [PubMed - indexed for MEDLINE]

41. Malar J. 2012 Jan 11;11:18. doi: 10.1186/1475-2875-11-18. Distance to health services influences insecticide-treated net possession and use among six to 59 month-old children in Malawi. Larson PS, Mathanga DP, Campbell CH Jr, Wilson ML. Department of Epidemiology, School of Public Health, University of Michigan, 09 Observatory, Ann Arbor, MI 48109-2029, USA. anfangen@umich.edu BACKGROUND: Health ministries and providers are rapidly scaling up insecticide-treated nets (ITN) distribution to control malaria, yet possession and proper use typically remain below targeted levels. In Malawi, health facilities (HFs) are currently the principal points of ITN distribution, making it important to understand how access to these ITN sources affects ownership, possession, and use. The authors evaluated the association between proximity to HFs and ITN possession or use among Malawian children six to 59 months of age. METHODS: A household malaria survey undertaken in eight districts of Malawi during 2007 was used to characterize ITN possession and use. The location of each respondent's household was geocoded as was those of Ministry of Health (MoH) HFs and other health centres. Euclidean distance from each household to the nearest HF was calculated. Patterns of net possession and use were determined through descriptive methods. The authors then analysed the significance of distance and ITN possession/use through standard statistical tests, including logistic regression. RESULTS: Median distance to HFs was greater among households that did not possess ITNs and did not use an ITN the previous evening. Descriptive statistical methods confirmed a pattern of decreasing ITN possession and use with increasing distance from HFs. Logistic regression showed the same statistically significant association of distance to HFs, even when controlling for age and gender of the child, ratio of nets to children in household, community net possession and use, and household material wealth.

CONCLUSIONS: Strategies that exclusively distribute ITNs through HFs are likely to be less effective in increasing possession and use in communities that are more distant from those health services. Health providers should look towards community-based distribution services that take ITNs directly to community members to more effectively scale up ITN possession and regular use aimed at protecting children from malaria. PMCID: PMC3283522 PMID: 22236395 [PubMed - indexed for MEDLINE] 42. Malar J. 2012 Jan 11;11:17. doi: 10.1186/1475-2875-11-17. Target product profiles for protecting against outdoor malaria transmission. Killeen GF, Moore SJ. Biomedical and Environmental Thematic Group, Ifakara Health Institute, PO Box 53, Ifakara, Morogoro, United Republic of Tanzania. gkilleen@ihi.or.tz BACKGROUND: Long-lasting insecticidal nets (LLINs) and indoor residual sprays (IRS) have decimated malaria transmission by killing indoor-feeding mosquitoes. However, complete elimination of malaria transmission with these proven methods is confounded by vectors that evade pesticide contact by feeding outdoors. METHODS: For any assumed level of indoor coverage and personal protective efficacy with insecticidal products, process-explicit malaria transmission models suggest that insecticides that repel mosquitoes will achieve less impact upon transmission than those that kill them outright. Here such models are extended to explore how outdoor use of products containing either contact toxins or spatial repellents might augment or attenuate impact of high indoor coverage of LLINs relying primarily upon contact toxicity. RESULTS: LLIN impact could be dramatically enhanced by high coverage with spatial repellents conferring near-complete personal protection, but only if combined indoor use of both measures can be avoided where vectors persist that prefer feeding indoors upon humans. While very high levels of coverage and efficacy will be required for spatial repellents to substantially augment the impact of LLINs

or IRS, these ambitious targets may well be at least as practically achievable as the lower requirements for equivalent impact using contact insecticides. CONCLUSIONS: Vapour-phase repellents may be more acceptable, practical and effective than contact insecticides for preventing outdoor malaria transmission because they need not be applied to skin or clothing and may protect multiple occupants of spaces outside of treatable structures such as nets or houses. PMCID: PMC3298720 PMID: 22236388 [PubMed - indexed for MEDLINE] 43. Am J Trop Med Hyg. 2012 Jan;86(1):96-8. doi: 10.4269/ajtmh.2012.110397. Rolling Malaria Indicator Surveys (rMIS): a potential district-level malaria monitoring and evaluation (M&E) tool for program managers. Roca-Feltrer A, Lalloo DG, Phiri K, Terlouw DJ. Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi. arfeltrer@mlw.medcol.mw Novel malaria monitoring and evaluation (M&E) tools are urgently needed to complement the current "gold standard" Malaria Indicator Surveys (MIS). Rapid up scaling of malaria control efforts is resulting in substantial reductions in malaria burden across sub-Saharan Africa. As transmission goes down, timely, accurate, sub-national, and district level burden estimates are needed to guide increasingly targeted control efforts in remaining hotspot areas. To test a novel district level M&E tool, we have conducted a continuous ("rolling") MIS (rMIS) since May 2010 covering 50 villages in Chikhwawa district in southern Malawi, essentially adapting an existing cross-sectional evaluation tool into a continuous monitoring tool. Here, we report on our experience after completing the first full year of monthly data collection focusing on the methods, operational aspects, and estimated costs of rMIS in a programmatic setting. The potential applicability of this promising M&E approach for district-level program managers and control efforts is discussed. PMCID: PMC3247115 PMID: 22232457 [PubMed - indexed for MEDLINE]

44. Malar J. 2012 Jan 9;11:9. doi: 10.1186/1475-2875-11-9. Malaria control in Bhutan: case study of a country embarking on elimination. Yangzom T, Gueye CS, Namgay R, Galappaththy GN, Thimasarn K, Gosling R, Murugasampillay S, Dev V. Vector-Borne Disease Control Programme, Ministry of Health, Royal Government of Bhutan, Gelephu, Bhutan. BACKGROUND: Bhutan has achieved a major reduction in malaria incidence amid multiple challenges. This case study seeks to characterize the Bhutan malaria control programme over the last 10 years. METHODS: A review of the malaria epidemiology, control strategies, and elimination strategies employed in Bhutan was carried out through a literature review of peer-reviewed and grey national and international literature with the addition of reviewing the surveillance and vector control records of the Bhutan Vector-Borne Disease Control Programme (VDCP). Data triangulation was used to identify trends in epidemiology and key strategies and interventions through analysis of the VDCP surveillance and programme records and the literature review. Enabling and challenging factors were identified through analysis of socio-economic and health indicators, corroborated through a review of national and international reports and peer-review articles. FINDINGS: Confirmed malaria cases in Bhutan declined by 98.7% from 1994 to 2010. The majority of indigenous cases were due to Plasmodium vivax (59.9%) and adult males are most at-risk of malaria. Imported cases, or those in foreign nationals, varied over the years, reaching 21.8% of all confirmed cases in 2006. Strategies implemented by the VDCP are likely to be related to the decline in cases over the last 10 years. Access to malaria diagnosis in treatment was expanded throughout the country and evidence-based case management, including the introduction of artemisinin-based combination therapy (ACT) for P. falciparum, increasing coverage of high risk areas with Indoor Residual Spraying, insecticidetreated bed nets, and long-lasting insecticidal nets are likely to have contributed to the decline alongside enabling factors such as economic development and

increasing access to health services. CONCLUSION: Bhutan has made significant strides towards elimination and has adopted a goal of national elimination. A major challenge in the future will be prevention and management of imported malaria infections from neighbouring Indian states. Bhutan plans to implement screening at border points to prevent importation of malaria and to targeted prevention and surveillance efforts towards at-risk Bhutanese and migrant workers in construction sites. PMCID: PMC3278342 PMID: 22230355 [PubMed - indexed for MEDLINE] 45. Malar J. 2012 Jan 6;11:8. doi: 10.1186/1475-2875-11-8. The effect of household heads training about the use of treated bed nets on the burden of malaria and anaemia in under-five children: a cluster randomized trial in Ethiopia. Deribew A, Birhanu Z, Sena L, Dejene T, Reda AA, Sudhakar M, Alemseged F, Tessema F, Zeynudin A, Biadgilign S, Deribe K. Department of Epidemiology, Jimma University, Jimma, Ethiopia. amare_deribew@yahoo.com BACKGROUND: Long-lasting insecticide-treated bed nets (LLITN) have demonstrated a significant effect in reducing malaria-related morbidity and mortality. However, barriers on the utilization of LLITN have hampered the desired outcomes. The aim of this study was to assess the effect of community empowerment on the burden of malaria and anaemia in under-five children in Ethiopia. METHODS: A cluster randomized trial was done in 22 (11 intervention and 11 control) villages in south-west Ethiopia. The intervention consisted of tailored training of household heads about the proper use of LLITN and community network system. The burden of malaria and anaemia in under-five children was determined through mass blood investigation at baseline, six and 12 months of the project period. Cases of malaria and anaemia were treated based on the national protocol. The burden of malaria and anaemia between the intervention and control villages was compared using the complex logistic regression model by taking into account

the clustering effect. Eight Focus group discussions were conducted to complement the quantitative findings. RESULTS: A total of 2,105 household heads received the intervention and the prevalence of malaria and anaemia was assessed among 2410, 2037 and 2612 under-five children at baseline, six and 12 months of the project period respectively. During the high transmission/epidemic season, children in the intervention arm were less likely to have malaria as compared to children in the control arm (OR = 0.42; 95%CI: 0.32, 0.57). Symptomatic malaria also steadily declined in the intervention villages compared to the control villages in the follow up periods. Children in the intervention arm were less likely to be anaemic compared to those in the control arm both at the high (OR = 0.84; 95%CI: 0.71, 0.99)) and low (OR = 0.73; 95%CI: 0.60, 0.89) transmission seasons. CONCLUSION: Training of household heads on the utilization of LLITN significantly reduces the burden of malaria in under-five children. The Ministry of Health of Ethiopia in collaboration with other partners should design similar strategies in high-risk areas to control malaria in Ethiopia. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12610000035022. PMCID: PMC3274442 PMID: 22225997 [PubMed - indexed for MEDLINE] 46. Bull Math Biol. 2012 May;74(5):1098-124. doi: 10.1007/s11538-0119710-0. Epub 2012 Jan 5. A periodically-forced mathematical model for the seasonal dynamics of malaria in mosquitoes. Chitnis N, Hardy D, Smith T. Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland. Nakul.Chitnis@unibas.ch We describe and analyze a periodically-forced difference equation model for malaria in mosquitoes that captures the effects of seasonality and allows the mosquitoes to feed on a heterogeneous population of hosts. We numerically show the existence of a unique globally asymptotically stable periodic orbit and

calculate periodic orbits of field-measurable quantities that measure malaria transmission. We integrate this model with an individual-based stochastic simulation model for malaria in humans to compare the effects of insecticide-treated nets (ITNs) and indoor residual spraying (IRS) in reducing malaria transmission, prevalence, and incidence. We show that ITNs are more effective than IRS in reducing transmission and prevalence though IRS would achieve its maximal effects within 2 years while ITNs would need two mass distribution campaigns over several years to do so. Furthermore, the combination of both interventions is more effective than either intervention alone. However, although these interventions reduce transmission and prevalence, they can lead to increased clinical malaria; and all three malaria indicators return to preintervention levels within 3 years after the interventions are withdrawn. PMCID: PMC3339865 PMID: 22218880 [PubMed - indexed for MEDLINE] 47. Malar J. 2011 Dec 20;10:379. doi: 10.1186/1475-2875-10-379. Rapid assessment of the performance of malaria control strategies implemented by countries in the Amazon subregion using adequacy criteria: case study. Flores W, Chang J, Barillas E. Strengthening Pharmaceutical Systems/Management Sciences for Health, 6a avenida 11-77 zona 10, Edificio Punto Diez oficina 1 F Guatemala City, Guatemala. waltergflores@gmail.com BACKGROUND: The objective of this study was to implement a rapid assessment of the performance of four malaria control strategies (indoor spraying, insecticide-treated bed nets, timely diagnosis, and artemisinin-based combination therapy) using adequacy criteria. The assessment was carried out in five countries of the Amazon subregion (Bolivia, Colombia, Ecuador, Guyana, and Peru). METHODS: A list of criteria in three areas was created for each of the four strategies: preliminary research that supports the design and adaptation of the control strategies, coverage of the control strategies and quality of the implementation of the strategies. The criteria were selected by the research team and based on the technical guidelines established by the World Health Organization. Each criterion included in the four lists was graded relative to

whether evidence exists that the criterion is satisfied (value 1), not satisfied (value 0) or partially satisfied (value 0.5). The values obtained were added and reported according to a scale of three implementation categories: adequate, intermediate and deficient. RESULTS: Implementation of residual indoor spraying and timely diagnosis was adequate in one country and intermediate or deficient in the rest. Insecticide-treated bed nets ranged between deficient and intermediate in all the countries, while implementation of artemisinin-based combination therapy (ACT) was adequate in three countries and intermediate in the other two countries evaluated. CONCLUSIONS: Although ACT is the strategy with the better implementation in all countries, major gaps exist in implementation of the other three malaria control strategies in terms of technical criteria, coverage and quality desired. The countries must implement action plans to close the gaps in the various criteria and thereby improve the performance of the interventions. The assessment tools developed, based on adequacy criteria, are considered useful for a rapid assessment by malaria control authorities in the different countries. PMCID: PMC3297539 PMID: 22185638 [PubMed - indexed for MEDLINE] 48. Bull Soc Pathol Exot. 2012 Feb;105(1):36-9. doi: 10.1007/s13149-0110193-x. Epub 2011 Dec 16. [Evaluation of the use of insecticide-treated nets and intermittent preventive treatment in three health zones in Benin]. [Article in French] Kinde-Gazard D, Vignon Makong J, Kossou HD, Sossa CJ. Universit d'Abomey-Calavi, Cotonou, Bnin. kindegazard@yahoo.fr This study aims to evaluate the results of the Project to Support the Fight against Malaria in the departments of Mono and Couffo in Benin on insecticide-treated nets (ITNs) use by children under 5 years and pregnant women and the coverage by Intermittent Preventive Treatment (IPT) with Sulfadoxin-Pyrimethamin (SP). This assessment is made from two household surveys.

The first at the start up and the second after fifteen months of implementation. The availability of ITN in households and their use by pregnant women and children under 5 years have increased respectively from 8, 5 and 4% in 2005 to 24, 31 and 16 % in 2006. The percentage of pregnant women under IPT with sulfadoxine-pyrimethamine (SP) is 10% while 21% of pregnant women received at least one dose of SP. The availability of ITN in households and their use by children under 5 years and the prevention of malaria during pregnancy remains a concern in these health areas. The promotion of long lasting insecticide treated nets with effective communication strategies for behavior change could improve the results. Research on causes of poor compliance of IPT should be emphasized as well as strengthening management of drugs in health centers. PMID: 22180050 [PubMed - indexed for MEDLINE]

49. Malar J. 2011 Dec 13;10:353. doi: 10.1186/1475-2875-10-353. Larval source management for malaria control in Africa: myths and reality. Fillinger U, Lindsay SW. Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK. ulrike.fillinger@lshtm.ac.uk As malaria declines in many African countries there is a growing realization that new interventions need to be added to the front-line vector control tools of long-lasting impregnated nets (LLINs) and indoor residual spraying (IRS) that target adult mosquitoes indoors. Larval source management (LSM) provides the dual benefits of not only reducing numbers of house-entering mosquitoes, but, importantly, also those that bite outdoors. Large-scale LSM was a highly effective method of malaria control in the first half of the twentieth century, but was largely disbanded in favour of IRS with DDT. Today LSM continues to be used in large-scale mosquito abatement programmes in North America and Europe, but has only recently been tested in a few trials of malaria control in contemporary Africa. The results from these trials show that handapplication of larvicides can reduce transmission by 70-90% in settings where mosquito larval habitats are defined but is largely ineffectual where habitats are so extensive

that not all of them can be covered on foot, such as areas that experience substantial flooding. Importantly recent evidence shows that LSM can be an effective method of malaria control, especially when combined with LLINs. Nevertheless, there are a number of misconceptions or even myths that hamper the advocacy for LSM by leading international institutions and the uptake of LSM by Malaria Control Programmes. Many argue that LSM is not feasible in Africa due to the high number of small and temporary larval habitats for Anopheles gambiae that are difficult to find and treat promptly. Reference is often made to the Ross-Macdonald model to reinforce the view that larval control is ineffective. This paper challenges the notion that LSM cannot be successfully used for malaria control in African transmission settings by highlighting historical and recent successes, discussing its potential in an integrated vector management approach working towards malaria elimination and critically reviewing the most common arguments that are used against the adoption of LSM. PMCID: PMC3273449 PMID: 22166144 [PubMed - indexed for MEDLINE] 50. Malar J. 2011 Dec 13;10:357. doi: 10.1186/1475-2875-10-357. Free distribution of insecticidal bed nets improves possession and preferential use by households and is equitable: findings from two cross-sectional surveys in thirteen malaria endemic districts of Bangladesh. Ahmed SM, Hossain S, Kabir MM, Roy S. Research and Evaluation Division, BRAC Centre, 75 Mohakhali, Dhaka Dhaka1212, Bangladesh. ahmed.sm@brac.net BACKGROUND: BRAC, an indigenous non-governmental development organization (NGO), has been implementing a programme to prevent and control malaria in the 13 malaria-endemic districts of Bangladesh since 2007. One of the critical preventive interventions is the distribution of insecticidal bed nets (long-lasting insecticide-treated nets, LLINs and insecticide-treated ordinary nets, ITNs) to the community free of cost. This study aimed to assess progress in the possession, preferential use, and knowledge on use of the LLIN/ITNs including

the programme's avowed pro-poor inclination one and three and half years after intervention began. METHODS: A convenient sampling strategy based on malaria endemicity in the districts was adopted. First, thirty upazila (sub-district, with a population around 250,000)s were selected at random, with high prevalent districts contributing more upazilas; second, from each upazila, one (2008) to two (2011) villages (covered by insecticidal bed net distribution programme) were selected. From each village, households that had either one under-five child and/or a pregnant woman were included in the survey, one household being included only once. Data were collected using a pre-tested structured questionnaire. RESULTS: In all, 3,760 households in 2008 and 7,895 households in 2011 were surveyed for collecting relevant information. Proportion of households with at least one LLIN, and at least one LLIN/ITN increased (22-59 to 62-67% and 22-64% to 74-76% respectively) over time, including increase in the mean number of LLIN/ITNs per household ( 1 to 1 +). The programme achieved > 80% coverage in sleeping under an LLIN/ITN in the case of under-five children and pregnant women, especially in the high-endemic districts. Knowledge regarding critical time of hanging the net also increased over time (7-22 to 44-54%), but remained low. The pro-poor inclination of the programme is reflected in the status of relevant indicators according to self-rated poverty status of the households. CONCLUSIONS: There has been a substantial improvement in possession and usage of insecticidal bed nets especially for the two most vulnerable groups (under-five children and pregnant women), including a reduction of gaps between the high and low endemic districts, and the deficit and non-deficit households during the study period. PMCID: PMC3266224 PMID: 22165959 [PubMed - indexed for MEDLINE] 51. Malar J. 2011 Dec 13;10:356. doi: 10.1186/1475-2875-10-356. Impact of insecticide-treated bed nets on malaria transmission indices on the south coast of Kenya.

Mutuku FM, King CH, Mungai P, Mbogo C, Mwangangi J, Muchiri EM, Walker ED, Kitron U. Department of Environmental Studies, Emory University, Atlanta, Georgia, USA. fmutuku73@gmail.com BACKGROUND: Besides significantly reducing malaria vector densities, prolonged usage of bed nets has been linked to decline of Anopheles gambiae s.s. relative to Anopheles arabiensis, changes in host feeding preference of malaria vectors, and behavioural shifts to exophagy (outdoor biting) for the two important malaria vectors in Africa, An. gambiae s.l. and Anopheles funestus. In southern coastal Kenya, bed net use was negligible in 1997-1998 when Anopheles funestus and An. gambiae s.s. were the primary malaria vectors, with An. arabiensis and Anopheles merus playing a secondary role. Since 2001, bed net use has increased progressively and reached high levels by 2009-2010 with corresponding decline in malaria transmission. METHODS: To evaluate the impact of the substantial increase in household bed net use within this area on vector density, vector composition, and humanvector contact, indoor and outdoor resting mosquitoes were collected in the same region during 2009-2010 using pyrethrum spray catches and clay pots for indoor and outdoor collections respectively. Information on bed net use per sleeping spaces and factors influencing mosquito density were determined in the same houses using Poisson regression analysis. Species distribution was determined, and number of mosquitoes per house, human-biting rates (HBR), and entomological inoculation rate (EIR) were compared to those reported for the same area during 19971998, when bed net coverage had been minimal. RESULTS: Compared to 1997-1998, a significant decline in the relative proportion of An. gambiae s.s. among collected mosquitoes was noted, coupled with a proportionate increase of An. arabiensis. Following > 5 years of 60-86% coverage with bed nets, the density, human biting rate and EIR of indoor resting mosquitoes were reduced by more than 92% for An. funestus and by 75% for An. gambiae s.l. In addition, the host feeding choice of both vectors shifted more toward non-human vertebrates. Besides bed net use, malaria vector abundance was

also influenced by type of house construction and according to whether one sleeps on a bed or a mat (both of these are associated with household wealth). Mosquito density was positively associated with presence of domestic animals. CONCLUSIONS: These entomological indices indicate a much reduced human biting rate and a diminishing role of An. gambiae s.s. in malaria transmission following high bed net coverage. While increasing bed net coverage beyond the current levels may not significantly reduce the transmission potential of An. arabiensis, it is anticipated that increasing or at least sustaining high bed net coverage will result in a diminished role for An. funestus in malaria transmission. PMCID: PMC3322380 PMID: 22165904 [PubMed - indexed for MEDLINE] 52. Malar J. 2011 Dec 13;10:363. doi: 10.1186/1475-2875-10-363. Assessing healthcare providers' knowledge and practices relating to insecticide-treated nets and the prevention of malaria in Ghana, Laos, Senegal and Tanzania. Hoffman SJ, Guindon GE, Lavis JN, Ndossi GD, Osei EJ, Sidibe MF, Boupha B; Research to Policy & Practice Study Team. Collaborators: Lavis JN, Guindon G, Cameron D, Hoffman SJ, Shi G, Qiu T, Osei EJ, Dovlo K, Yesudian CA, Ramachandran P, Malek-Afzali H, Dejman M, Falahat K, Baradaran M, Habibi E, Kohanzad H, Nasehi M, Salek S, Akanov AA, Turdaliyeva BS, Hamzina NK, Tulebaev KA, Clazhneva TI, Battakova G, Boupha B, Kounnavong S, Siengsounthone L, Becerra-Posada F, Ramos LA, Mejia I, Akhtar T, Khan MM, Sidibe MF, Sidibe A, Ndiaye D, Ndossi GD, Massaga J, Sadana R, Pang T. McMaster Health Forum, McMaster University, Hamilton, Ontario, Canada. BACKGROUND: Research evidence is not always being disseminated to healthcare providers who need it to inform their clinical practice. This can result in the provision of ineffective services and an inefficient use of resources, the implications of which might be felt particularly acutely in low- and middle-income countries. Malaria prevention is a particularly compelling domain

to study evidence/practice gaps given the proven efficacy, costeffectiveness and disappointing utilization of insecticide-treated nets (ITNs). METHODS: This study compares what is known about ITNs to the related knowledge and practices of healthcare providers in four low- and middle-income countries. A new questionnaire was developed, pilot tested, translated and administered to 497 healthcare providers in Ghana (140), Laos (136), Senegal (100) and Tanzania (121). Ten questions tested participants' knowledge and clinical practice related to malaria prevention. Additional questions addressed their individual characteristics, working context and research-related activities. Ordinal logistic regressions with knowledge and practices as the dependent variable were conducted in addition to descriptive statistics. RESULTS: The survey achieved a 75% response rate (372/497) across Ghana (107/140), Laos (136/136), Senegal (51/100) and Tanzania (78/121). Few participating healthcare providers correctly answered all five knowledge questions about ITNs (13%) or self-reported performing all five clinical practices according to established evidence (2%). Statistically significant factors associated with higher knowledge within each country included: 1) training in acquiring systematic reviews through the Cochrane Library (OR 2.48, 95% CI 1.30-4.73); and 2) ability to read and write English well or very well (OR 1.69, 95% CI 1.05-2.70). Statistically significant factors associated with better clinical practices within each country include: 1) reading scientific journals from their own country (OR 1.67, 95% CI 1.10-2.54); 2) working with researchers to improve their clinical practice or quality of working life (OR 1.44, 95% CI 1.04-1.98); 3) training on malaria prevention since their last degree (OR 1.68, 95% CI 1.17-2.39); and 4) easy access to the internet (OR 1.52, 95% CI 1.08-2.14). CONCLUSIONS: Improving healthcare providers' knowledge and practices is an untapped opportunity for expanding ITN utilization and preventing malaria. This study points to several strategies that may help bridge the gap between what is known from research evidence and the knowledge and practices of healthcare providers. Training on acquiring systematic reviews and facilitating internet access may be particularly helpful. PMCID: PMC3265439 PMID: 22165841 [PubMed - indexed for MEDLINE]

53. Malar J. 2011 Dec 13;10:354. doi: 10.1186/1475-2875-10-354. Factors associated with mosquito net use by individuals in households owning nets in Ethiopia. Graves PM, Ngondi JM, Hwang J, Getachew A, Gebre T, Mosher AW, Patterson AE, Shargie EB, Tadesse Z, Wolkon A, Reithinger R, Emerson PM, Richards FO Jr. The Carter Center, Atlanta, GA, USA. pgraves.work@gmail.com BACKGROUND: Ownership of insecticidal mosquito nets has dramatically increased in Ethiopia since 2006, but the proportion of persons with access to such nets who use them has declined. It is important to understand individual level net use factors in the context of the home to modify programmes so as to maximize net use. METHODS: Generalized linear latent and mixed models (GLLAMM) were used to investigate net use using individual level data from people living in net-owning households from two surveys in Ethiopia: baseline 2006 included 12,678 individuals from 2,468 households and a sub-sample of the Malaria Indicator Survey (MIS) in 2007 included 14,663 individuals from 3,353 households. Individual factors (age, sex, pregnancy); net factors (condition, age, net density); household factors (number of rooms [2006] or sleeping spaces [2007], IRS, women's knowledge and school attendance [2007 only], wealth, altitude); and cluster level factors (rural or urban) were investigated in univariate and multi-variable models for each survey. RESULTS: In 2006, increased net use was associated with: age 25-49 years (adjusted (a) OR = 1.4, 95% confidence interval (CI) 1.2-1.7) compared to children U5; female gender (aOR = 1.4; 95% CI 1.2-1.5); fewer nets with holes (Ptrend = 0.002); and increasing net density (Ptrend < 0.001). Reduced net use was associated with: age 5-24 years (aOR = 0.2; 95% CI 0.2-0.3). In 2007, increased net use was associated with: female gender (aOR = 1.3; 95% CI 1.1-1.6); fewer nets with holes (aOR [all nets in HH good] = 1.6; 95% CI 1.2-2.1); increasing net density (Ptrend < 0.001); increased women's malaria knowledge (Ptrend < 0.001); and urban clusters (aOR = 2.5; 95% CI 1.5-4.1). Reduced net use was associated with: age 5-24 years (aOR = 0.3; 95% CI 0.2-0.4); number of sleeping spaces (aOR [per additional space] = 0.6, 95% CI 0.5-0.7); more old nets

(aOR [all nets in HH older than 12 months] = 0.5; 95% CI 0.3-0.7); and increasing household altitude (Ptrend < 0.001). CONCLUSION: In both surveys, net use was more likely by women, if nets had fewer holes and were at higher net per person density within households. School-age children and young adults were much less likely to use a net. Increasing availability of nets within households (i.e. increasing net density), and improving net condition while focusing on education and promotion of net use, especially in school-age children and young adults in rural areas, are crucial areas for intervention to ensure maximum net use and consequent reduction of malaria transmission. PMCID: PMC3258293 PMID: 22165821 [PubMed - indexed for MEDLINE] 54. Am J Trop Med Hyg. 2011 Dec;85(6):1080-6. doi: 10.4269/ajtmh.2011.100684. The combination of indoor residual spraying and insecticide-treated nets provides added protection against malaria compared with insecticide-treated nets alone. Hamel MJ, Otieno P, Bayoh N, Kariuki S, Were V, Marwanga D, Laserson KF, Williamson J, Slutsker L, Gimnig J. Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia 30301, USA. mhamel@cdc.gov Both insecticide-treated bed nets (ITNs) and indoor residual spraying (IRS) reduce malaria in high malaria transmission areas. The combined effect of these interventions is unknown. We conducted a non-randomized prospective cohort study to determine protective efficacy of IRS with ITNs (ITN + IRS) compared with ITNs alone (ITN only) in preventing Plasmodium falciparum parasitemia. At baseline, participants provided blood samples for malaria smears, were presumptively treated for malaria, and received ITNs. Blood smears were made monthly and at sick visits. In total, 1,804 participants were enrolled. Incidence of P. falciparum parasitemia in the ITN + IRS and ITN only groups was 18 and 44 infections per 100 persons-years at risk, respectively (unadjusted rate ratio = 0.41; 95% confidence interval [CI] = 0.31-0.56). Adjusted protective efficacy of

ITN + IRS compared with ITN only was 62% (95% CI = 0.50-0.72). The combination of IRS and ITN might be a feasible strategy to further reduce malaria transmission in areas of persistent perennial malaria transmission. PMCID: PMC3225156 [Available on 2012/12/1] PMID: 22144448 [PubMed - indexed for MEDLINE] 55. Acta Trop. 2012 Mar;121(3):166-74. doi: 10.1016/j.actatropica.2011.11.005. Epub 2011 Nov 19. Sahel, savana, riverine and urban malaria in West Africa: Similar control policies with different outcomes. Ceesay SJ, Bojang KA, Nwakanma D, Conway DJ, Koita OA, Doumbia SO, Ndiaye D, Coulibaly TF, Diakit M, Traor SF, Coulibaly M, Ndiaye JL, Sarr O, Gaye O, Konat L, Sy N, Faye B, Faye O, Sogoba N, Jawara M, Dao A, Poudiougou B, Diawara S, Okebe J, Sangar L, Abubakar I, Sissako A, Diarra A, Kita M, Kandeh B, Long CA, Fairhurst RM, Duraisingh M, Perry R, Muskavitch MA, Valim C, Volkman SK, Wirth DF, Krogstad DJ. International Center for Excellence in Malaria Research in West Africa at the Medical Research Council Laboratories, Fajara, Gambia. The study sites for the West African ICEMR are in three countries (The Gambia, Senegal, Mali) and are located within 750 km of each other. In addition, the National Malaria Control Programmes of these countries have virtually identical policies: (1) Artemisinin Combination Therapies (ACTs) for the treatment of symptomatic Plasmodium falciparum infection, (2) Long-Lasting Insecticide-treated bed Nets (LLINs) to reduce the Entomololgic Inoculation Rate (EIR), and (3) sulfadoxine-pyrimethamine for the Intermittent Preventive Treatment of malaria during pregnancy (IPTp). However, the prevalence of P. falciparum malaria and the status of malaria control vary markedly across the four sites with differences in the duration of the transmission season (from 4-5 to 10-11 months), the intensity of transmission (with EIRs from unmeasurably low to 4-5 per person per month), multiplicity of infection (from a mean of 1.0 to means of 2-5) and the status of

malaria control (from areas which have virtually no control to areas that are at the threshold of malaria elimination). The most important priority is the need to obtain comparable data on the population-based prevalence, incidence and transmission of malaria before new candidate interventions or combinations of interventions are introduced for malaria control. Copyright 2011 Elsevier B.V. All rights reserved. PMCID: PMC3294051 [Available on 2013/3/1] PMID: 22119584 [PubMed - indexed for MEDLINE] 56. Malar J. 2011 Nov 23;10:344. doi: 10.1186/1475-2875-10-344. What drives community adherence to indoor residual spraying (IRS) against malaria in Manhia district, rural Mozambique: a qualitative study. Munguambe K, Pool R, Montgomery C, Bavo C, Nhacolo A, Fiosse L, Sacoor C, Nhalungo D, Mabunda S, Macete E, Alonso P. Centro de Investigao em Sade de Manhia, Rua 12, CP 1929 Manhia, Mozambique. khatia.munguambe@manhica.net BACKGROUND: Malaria control remains a challenge in sub-Saharan Africa. In 2006, the World Health Organization (WHO) reinforced the recommendation of indoor residual spraying (IRS) with dichlorodiphenyltrichloroethane (DDT) to reduce malaria transmission. The National Malaria Control Programme has been reporting high coverage rates of IRS in Mozambique. It is important to establish to what extent these rates are a reflection of community acceptability, and to explore the factors associated with adherence, in order to recommend suitable approaches for interventions of this nature. OBJECTIVE: To understand the implementation process, reception and acceptability of the IRS program in Manhia district, Southern Mozambique. METHODS: Qualitative data was collected through in-depth interviews, participant observation of IRS activities, informal interviews, and focus group discussions. Study participants comprised householders, community leaders, health care providers, sprayers, and community members. Qualitative data analysis was based on grounded theory. Secondary data from the Manhia Demographic Surveillance System was used to complement the qualitative data.

RESULTS: IRS was well received in most neighbourhoods. The overall coverage rates varied between 29% and 41% throughout the study period. The factors related to adherence to IRS were: immediate impact on insects in general, trust and obedience in the health authority, community leaders' influence, and acquaintance with the sprayers. Fighting malaria was not an important motivation for IRS adherence. There was a perception of limited efficacy of IRS against mosquitoes, but this did not affect adherence. Non-adherence to the intervention was mainly due to the unavailability of key householders, disagreement with the procedures, and the perception that spraying increased the burden of insects. Most respondents strongly favoured bed nets over IRS. CONCLUSION: The study suggests that the contribution of IRS to malaria and mosquito control is not entirely perceived by the beneficiaries, and that other as cost effective interventions such as insecticide-treated nets are favoured over IRS. Adherence to IRS was found to be influenced by socio-political factors. There is a need to redefine the community sensitization approaches in order to make IRS a genuinely participative, acceptable, and sustainable programme. PMCID: PMC3339361 PMID: 22111698 [PubMed - indexed for MEDLINE] 57. PLoS One. 2011;6(11):e27516. doi: 10.1371/journal.pone.0027516. Epub 2011 Nov 11. Infections in infants during the first 12 months of life: role of placental malaria and environmental factors. Le Port A, Watier L, Cottrell G, Oudraogo S, Dechavanne C, Pierrat C, Rachas A, Bouscaillou J, Bouraima A, Massougbodji A, Fayomi B, Thibaut A, Chandre F, Migot-Nabias F, Martin-Prevel Y, Garcia A, Cot M. UMR216 Mre et enfant face aux infections tropicales, Institut de Recherche pour le Dveloppement, Paris, France. agnesleport@yahoo.fr BACKGROUND: The association between placental malaria (PM) and first peripheral parasitaemias in early infancy was assessed in Tori Bossito, a rural area of Benin with a careful attention on transmission factors at an individual level.

METHODOLOGY: Statistical analysis was performed on 550 infants followed weekly from birth to 12 months. Malaria transmission was assessed by anopheles human landing catches every 6 weeks in 36 sampling houses and season defined by rainfall. Each child was located by GPS and assigned to the closest anopheles sampling house. Data were analysed by survival Cox models, stratified on the possession of insecticide-treated mosquito nets (ITNs) at enrolment. PRINCIPAL FINDINGS: Among infants sleeping in a house with an ITN, PM was found to be highly associated to first malaria infections, after adjusting on season, number of anopheles, antenatal care (ANC) visits and maternal severe anaemia. Infants born from a malaria infected placenta had a 2.13 fold increased risk to present a first malaria infection than those born from a non infected placenta ([1.24-3.67], p<0.01) when sleeping in a house with an ITN. The risk to present a first malaria infection was increased by 3.2 to 6.5, according to the level of anopheles exposure (moderate or high levels, compared to the absence of anopheles). CONCLUSIONS: First malaria infections in early childhood can be attributed simultaneously to both PM and high levels of exposure to infected anopheles. Protective measures as Intermittent Preventive Treatment during pregnancy (IPTp) and ITNs, targeted on both mothers and infants should be reinforced, as well as the research on new drugs and insecticides. In parallel, investigations on placental malaria have to be strengthened to better understand the mechanisms involved, and thus to protect adequately the infants high risk group. PMCID: PMC3214070 PMID: 22096588 [PubMed - indexed for MEDLINE] 58. PLoS One. 2011;6(11):e26746. doi: 10.1371/journal.pone.0026746. Epub 2011 Nov 11. Effect of transmission reduction by insecticide-treated bednets (ITNs) on antimalarial drug resistance in western Kenya. Shah M, Kariuki S, Vanden Eng J, Blackstock AJ, Garner K, Gatei W, Gimnig JE, Lindblade K, Terlouw D, ter Kuile F, Hawley WA, Phillips-Howard P, Nahlen B, Walker E, Hamel MJ, Slutsker L, Shi YP.

Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America. Despite the clear public health benefit of insecticide-treated bednets (ITNs), the impact of malaria transmission-reduction by vector control on the spread of drug resistance is not well understood. In the present study, the effect of sustained transmission reduction by ITNs on the prevalence of Plasmodium falciparum gene mutations associated with resistance to the antimalarial drugs sulfadoxine-pyrimethamine (SP) and chloroquine (CQ) in children under the age of five years was investigated during an ITN trial in Asembo area, western Kenya. During the ITN trial, the national first line antimalarial treatment changed from CQ to SP. Smear-positive samples collected from cross sectional surveys prior to ITN introduction (baseline, n=250) and five years post-ITN intervention (year 5 survey, n=242) were genotyped for single nucleotide polymorphisms (SNPs) at dhfr-51, 59, 108, 164 and dhps-437, 540 (SP resistance), and pfcrt-76 and pfmdr1-86 (CQ resistance). The association between the drug resistance mutations and epidemiological variables was evaluated. There were significant increases in the prevalence of SP dhps mutations and the dhfr/dhps quintuple mutant, and a significant reduction in the proportion of mixed infections detected at dhfr-51, 59 and dhps-437, 540 SNPs from baseline to the year 5 survey. There was no change in the high prevalence of pfcrt-76 and pfmdr1-86 mutations. Multivariable regression analysis further showed that current antifolate use and year of survey were significantly associated with more SP drug resistance mutations. These results suggest that increased antifolate drug use due to drug policy change likely led to the high prevalence of SP mutations 5 years post-ITN intervention and reduced transmission had no apparent effect on the existing high prevalence of CQ mutations. There is no evidence from the current study that sustained transmission reduction by ITNs reduces the prevalence of genes associated with malaria drug resistance. PMCID: PMC3214025 PMID: 22096496 [PubMed - indexed for MEDLINE]

59. Educ Health (Abingdon). 2011 Aug;24(2):474. Epub 2011 Jul 22. A community health worker program for the prevention of malaria in eastern Kenya. Stromberg DG, Frederiksen J, Hruschka J, Tomedi A, Mwanthi M. University of New Mexico Albuquerque, New Mexico, USA. david0stromberg@gmail.com OBJECTIVE: To assess whether the development and implementation of a community health worker (CHW) project in rural Kenya was associated with an increase in knowledge about malaria and the use of insecticide-treated nets (ITNs) in children under five years of age. METHODS: A baseline knowledge and behavior questionnaire, adopted from the Kenyan Demographic Health Survey, was conducted in August 2007 by Kenyan health officials in 75 villages. Two CHWs were chosen from each village and trained in appropriate use of ITNs. The CHWs provided educational sessions and ITNs to mothers in their respective villages. A follow-up survey was conducted in March 2008 of all families with children less than five years of age within randomly selected villages. The main questions addressed during the follow-up survey included knowledge about malaria and the practice of correctly using ITNs. FINDINGS: There were 267 surveys compiled for knowledge assessment before the intervention and 340 in the post-intervention analysis with an approximate 99% family participation rate. Of the families surveyed, 81% correctly knew the cause for malaria before the study and 93% after the CHW intervention (p < 0.01). Of those surveyed before the intervention, 70% owned and correctly used mosquito nets compared with 88% after the CHW intervention (p < 0.01). CONCLUSIONS: There was a significant increase in knowledge about malaria and use of ITNs after the implementation of the CHW program. PMID: 22081652 [PubMed - indexed for MEDLINE]

60. Malar J. 2011 Nov 13;10:341. doi: 10.1186/1475-2875-10-341. Who attends antenatal care and expanded programme on immunization services in Chad, Mali and Niger? The implications for insecticide-treated net delivery.

Carlson M, Smith Paintain L, Bruce J, Webster J, Lines J. Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK. mcarlson318@gmail.com BACKGROUND: Malaria remains one of the largest public health problems facing the developing world. Insecticide-treated nets (ITNs) are an effective intervention against malaria. ITN delivery through routine health services, such as antenatal care (ANC) and childhood vaccination (EPI), is a promising channel of delivery to reach individuals with the highest risk (pregnant women and children under five years old). Decisions on whether to deliver ITNs through both channels depends upon the reach of each of these systems, whether these are independent and the effectiveness and cost effectiveness of each. Predictors of women attending ANC and EPI separately have been studied, but the predictors of those who attend neither service have not been identified. METHODS: Data from Chad, Mali and Niger demographic and health surveys (DHS) were analyzed to determine risk factors for attending neither service. A conceptual framework for preventative health care-seeking behaviour was created to illustrate the hierarchical relationships between the potential risk factors. The independence of attending both ANC and EPI was investigated. A multivariate model of predictors for non-attendance was developed using logistic regression. RESULTS: ANC and EPI attendance were found to be strongly associated in all three countries. However, 47% of mothers in Chad, 12% in Mali and 36% in Niger did not attend either ANC or EPI. Region, mother's education and partner's education were predictors of non-attendance in all three countries. Wealth index, ethnicity, and occupation were associated with non-attendance in Mali and Niger. Other predictors included religion, healthcare autonomy, household size and number of children under five. CONCLUSIONS: Attendance of ANC and EPI are not independent and therefore the majority of pregnant women in these countries will have the opportunity to receive ITNs through both services. Although attendance at ANC and EPI are not independent, delivery through both systems may still add incrementally to delivery through one alone. Therefore, there is potential to increase the proportion of women and children receiving ITNs by delivering through both of

these channels. However, modelling is required to determine the level of attendance and incremental potential at which it's cost effective to deliver through both services. 41. Malar J. 2012 Jan 11;11:18. doi: 10.1186/1475-2875-11-18. Distance to health services influences insecticide-treated net possession and use among six to 59 month-old children in Malawi. Larson PS, Mathanga DP, Campbell CH Jr, Wilson ML. Department of Epidemiology, School of Public Health, University of Michigan, 09 Observatory, Ann Arbor, MI 48109-2029, USA. anfangen@umich.edu BACKGROUND: Health ministries and providers are rapidly scaling up insecticide-treated nets (ITN) distribution to control malaria, yet possession and proper use typically remain below targeted levels. In Malawi, health facilities (HFs) are currently the principal points of ITN distribution, making it important to understand how access to these ITN sources affects ownership, possession, and use. The authors evaluated the association between proximity to HFs and ITN possession or use among Malawian children six to 59 months of age. METHODS: A household malaria survey undertaken in eight districts of Malawi during 2007 was used to characterize ITN possession and use. The location of each respondent's household was geocoded as was those of Ministry of Health (MoH) HFs and other health centres. Euclidean distance from each household to the nearest HF was calculated. Patterns of net possession and use were determined through descriptive methods. The authors then analysed the significance of distance and ITN possession/use through standard statistical tests, including logistic regression. RESULTS: Median distance to HFs was greater among households that did not possess ITNs and did not use an ITN the previous evening. Descriptive statistical methods confirmed a pattern of decreasing ITN possession and use with increasing distance from HFs. Logistic regression showed the same statistically significant association of distance to HFs, even when controlling for age and gender of the child, ratio of nets to children in household, community net possession and use, and household material wealth. CONCLUSIONS: Strategies that exclusively distribute ITNs through HFs are likely

to be less effective in increasing possession and use in communities that are more distant from those health services. Health providers should look towards community-based distribution services that take ITNs directly to community members to more effectively scale up ITN possession and regular use aimed at protecting children from malaria. PMCID: PMC3283522 PMID: 22236395 [PubMed - indexed for MEDLINE] 42. Malar J. 2012 Jan 11;11:17. doi: 10.1186/1475-2875-11-17. Target product profiles for protecting against outdoor malaria transmission. Killeen GF, Moore SJ. Biomedical and Environmental Thematic Group, Ifakara Health Institute, PO Box 53, Ifakara, Morogoro, United Republic of Tanzania. gkilleen@ihi.or.tz BACKGROUND: Long-lasting insecticidal nets (LLINs) and indoor residual sprays (IRS) have decimated malaria transmission by killing indoor-feeding mosquitoes. However, complete elimination of malaria transmission with these proven methods is confounded by vectors that evade pesticide contact by feeding outdoors. METHODS: For any assumed level of indoor coverage and personal protective efficacy with insecticidal products, process-explicit malaria transmission models suggest that insecticides that repel mosquitoes will achieve less impact upon transmission than those that kill them outright. Here such models are extended to explore how outdoor use of products containing either contact toxins or spatial repellents might augment or attenuate impact of high indoor coverage of LLINs relying primarily upon contact toxicity. RESULTS: LLIN impact could be dramatically enhanced by high coverage with spatial repellents conferring near-complete personal protection, but only if combined indoor use of both measures can be avoided where vectors persist that prefer feeding indoors upon humans. While very high levels of coverage and efficacy will be required for spatial repellents to substantially augment the impact of LLINs or IRS, these ambitious targets may well be at least as practically achievable as

the lower requirements for equivalent impact using contact insecticides. CONCLUSIONS: Vapour-phase repellents may be more acceptable, practical and effective than contact insecticides for preventing outdoor malaria transmission because they need not be applied to skin or clothing and may protect multiple occupants of spaces outside of treatable structures such as nets or houses. PMCID: PMC3298720 PMID: 22236388 [PubMed - indexed for MEDLINE] 43. Am J Trop Med Hyg. 2012 Jan;86(1):96-8. doi: 10.4269/ajtmh.2012.110397. Rolling Malaria Indicator Surveys (rMIS): a potential district-level malaria monitoring and evaluation (M&E) tool for program managers. Roca-Feltrer A, Lalloo DG, Phiri K, Terlouw DJ. Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi. arfeltrer@mlw.medcol.mw Novel malaria monitoring and evaluation (M&E) tools are urgently needed to complement the current "gold standard" Malaria Indicator Surveys (MIS). Rapid up scaling of malaria control efforts is resulting in substantial reductions in malaria burden across sub-Saharan Africa. As transmission goes down, timely, accurate, sub-national, and district level burden estimates are needed to guide increasingly targeted control efforts in remaining hotspot areas. To test a novel district level M&E tool, we have conducted a continuous ("rolling") MIS (rMIS) since May 2010 covering 50 villages in Chikhwawa district in southern Malawi, essentially adapting an existing cross-sectional evaluation tool into a continuous monitoring tool. Here, we report on our experience after completing the first full year of monthly data collection focusing on the methods, operational aspects, and estimated costs of rMIS in a programmatic setting. The potential applicability of this promising M&E approach for district-level program managers and control efforts is discussed. PMCID: PMC3247115 PMID: 22232457 [PubMed - indexed for MEDLINE]

44. Malar J. 2012 Jan 9;11:9. doi: 10.1186/1475-2875-11-9. Malaria control in Bhutan: case study of a country embarking on elimination. Yangzom T, Gueye CS, Namgay R, Galappaththy GN, Thimasarn K, Gosling R, Murugasampillay S, Dev V. Vector-Borne Disease Control Programme, Ministry of Health, Royal Government of Bhutan, Gelephu, Bhutan. BACKGROUND: Bhutan has achieved a major reduction in malaria incidence amid multiple challenges. This case study seeks to characterize the Bhutan malaria control programme over the last 10 years. METHODS: A review of the malaria epidemiology, control strategies, and elimination strategies employed in Bhutan was carried out through a literature review of peer-reviewed and grey national and international literature with the addition of reviewing the surveillance and vector control records of the Bhutan Vector-Borne Disease Control Programme (VDCP). Data triangulation was used to identify trends in epidemiology and key strategies and interventions through analysis of the VDCP surveillance and programme records and the literature review. Enabling and challenging factors were identified through analysis of socio-economic and health indicators, corroborated through a review of national and international reports and peer-review articles. FINDINGS: Confirmed malaria cases in Bhutan declined by 98.7% from 1994 to 2010. The majority of indigenous cases were due to Plasmodium vivax (59.9%) and adult males are most at-risk of malaria. Imported cases, or those in foreign nationals, varied over the years, reaching 21.8% of all confirmed cases in 2006. Strategies implemented by the VDCP are likely to be related to the decline in cases over the last 10 years. Access to malaria diagnosis in treatment was expanded throughout the country and evidence-based case management, including the introduction of artemisinin-based combination therapy (ACT) for P. falciparum, increasing coverage of high risk areas with Indoor Residual Spraying, insecticidetreated bed nets, and long-lasting insecticidal nets are likely to have contributed to the decline alongside enabling factors such as economic development and increasing access to health services.

CONCLUSION: Bhutan has made significant strides towards elimination and has adopted a goal of national elimination. A major challenge in the future will be prevention and management of imported malaria infections from neighbouring Indian states. Bhutan plans to implement screening at border points to prevent importation of malaria and to targeted prevention and surveillance efforts towards at-risk Bhutanese and migrant workers in construction sites. PMCID: PMC3278342 PMID: 22230355 [PubMed - indexed for MEDLINE] 45. Malar J. 2012 Jan 6;11:8. doi: 10.1186/1475-2875-11-8. The effect of household heads training about the use of treated bed nets on the burden of malaria and anaemia in under-five children: a cluster randomized trial in Ethiopia. Deribew A, Birhanu Z, Sena L, Dejene T, Reda AA, Sudhakar M, Alemseged F, Tessema F, Zeynudin A, Biadgilign S, Deribe K. Department of Epidemiology, Jimma University, Jimma, Ethiopia. amare_deribew@yahoo.com BACKGROUND: Long-lasting insecticide-treated bed nets (LLITN) have demonstrated a significant effect in reducing malaria-related morbidity and mortality. However, barriers on the utilization of LLITN have hampered the desired outcomes. The aim of this study was to assess the effect of community empowerment on the burden of malaria and anaemia in under-five children in Ethiopia. METHODS: A cluster randomized trial was done in 22 (11 intervention and 11 control) villages in south-west Ethiopia. The intervention consisted of tailored training of household heads about the proper use of LLITN and community network system. The burden of malaria and anaemia in under-five children was determined through mass blood investigation at baseline, six and 12 months of the project period. Cases of malaria and anaemia were treated based on the national protocol. The burden of malaria and anaemia between the intervention and control villages was compared using the complex logistic regression model by taking into account the clustering effect. Eight Focus group discussions were conducted to complement

the quantitative findings. RESULTS: A total of 2,105 household heads received the intervention and the prevalence of malaria and anaemia was assessed among 2410, 2037 and 2612 under-five children at baseline, six and 12 months of the project period respectively. During the high transmission/epidemic season, children in the intervention arm were less likely to have malaria as compared to children in the control arm (OR = 0.42; 95%CI: 0.32, 0.57). Symptomatic malaria also steadily declined in the intervention villages compared to the control villages in the follow up periods. Children in the intervention arm were less likely to be anaemic compared to those in the control arm both at the high (OR = 0.84; 95%CI: 0.71, 0.99)) and low (OR = 0.73; 95%CI: 0.60, 0.89) transmission seasons. CONCLUSION: Training of household heads on the utilization of LLITN significantly reduces the burden of malaria in under-five children. The Ministry of Health of Ethiopia in collaboration with other partners should design similar strategies in high-risk areas to control malaria in Ethiopia. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12610000035022. PMCID: PMC3274442 PMID: 22225997 [PubMed - indexed for MEDLINE] 46. Bull Math Biol. 2012 May;74(5):1098-124. doi: 10.1007/s11538-0119710-0. Epub 2012 Jan 5. A periodically-forced mathematical model for the seasonal dynamics of malaria in mosquitoes. Chitnis N, Hardy D, Smith T. Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland. Nakul.Chitnis@unibas.ch We describe and analyze a periodically-forced difference equation model for malaria in mosquitoes that captures the effects of seasonality and allows the mosquitoes to feed on a heterogeneous population of hosts. We numerically show the existence of a unique globally asymptotically stable periodic orbit and calculate periodic orbits of field-measurable quantities that measure malaria

transmission. We integrate this model with an individual-based stochastic simulation model for malaria in humans to compare the effects of insecticide-treated nets (ITNs) and indoor residual spraying (IRS) in reducing malaria transmission, prevalence, and incidence. We show that ITNs are more effective than IRS in reducing transmission and prevalence though IRS would achieve its maximal effects within 2 years while ITNs would need two mass distribution campaigns over several years to do so. Furthermore, the combination of both interventions is more effective than either intervention alone. However, although these interventions reduce transmission and prevalence, they can lead to increased clinical malaria; and all three malaria indicators return to preintervention levels within 3 years after the interventions are withdrawn. PMCID: PMC3339865 PMID: 22218880 [PubMed - indexed for MEDLINE] 47. Malar J. 2011 Dec 20;10:379. doi: 10.1186/1475-2875-10-379. Rapid assessment of the performance of malaria control strategies implemented by countries in the Amazon subregion using adequacy criteria: case study. Flores W, Chang J, Barillas E. Strengthening Pharmaceutical Systems/Management Sciences for Health, 6a avenida 11-77 zona 10, Edificio Punto Diez oficina 1 F Guatemala City, Guatemala. waltergflores@gmail.com BACKGROUND: The objective of this study was to implement a rapid assessment of the performance of four malaria control strategies (indoor spraying, insecticide-treated bed nets, timely diagnosis, and artemisinin-based combination therapy) using adequacy criteria. The assessment was carried out in five countries of the Amazon subregion (Bolivia, Colombia, Ecuador, Guyana, and Peru). METHODS: A list of criteria in three areas was created for each of the four strategies: preliminary research that supports the design and adaptation of the control strategies, coverage of the control strategies and quality of the implementation of the strategies. The criteria were selected by the research team and based on the technical guidelines established by the World Health Organization. Each criterion included in the four lists was graded relative to whether evidence exists that the criterion is satisfied (value 1), not satisfied

(value 0) or partially satisfied (value 0.5). The values obtained were added and reported according to a scale of three implementation categories: adequate, intermediate and deficient. RESULTS: Implementation of residual indoor spraying and timely diagnosis was adequate in one country and intermediate or deficient in the rest. Insecticide-treated bed nets ranged between deficient and intermediate in all the countries, while implementation of artemisinin-based combination therapy (ACT) was adequate in three countries and intermediate in the other two countries evaluated. CONCLUSIONS: Although ACT is the strategy with the better implementation in all countries, major gaps exist in implementation of the other three malaria control strategies in terms of technical criteria, coverage and quality desired. The countries must implement action plans to close the gaps in the various criteria and thereby improve the performance of the interventions. The assessment tools developed, based on adequacy criteria, are considered useful for a rapid assessment by malaria control authorities in the different countries. PMCID: PMC3297539 PMID: 22185638 [PubMed - indexed for MEDLINE] 48. Bull Soc Pathol Exot. 2012 Feb;105(1):36-9. doi: 10.1007/s13149-0110193-x. Epub 2011 Dec 16. [Evaluation of the use of insecticide-treated nets and intermittent preventive treatment in three health zones in Benin]. [Article in French] Kinde-Gazard D, Vignon Makong J, Kossou HD, Sossa CJ. Universit d'Abomey-Calavi, Cotonou, Bnin. kindegazard@yahoo.fr This study aims to evaluate the results of the Project to Support the Fight against Malaria in the departments of Mono and Couffo in Benin on insecticide-treated nets (ITNs) use by children under 5 years and pregnant women and the coverage by Intermittent Preventive Treatment (IPT) with Sulfadoxin-Pyrimethamin (SP). This assessment is made from two household surveys. The first at the start up and the second after fifteen months of implementation. The availability of ITN in households and their use by pregnant women and

children under 5 years have increased respectively from 8, 5 and 4% in 2005 to 24, 31 and 16 % in 2006. The percentage of pregnant women under IPT with sulfadoxine-pyrimethamine (SP) is 10% while 21% of pregnant women received at least one dose of SP. The availability of ITN in households and their use by children under 5 years and the prevention of malaria during pregnancy remains a concern in these health areas. The promotion of long lasting insecticide treated nets with effective communication strategies for behavior change could improve the results. Research on causes of poor compliance of IPT should be emphasized as well as strengthening management of drugs in health centers. PMID: 22180050 [PubMed - indexed for MEDLINE]

49. Malar J. 2011 Dec 13;10:353. doi: 10.1186/1475-2875-10-353. Larval source management for malaria control in Africa: myths and reality. Fillinger U, Lindsay SW. Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK. ulrike.fillinger@lshtm.ac.uk As malaria declines in many African countries there is a growing realization that new interventions need to be added to the front-line vector control tools of long-lasting impregnated nets (LLINs) and indoor residual spraying (IRS) that target adult mosquitoes indoors. Larval source management (LSM) provides the dual benefits of not only reducing numbers of house-entering mosquitoes, but, importantly, also those that bite outdoors. Large-scale LSM was a highly effective method of malaria control in the first half of the twentieth century, but was largely disbanded in favour of IRS with DDT. Today LSM continues to be used in large-scale mosquito abatement programmes in North America and Europe, but has only recently been tested in a few trials of malaria control in contemporary Africa. The results from these trials show that handapplication of larvicides can reduce transmission by 70-90% in settings where mosquito larval habitats are defined but is largely ineffectual where habitats are so extensive that not all of them can be covered on foot, such as areas that experience

substantial flooding. Importantly recent evidence shows that LSM can be an effective method of malaria control, especially when combined with LLINs. Nevertheless, there are a number of misconceptions or even myths that hamper the advocacy for LSM by leading international institutions and the uptake of LSM by Malaria Control Programmes. Many argue that LSM is not feasible in Africa due to the high number of small and temporary larval habitats for Anopheles gambiae that are difficult to find and treat promptly. Reference is often made to the Ross-Macdonald model to reinforce the view that larval control is ineffective. This paper challenges the notion that LSM cannot be successfully used for malaria control in African transmission settings by highlighting historical and recent successes, discussing its potential in an integrated vector management approach working towards malaria elimination and critically reviewing the most common arguments that are used against the adoption of LSM. PMCID: PMC3273449 PMID: 22166144 [PubMed - indexed for MEDLINE] 50. Malar J. 2011 Dec 13;10:357. doi: 10.1186/1475-2875-10-357. Free distribution of insecticidal bed nets improves possession and preferential use by households and is equitable: findings from two cross-sectional surveys in thirteen malaria endemic districts of Bangladesh. Ahmed SM, Hossain S, Kabir MM, Roy S. Research and Evaluation Division, BRAC Centre, 75 Mohakhali, Dhaka Dhaka1212, Bangladesh. ahmed.sm@brac.net BACKGROUND: BRAC, an indigenous non-governmental development organization (NGO), has been implementing a programme to prevent and control malaria in the 13 malaria-endemic districts of Bangladesh since 2007. One of the critical preventive interventions is the distribution of insecticidal bed nets (long-lasting insecticide-treated nets, LLINs and insecticide-treated ordinary nets, ITNs) to the community free of cost. This study aimed to assess progress in the possession, preferential use, and knowledge on use of the LLIN/ITNs including the programme's avowed pro-poor inclination one and three and half years after intervention began.

METHODS: A convenient sampling strategy based on malaria endemicity in the districts was adopted. First, thirty upazila (sub-district, with a population around 250,000)s were selected at random, with high prevalent districts contributing more upazilas; second, from each upazila, one (2008) to two (2011) villages (covered by insecticidal bed net distribution programme) were selected. From each village, households that had either one under-five child and/or a pregnant woman were included in the survey, one household being included only once. Data were collected using a pre-tested structured questionnaire. RESULTS: In all, 3,760 households in 2008 and 7,895 households in 2011 were surveyed for collecting relevant information. Proportion of households with at least one LLIN, and at least one LLIN/ITN increased (22-59 to 62-67% and 22-64% to 74-76% respectively) over time, including increase in the mean number of LLIN/ITNs per household ( 1 to 1 +). The programme achieved > 80% coverage in sleeping under an LLIN/ITN in the case of under-five children and pregnant women, especially in the high-endemic districts. Knowledge regarding critical time of hanging the net also increased over time (7-22 to 44-54%), but remained low. The pro-poor inclination of the programme is reflected in the status of relevant indicators according to self-rated poverty status of the households. CONCLUSIONS: There has been a substantial improvement in possession and usage of insecticidal bed nets especially for the two most vulnerable groups (under-five children and pregnant women), including a reduction of gaps between the high and low endemic districts, and the deficit and non-deficit households during the study period. PMCID: PMC3266224 PMID: 22165959 [PubMed - indexed for MEDLINE] 51. Malar J. 2011 Dec 13;10:356. doi: 10.1186/1475-2875-10-356. Impact of insecticide-treated bed nets on malaria transmission indices on the south coast of Kenya. Mutuku FM, King CH, Mungai P, Mbogo C, Mwangangi J, Muchiri EM, Walker ED, Kitron U.

Department of Environmental Studies, Emory University, Atlanta, Georgia, USA. fmutuku73@gmail.com BACKGROUND: Besides significantly reducing malaria vector densities, prolonged usage of bed nets has been linked to decline of Anopheles gambiae s.s. relative to Anopheles arabiensis, changes in host feeding preference of malaria vectors, and behavioural shifts to exophagy (outdoor biting) for the two important malaria vectors in Africa, An. gambiae s.l. and Anopheles funestus. In southern coastal Kenya, bed net use was negligible in 1997-1998 when Anopheles funestus and An. gambiae s.s. were the primary malaria vectors, with An. arabiensis and Anopheles merus playing a secondary role. Since 2001, bed net use has increased progressively and reached high levels by 2009-2010 with corresponding decline in malaria transmission. METHODS: To evaluate the impact of the substantial increase in household bed net use within this area on vector density, vector composition, and humanvector contact, indoor and outdoor resting mosquitoes were collected in the same region during 2009-2010 using pyrethrum spray catches and clay pots for indoor and outdoor collections respectively. Information on bed net use per sleeping spaces and factors influencing mosquito density were determined in the same houses using Poisson regression analysis. Species distribution was determined, and number of mosquitoes per house, human-biting rates (HBR), and entomological inoculation rate (EIR) were compared to those reported for the same area during 19971998, when bed net coverage had been minimal. RESULTS: Compared to 1997-1998, a significant decline in the relative proportion of An. gambiae s.s. among collected mosquitoes was noted, coupled with a proportionate increase of An. arabiensis. Following > 5 years of 60-86% coverage with bed nets, the density, human biting rate and EIR of indoor resting mosquitoes were reduced by more than 92% for An. funestus and by 75% for An. gambiae s.l. In addition, the host feeding choice of both vectors shifted more toward non-human vertebrates. Besides bed net use, malaria vector abundance was also influenced by type of house construction and according to whether one sleeps on a bed or a mat (both of these are associated with household wealth). Mosquito

density was positively associated with presence of domestic animals. CONCLUSIONS: These entomological indices indicate a much reduced human biting rate and a diminishing role of An. gambiae s.s. in malaria transmission following high bed net coverage. While increasing bed net coverage beyond the current levels may not significantly reduce the transmission potential of An. arabiensis, it is anticipated that increasing or at least sustaining high bed net coverage will result in a diminished role for An. funestus in malaria transmission. PMCID: PMC3322380 PMID: 22165904 [PubMed - indexed for MEDLINE] 52. Malar J. 2011 Dec 13;10:363. doi: 10.1186/1475-2875-10-363. Assessing healthcare providers' knowledge and practices relating to insecticide-treated nets and the prevention of malaria in Ghana, Laos, Senegal and Tanzania. Hoffman SJ, Guindon GE, Lavis JN, Ndossi GD, Osei EJ, Sidibe MF, Boupha B; Research to Policy & Practice Study Team. Collaborators: Lavis JN, Guindon G, Cameron D, Hoffman SJ, Shi G, Qiu T, Osei EJ, Dovlo K, Yesudian CA, Ramachandran P, Malek-Afzali H, Dejman M, Falahat K, Baradaran M, Habibi E, Kohanzad H, Nasehi M, Salek S, Akanov AA, Turdaliyeva BS, Hamzina NK, Tulebaev KA, Clazhneva TI, Battakova G, Boupha B, Kounnavong S, Siengsounthone L, Becerra-Posada F, Ramos LA, Mejia I, Akhtar T, Khan MM, Sidibe MF, Sidibe A, Ndiaye D, Ndossi GD, Massaga J, Sadana R, Pang T. McMaster Health Forum, McMaster University, Hamilton, Ontario, Canada. BACKGROUND: Research evidence is not always being disseminated to healthcare providers who need it to inform their clinical practice. This can result in the provision of ineffective services and an inefficient use of resources, the implications of which might be felt particularly acutely in low- and middle-income countries. Malaria prevention is a particularly compelling domain to study evidence/practice gaps given the proven efficacy, costeffectiveness and disappointing utilization of insecticide-treated nets (ITNs). METHODS: This study compares what is known about ITNs to the related knowledge

and practices of healthcare providers in four low- and middle-income countries. A new questionnaire was developed, pilot tested, translated and administered to 497 healthcare providers in Ghana (140), Laos (136), Senegal (100) and Tanzania (121). Ten questions tested participants' knowledge and clinical practice related to malaria prevention. Additional questions addressed their individual characteristics, working context and research-related activities. Ordinal logistic regressions with knowledge and practices as the dependent variable were conducted in addition to descriptive statistics. RESULTS: The survey achieved a 75% response rate (372/497) across Ghana (107/140), Laos (136/136), Senegal (51/100) and Tanzania (78/121). Few participating healthcare providers correctly answered all five knowledge questions about ITNs (13%) or self-reported performing all five clinical practices according to established evidence (2%). Statistically significant factors associated with higher knowledge within each country included: 1) training in acquiring systematic reviews through the Cochrane Library (OR 2.48, 95% CI 1.30-4.73); and 2) ability to read and write English well or very well (OR 1.69, 95% CI 1.05-2.70). Statistically significant factors associated with better clinical practices within each country include: 1) reading scientific journals from their own country (OR 1.67, 95% CI 1.10-2.54); 2) working with researchers to improve their clinical practice or quality of working life (OR 1.44, 95% CI 1.04-1.98); 3) training on malaria prevention since their last degree (OR 1.68, 95% CI 1.17-2.39); and 4) easy access to the internet (OR 1.52, 95% CI 1.08-2.14). CONCLUSIONS: Improving healthcare providers' knowledge and practices is an untapped opportunity for expanding ITN utilization and preventing malaria. This study points to several strategies that may help bridge the gap between what is known from research evidence and the knowledge and practices of healthcare providers. Training on acquiring systematic reviews and facilitating internet access may be particularly helpful. PMCID: PMC3265439 PMID: 22165841 [PubMed - indexed for MEDLINE] 53. Malar J. 2011 Dec 13;10:354. doi: 10.1186/1475-2875-10-354. Factors associated with mosquito net use by individuals in households owning nets in Ethiopia.

Graves PM, Ngondi JM, Hwang J, Getachew A, Gebre T, Mosher AW, Patterson AE, Shargie EB, Tadesse Z, Wolkon A, Reithinger R, Emerson PM, Richards FO Jr. The Carter Center, Atlanta, GA, USA. pgraves.work@gmail.com BACKGROUND: Ownership of insecticidal mosquito nets has dramatically increased in Ethiopia since 2006, but the proportion of persons with access to such nets who use them has declined. It is important to understand individual level net use factors in the context of the home to modify programmes so as to maximize net use. METHODS: Generalized linear latent and mixed models (GLLAMM) were used to investigate net use using individual level data from people living in net-owning households from two surveys in Ethiopia: baseline 2006 included 12,678 individuals from 2,468 households and a sub-sample of the Malaria Indicator Survey (MIS) in 2007 included 14,663 individuals from 3,353 households. Individual factors (age, sex, pregnancy); net factors (condition, age, net density); household factors (number of rooms [2006] or sleeping spaces [2007], IRS, women's knowledge and school attendance [2007 only], wealth, altitude); and cluster level factors (rural or urban) were investigated in univariate and multi-variable models for each survey. RESULTS: In 2006, increased net use was associated with: age 25-49 years (adjusted (a) OR = 1.4, 95% confidence interval (CI) 1.2-1.7) compared to children U5; female gender (aOR = 1.4; 95% CI 1.2-1.5); fewer nets with holes (Ptrend = 0.002); and increasing net density (Ptrend < 0.001). Reduced net use was associated with: age 5-24 years (aOR = 0.2; 95% CI 0.2-0.3). In 2007, increased net use was associated with: female gender (aOR = 1.3; 95% CI 1.1-1.6); fewer nets with holes (aOR [all nets in HH good] = 1.6; 95% CI 1.2-2.1); increasing net density (Ptrend < 0.001); increased women's malaria knowledge (Ptrend < 0.001); and urban clusters (aOR = 2.5; 95% CI 1.5-4.1). Reduced net use was associated with: age 5-24 years (aOR = 0.3; 95% CI 0.2-0.4); number of sleeping spaces (aOR [per additional space] = 0.6, 95% CI 0.5-0.7); more old nets (aOR [all nets in HH older than 12 months] = 0.5; 95% CI 0.3-0.7); and increasing household altitude (Ptrend < 0.001). CONCLUSION: In both surveys, net use was more likely by women, if nets had fewer

holes and were at higher net per person density within households. School-age children and young adults were much less likely to use a net. Increasing availability of nets within households (i.e. increasing net density), and improving net condition while focusing on education and promotion of net use, especially in school-age children and young adults in rural areas, are crucial areas for intervention to ensure maximum net use and consequent reduction of malaria transmission. PMCID: PMC3258293 PMID: 22165821 [PubMed - indexed for MEDLINE] 54. Am J Trop Med Hyg. 2011 Dec;85(6):1080-6. doi: 10.4269/ajtmh.2011.100684. The combination of indoor residual spraying and insecticide-treated nets provides added protection against malaria compared with insecticide-treated nets alone. Hamel MJ, Otieno P, Bayoh N, Kariuki S, Were V, Marwanga D, Laserson KF, Williamson J, Slutsker L, Gimnig J. Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia 30301, USA. mhamel@cdc.gov Both insecticide-treated bed nets (ITNs) and indoor residual spraying (IRS) reduce malaria in high malaria transmission areas. The combined effect of these interventions is unknown. We conducted a non-randomized prospective cohort study to determine protective efficacy of IRS with ITNs (ITN + IRS) compared with ITNs alone (ITN only) in preventing Plasmodium falciparum parasitemia. At baseline, participants provided blood samples for malaria smears, were presumptively treated for malaria, and received ITNs. Blood smears were made monthly and at sick visits. In total, 1,804 participants were enrolled. Incidence of P. falciparum parasitemia in the ITN + IRS and ITN only groups was 18 and 44 infections per 100 persons-years at risk, respectively (unadjusted rate ratio = 0.41; 95% confidence interval [CI] = 0.31-0.56). Adjusted protective efficacy of ITN + IRS compared with ITN only was 62% (95% CI = 0.50-0.72). The combination of IRS and ITN might be a feasible strategy to further reduce malaria transmission in areas of persistent perennial malaria transmission.

PMCID: PMC3225156 [Available on 2012/12/1] PMID: 22144448 [PubMed - indexed for MEDLINE] 55. Acta Trop. 2012 Mar;121(3):166-74. doi: 10.1016/j.actatropica.2011.11.005. Epub 2011 Nov 19. Sahel, savana, riverine and urban malaria in West Africa: Similar control policies with different outcomes. Ceesay SJ, Bojang KA, Nwakanma D, Conway DJ, Koita OA, Doumbia SO, Ndiaye D, Coulibaly TF, Diakit M, Traor SF, Coulibaly M, Ndiaye JL, Sarr O, Gaye O, Konat L, Sy N, Faye B, Faye O, Sogoba N, Jawara M, Dao A, Poudiougou B, Diawara S, Okebe J, Sangar L, Abubakar I, Sissako A, Diarra A, Kita M, Kandeh B, Long CA, Fairhurst RM, Duraisingh M, Perry R, Muskavitch MA, Valim C, Volkman SK, Wirth DF, Krogstad DJ. International Center for Excellence in Malaria Research in West Africa at the Medical Research Council Laboratories, Fajara, Gambia. The study sites for the West African ICEMR are in three countries (The Gambia, Senegal, Mali) and are located within 750 km of each other. In addition, the National Malaria Control Programmes of these countries have virtually identical policies: (1) Artemisinin Combination Therapies (ACTs) for the treatment of symptomatic Plasmodium falciparum infection, (2) Long-Lasting Insecticide-treated bed Nets (LLINs) to reduce the Entomololgic Inoculation Rate (EIR), and (3) sulfadoxine-pyrimethamine for the Intermittent Preventive Treatment of malaria during pregnancy (IPTp). However, the prevalence of P. falciparum malaria and the status of malaria control vary markedly across the four sites with differences in the duration of the transmission season (from 4-5 to 10-11 months), the intensity of transmission (with EIRs from unmeasurably low to 4-5 per person per month), multiplicity of infection (from a mean of 1.0 to means of 2-5) and the status of malaria control (from areas which have virtually no control to areas that are at the threshold of malaria elimination). The most important priority is the need to obtain comparable data on the population-based prevalence, incidence and

transmission of malaria before new candidate interventions or combinations of interventions are introduced for malaria control. Copyright 2011 Elsevier B.V. All rights reserved. PMCID: PMC3294051 [Available on 2013/3/1] PMID: 22119584 [PubMed - indexed for MEDLINE] 56. Malar J. 2011 Nov 23;10:344. doi: 10.1186/1475-2875-10-344. What drives community adherence to indoor residual spraying (IRS) against malaria in Manhia district, rural Mozambique: a qualitative study. Munguambe K, Pool R, Montgomery C, Bavo C, Nhacolo A, Fiosse L, Sacoor C, Nhalungo D, Mabunda S, Macete E, Alonso P. Centro de Investigao em Sade de Manhia, Rua 12, CP 1929 Manhia, Mozambique. khatia.munguambe@manhica.net BACKGROUND: Malaria control remains a challenge in sub-Saharan Africa. In 2006, the World Health Organization (WHO) reinforced the recommendation of indoor residual spraying (IRS) with dichlorodiphenyltrichloroethane (DDT) to reduce malaria transmission. The National Malaria Control Programme has been reporting high coverage rates of IRS in Mozambique. It is important to establish to what extent these rates are a reflection of community acceptability, and to explore the factors associated with adherence, in order to recommend suitable approaches for interventions of this nature. OBJECTIVE: To understand the implementation process, reception and acceptability of the IRS program in Manhia district, Southern Mozambique. METHODS: Qualitative data was collected through in-depth interviews, participant observation of IRS activities, informal interviews, and focus group discussions. Study participants comprised householders, community leaders, health care providers, sprayers, and community members. Qualitative data analysis was based on grounded theory. Secondary data from the Manhia Demographic Surveillance System was used to complement the qualitative data. RESULTS: IRS was well received in most neighbourhoods. The overall coverage rates varied between 29% and 41% throughout the study period. The factors related to adherence to IRS were: immediate impact on insects in general, trust and

obedience in the health authority, community leaders' influence, and acquaintance with the sprayers. Fighting malaria was not an important motivation for IRS adherence. There was a perception of limited efficacy of IRS against mosquitoes, but this did not affect adherence. Non-adherence to the intervention was mainly due to the unavailability of key householders, disagreement with the procedures, and the perception that spraying increased the burden of insects. Most respondents strongly favoured bed nets over IRS. CONCLUSION: The study suggests that the contribution of IRS to malaria and mosquito control is not entirely perceived by the beneficiaries, and that other as cost effective interventions such as insecticide-treated nets are favoured over IRS. Adherence to IRS was found to be influenced by socio-political factors. There is a need to redefine the community sensitization approaches in order to make IRS a genuinely participative, acceptable, and sustainable programme. PMCID: PMC3339361 PMID: 22111698 [PubMed - indexed for MEDLINE] 57. PLoS One. 2011;6(11):e27516. doi: 10.1371/journal.pone.0027516. Epub 2011 Nov 11. Infections in infants during the first 12 months of life: role of placental malaria and environmental factors. Le Port A, Watier L, Cottrell G, Oudraogo S, Dechavanne C, Pierrat C, Rachas A, Bouscaillou J, Bouraima A, Massougbodji A, Fayomi B, Thibaut A, Chandre F, Migot-Nabias F, Martin-Prevel Y, Garcia A, Cot M. UMR216 Mre et enfant face aux infections tropicales, Institut de Recherche pour le Dveloppement, Paris, France. agnesleport@yahoo.fr BACKGROUND: The association between placental malaria (PM) and first peripheral parasitaemias in early infancy was assessed in Tori Bossito, a rural area of Benin with a careful attention on transmission factors at an individual level. METHODOLOGY: Statistical analysis was performed on 550 infants followed weekly from birth to 12 months. Malaria transmission was assessed by anopheles human landing catches every 6 weeks in 36 sampling houses and season defined by

rainfall. Each child was located by GPS and assigned to the closest anopheles sampling house. Data were analysed by survival Cox models, stratified on the possession of insecticide-treated mosquito nets (ITNs) at enrolment. PRINCIPAL FINDINGS: Among infants sleeping in a house with an ITN, PM was found to be highly associated to first malaria infections, after adjusting on season, number of anopheles, antenatal care (ANC) visits and maternal severe anaemia. Infants born from a malaria infected placenta had a 2.13 fold increased risk to present a first malaria infection than those born from a non infected placenta ([1.24-3.67], p<0.01) when sleeping in a house with an ITN. The risk to present a first malaria infection was increased by 3.2 to 6.5, according to the level of anopheles exposure (moderate or high levels, compared to the absence of anopheles). CONCLUSIONS: First malaria infections in early childhood can be attributed simultaneously to both PM and high levels of exposure to infected anopheles. Protective measures as Intermittent Preventive Treatment during pregnancy (IPTp) and ITNs, targeted on both mothers and infants should be reinforced, as well as the research on new drugs and insecticides. In parallel, investigations on placental malaria have to be strengthened to better understand the mechanisms involved, and thus to protect adequately the infants high risk group. PMCID: PMC3214070 PMID: 22096588 [PubMed - indexed for MEDLINE] 58. PLoS One. 2011;6(11):e26746. doi: 10.1371/journal.pone.0026746. Epub 2011 Nov 11. Effect of transmission reduction by insecticide-treated bednets (ITNs) on antimalarial drug resistance in western Kenya. Shah M, Kariuki S, Vanden Eng J, Blackstock AJ, Garner K, Gatei W, Gimnig JE, Lindblade K, Terlouw D, ter Kuile F, Hawley WA, Phillips-Howard P, Nahlen B, Walker E, Hamel MJ, Slutsker L, Shi YP. Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.

Despite the clear public health benefit of insecticide-treated bednets (ITNs), the impact of malaria transmission-reduction by vector control on the spread of drug resistance is not well understood. In the present study, the effect of sustained transmission reduction by ITNs on the prevalence of Plasmodium falciparum gene mutations associated with resistance to the antimalarial drugs sulfadoxine-pyrimethamine (SP) and chloroquine (CQ) in children under the age of five years was investigated during an ITN trial in Asembo area, western Kenya. During the ITN trial, the national first line antimalarial treatment changed from CQ to SP. Smear-positive samples collected from cross sectional surveys prior to ITN introduction (baseline, n=250) and five years post-ITN intervention (year 5 survey, n=242) were genotyped for single nucleotide polymorphisms (SNPs) at dhfr-51, 59, 108, 164 and dhps-437, 540 (SP resistance), and pfcrt-76 and pfmdr1-86 (CQ resistance). The association between the drug resistance mutations and epidemiological variables was evaluated. There were significant increases in the prevalence of SP dhps mutations and the dhfr/dhps quintuple mutant, and a significant reduction in the proportion of mixed infections detected at dhfr-51, 59 and dhps-437, 540 SNPs from baseline to the year 5 survey. There was no change in the high prevalence of pfcrt-76 and pfmdr1-86 mutations. Multivariable regression analysis further showed that current antifolate use and year of survey were significantly associated with more SP drug resistance mutations. These results suggest that increased antifolate drug use due to drug policy change likely led to the high prevalence of SP mutations 5 years post-ITN intervention and reduced transmission had no apparent effect on the existing high prevalence of CQ mutations. There is no evidence from the current study that sustained transmission reduction by ITNs reduces the prevalence of genes associated with malaria drug resistance. PMCID: PMC3214025 PMID: 22096496 [PubMed - indexed for MEDLINE] 59. Educ Health (Abingdon). 2011 Aug;24(2):474. Epub 2011 Jul 22. A community health worker program for the prevention of malaria in eastern Kenya.

Stromberg DG, Frederiksen J, Hruschka J, Tomedi A, Mwanthi M. University of New Mexico Albuquerque, New Mexico, USA. david0stromberg@gmail.com OBJECTIVE: To assess whether the development and implementation of a community health worker (CHW) project in rural Kenya was associated with an increase in knowledge about malaria and the use of insecticide-treated nets (ITNs) in children under five years of age. METHODS: A baseline knowledge and behavior questionnaire, adopted from the Kenyan Demographic Health Survey, was conducted in August 2007 by Kenyan health officials in 75 villages. Two CHWs were chosen from each village and trained in appropriate use of ITNs. The CHWs provided educational sessions and ITNs to mothers in their respective villages. A follow-up survey was conducted in March 2008 of all families with children less than five years of age within randomly selected villages. The main questions addressed during the follow-up survey included knowledge about malaria and the practice of correctly using ITNs. FINDINGS: There were 267 surveys compiled for knowledge assessment before the intervention and 340 in the post-intervention analysis with an approximate 99% family participation rate. Of the families surveyed, 81% correctly knew the cause for malaria before the study and 93% after the CHW intervention (p < 0.01). Of those surveyed before the intervention, 70% owned and correctly used mosquito nets compared with 88% after the CHW intervention (p < 0.01). CONCLUSIONS: There was a significant increase in knowledge about malaria and use of ITNs after the implementation of the CHW program. PMID: 22081652 [PubMed - indexed for MEDLINE]

60. Malar J. 2011 Nov 13;10:341. doi: 10.1186/1475-2875-10-341. Who attends antenatal care and expanded programme on immunization services in Chad, Mali and Niger? The implications for insecticide-treated net delivery. Carlson M, Smith Paintain L, Bruce J, Webster J, Lines J. Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK. mcarlson318@gmail.com

BACKGROUND: Malaria remains one of the largest public health problems facing the developing world. Insecticide-treated nets (ITNs) are an effective intervention against malaria. ITN delivery through routine health services, such as antenatal care (ANC) and childhood vaccination (EPI), is a promising channel of delivery to reach individuals with the highest risk (pregnant women and children under five years old). Decisions on whether to deliver ITNs through both channels depends upon the reach of each of these systems, whether these are independent and the effectiveness and cost effectiveness of each. Predictors of women attending ANC and EPI separately have been studied, but the predictors of those who attend neither service have not been identified. METHODS: Data from Chad, Mali and Niger demographic and health surveys (DHS) were analyzed to determine risk factors for attending neither service. A conceptual framework for preventative health care-seeking behaviour was created to illustrate the hierarchical relationships between the potential risk factors. The independence of attending both ANC and EPI was investigated. A multivariate model of predictors for non-attendance was developed using logistic regression. RESULTS: ANC and EPI attendance were found to be strongly associated in all three countries. However, 47% of mothers in Chad, 12% in Mali and 36% in Niger did not attend either ANC or EPI. Region, mother's education and partner's education were predictors of non-attendance in all three countries. Wealth index, ethnicity, and occupation were associated with non-attendance in Mali and Niger. Other predictors included religion, healthcare autonomy, household size and number of children under five. CONCLUSIONS: Attendance of ANC and EPI are not independent and therefore the majority of pregnant women in these countries will have the opportunity to receive ITNs through both services. Although attendance at ANC and EPI are not independent, delivery through both systems may still add incrementally to delivery through one alone. Therefore, there is potential to increase the proportion of women and children receiving ITNs by delivering through both of these channels. However, modelling is required to determine the level of attendance and incremental potential at which it's cost effective to deliver through both services.

81. J Health Popul Nutr. 2011 Jun;29(3):200-6. Factors influencing people's willingness-to-buy insecticide-treated bednets in Arbaminch Zuria District, southern Ethiopia. Gebresilassie FE, Mariam DH. CDC-Ethiopia, P.O. Box 11531, Addis Ababa, Ethiopia. freeshetu@yahoo.com Promoting self-financing healthcare helps restore efficiency and equity to national health systems. This study was conducted in malaria-endemic areas of southern Ethiopia to assess the bednet possession of the community, determine the people's willingness-to-pay for insecticide-treated bednets (ITNs), and identify what factors influence it. The study provided relevant information for programme planners and policymakers for evidence-based decision-making. This quantitative cross-sectional community-based study was conducted in four selected malarious Kebeles of Arbaminch Zuria district using a pretested interviewadministered structured questionnaire. In total, 982 household heads were interviewed. The community's willingness-to-pay was assessed by contingent valuation, technique using binary with follow-up method. The advantage, the distribution, and the payment mechanism were explained, and three different qualities of ITN were shown by constructing a hypothetical market scenario. Of the 982 respondents, 466 (47.5%) households had at least one functional bednet. Of 849 children aged less than five years in the 982 households, 185 (21.8%) slept under a net the night preceding the survey. The results of the study revealed that around 86% of the respondents were willing to buy ITNs. The average maximum willingness-topay for three different types of bednets was statistically different. The maximum amount the people were willing to pay was US$ 3.3 for a blue conical ITN, US$ 3.2 for a white conical one, and US$ 1.7 for a blue rectangular ITN. The community's willingness-to-pay was significantly affected by gender, educational status, perceived benefit of ITN, previous source of bednet, and characteristics of bednet. The results showed that a significant proportion of the community people

were willing to pay for ITNs. Therefore, introducing a subsidized ITN market rather than free distribution for all should be considered to ensure sustainability and self-reliance in the prevention and control of malaria. PMCID: PMC3131120 PMID: 21766555 [PubMed - indexed for MEDLINE] 82. Acta Trop. 2012 Mar;121(3):212-7. doi: 10.1016/j.actatropica.2011.06.017. Epub 2011 Jul 8. Malaria control in Malawi: current status and directions for the future. Mathanga DP, Walker ED, Wilson ML, Ali D, Taylor TE, Laufer MK. Department of Community Health, University of Malawi College of Medicine, Blantyre, Malawi. dmathang@mac.medcol.mw The last decade has seen an increase in investment and concerted efforts by the Malawi Ministry of Health and partners to control malaria disease. This report summarizes what is known about the burden of malaria and the strategies being implemented to control it in Malawi. Over the past 5 years, roll out of treatment and prevention efforts have been successful in the country, as demonstrated by increased use of insecticide treated nets, improved access to prompt and effective treatment and the initiation of pilot studies of indoor residual spraying. However, unlike other countries in the region, the recent data have not suggested a decrease in the burden of disease. We describe the environment in which the activities of Malawi's International Center for Excellence in Malaria Research (ICEMR) will be carried out and provide the rationale for the clinical, entomological and molecular studies. Our approach is to establish consistent, stainable data collection systems that are embedded within the public health sector. Through standardized and long-term studies of hosts, parasites and vectors, we hope to contribute to assessment of malaria disease burden, the appropriate application of interventions and policies and provide both the data collection and the health care infrastructure to ultimately eliminate the disease. Copyright 2011 Elsevier B.V. All rights reserved.

PMID: 21763670

[PubMed - indexed for MEDLINE]

83. Acta Trop. 2012 Mar;121(3):202-6. doi: 10.1016/j.actatropica.2011.06.012. Epub 2011 Jul 2. Malaria epidemiology and control in Southern Africa. Mharakurwa S, Thuma PE, Norris DE, Mulenga M, Chalwe V, Chipeta J, Munyati S, Mutambu S, Mason PR; Southern Africa ICEMR Team. Collaborators: Agre P, Glass G, Hackman A, Kobayashi T, Louis TA, Moss WJ, Scott A, Shields T, Shiff C, Gwanzura L, Coetzee M. Johns Hopkins Malaria Research Institute, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA. smharaku@jhsph.edu The burden of malaria has decreased dramatically within the past several years in parts of sub-Saharan Africa, following the scale-up of interventions supported by the Roll Back Malaria Partnership, the President's Malaria Initiative and other partners. It is important to appreciate that the reductions in malaria have not been uniform between and within countries, with some areas experiencing resurgence instead. Furthermore, while interventions have greatly reduced the burden of malaria in many countries, it is also recognized that the malaria decline pre-dated widespread intervention efforts, at least in some cases where data are available. This raises more questions as what other factors may have been contributing to the reduction in malaria transmission and to what extent. The International Center of Excellence for Malaria Research (ICEMR) in Southern Africa aims to better understand the underlying malaria epidemiology, vector ecology and parasite genomics using three contrasting settings of malaria transmission in Zambia and Zimbabwe: an area of successful malaria control, an area of resurgent malaria and an area where interventions have not been effective. The Southern Africa ICEMR will capitalize on the opportunity to investigate the complexities of malaria transmission while adapting to intervention and establish the evidence-base to guide effective and sustainable malaria intervention strategies. Key approaches to attain this goal for the region will include close collaboration with national malaria control programs

and contribution to capacity building at the individual, institutional and national levels. Copyright 2011 Elsevier B.V. All rights reserved. PMCID: PMC3214248 [Available on 2013/3/1] PMID: 21756864 [PubMed - indexed for MEDLINE] 84. Acta Trop. 2012 Mar;121(3):196-201. doi: 10.1016/j.actatropica.2011.06.013. Epub 2011 Jul 2. Malaria in Uganda: challenges to control on the long road to elimination. II. The path forward. Talisuna A, Adibaku S, Dorsey G, Kamya MR, Rosenthal PJ. Infectious Diseases Research Collaboration, Kampala, Uganda. In the recent past there have been several reports of successes in malaria control, leading some public health experts to conclude that Africa is witnessing an epidemiological transition, from an era of failed malaria control to progression from successful control to elimination. Successes in control have been attributed to increased international donor support leading to increased intervention coverage. However, these changes are not uniform across Africa. In Uganda, where baseline transmission is very high and intervention coverage not yet to scale, the malaria burden is not declining and has even likely increased in the last decade. In this article we present perspectives for the future for Uganda and other malaria endemic countries with high baseline transmission intensity and significant health system challenges. For these high burden areas, malaria elimination is currently not feasible, and early elimination programs are inappropriate, as they would further fragment already fragmented and inefficient malaria control systems. Rather, health impacts will be maximized by aiming to achieve universal coverage of proven interventions in the context of a strengthened health system. Copyright 2011 Elsevier B.V. All rights reserved. PMCID: PMC3439212 [Available on 2013/3/1] PMID: 21756863 [PubMed - indexed for MEDLINE]

85. Malar J. 2011 Jun 22;10:170. doi: 10.1186/1475-2875-10-170. Relationship between care-givers' misconceptions and non-use of ITNs by under-five Nigerian children. Arogundade ED, Adebayo SB, Anyanti J, Nwokolo E, Ladipo O, Ankomah A, Meremikwu MM. Department of Paediatrics, University of Calabar, Calabar, Nigeria. BACKGROUND: Malaria has been a major public health problem in Nigeria and many other sub-Saharan African countries. Insecticide-treated nets have shown to be cost-effective in the prevention of malaria, but the number of people that actually use these nets has remained generally low. Studies that explore the determinants of use of ITN are desirable. METHODS: Structured questionnaires based on thematic areas were administered by trained interviewers to 7,223 care-givers of under-five children selected from all the six geo-political zones of Nigeria. Bivariate analysis and multinomial logit model were used to identify possible determinants of use of ITN. RESULTS: Bivariate analysis showed that under-five children whose caregivers had some misconceptions about causes and prevention of malaria were significantly less likely to use ITN even though the household may own a net (p < 0.0001). Education and correct knowledge about modes of prevention of malaria, knowing that malaria is dangerous and malaria can kill were also significantly associated with use of ITN (p < 0.0001). Knowledge of symptoms of malaria did not influence use of ITN. Association of non-use of ITN with misconceptions about prevention of malaria persisted with logistic regression (Odds ratio 0.847; 95% CI 0.747 to 0.960). CONCLUSIONS: Misconceptions about causes and prevention of malaria by caregivers adversely influence the use ITN by under-five children. Appropriate communication strategies should correct these misconceptions. PMCID: PMC3146898 PMID: 21696622 [PubMed - indexed for MEDLINE] 86. PLoS One. 2011;6(6):e20805. doi: 10.1371/journal.pone.0020805. Epub 2011 Jun 14.

A sub-microscopic gametocyte reservoir can sustain malaria transmission. Karl S, Gurarie D, Zimmerman PA, King CH, St Pierre TG, Davis TM. School of Physics, The University of Western Australia, Crawley, Western Australia, Australia. stephan.karl@physics.uwa.edu.au BACKGROUND: Novel diagnostic tools, including PCR and high field gradient magnetic fractionation (HFGMF), have improved detection of asexual Plasmodium falciparum parasites and especially infectious gametocytes in human blood. These techniques indicate a significant number of people carry gametocyte densities that fall below the conventional threshold of detection achieved by standard light microscopy (LM). METHODOLOGY/PRINCIPAL FINDINGS: To determine how low-level gametocytemia may affect transmission in present large-scale efforts for P. falciparum control in endemic areas, we developed a refinement of the classical Ross-Macdonald model of malaria transmission by introducing multiple infective compartments to model the potential impact of highly prevalent, low gametocytaemic reservoirs in the population. Models were calibrated using field-based data and several numerical experiments were conducted to assess the effect of high and low gametocytemia on P. falciparum transmission and control. Special consideration was given to the impact of long-lasting insecticide-treated bed nets (LLIN), presently considered the most efficient way to prevent transmission, and particularly LLIN coverage similar to goals targeted by the Roll Back Malaria and Global Fund malaria control campaigns. Our analyses indicate that models which include only moderate-to-high gametocytemia (detectable by LM) predict finite eradication times after LLIN introduction. Models that include a low gametocytemia reservoir (requiring PCR or HFGMF detection) predict much more stable, persistent transmission. Our modeled outcomes result in significantly different estimates for the level and duration of control needed to achieve malaria elimination if submicroscopic gametocytes are included. CONCLUSIONS/SIGNIFICANCE: It will be very important to complement current methods of surveillance with enhanced diagnostic techniques to detect asexual parasites and gametocytes to more accurately plan, monitor and guide malaria control

programs aimed at eliminating malaria. PMCID: PMC3114851 PMID: 21695129 [PubMed - indexed for MEDLINE] 87. Soc Sci Med. 2011 Jul;73(1):160-8. doi: 10.1016/j.socscimed.2011.04.028. Epub 2011 May 27. Price subsidies and the market for mosquito nets in developing countries: A study of Tanzania's discount voucher scheme. Gingrich CD, Hanson K, Marchant T, Mulligan JA, Mponda H. Department of Business and Economics, Eastern Mennonite University, Harrisonburg, VA 22802, USA. chris.gingrich@emu.edu This study uses a partial equilibrium simulation model to explore how price subsidies for insecticide-treated mosquito nets (ITNs) affect households' purchases of ITNs. The model describes the ITN market in a typical developing country and is applied to the situation in Tanzania, where the Tanzania National Voucher Scheme (TNVS) provides a targeted subsidy to vulnerable population groups by means of a discount voucher. The data for this study come from a nationally-representative household survey completed July-August 2006 covering over 4300 households in 21 districts. The simulation results show the impact of the voucher program on ITN coverage among target households, namely those that experienced the birth of a child. More specifically, the share of target households purchasing an ITN increased from 18 to 62 percent because of the discount voucher. The model also suggests that the voucher program could cause the retail ITN price to rise due to an overall increase in demand. As a result, ITN purchases by households without a voucher may actually decline. The simulation model suggests that additional increases toward the stated goal of 80 percent ITN coverage for pregnant women and children could best be achieved through a combination of "catch up" mass distribution programs and expanding the target group for the voucher program to cover additional households. The model can be employed in other countries considering use of a targeted price subsidy for ITNs, and could be adapted to assess the impact of subsidies for other public health commodities.

Copyright 2011 Elsevier Ltd. All rights reserved. PMID: 21684054 [PubMed - indexed for MEDLINE]

88. Parasit Vectors. 2011 Jun 18;4:113. doi: 10.1186/1756-3305-4-113. Insecticide-treated net (ITN) ownership, usage, and malaria transmission in the highlands of western Kenya. Atieli HE, Zhou G, Afrane Y, Lee MC, Mwanzo I, Githeko AK, Yan G. Climate and Human Health Research Unit, Centre for Global Health Research, Kenya Medical Research Institute, PO Box 1578-40100, Kisumu, Kenya. hatieli@yahoo.com BACKGROUND: Insecticide-treated bed nets (ITNs) are known to be highly effective in reducing malaria morbidity and mortality. However, usage varies among households, and such variations in actual usage may seriously limit the potential impact of nets and cause spatial heterogeneity on malaria transmission. This study examined ITN ownership and underlying factors for among-household variation in use, and malaria transmission in two highland regions of western Kenya. METHODS: Cross-sectional surveys were conducted on ITN ownership (possession), compliance (actual usage among those who own ITNs), and malaria infections in occupants of randomly sampled houses in the dry and the rainy seasons of 2009. RESULTS: Despite ITN ownership reaching more than 71%, compliance was low at 56.3%. The compliance rate was significantly higher during the rainy season compared with the dry season (62% vs. 49.6%). Both malaria parasite prevalence (11.8% vs. 5.1%) and vector densities (1.0 vs.0.4 female/house/night) were significantly higher during the rainy season than during the dry season. Other important factors affecting the use of ITNs include: a household education level of at least primary school level, significantly high numbers of nuisance mosquitoes, and low indoor temperatures. Malaria prevalence in the rainy season was about 30% lower in ITN users than in non-ITN users, but this percentage was not significantly different during the dry season. CONCLUSION: In malaria hypo-mesoendemic highland regions of western Kenya, the

gap between ITNownership and usage is generally high with greater usage recorded during the high transmission season. Because of the low compliance among those who own ITNs, there is a need to sensitize households on sustained use of ITNs in order to optimize their role as a malaria control tool. PMCID: PMC3135563 PMID: 21682919 [PubMed - indexed for MEDLINE] 89. Acta Trop. 2011 Aug;119(2-3):172-7. doi: 10.1016/j.actatropica.2011.05.013. Epub 2011 Jun 6. Laboratory wash-resistance and field evaluation of deltamethrin incorporated long-lasting polyethylene netting (Netprotect()) against malaria transmission in Assam, north-east India. Dev V, Phookan S, Padhan K, Tewari GG, Khound K. National Institute of Malaria Research, Assam, India. mrcassam@hotmail.com North-east India is co-endemic for Plasmodium falciparum and P. vivax malaria, and disease transmission is perennial and persistent. This study reports the results of a field-based village scale trial of deltamethrin incorporated long-lasting polyethylene netting (Netprotect()) conducted in P. falciparum predominant pocket of Assam, north-east India to assess operational feasibility, acceptability and sustainability against disease vectors and malaria transmission. The study monitored the residual efficacy of the longlasting net in relation to serial washings in the laboratory and malaria prevalence in experimental villages for the first year of investigations from September 2008 to June 2009. The mosquito vector populations of Anopheles minimus were observed to be highly susceptible to deltamethrin (0.05%), and follow up investigations revealed that the vector mosquito had virtually disappeared in Netprotect() intervention villages. Concurrently, there was consistent decline in malaria cases in Netprotect() villages and transmission reduction was statistically significant compared to untreated net (net without insecticide) and nonet control villages for the corresponding study period. The contact conebioassay

investigations against malaria transmitting mosquito species revealed that the bioavailability of the insecticide on the net fiber was persistent up to 20th serial wash resulting in 80% mortality. Community compliance and acceptance were high, and users reported decreased nuisance due to biting mosquitoes. It was concluded that deltamethrin incorporated polyethylene long-lasting netting was safe, wash-resistant, and assessed to be an operationally feasible, community-based intervention for sustainable management of disease vectors to prevent malaria transmission. Copyright 2011 Elsevier B.V. All rights reserved. PMID: 21679681 [PubMed - indexed for MEDLINE]

90. World Health Popul. 2011;12(3):42-51. Assessing the progress of malaria control in Nigeria. Amzat J. Department of Sociology, Usmanu Danfodiyo University, Sokoto, Nigeria. greatjoa@yahoo.co.uk One third of the world's malaria deaths occur in Nigeria. It is doubtful whether Nigeria will meet the malaria control target of the Millennium Development Goals by 2015, having failed to meet the Abuja target to halve the burden of malaria by 2010. This paper assesses the current malaria burden and progress toward malaria control. Substantial data were obtained from the 2008 Nigeria Demographic and Health Survey and other secondary sources. Data showed that the malaria burden is still enormous because of inadequate control efforts. In 2008, only 17% of Nigerians owned at least one net, compared with 12% in 2003. Eight percent owned an insecticide-treated mosquito net (ITN), but only 6% of under-five children and 5% of pregnant women slept under an ITN. Only one third of under-five children with fever received antimalarial drugs, while one fifth of pregnant women took antimalarial drugs for prevention. Chloroquine is still the most common drug used in malaria treatment, despite its ban in first-line treatment since 2005. The paper concludes that scaling up home management of malaria and a

community-centred approach to ITN and artemisinin-based combination therapy provisioning should be prioritized. PMID: 21677528 [PubMed - indexed for MEDLINE]

91. World Health Popul. 2011;12(3):13-22. Knowledge of malaria and preventive measures among pregnant women attending antenatal clinics in a rural local government area in Southwestern Nigeria. Akinleye SO, Ajayi IO. Department of Epidemiology, Medical Statistics and Environmental Health, College of Medicine, University of Ibadan, Nigeria. stellakinleye@yahoo.com OBJECTIVE: This study determined the level of knowledge of malaria and preventive measures among pregnant women and its influence on the uptake of preventive measures. METHODS: A cross-sectional survey was carried out among 209 participants selected from pregnant women attending antenatal clinics in primary healthcare centres in Irepodun/Ifelodun, a local government area in Ekiti state, Nigeria. RESULTS: Knowledge of malaria was found to be very good, average and poor among two (1.0%), 165 (78.9%) and 42 (20.1%) respondents, respectively. Of the 109 (52.2%) respondents who had heard about intermittent preventive treatment, eight (7.3%) scored "very good" on knowledge, while 53 (48.6%) and 48 (44.1%) scored "average" and "poor," respectively. Of the 144 (68.9%) respondents who had heard about insecticide-treated nets, 95 (66.0%) scored "good" on knowledge, while 49 (34.0%) scored "poor." Factors that significantly influenced knowledge about malaria were occupation, level of education, months at first appearance at antenatal clinic and transportation cost. Knowledge significantly influenced uptake of insecticide-treated nets and intermittent preventive treatment in pregnancy ( p < .05). CONCLUSION: There is a need to intensify efforts to provide health education on malaria and preventive measures as well as to encourage preventive practices among pregnant women.

PMID: 21677525

[PubMed - indexed for MEDLINE]

92. Trials. 2011 Jun 10;12:147. doi: 10.1186/1745-6215-12-147. To assess whether indoor residual spraying can provide additional protection against clinical malaria over current best practice of long-lasting insecticidal mosquito nets in The Gambia: study protocol for a two-armed clusterrandomised trial. Pinder M, Jawara M, Jarju LB, Kandeh B, Jeffries D, Lluberas MF, Mueller J, Parker D, Bojang K, Conway DJ, Lindsay SW. London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK. BACKGROUND: Recently, there has been mounting interest in scaling-up vector control against malaria in Africa. It needs to be determined if indoor residual spraying (IRS with DDT) will provide significant marginal protection against malaria over current best practice of long-lasting insecticidal nets (LLINs) and prompt treatment in a controlled trial, given that DDT is currently the most persistent insecticide for IRS. METHODS: A 2 armed cluster-randomised controlled trial will be conducted to assess whether DDT IRS and LLINs combined provide better protection against clinical malaria in children than LLINs alone in rural Gambia. Each cluster will be a village, or a group of small adjacent villages; all clusters will receive LLINs and half will receive IRS in addition. Study children, aged 6 months to 13 years, will be enrolled from all clusters and followed for clinical malaria using passive case detection to estimate malaria incidence for 2 malaria transmission seasons in 2010 and 2011. This will be the primary endpoint. Exposure to malaria parasites will be assessed using light and exit traps followed by detection of Anopheles gambiae species and sporozoite infection. Study children will be surveyed at the end of each transmission season to estimate the prevalence of Plasmodium falciparum infection and the prevalence of anaemia. DISCUSSION: Practical issues concerning intervention implementation, as well as

the potential benefits and risks of the study, are discussed. TRIAL REGISTRATION: ISRCTN01738840 - Spraying And Nets Towards malaria Elimination (SANTE). PMCID: PMC3121610 PMID: 21663656 [PubMed - indexed for MEDLINE] 93. Health Policy Plan. 2012 Jul;27(4):316-25. doi: 10.1093/heapol/czr042. Epub 2011 Jun 6. Determinants of hanging and use of ITNs in the context of near universal coverage in Zambia. Macintyre K, Littrell M, Keating J, Hamainza B, Miller J, Eisele TP. Department of International Health and Development, Tulane University, New Orleans, LA, USA. kmacint@tulane.edu Roll Back Malaria recently recommended a policy of universal coverage with insecticide-treated nets (ITNs) so that all age groups can benefit from protection against malaria. Countries adopting the 'universal access' policy include Zambia. Policy implementation in many settings involves mass distribution of free ITNs to achieve a measure of universal coverage. This study examines ITN deployment and use in the context of mass distribution efforts towards achieving universal coverage in a malaria-endemic district in Zambia. We use multiple logistic regression to identify predictors of ITN deployment and use by anyone in the household and by children under five. Among ITN-owning households with a child under five, 69% used at least one ITN the night before the survey. About half of those children (54%) in ITN-owning households were covered the previous night. A strong and consistent predictor of use is household deployment of at least one ITN. Just over half of all ITNs were observed hanging, and reported use of nets for purposes other than malaria prevention was only 3%. Net characteristics, including shape, colour and whether or not the ITN was purchased, were not associated with net deployment. However, ITNs in poor condition are more likely to be observed hanging than ITNs in new or good condition. In the context of free mass distribution of ITNs, behaviour change communication and activities are necessary to improve use. Results suggest campaigns and messages that persuade recipients to hang up their ITNs would

contribute towards closing the gap between ownership and use. PMID: 21652576 [PubMed - indexed for MEDLINE]

94. Malar J. 2011 Jun 8;10:157. doi: 10.1186/1475-2875-10-157. Best practices for an insecticide-treated bed net distribution programme in sub-Saharan eastern Africa. Sexton AR. Graduate School of Public Health, College of Health and Human Services, San Diego State University, 5500 Campanile Drive, San Diego, CA 92182-4162, USA. arsexton@gmail.com Insecticide-treated bed nets are the preeminent malaria control means; though there is no consensus as to a best practice for large-scale insecticidetreated bed net distribution. In order to determine the paramount distribution method, this review assessed literature on recent insecticide treated bed net distribution programmes throughout sub-Saharan Eastern Africa. Inclusion criteria were that the study had taken place in sub-Saharan Eastern Africa, targeted malaria prevention and control, and occurred between 1996 and 2007. Forty-two studies were identified and reviewed. The results indicate that distribution frameworks varied greatly; and consequently so did outcomes of insecticide-treated bed net use. Studies revealed consistent inequities between urban and rural populations; which were most effectively alleviated through a free insecticide-treated bed net delivery and distribution framework. However, cost sharing through subsidies was shown to increase programme sustainability, which may lead to more long-term coverage. Thus, distribution should employ a catch up/keep up programme strategy. The catch-up programme rapidly scales up coverage, while the keep-up programme maintains coverage levels. Future directions for malaria should include progress toward distribution of long-lasting insecticide-treated nets. PMCID: PMC3121652 PMID: 21651815 [PubMed - indexed for MEDLINE] 95. Am J Trop Med Hyg. 2011 Jun;84(6):951-6. doi: 10.4269/ajtmh.2011.110016.

Net risk: a risk assessment of long-lasting insecticide bed nets used for malaria management. Peterson RK, Barber LM, Schleier JJ 3rd. Department of Land Resources and Environmental Sciences, Montana State University, Bozeman, MT 59717, USA. bpeterson@montana.edu Despite the demonstrated ability of bed nets that have been factoryimpregnated with long-lasting insecticides (LLINs) to protect people from malaria and despite the ambitious plans for their widespread use, the health risks from the LLINs themselves have not been adequately investigated and reported in the peer-reviewed science literature. Here, we use a probabilistic risk assessment approach to estimate the risks to Africans from inhalation, dermal, and oral exposures to the newer LLINs with permethrin, -cypermethrin, or deltamethrin as the insecticide active ingredient. We estimated exposures to LLINs using 17 age groups to incorporate different body weights and sleeping behaviors. Risk quotients (exposure divided by toxic threshold) at the 50th and 90th percentiles for non-cancer risks were < 1.0 for lifetime adjusted risk and all youth and adult age groups. Risk quotients for infants and toddlers (0-3 years) and child groups from 3 to 10 years were 1.0 for specific bed nets. PMCID: PMC3110360 PMID: 21633033 [PubMed - indexed for MEDLINE] 96. PLoS One. 2011;6(5):e20179. doi: 10.1371/journal.pone.0020179. Epub 2011 May 24. The potential contribution of mass treatment to the control of Plasmodium falciparum malaria. Okell LC, Griffin JT, Kleinschmidt I, Hollingsworth TD, Churcher TS, White MJ, Bousema T, Drakeley CJ, Ghani AC. Department of Infectious Disease Epidemiology, MRC Centre for Outbreak Analysis and Modeling, Imperial College London, London, United Kingdom. l.okell@imperial.ac.uk Mass treatment as a means to reducing P. falciparum malaria transmission was used during the first global malaria eradication campaign and is increasingly being considered for current control programmes. We used a previously developed

mathematical transmission model to explore both the short and long-term impact of possible mass treatment strategies in different scenarios of endemic transmission. Mass treatment is predicted to provide a longer-term benefit in areas with lower malaria transmission, with reduced transmission levels for at least 2 years after mass treatment is ended in a scenario where the baseline slide-prevalence is 5%, compared to less than one year in a scenario with baseline slide-prevalence at 50%. However, repeated annual mass treatment at 80% coverage could achieve around 25% reduction in infectious bites in moderate-to-high transmission settings if sustained. Using vector control could reduce transmission to levels at which mass treatment has a longer-term impact. In a limited number of settings (which have isolated transmission in small populations of 1000-10,000 with low-to-medium levels of baseline transmission) we find that five closely spaced rounds of mass treatment combined with vector control could make at least temporary elimination a feasible goal. We also estimate the effects of using gametocytocidal treatments such as primaquine and of restricting treatment to parasite-positive individuals. In conclusion, mass treatment needs to be repeated or combined with other interventions for long-term impact in many endemic settings. The benefits of mass treatment need to be carefully weighed against the risks of increasing drug selection pressure. PMCID: PMC3101232 PMID: 21629651 [PubMed - indexed for MEDLINE] 97. Parasit Vectors. 2011 May 25;4:90. doi: 10.1186/1756-3305-4-90. Sustained reduction in prevalence of lymphatic filariasis infection in spite of missed rounds of mass drug administration in an area under mosquito nets for malaria control. Njenga SM, Mwandawiro CS, Wamae CN, Mukoko DA, Omar AA, Shimada M, Bockarie MJ, Molyneux DH. Kenya Medical Research Institute (KEMRI), Nairobi, Kenya. sammynjenga@gmail.com BACKGROUND: The Global Programme to Eliminate Lymphatic Filariasis (GPELF) was

established by the World Health Organisation (WHO) in 2000 with the goal of eliminating lymphatic filariasis (LF) as a public health problem globally by 2020. Mass drug administration (MDA) of antifilarial drugs is the principal strategy recommended for global elimination. Kenya launched a National Programme for Elimination of Lymphatic Filariasis (NPELF) in Coast Region in 2002. During the same year a longitudinal research project to monitor trends of LF infection during MDA started in a highly endemic area in Malindi District. High coverage of insecticide treated nets (ITNs) in the coastal region has been associated with dramatic decline in hospital admissions due to malaria; high usage of ITNs is also expected to have an impact on LF infection, also transmitted by mosquitoes. RESULTS: Four rounds of MDA with diethylcarbamazine citrate (DEC) and albendazole were given to 8 study villages over an 8-year period. Although annual MDA was not administered for several years the overall prevalence of microfilariae declined significantly from 20.9% in 2002 to 0.9% in 2009. Similarly, the prevalence of filarial antigenaemia declined from 34.6% in 2002 to 10.8% in 2009. All the examined children born since the start of the programme were negative for filarial antigen in 2009. CONCLUSIONS: Despite the fact that the study villages missed MDA in some of the years, significant reductions in infection prevalence and intensity were observed at each survey. More importantly, there were no rebounds in infection prevalence between treatment rounds. However, because of confounding variables such as insecticide-treated bed nets (ITNs), it is difficult to attribute the reduction to MDA alone as ITNs can lead to a significant reduction in exposure to filariasis vectors. The results indicate that national LF elimination programmes should be encouraged to continue provision of MDA albeit constraints that may lead to missing of MDA in some years. PMCID: PMC3125382 PMID: 21612649 [PubMed - indexed for MEDLINE] 98. Am J Public Health. 2011 Dec;101(12):2333-41. doi: 10.2105/AJPH.2010.300068. Epub 2011 May 12.

Impact of a malaria-control project in Benin that included the integrated management of childhood illness strategy. Rowe AK, Onikpo F, Lama M, Osterholt DM, Deming MS. Division of Parasitic Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30341-3724, USA. axr9@cdc.gov OBJECTIVES: To estimate the impact of the Integrated Management of Childhood Illness (IMCI) strategy on early-childhood mortality, we evaluated a malaria-control project in Benin that implemented IMCI and promoted insecticide-treated nets (ITNs). METHODS: We conducted a before-and-after intervention study that included a nonrandomized comparison group. We used the preceding birth technique to measure early-childhood mortality (risk of dying before age 30 months), and we used health facility surveys and household surveys to measure process indicators. RESULTS: Most process indicators improved in the area covered by the intervention. Notably, because ITNs were also promoted in the comparison area children's ITN use increased by about 20 percentage points in both areas. Regarding early-childhood mortality, the trend from baseline (1999-2001) to follow-up (2002-2004) for the intervention area (13.0% decrease; P < .001) was 14.1% (P < .001) lower than was the trend for the comparison area (1.3% increase; P = .46). CONCLUSIONS: Mortality decreased in the intervention area after IMCI and ITN promotion. ITN use increased similarly in both study areas, so the mortality impact of ITNs in the 2 areas might have canceled each other out. Thus, the mortality reduction could have been primarily attributable to IMCI's effect on health care quality and care-seeking. PMID: 21566036 [PubMed - indexed for MEDLINE]

99. Acta Trop. 2011 Aug;119(2-3):107-13. doi: 10.1016/j.actatropica.2011.04.015. Epub 2011 May 4. Evaluating indoor residual spray for reducing malaria infection prevalence in Eritrea: results from a community randomized control trial. Keating J, Locatelli A, Gebremichael A, Ghebremeskel T, Mufunda J, Mihreteab S, Berhane D, Carneiro P.

Department of International Health and Development, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA 70112, United States. jkeating@tulane.edu This paper examines the relationship between indoor residual spray (IRS) and malaria parasite infection in Gash Barka Zone, Eritrea, an area with near universal coverage of insecticide treated bednets (ITN) and already low malaria parasite prevalence. A community randomized control trial was conducted in 2009. Malaria parasite infection prevalence was 0.5% [95% confidence interval (CI): 0.37-0.78%], with no significant difference detected between treatment and control areas. ITN possession remains high, with over 70% of households reporting ITN ownership [95% CI: 68.4-72.9]. ITN use among individuals within ITNowning households was just under half [46.7% (95% CI: 45.4-48.0)]. Slight differences in ITN possession and use were detected between treatment and control areas. There was no significant difference in malaria parasite infection prevalence among individuals in households with 1 ITN compared to those in households without ITNs, nor among individuals reporting ITN use. Among individuals in ITNowning households, sleeping under an ITN offered no statistically significant protection from malaria parasite infection. Community participation in environmental and larval habitat management activities was low: 17.9% (95% CI: 16.0-19.7). It is likely that IRS, larval habitat management and ITN distribution alone may be insufficient to interrupt transmission without corresponding high ITN use, sustained IRS application in areas where infections are clustered, and promptly seeking laboratory diagnosis and treatment of all fevers. Eritrea is ready for elimination, irrespective of inconclusive impact evaluation results. Copyright 2011 Elsevier B.V. All rights reserved. PMID: 21565149 [PubMed - indexed for MEDLINE]

100. Trans R Soc Trop Med Hyg. 2011 Jun;105(6):327-32. doi: 10.1016/j.trstmh.2011.02.008. Epub 2011 May 6. Malaria control in a forest fringe area of Assam, India: a pilot study.

Dutta P, Khan AM, Khan SA, Borah J, Sharma CK, Mahanta J. Regional Medical Research Centre (ICMR), Northeastern Region, Dibrugarh 786001, Assam, India. duttaprafulla@yahoo.com A study was conducted to evaluate the preventive efficacy of insecticidetreated mosquito nets (ITMNs) and mosquito repellent (MR) in a malaria-endemic foothill area of Assam, India, with forest ecosystem. During the first year, a survey was conducted in four demarcated sectors (A-D) to observe the malaria endemicity and vector prevalence patterns before implementing intervention measures. All four sectors were endemic for malaria. The prevalence of established malaria vectors such as Anopheles dirus, A. minimus and A. philippinensis was observed. During the second year, intervention measures were implemented in the four sectors as follows: A, ITMN + MR; B, ITMN; C, MR; D, no intervention. The most effective intervention was in sector A, followed by sectors B and C. Sectors A and B exhibited significantly higher (P < 0.001) malaria protective efficacy during both the first and second years of intervention compared with sector D. The total vector population in the three intervention sectors decreased significantly compared with that of the non-intervention one. Information-education-communication activities motivated the residents to participate actively in the intervention programme. The finding could be an effective model for containment of high malaria morbidity in inaccessible forest fringe areas of the northeastern region of India. Copyright 2011 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved.

101. Med Trop (Mars). 2010 Dec;70(5-6):479-84. [Malaria transmission in an area of high coverage with long lasting insecticidal nets in central Cte d'Ivoire]. [Article in French]

Koudou BG, Ouattara FA, Edi AV, Nsanzabana C, Tia E, Tchicaya ES, Tanner M, Bonfoh B, Dagnogo M, Utzinger J. Centre suisse de recherches scientifiques en Cte d'Ivoire, Abidjan, Cte d'Ivoire. guibehi.koudou@csrs.ci The purpose of this study was to assess malaria transmission in an area of high coverage with long-lasting insecticidal nets (LLINs) in central Cte d'Ivoire. Two four-day larva collections were carried out in April and July 2008. Adult mosquito samples were collected by conducting human bait catches during a total of 80 man-nights. Vector infection rates were determined using an ELISA circumsporozoite antibody test. A total of 1582 mosquitoes were captured. Mansonia was the dominant genus in the culcidian fauna followed by Anopheles that was dominant in the anopheline fauna. The only Plasmodium vector was An. gambiae s.l. The high household bednet coverage rate probably accounted for the relatively low biting rate: 0.75 to 4.15 bites per person per night (b/p/n). Households not using bednets appear to have benefited from a passive protection effect associated with high LLIN coverage. Biting and entomological inoculation rates were 2.25 to 4.1 b/p/n (range) and 0.184 ib/p/n respectively in households that did not use LLINs and 0.75 to 4.15 b/p/n (range) and 0.341 ib/p/n respectively in households using LLINs. PMID: 21520651 [PubMed - indexed for MEDLINE]

102. MMWR Morb Mortal Wkly Rep. 2011 Apr 22;60(15):476-80. Grand rounds: The opportunity for and challenges to malaria eradication. Centers for Disease Control and Prevention (CDC). In 2009, malaria, a disease transmitted by the bite of an infective Anopheles mosquito, caused an estimated 225 million clinical cases and 781,000 deaths worldwide, of which more than 90% occurred in children aged <5 years in Africa. Approximately half of the world's population, or 3 billion persons, are at risk for acquiring the illness. Malaria is transmitted most intensely in central and western Africa, where in some areas >40% of children aged <10 years are infected and residents can be bitten by more than one infective mosquito every day of the year.

PMID: 21508924

[PubMed - indexed for MEDLINE]

103. Malar J. 2011 Apr 20;10:98. doi: 10.1186/1475-2875-10-98. Malaria risk factors in north-east Tanzania. Winskill P, Rowland M, Mtove G, Malima RC, Kirby MJ. London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK. p.winskill@imperial.ac.uk BACKGROUND: Understanding the factors which determine a household's or individual's risk of malaria infection is important for targeting control interventions at all intensities of transmission. Malaria ecology in Tanzania appears to have reduced over recent years. This study investigated potential risk factors and clustering in face of changing infection dynamics. METHODS: Household survey data were collected in villages of rural Muheza district. Children aged between six months and thirteen years were tested for presence of malaria parasites using microscopy. A multivariable logistic regression model was constructed to identify significant risk factors for children. Geographical information systems combined with global positioning data and spatial scan statistic analysis were used to identify clusters of malaria. RESULTS: Using an insecticide-treated mosquito net of any type proved to be highly protective against malaria (OR 0.75, 95% CI 0.59-0.96). Children aged five to thirteen years were at higher risk of having malaria than those aged under five years (OR 1.71, 95% CI 1.01-2.91). The odds of malaria were less for females when compared to males (OR 0.62, 95% CI 0.39-0.98). Two spatial clusters of significantly increased malaria risk were identified in two out of five villages. CONCLUSIONS: This study provides evidence that recent declines in malaria transmission and prevalence may shift the age groups at risk of malaria infection to older children. Risk factor analysis provides support for universal coverage and targeting of long-lasting insecticide-treated nets (LLINs) to all age groups. Clustering of cases indicates heterogeneity of risk. Improved targeting of LLINs or additional supplementary control interventions to high risk clusters may improve outcomes and efficiency as malaria transmission continues to fall under intensified control.

PMCID: PMC3094229 PMID: 21507217 [PubMed - indexed for MEDLINE] 104. Med Mal Infect. 2011 Jun;41(6):301-6. doi: 10.1016/j.medmal.2011.02.004. Epub 2011 Apr 16. [Malaria in France: Mainland and territories]. [Article in French] Tarantola A, Eltges F, Ardillon V, Lernout T, Sissoko D, Kendjo E, Achirafi A, Thiria J, Flamand C, D'Ortenzio E, Cohuet S, Quatresous I, Quenel P, Filleul L, Gastellu-Etchegorry M. Dpartement international et tropical, institut de veille sanitaire, direction scientifique, 12, rue du Val d'Osne, 94415 Saint-Maurice, France. atarantola@pasteur-kh.org Malaria, which was eliminated first from Metropolitan France (mainland and Corsica), then in the French West Indies and the Reunion Island during the 20(th) century, remains endemic in two French territories: French Guiana and the Indian Ocean Mayotte island. Despite differences in the dominating plasmodial species and epidemiological patterns, these two territories have achieved marked quantitative improvements (in the reported number of cases and severe cases) thanks to efforts undertaken over the past decade. The situation, however, remains a concern from a qualitative standpoint with the emergence of resistance to antimalarial drugs and logistical and administrative issues which hinder access to treatment. Although malaria was eradicated in Metropolitan France half a century ago, competent vectors remain present in part or all of these territories and can give rise to limited outbreaks. Copyright 2011 Elsevier Masson SAS. All rights reserved. PMID: 21498013 [PubMed - indexed for MEDLINE]

105. Niger J Clin Pract. 2011 Jan-Mar;14(1):19-22. doi: 10.4103/11193077.79234. The effect of free distribution of insecticide-treated nets on asymptomatic Plasmodium parasitemia in pregnant and nursing mothers in a rural Nigerian

community. Anyaehie U, Nwagha UI, Aniebue PN, Nwagha TU. Department of Physiology/Obstetrics and Gynaecology, College of Medicine, University of Nigeria, Enugu Campus, Nigeria. INTRODUCTION: Malaria is a major public health problem in Nigeria, with adverse outcomes on the poor, pregnant women and children living in rural communities. A major component of current intervention in roll back malaria (RBM) initiative is vector control and insecticide-treated nets (ITNs). AIMS AND OBJECTIVE: This research studied the impact of free distribution of ITNs on malaria parasitemia in a rural community in Nigeria. MATERIALS AND METHODS: This is a longitudinal survey involving 990 pregnant and nursing mothers who received free ITNs between February 2007 and September 2008. Blood samples were collected at contact, then every 2 months to check for malaria parasites using standard methods. RESULT: There was a sustained but insignificant rise in asymptomatic malaria parasitemia post-distribution of ITNs. CONCLUSION: We conclude that ITN intervention remains important in malaria prophylaxis but must be complemented with awareness campaigns and other vector control strategies. PMID: 21493986 [PubMed - indexed for MEDLINE]

106. Malar J. 2011 Apr 13;10:86. doi: 10.1186/1475-2875-10-86. Success of Senegal's first nationwide distribution of long-lasting insecticide-treated nets to children under five - contribution toward universal coverage. Thwing JI, Perry RT, Townes DA, Diouf MB, Ndiaye S, Thior M. Malaria Branch, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA. jthwing@cdc.gov BACKGROUND: In 2009, the first national long-lasting insecticide-treated net (LLIN) distribution campaign in Senegal resulted in the distribution of 2.2 million LLINs in two phases to children aged 6-59 months. Door-to-door teams visited all households to administer vitamin A and mebendazole, and to give a coupon to redeem later for an LLIN.

METHODS: A nationwide community-based two-stage cluster survey was conducted, with clusters selected within regions by probability proportional to size sampling, followed by GPS-assisted mapping, simple random selection of households in each cluster, and administration of a questionnaire using personal digital assistants (PDAs). The questionnaire followed the Malaria Indicator Survey format, with rosters of household members and bed nets, and questions on campaign participation. RESULTS: There were 3,280 households in 112 clusters representing 33,993 people. Most (92.1%) guardians of eligible children had heard about the campaign, the primary sources being health workers (33.7%), neighbours (26.2%), and radio (22.0%). Of eligible children, 82.4% received mebendazole, 83.8% received vitamin A, and 75.4% received LLINs. Almost all (91.4%) LLINs received during the campaign remained in the household; of those not remaining, 74.4% had been given away and none were reported sold. At least one insecticide-treated net (ITN) was present in 82.3% of all households, 89.2% of households with a child < 5 years and 57.5% of households without a child < 5 years. Just over half (52.4%) of ITNs had been received during the campaign. Considering possible indicators of universal coverage, 39.8% of households owned at least one ITN per two people, 21.6% owned at least one ITN per sleeping space and 34.7% of the general population slept under an ITN the night before the survey. In addition, 45.6% of children < 5 years, and 49.2% of pregnant women had slept under an ITN. CONCLUSIONS: The nationwide integrated LLIN distribution campaign allowed household ITN ownership of one or more ITNs to surpass the RBM target of 80% set for 2010, though additional distribution strategies are needed to reach populations missed by the targeted campaign and to reach the universal coverage targets of one ITN per sleeping space and 80% of the population using an ITN. PMCID: PMC3083382 PMID: 21489278 [PubMed - indexed for MEDLINE] 107. BMC Med. 2011 Apr 13;9:37. doi: 10.1186/1741-7015-9-37. Increasing malaria hospital admissions in Uganda between 1999 and 2009. Okiro EA, Bitira D, Mbabazi G, Mpimbaza A, Alegana VA, Talisuna AO, Snow RW.

Malaria Public Health & Epidemiology Group, Centre for Geographic Medicine Research - Coast, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya. eokiro@nairobi.kemri-wellcome.org BACKGROUND: Some areas of Africa are witnessing a malaria transition, in part due to escalated international donor support and intervention coverage. Areas where declining malaria rates have been observed are largely characterized by relatively low baseline transmission intensity and rapid scaling of interventions. Less well described are changing patterns of malaria burden in areas of high parasite transmission and slower increases in control and treatment access. METHODS: Uganda is a country predominantly characterized by intense, perennial malaria transmission. Monthly pediatric admission data from five Ugandan hospitals and their catchments have been assembled retrospectively across 11 years from January 1999 to December 2009. Malaria admission rates adjusted for changes in population density within defined catchment areas were computed across three time periods that correspond to periods where intervention coverage data exist and different treatment and prevention policies were operational. Time series models were developed adjusting for variations in rainfall and hospital use to examine changes in malaria hospitalization over 132 months. The temporal changes in factors that might explain changes in disease incidence were qualitatively examined sequentially for each hospital setting and compared between hospital settings RESULTS: In four out of five sites there was a significant increase in malaria admission rates. Results from time series models indicate a significant month-to-month increase in the mean malaria admission rates at four hospitals (trend P < 0.001). At all hospitals malaria admissions had increased from 1999 by 47% to 350%. Observed changes in intervention coverage within the catchments of each hospital showed a change in insecticide-treated net coverage from <1% in 2000 to 33% by 2009 but accompanied by increases in access to nationally recommended drugs at only two of the five hospital areas studied. CONCLUSIONS: The declining malaria disease burden in some parts of Africa is not a universal phenomena across the continent. Despite moderate increases in the coverage of measures to reduce infection and disease without significant

coincidental increasing access to effective medicines to treat disease may not lead to severe disease burden reductions in high transmission areas of Africa. More data is needed from a wider range of malaria settings to provide an honest tracking progress of the impact of scaled intervention coverage in Africa. PMCID: PMC3096581 PMID: 21486498 [PubMed - indexed for MEDLINE] 108. Malar J. 2011 Apr 9;10:80. doi: 10.1186/1475-2875-10-80. Increased proportions of outdoor feeding among residual malaria vector populations following increased use of insecticide-treated nets in rural Tanzania. Russell TL, Govella NJ, Azizi S, Drakeley CJ, Kachur SP, Killeen GF. Ifakara Health Institute, Biomedical and Environmental Thematic Group, Ifakara, Tanzania. t.russell2@uq.edu.au BACKGROUND: Insecticide-treated nets (ITNs) and indoor residual spraying (IRS) represent the front-line tools for malaria vector control globally, but are optimally effective where the majority of baseline transmission occurs indoors. In the surveyed area of rural southern Tanzania, bed net use steadily increased over the last decade, reducing malaria transmission intensity by 94%. METHODS: Starting before bed nets were introduced (1997), and then after two milestones of net use had been reached-75% community-wide use of untreated nets (2004) and then 47% use of ITNs (2009)-hourly biting rates of malaria vectors from the Anopheles gambiae complex and Anopheles funestus group were surveyed. RESULTS: In 1997, An. gambiae s.l. and An. funestus mosquitoes exhibited a tendency to bite humans inside houses late at night. For An. gambiae s.l., by 2009, nocturnal activity was less (p = 0.0018). At this time, the sibling species composition of the complex had shifted from predominantly An. gambiae s.s. to predominantly An. arabiensis. For An. funestus, by 2009, nocturnal activity was less (p = 0.0054) as well as the proportion biting indoors (p < 0.0001). At this time, An. funestus s.s. remained the predominant species within this group. As a

consequence of these altered feeding patterns, the proportion (mean standard error) of human contact with mosquitoes (bites per person per night) occurring indoors dropped from 0.99 0.002 in 1997 to 0.82 0.008 in 2009 for the An. gambiae complex (p = 0.0143) and from 1.00 <0.001 to only 0.50 0.048 for the An. funestus complex (p = 0.0004) over the same time period. CONCLUSIONS: High usage of ITNs can dramatically alter African vector populations so that intense, predominantly indoor transmission is replaced by greatly lowered residual transmission, a greater proportion of which occurs outdoors. Regardless of the underlying mechanism, the residual, self-sustaining transmission will respond poorly to further insecticidal measures within houses. Additional vector control tools which target outdoor biting mosquitoes at the adult or immature stages are required to complement ITNs and IRS. PMCID: PMC3084176 PMID: 21477321 [PubMed - indexed for MEDLINE] 109. Malar J. 2011 Mar 31;10:73. doi: 10.1186/1475-2875-10-73. Design, implementation and evaluation of a national campaign to distribute nine million free LLINs to children under five years of age in Tanzania. Bonner K, Mwita A, McElroy PD, Omari S, Mzava A, Lengeler C, Kaspar N, Nathan R, Ngegba J, Mtung'e R, Brown N. National Malaria Control Programme, Ministry of Health and Social Welfare, PO Box 9083, Dar es Salaam, Tanzania. kimberly.bonner@gmail.com BACKGROUND: After a national voucher scheme in 2004 provided pregnant women and infants with highly subsidized insecticide-treated nets (ITNs), use among children under five years (U5s) in mainland Tanzania increased from 16% in 2004 to 26.2% in 2007. In 2008, the Ministry of Health and Social Welfare planned a catch-up campaign to rapidly and equitably deliver a free long-lasting insecticidal net (LLIN) to every child under five years in Tanzania. METHODS: The ITN Cell, a unit within the National Malaria Control Programme (NMCP), coordinated the campaign on behalf of the Ministry of Health and Social Welfare. Government contractors trained and facilitated local government officials to supervise village-level volunteers on a registration of all U5s and

the distribution and issuing of LLINs. The registration results formed the basis for the LLIN order and delivery to village level. Caregivers brought their registration coupons to village issuing posts during a three-day period where they received LLINs for their U5s. Household surveys in five districts assessed ITN ownership and use immediately after the campaign. RESULTS: Nine donors contributed to the national campaign that purchased and distributed 9.0 million LLINs at an average cost of $7.07 per LLIN, including all campaign-associated activities. The campaign covered all eight zones of mainland Tanzania, the first region being covered separately during an integrated measles immunization/malaria LLIN distribution in August 2008, and was implemented one zone at a time from March 2009 until May 2010. ITN ownership at household level increased from Tanzania's 2008 national average of 45.7% to 63.4%, with significant regional variations. ITN use among U5s increased from 28.8% to 64.1%, a 2.2-fold increase, with increases ranging from 22.1-38.3% percentage points in different regions. CONCLUSION: A national-level LLIN distribution strategy that fully engaged local government authorities helped avoid additional burden on the healthcare system. Distribution costs per net were comparable to other public health interventions. Particularly among rural residents, ITN ownership and use increased significantly for the intended beneficiaries. The upcoming universal LLIN distribution and further behaviour change communication will further improve ITN ownership and use in 2010-2011. PMCID: PMC3078903 PMID: 21453519 [PubMed - indexed for MEDLINE] 110. Acta Trop. 2012 Mar;121(3):184-95. doi: 10.1016/j.actatropica.2011.03.004. Epub 2011 Mar 21. Malaria in Uganda: challenges to control on the long road to elimination: I. Epidemiology and current control efforts. Yeka A, Gasasira A, Mpimbaza A, Achan J, Nankabirwa J, Nsobya S, Staedke SG, Donnelly MJ, Wabwire-Mangen F, Talisuna A, Dorsey G, Kamya MR, Rosenthal PJ.

Infectious Diseases Research Collaboration, Kampala, Uganda. Malaria remains one of the leading health problems of the developing world, and Uganda bears a particularly large burden from the disease. Our understanding is limited by a lack of reliable data, but it is clear that the prevalence of malaria infection, incidence of disease, and mortality from severe malaria all remain very high. Uganda has made progress in implementing key malaria control measures, in particular distribution of insecticide-impregnated bednets, indoor residual spraying of insecticides, utilization of artemisinin-based combination therapy to treat uncomplicated malaria, and provision of intermittent preventive therapy for pregnant women. However, despite enthusiasm regarding the potential for the elimination of malaria in other areas, there is no convincing evidence that the burden of malaria has decreased in Uganda in recent years. Major challenges to malaria control in Uganda include very high malaria transmission intensity, inadequate health care resources, a weak health system, inadequate understanding of malaria epidemiology and the impact of control interventions, increasing resistance of parasites to drugs and of mosquitoes to insecticides, inappropriate case management, inadequate utilization of drugs to prevent malaria, and inadequate epidemic preparedness and response. Despite these challenges, prospects for the control of malaria have improved, and with attention to underlying challenges, progress toward the control of malaria in Uganda can be expected. Copyright 2011 Elsevier B.V. All rights reserved. PMCID: PMC3156969 [Available on 2013/3/1] PMID: 21420377 [PubMed - indexed for MEDLINE] 111. Acta Trop. 2012 Mar;121(3):227-39. doi: 10.1016/j.actatropica.2011.02.016. Epub 2011 Mar 5. Malaria in the Greater Mekong Subregion: heterogeneity and complexity. Cui L, Yan G, Sattabongkot J, Cao Y, Chen B, Chen X, Fan Q, Fang Q, Jongwutiwes S, Parker D, Sirichaisinthop J, Kyaw MP, Su XZ, Yang H, Yang Z, Wang B, Xu J, Zheng B, Zhong D, Zhou G.

Department of Entomology, The Pennsylvania State University, University Park, 16801, USA. luc2@psu.edu The Greater Mekong Subregion (GMS), comprised of six countries including Cambodia, China's Yunnan Province, Lao PDR, Myanmar (Burma), Thailand and Vietnam, is one of the most threatening foci of malaria. Since the initiation of the WHO's Mekong Malaria Program a decade ago, malaria situation in the GMS has greatly improved, reflected in the continuous decline in annual malaria incidence and deaths. However, as many nations are moving towards malaria elimination, the GMS nations still face great challenges. Malaria epidemiology in this region exhibits enormous geographical heterogeneity with Myanmar and Cambodia remaining high-burden countries. Within each country, malaria distribution is also patchy, exemplified by 'border malaria' and 'forest malaria' with high transmission occurring along international borders and in forests or forest fringes, respectively. 'Border malaria' is extremely difficult to monitor, and frequent malaria introductions by migratory human populations constitute a major threat to neighboring, malaria-eliminating countries. Therefore, coordination between neighboring countries is essential for malaria elimination from the entire region. In addition to these operational difficulties, malaria control in the GMS also encounters several technological challenges. Contemporary malaria control measures rely heavily on effective chemotherapy and insecticide control of vector mosquitoes. However, the spread of multidrug resistance and potential emergence of artemisinin resistance in Plasmodium falciparum make resistance management a high priority in the GMS. This situation is further worsened by the circulation of counterfeit and substandard artemisinin-related drugs. In most endemic areas of the GMS, P. falciparum and Plasmodium vivax coexist, and in recent malaria control history, P. vivax has demonstrated remarkable resilience to control measures. Deployment of the only registered drug (primaquine) for the radical cure of vivax malaria is severely undermined due to high prevalence of glucose-6-phosphate dehydrogenase deficiency in target human populations. In the GMS, the dramatically different ecologies, diverse vector systems, and insecticide resistance render traditional mosquito control less efficient. Here

we attempt to review the changing malaria epidemiology in the GMS, analyze the vector systems and patterns of malaria transmission, and identify the major challenges the malaria control community faces on its way to malaria elimination. Copyright 2011 Elsevier B.V. All rights reserved. PMCID: PMC3132579 [Available on 2013/3/1] PMID: 21382335 [PubMed - indexed for MEDLINE] 112. BMC Infect Dis. 2011 Mar 2;11:57. doi: 10.1186/1471-2334-11-57. Malaria prevention reduces in-hospital mortality among severely ill tuberculosis patients: a three-step intervention in Bissau, Guinea-Bissau. Colombatti R, Penazzato M, Bassani F, Vieira CS, Loureno AA, Vieira F, Teso S, Giaquinto C, Riccardi F. Clinic of Pediatric Hematology-Oncology, Department of Pediatrics, University of Padova, Padova, Italy. rcolombatti@gmail.com BACKGROUND: Malaria and Tuberculosis (TB) are important causes of morbidity and mortality in Africa. Malaria prevention reduces mortality among HIV patients, pregnant women and children, but its role in TB patients is not clear. In the TB National Reference Center in Guinea-Bissau, admitted patients are in severe clinical conditions and mortality during the rainy season is high. We performed a three-step malaria prevention program to reduce mortality in TB patients during the rainy season. METHODS: Since 2005 Permethrin treated bed nets were given to every patient. Since 2006 environmental prevention with permethrin derivates was performed both indoor and outdoor during the rainy season. In 2007 cotrimoxazole prophylaxis was added during the rainy season. Care was without charge; health education on malaria prevention was performed weekly. Primary outcomes were death, discharge, drop-out. RESULTS: 427, 346, 549 patients were admitted in 2005, 2006, 2007, respectively. Mortality dropped from 26.46% in 2005 to 18.76% in 2007 (p-value 0.003), due to the significant reduction in rainy season mortality (death/discharge ratio: 0.79,

0.55 and 0.26 in 2005, 2006 and 2007 respectively; p-value 0.001) while dry season mortality remained constant (0.39, 0.37 and 0.32; p-value 0.647). Costs of malaria prevention were limited: 2/person. No drop-outs were observed. Health education attendance was 96-99%. CONCLUSIONS: Malaria prevention in African tertiary care hospitals seems feasible with limited costs. Vector control, personal protection and cotrimoxazole prophylaxis seem to reduce mortality in severely ill TB patients. Prospective randomized trials are needed to confirm our findings in similar settings. PMCID: PMC3056796 PMID: 21366907 [PubMed - indexed for MEDLINE] 113. Southeast Asian J Trop Med Public Health. 2010 Nov;41(6):1297-305. Progress of partial integration of malaria control with other vector borne diseases control in northern Thailand. Suwonkerd W, Vryheid R, Suwannachote N. Vector Borne Disease Section, Office of Disease Prevention and Control No. 10, Chiang Mai, Thailand. suwannapa@yahoo.com Thailand partially integrated the malaria program into the provincial and local Public Health system starting in 2003 by adding it to the control of other vector borne diseases and by transferring some activities to the Public Health Department. This study evaluates the results of this transfer on 8 high malaria incidence districts of Mae Hong Son and Chiang Mai Provinces. Indicators were measured for all community hospitals, Vector Borne Disease Control Units, (VBDU), health centers (HC), malaria clinics, and malaria posts in 2003 and 2004 during the first two years of partial integration. The number of Vector Borne Disease Control staff decreased 1.8 - 3%, and their operational budgets decreased 25%. The VBDU staff did all the indoor residual spraying (IRS), insecticide treated net (ITN) work and entomology surveys, they took 80.6% of the blood films, and treated 72% of the patients, while Public Health system did the remainder. The Annual Parasite Incidence (API) (1 - 10/1,000) and IRS coverage (88 100%) remained adequate in most areas during the first years after partial integration,

but the API increased (to 31.6 - 57.6/1,000) in some populations. The percentage of insecticide treated bed net coverage was adequate in Mae Hong Son (95.4%), but inadequate in Chiang Mai (52.2%). Early diagnosis and prompt treatment (4 - 23 days), hospitals reporting disruption of anti-malarial drugs (3 of 7), and health centers having all needed equipment, training, and drugs for malaria diagnosis (9%) remain inadequate. If the program is allowed to diminish, malaria could spread again among the population. Integration of antimalarial activities into the general Public Health system has only been partially successful. We recommend the integration process and results should be monitored and evaluated to find and mitigate problems as they occur, and modify the integration process if needed. PMID: 21329301 [PubMed - indexed for MEDLINE]

114. Afr Health Sci. 2010 Jun;10(2):117-9. Awareness and use of insecticide-treated bed nets among children attending outpatient clinic at UNTH, Enugu - the need for an effective mobilization process. Edelu BO, Ikefuna AN, Emodi JI, Adimora GN. Department of Paediatrics, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria. onyedelu@yahoo.com BACKGROUND: The promotion of insecticide-treated net (ITN) can be a key approach towards the reduction of morbidity and mortality from malaria. OBJECTIVE: To determine the proportion of mothers using insecticide treated nets for their children and reasons for nonuse. STUDY DESIGN: Prospective hospital-based study. METHOD: Consecutive mothers attending the children's out patient clinic of UNTH, Ituku-Ozalla, Enugu, whose children presented with fever without localizing focus were interviewed with the aid of an open-ended structured questionnaire. RESULTS: Awareness of ITN was found in 184 (80%) of the 230 mothers interviewed, while only 48 (26.1%) use it for their children. There was statistically significant difference in terms of ITN awareness between the highly educated mothers and those with lower educational qualification (p = 0.000) but, in terms

of ITN usage, there was no significant difference between the two groups (p = 0.40). Socio economic class did not influence the use of ITN (p = 0.153). A greater number; 56 (41.2%) have no reason for non-use. Reasons for nonuse include use of windows and door nets 22 (16.2%) and not convenient to spread 18 (13.2%). CONCLUSION: There was a high awareness of ITN, which did not influence usage. PMCID: PMC2956296 PMID: 21326961 [PubMed - indexed for MEDLINE] 115. PLoS Med. 2011 Feb 1;8(2):e1000408. doi: 10.1371/journal.pmed.1000408. Intermittent preventive treatment of malaria provides substantial protection against malaria in children already protected by an insecticide-treated bednet in Burkina Faso: a randomised, double-blind, placebo-controlled trial. Konat AT, Yaro JB, Oudraogo AZ, Diarra A, Gansan A, Soulama I, Kangoy DT, Kabor Y, Oudraogo E, Oudraogo A, Tiono AB, Oudraogo IN, Chandramohan D, Cousens S, Milligan PJ, Sirima SB, Greenwood B, Diallo DA. Centre National de Recherche et de Formation sur Paludisme, Ouagadougou, Burkina Faso. BACKGROUND: Intermittent preventive treatment of malaria in children (IPTc) is a promising new approach to the control of malaria in areas of seasonal malaria transmission but it is not known if IPTc adds to the protection provided by an insecticide-treated net (ITN). METHODS AND FINDINGS: An individually randomised, double-blind, placebo-controlled trial of seasonal IPTc was conducted in Burkina Faso in children aged 3 to 59 months who were provided with a long-lasting insecticide-treated bednet (LLIN). Three rounds of treatment with sulphadoxine pyrimethamine plus amodiaquine or placebos were given at monthly intervals during the malaria transmission season. Passive surveillance for malaria episodes was established, a cross-sectional survey was conducted at the end of the malaria transmission season, and use of ITNs was monitored during the intervention period. Incidence rates of malaria were compared using a Cox regression model and

generalized linear models were fitted to examine the effect of IPTc on the prevalence of malaria infection, anaemia, and on anthropometric indicators. 3,052 children were screened and 3,014 were enrolled in the trial; 1,505 in the control arm and 1,509 in the intervention arm. Similar proportions of children in the two treatment arms were reported to sleep under an LLIN during the intervention period (93%). The incidence of malaria, defined as fever or history of fever with parasitaemia 5,000/l, was 2.88 (95% confidence interval [CI] 2.703.06) per child during the intervention period in the control arm versus 0.87 (95% CI 0.78-0.97) in the intervention arm, a protective efficacy (PE) of 70% (95% CI 66%-74%) (p<0.001). There was a 69% (95% CI 6%-90%) reduction in incidence of severe malaria (p = 0.04) and a 46% (95% CI 7%-69%) (p = 0.03) reduction in the incidence of all-cause hospital admissions. IPTc reduced the prevalence of malaria infection at the end of the malaria transmission season by 73% (95% CI 68%-77%) (p<0.001) and that of moderately severe anaemia by 56% (95% CI 36%-70%) (p<0.001). IPTc reduced the risks of wasting (risk ratio [RR]= 0.79; 95% CI 0.65-1.00) (p = 0.05) and of being underweight (RR = 0.84; 95% CI 0.720.99) (p = 0.03). Children who received IPTc were 2.8 (95% CI 2.3-3.5) (p<0.001) times more likely to vomit than children who received placebo but no drug-related serious adverse event was recorded. CONCLUSIONS: IPT of malaria provides substantial protection against malaria in children who sleep under an ITN. There is now strong evidence to support the integration of IPTc into malaria control strategies in areas of seasonal malaria transmission. TRIAL REGISTRATION: ClinicalTrials.govNCT00738946. Please see later in the article for the Editors' Summary. PMCID: PMC3032552 PMID: 21304925 [PubMed - indexed for MEDLINE] 116. PLoS Med. 2011 Feb 1;8(2):e1000407. doi: 10.1371/journal.pmed.1000407. Intermittent preventive treatment of malaria provides substantial protection

against malaria in children already protected by an insecticide-treated bednet in Mali: a randomised, double-blind, placebo-controlled trial. Dicko A, Diallo AI, Tembine I, Dicko Y, Dara N, Sidibe Y, Santara G, Diawara H, Conar T, Djimde A, Chandramohan D, Cousens S, Milligan PJ, Diallo DA, Doumbo OK, Greenwood B. Malaria Research and Training Centre, Faculty of Medicine Pharmacy and Dentistry, University of Bamako, Bamako, Mali. adicko@icermali.org BACKGROUND: Previous studies have shown that in areas of seasonal malaria transmission, intermittent preventive treatment of malaria in children (IPTc), targeting the transmission season, reduces the incidence of clinical malaria. However, these studies were conducted in communities with low coverage with insecticide-treated nets (ITNs). Whether IPTc provides additional protection to children sleeping under an ITN has not been established. METHODS AND FINDINGS: To assess whether IPTc provides additional protection to children sleeping under an ITN, we conducted a randomised, double-blind, placebo-controlled trial of IPTc with sulphadoxine pyrimethamine (SP) plus amodiaquine (AQ) in three localities in Kati, Mali. After screening, eligible children aged 3-59 mo were given a long-lasting insecticide-treated net (LLIN) and randomised to receive three rounds of active drugs or placebos. Treatments were administered under observation at monthly intervals during the high malaria transmission season in August, September, and October 2008. Adverse events were monitored immediately after the administration of each course of IPTc and throughout the follow-up period. The primary endpoint was clinical episodes of malaria recorded through passive surveillance by study clinicians available at all times during the follow-up. Cross-sectional surveys were conducted in 150 randomly selected children weekly and in all children at the end of the malaria transmission season to assess usage of ITNs and the impact of IPTc on the prevalence of malaria, anaemia, and malnutrition. Cox regression was used to compare incidence rates between intervention and control arms. The effects of IPTc on the prevalence of malaria infection and anaemia were estimated using logistic regression. 3,065 children were screened and 3,017 (1,508 in the control

and 1,509 in the intervention arm) were enrolled in the study. 1,485 children (98.5%) in the control arm and 1,481 (98.1%) in the intervention arm completed follow-up. During the intervention period, the proportion of children reported to have slept under an ITN was 99.7% in the control and 99.3% in intervention arm (p = 0.45). A total of 672 episodes of clinical malaria defined as fever or a history of fever and the presence of at least 5,000 asexual forms of Plasmodium falciparum per microlitre (incidence rate of 1.90; 95% confidence interval [CI] 1.76-2.05 episodes per person year) were observed in the control arm versus 126 (incidence rate of 0.34; 95% CI 0.29-0.41 episodes per person year) in the intervention arm, indicating a protective effect (PE) of 82% (95% CI 78%85%) (p<0.001) on the primary endpoint. There were 15 episodes of severe malaria in children in the control arm compared to two in children in the intervention group giving a PE of 87% (95% CI 42%-99%) (p = 0.001). IPTc reduced the prevalence of malaria infection by 85% (95% CI 73%-92%) (p<0.001) during the intervention period and by 46% (95% CI 31%-68%) (p<0.001) at the end of the intervention period. The prevalence of moderate anaemia (haemoglobin [Hb] <8 g/dl) was reduced by 47% (95% CI 15%-67%) (p<0.007) at the end of intervention period. The frequencies of adverse events were similar between the two arms. There was no drug-related serious adverse event. CONCLUSIONS: IPTc given during the malaria transmission season provided substantial protection against clinical episodes of malaria, malaria infection, and anaemia in children using an LLIN. SP+AQ was safe and well tolerated. These findings indicate that IPTc could make a valuable contribution to malaria control in areas of seasonal malaria transmission alongside other interventions. TRIAL REGISTRATION: ClinicalTrials.gov NCT00738946. Please see later in the article for the Editors' Summary. PMCID: PMC3032550 PMID: 21304923 [PubMed - indexed for MEDLINE] 117. PLoS Med. 2011 Feb 1;8(2):e1000409. doi: 10.1371/journal.pmed.1000409. Two strategies for the delivery of IPTc in an area of seasonal malaria transmission in the Gambia: a randomised controlled trial.

Bojang KA, Akor F, Conteh L, Webb E, Bittaye O, Conway DJ, Jasseh M, Wiseman V, Milligan PJ, Greenwood B. Medical Research Council Laboratories, Banjul, The Gambia. kbojang@mrc.gm BACKGROUND: The Expanded Programme on Immunisation (EPI) provides an effective way of delivering intermittent preventive treatment for malaria (IPT) to infants. However, it is uncertain how IPT can be delivered most effectively to older children. Therefore, we have compared two approaches to the delivery of IPT to Gambian children: distribution by village health workers (VHWs) or through reproductive and child health (RCH) trekking teams. In rural areas, RCH trekking teams provide most of the health care to children under the age of 5 years in the Infant Welfare Clinic, and provide antenatal care for pregnant women. METHODS AND FINDINGS: During the 2006 malaria transmission season, the catchment populations of 26 RCH trekking clinics in The Gambia, each with 400-500 children 6 years of age and under, were randomly allocated to receive IPT from an RCH trekking team or from a VHW. Treatment with a single dose of sulfadoxine pyrimethamine (SP) plus three doses of amodiaquine (AQ) were given at monthly intervals during the malaria transmission season. Morbidity from malaria was monitored passively throughout the malaria transmission season in all children, and a random sample of study children from each cluster was examined at the end of the malaria transmission season. The primary study endpoint was the incidence of malaria. Secondary endpoints included coverage of IPTc, mean haemoglobin (Hb) concentration, and the prevalence of asexual malaria parasitaemia at the end of malaria transmission period. Financial and economic costs associated with the two delivery strategies were collected and incremental cost and effects were compared. A nested case-control study was used to estimate efficacy of IPT treatment courses. Treatment with SP plus AQ was safe and well tolerated. There were 49 cases of malaria with parasitaemia above 5,000/l in the areas where IPT was delivered through RCH clinics and 21 cases in the areas where IPT was delivered by VHWs, (incidence rates 2.8 and 1.2 per 1,000 child months, respectively, rate difference 1.6 [95% confidence interval (CI) -0.24 to 3.5]).

Delivery through VHWs achieved a substantially higher coverage level of three courses of IPT than delivery by RCH trekking teams (74% versus 48%, a difference of 27% [95% CI 16%-38%]). For both methods of delivery, coverage was unrelated to indices of wealth, with similar coverage being achieved in the poorest and wealthiest groups. The prevalence of anaemia was low in both arms of the trial at the end of the transmission season. Efficacy of IPTc against malaria during the month after each treatment course was 87% (95% CI 54%-96%). Delivery of IPTc by VHWs was less costly in both economic and financial terms than delivery through RCH trekking teams, resulting in incremental savings of US$872 and US$1,244 respectively. The annual economic cost of delivering at least the first dose of each course of IPTc was US$3.47 and US$1.63 per child using trekking team and VHWs respectively. CONCLUSIONS: In this setting in The Gambia, delivery of IPTc to children 6 years of age and under by VHWs is more effective and less costly than delivery through RCH trekking clinics. TRIAL REGISTRATION: ClinicalTrials.gov NCT00376155. Please see later in the article for the Editors' Summary. PMCID: PMC3032548 PMID: 21304921 [PubMed - indexed for MEDLINE] 118. Popul Stud (Camb). 2011 Mar;65(1):57-71. doi: 10.1080/00324728.2010.544323. The problems of eligibility and endogenous confounders when assessing the mortality impact of a nationwide disease-prevention programme: the case of insecticide-treated nets in Togo. Ishida K, Stupp P, Erskine M, Goldberg H, Morgah K. Centers for Disease Control and Prevention, Division of Reproductive Health, 4770 Buford Hwy NE, Mail Stop K-23, Atlanta, GA 30341, USA. guk6@cdc.gov Evaluation of the mortality impact of nationwide disease-prevention efforts is complicated by potential endogeneity: programme recipients may have unobserved characteristics that simultaneously make them both more likely to become recipients and more likely to survive as a result of other health practices. This

population-based study assesses the mortality impact of a nationwide programme that distributed insecticide-treated nets (ITNs) to mothers of children aged 9-59 months in Togo. By comparing mortality rates before and after the programme according to households' eligibility status, we demonstrate that a onetime programme that restricts eligibility to households with a surviving child excludes some households with a high risk of child mortality. We then apply simultaneous estimation models to untangle the mortality impact of ITNs from the effects of unobserved confounders and show that among eligible households, living in a household with ITNs significantly reduces mortality for children aged 20-59 months, even after controlling for endogeneity. PMID: 21294055 [PubMed - indexed for MEDLINE]

119. Lancet Infect Dis. 2011 Mar;11(3):190-207. doi: 10.1016/S14733099(10)70295-4. Epub 2011 Jan 26. Coverage of malaria protection in pregnant women in sub-Saharan Africa: a synthesis and analysis of national survey data. van Eijk AM, Hill J, Alegana VA, Kirui V, Gething PW, ter Kuile FO, Snow RW. Child and Reproductive Health Group, Liverpool School of Tropical Medicine, Liverpool, UK. avaneijk@liv.ac.uk Comment in Lancet Infect Dis. 2011 Mar;11(3):157-9. BACKGROUND: Insecticide-treated nets and intermittent preventive treatment with sulfadoxine-pyrimethamine are recommended for the control of malaria during pregnancy in endemic areas in Africa, but there has been no analysis of coverage data at a subnational level. We aimed to synthesise data from national surveys about these interventions, accounting for disparities in malaria risk within national borders. METHODS: We extracted data for specific strategies for malaria control in pregnant women from national malaria policies from endemic countries in Africa. We identified the most recent national household cluster-sample surveys recording intermittent preventive treatment with sulfadoxine-pyrimethamine and use of

insecticide-treated nets. We reconciled data to subnational administrative units to construct a model to estimate the number of pregnant women covered by a recommended intervention in 2007. FINDINGS: 45 (96%) of 47 countries surveyed had a policy for distribution of insecticide-treated nets for pregnant women; estimated coverage in 2007 was 47 million (17%) of 277 million pregnancies at risk of malaria in 32 countries with data. 39 (83%) of 47 countries surveyed had an intermittent preventive treatment policy; in 2007, an estimated 64 million (25%) of 256 million pregnant women received at least one dose of treatment and 198 million (77%) visited an antenatal clinic (31 countries). Estimated coverage was lowest in areas of high-intensity transmission of malaria. INTERPRETATION: Despite success in a few countries, coverage of insecticide-treated nets and intermittent preventive treatment in pregnant African women is inadequate; increased efforts towards scale-up are needed. FUNDING: The Malaria in Pregnancy Consortium and Wellcome Trust. Copyright 2011 Elsevier Ltd. All rights reserved. PMCID: PMC3119932 PMID: 21273130 [PubMed - indexed for MEDLINE] 120. Am J Trop Med Hyg. 2011 Jan;84(1):152-7. doi: 10.4269/ajtmh.2011.100287. Malaria infection and anemia prevalence in Zambia's Luangwa District: an area of near-universal insecticide-treated mosquito net coverage. Eisele TP, Miller JM, Moonga HB, Hamainza B, Hutchinson P, Keating J. Department of International Health and Development, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana 70112, USA. teisele@tulane.edu We examined the relationship between insecticide-treated mosquito nets (ITNs), malaria parasite infection, and severe anemia prevalence in children in Luangwa District, Zambia, an area with near-universal ITN coverage, at the end of the 2008 and 2010 malaria transmission seasons. Malaria parasite infection prevalence among children < 5 years old was 9.7% (95% confidence interval [CI] = 8.0-11.4%)

over both survey years. Prevalence of severe anemia among children 6-59 months old was 6.9% (95% CI = 5.4-8.5%) over both survey years. Within this context of near-universal ITN coverage, we were unable to detect a significant association between malaria parasite or severe anemia prevalence and ITNs (possession and use). In addition to maintaining universal ITN coverage, it will be essential for the malaria control program to achieve high ITN use and laboratory diagnosis and treatment of all fevers among all age groups to further reduce the malaria burden in this area. PMCID: PMC3005497

121. Soc Sci Med. 2011 Feb;72(3):408-17. doi: 10.1016/j.socscimed.2010.11.009. Epub 2010 Nov 24. Malaria risk behaviours, socio-cultural practices and rural livelihoods in southern Tanzania: implications for bednet usage. Dunn CE, Le Mare A, Makungu C. Durham University, Department of Geography, Science Site, South Road, Durham DH1 3LE, United Kingdom. c.e.dunn@durham.ac.uk Most malaria risk reduction strategies are firmly embedded in biomedical practices and public health perspectives. National and international programmes to 'control' malaria are particularly characterised by the promotion of public health interventions which converge on the disease vector, the malaria mosquito, notably through the use of indoor household spraying with insecticides, and the deployment of insecticide-treated bednets (ITNs). With convincing evidence for the effectiveness of ITNs in reducing the incidence of malaria, control programmes have emphasised the notion of 'scaling-up' bednet coverage. Much previous research on people's 'compliance' with bednet programmes has tended to focus on the quantification of bednet usage and on deriving explanations for 'non-compliance' based on household or individual indicators such as wealth, age, gender or educational level, or on climatic factors such as season and

temperature. However, malaria risk behaviours are also rooted in wider aspects of local livelihoods, and socio-cultural beliefs and practices which interplay with the use and, crucially, non-use, of bednets. This paper draws on empirical data derived from in-depth, one-to-one semi-structured interviews, focus groups and participatory methods (mapping and diagramming) with participants in two villages in rural Tanzania to explore the nature of these practices and vulnerabilities, and their potential impact on malaria exposure risk. Participants included farmers and pastoralists, both men and women, as well as village 'officials'. By eliciting local understandings of malaria-related behaviours we explore how malaria risks are played out in people's everyday lives, and the circumstances and decision-making which underpin non-usage of bednets. Our findings reveal the importance of shifting sleeping patterns in response to livelihood needs and socio-cultural practices and events. These arrangements militate against the consistent and sustained use of the bednet which are called for by public health policies. In particular we demonstrate the importance of the spatial and temporal dimensions of farming practices and the role of conflict over access to shared land; the impact of livelihood activities on malaria risks for schoolaged children; risk behaviours during 'special' socio-cultural events such as funeral ceremonies; and routine, outdoor activities around dawn and dusk and the gendered nature of these practices. Copyright 2010 Elsevier Ltd. All rights reserved. PMID: 21211875 [PubMed - indexed for MEDLINE]

122. Malar J. 2010 Dec 23;9:372. doi: 10.1186/1475-2875-9-372. Is staying overnight in a farming hut a risk factor for malaria infection in a setting with insecticide-treated bed nets in rural Laos? Nonaka D, Laimanivong S, Kobayashi J, Chindavonsa K, Kano S, Vanisaveth V, Yasuoka J, Phompida S, Jimba M. Department of Community and Global Health, Graduate School of Medicine, the

University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo, Japan. laodaisuke@hotmail.co.jp BACKGROUND: Overnight stays in farming huts are known to pose a risk of malaria infection. However, studies reporting the risk were conducted in the settings of poor net coverage. This study sought to assess whether an overnight stay in a farming hut is associated with an increased risk of malaria infection if insecticide-treated bed nets (ITNs) are properly used. METHODS: A pair of cross-sectional surveys was carried out in the Lamarm district of Sekong province, Laos, in March (dry season) and August (rainy season) in 2008. Questionnaire-based interviews and blood examinations were conducted with farmers and their household members from three randomly selected villages in March (127 households, 891 people) and August (128 households, 919 people). Logistic regression analysis, adjusted for potential confounding factors, was used to assess the association between malaria infection status and frequency of overnight stays for the two weeks prior to the study in both the seasons. RESULTS: In March, 13.7% of participants reported staying overnight in a farming hut at least once in the previous two weeks. The percentage increased to 74.6% in August. Not only adults but also young children stayed overnight as often as adults. The use of an ITN the preceding night was common both in farming huts (66.3% in March, 95.2% in August), and in main residences (85.8% in March, 92.5% in August). Logistic regression analysis showed no statistical association between malaria infection status and frequency of overnight stays in farming huts in either study period. However, people sharing one family type net with five people or more were significantly more likely to have malaria than those sharing a net with up to two people in the dry season. CONCLUSIONS: This study showed that staying overnight in farming huts was not associated with an increased risk of malaria infection in the setting where ITNs were widely used in farming huts. It suggests that malaria infection during overnight stays in farming huts might be preventable if ITNs are properly used in rural Laos. PMCID: PMC3224235 PMID: 21176242 [PubMed - indexed for MEDLINE]

123. Malar J. 2010 Dec 6;9:353. doi: 10.1186/1475-2875-9-353. Effects of transmission reduction by insecticide-treated bed nets (ITNs) on parasite genetics population structure: I. The genetic diversity of Plasmodium falciparum parasites by microsatellite markers in western Kenya. Gatei W, Kariuki S, Hawley W, ter Kuile F, Terlouw D, Phillips-Howard P, Nahlen B, Gimnig J, Lindblade K, Walker E, Hamel M, Crawford S, Williamson J, Slutsker L, Shi YP. Malaria Branch, Division of Parasitic Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA. BACKGROUND: Insecticide-treated bed nets (ITNs) reduce malaria transmission and are an important prevention tool. However, there are still information gaps on how the reduction in malaria transmission by ITNs affects parasite genetics population structure. This study examined the relationship between transmission reduction from ITN use and the population genetic diversity of Plasmodium falciparum in an area of high ITN coverage in western Kenya. METHODS: Parasite genetic diversity was assessed by scoring eight single copy neutral multilocus microsatellite (MS) markers in samples collected from P. falciparum-infected children (< five years) before introduction of ITNs (1996, baseline, n = 69) and five years after intervention (2001, follow-up, n = 74). RESULTS: There were no significant changes in overall high mixed infections and unbiased expected heterozygosity between baseline (%MA = 94% and He = 0.75) and follow up (%MA = 95% and He = 0.79) years. However, locus specific analysis detected significant differences for some individual loci between the two time points. Pfg377 loci, a gametocyte-specific MS marker showed significant increase in mixed infections and He in the follow up survey (%MA = 53% and He = 0.57) compared to the baseline (%MA = 30% and He = 0.29). An opposite trend was observed in the erythrocyte binding protein (EBP) MS marker. There was moderate genetic differentiation at the Pfg377 and TAA60 loci (FST = 0.117 and 0.137 respectively) between the baseline and post-ITN parasite populations. Further

analysis revealed linkage disequilibrium (LD) of the microsatellites in the baseline (14 significant pair-wise tests and ISA = 0.016) that was broken in the follow up parasite population (6 significant pairs and ISA = 0.0003). The locus specific change in He, the moderate population differentiation and break in LD between the baseline and follow up years suggest an underlying change in population sub-structure despite the stability in the overall genetic diversity and multiple infection levels. CONCLUSIONS: The results from this study suggest that although P. falciparum population maintained an overall stability in genetic diversity after five years of high ITN coverage, there was significant locus specific change associated with gametocytes, marking these for further investigation. PMCID: PMC3004940 PMID: 21134282 [PubMed - indexed for MEDLINE] 124. Malar J. 2010 Nov 30;9:345. doi: 10.1186/1475-2875-9-345. "Before we used to get sick all the time": perceptions of malaria and use of long-lasting insecticide-treated bed nets (LLINs) in a rural Kenyan community. Dye TD, Apondi R, Lugada ES, Kahn JG, Smith J, Othoro C. Department of Public Health and Preventive Medicine, State University of New York Upstate Medical University, SUNY Upstate Medical University, Institute for Human Performance, Syracuse, New York 13210, USA. dyet@upstate.edu BACKGROUND: Malaria is a leading global cause of preventable morbidity and mortality, especially in sub-Saharan Africa, despite recent advances in treatment and prevention technologies. Scale-up and wide distribution of longlasting insecticide-treated nets (LLINs) could rapidly decrease malarial disease in endemic areas, if used properly and continuously. Studies have shown that effective use of LLINs depends, in part, upon understanding causal factors associated with malaria. This study examined malaria beliefs, attitudes, and practices toward LLINs assessed during a large-scale integrated prevention campaign (IPC) in rural Kenya. METHODS: Qualitative interviews were conducted with 34 IPC participants who

received LLINs as part of a comprehensive prevention package of goods and services. One month after distribution, interviewers asked these individuals about their attitudes and beliefs regarding malaria, and about their use of LLINs. RESULTS: Virtually all participants noted that mosquitoes were involved in causing malaria, though a substantial proportion of participants (47 percent) also mentioned an incorrect cause in addition to mosquitoes. For example, participants commonly noted that the weather (rain, cold) or consumption of bad food and water caused malaria. Regardless, most participants used the LLINs they were given and most mentioned positive benefits from their use, namely reductions in malarial illness and in the costs associated with its diagnosis and treatment. CONCLUSIONS: Attitudes toward LLINs were positive in this rural community in Western Kenya, and respondents noted benefits with LLIN use. With improved understanding and clarification of the direct (mosquitoes) and indirect (e.g., standing water) causes of malaria, it is likely that LLIN use can be sustained, offering effective household-level protection against malaria. PMCID: PMC3225033 PMID: 21118550 [PubMed - indexed for MEDLINE] 125. Malar J. 2010 Nov 18;9:330. doi: 10.1186/1475-2875-9-330. How many mosquito nets are needed to achieve universal coverage? Recommendations for the quantification and allocation of long-lasting insecticidal nets for mass campaigns. Kilian A, Boulay M, Koenker H, Lynch M. Malaria Consortium, Development House, London EC2A 4LT, UK. a.kilian@malariaconsortium.org BACKGROUND: Long-lasting insecticidal nets are an effective tool for malaria prevention, and "universal coverage" with such nets is increasingly the goal of national malaria control programmes. However, national level campaigns in several countries have run out of nets in the course of distribution, indicating a problem in the method used to estimate the quantity needed. PRESENTATION OF

HYPOTHESIS: A major reason for the shortfall in estimation is the mismatch between the quantification factor used to plan procurement and the allocation algorithm used at community level, in particular the effect of needing to add an additional net to households with an odd number of inhabitants. To solve this problem a revised quantification factor is suggested. TESTING HYPOTHESIS: Based on data from a broad range of household surveys across Africa, the effect of odd-numbered households on numbers of nets distributed is estimated via two frequently used allocation methods. The impact of these algorithms on the proportion of households reaching a person to net ratio of 2:1, a frequently used marker of universal coverage is then calculated. IMPLICATIONS: In order to avoid stock-outs of nets during national coverage campaigns, it is recommended to use a quantification factor of 1.78 people per net, with an additional allocation factor suggested to account for other common problems at the community level resulting in a final recommended ratio of 1.60 people per net. It is also recommend that community level allocation procedures be aligned with procurement estimates to reduce shortages of nets during campaign distributions. These analyses should enable programme managers to make evidence-based decisions and support a more efficient and effective use of LLIN distribution campaign resources. PMCID: PMC2994892 PMID: 21087460 [PubMed - indexed for MEDLINE] 126. PLoS One. 2010 Nov 10;5(11):e13129. doi: 10.1371/journal.pone.0013129. Barriers to insecticide-treated mosquito net possession 2 years after a mass free distribution campaign in Luangwa District, Zambia. Larsen DA, Keating J, Miller J, Bennett A, Changufu C, Katebe C, Eisele TP. Department of International Health and Development, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, United States of America. BACKGROUND AND METHODS: Roll Back Malaria set the goal of 100% of households in

malaria endemic countries in Africa owning an insecticide-treated mosquito net (ITN) by 2010. Zambia has used mass free distribution campaigns and distribution through antenatal care (ANC) clinics to achieve high coverage. METHODOLOGY AND PRINCIPAL FINDINGS: We conducted a probability survey of 801 households in 2008 to assess factors associated with households that lacked an ITN after mass distribution. Community perceptions of barriers to ITN access were also obtained from in-depth interviews with household heads that reported not owning an ITN. Nearly 74% of households in Luangwa district reported owning 1 ITN. Logistic regression showed households without a child <5 years old during the ITN distribution campaigns were twice as likely to not have an ITN as those with a child <5 during distribution (Adjusted odds ratio (AOR) = 2.43; 95% confidence interval (CI): 1.67-3.55). Households without a woman who attended an ANC in the past 2 years were more likely to be without ITNs compared to households with a woman who attended an ANC in the past 2 years (AOR = 1.52; 95% CI: 1.04-2.21). In-depth interviews with heads of households without an ITN revealed that old age was a perceived barrier to receiving an ITN during distribution, and that ITNs wore out before they could be replaced. CONCLUSIONS AND SIGNIFICANCE: Delivery of a large number of ITNs does not translate directly into 100% household coverage. Due to their design, current ITN distribution strategies may miss households occupied by the elderly and those without children or ANC access. ITN distribution strategies targeting the elderly, those with limited access to distribution points, and others most likely to be missed are necessary if 100% ITN coverage of households is to be achieved. PMCID: PMC2978084 PMID: 21085711 [PubMed - indexed for MEDLINE] 127. Malar J. 2010 Nov 11;9:319. doi: 10.1186/1475-2875-9-319. Trends in malaria morbidity among health care-seeking children under age five in Mopti and Svar, Mali between 1998 and 2006. Rose-Wood A, Doumbia S, Traor B, Castro MC. Department of Global Health and Population, Harvard University, Boston, Massachusetts, USA. alyson.rose-wood@hhs.gov

BACKGROUND: In Mali, malaria is the leading cause of death and the primary cause of outpatient visits for children under five. The twin towns of Mopti and Svar have historically had high under-five mortality. This paper investigates the changing malaria burden in children under five in these two towns for the years 1998-2006, and the likely contribution of previous interventions aimed at reducing malaria. METHODS: A retrospective analysis of daily outpatient consultation records from urban community health centres (CSCOMs) located in Mopti and Svar for the years 1998-2006 was conducted. Risk factors for a diagnosis of presumptive malaria, using logistic regression and trends in presumptive malaria diagnostic rates, were assessed using multilevel analysis. RESULTS: Between 1998-2006, presumptive malaria accounted for 33.8% of all recorded consultation diagnoses (10,123 out of 29,915). The monthly presumptive malaria diagnostic rate for children under five decreased by 66% (average of 8 diagnoses per month per 1,000 children in 1998 to 2.7 diagnoses per month in 2006). The multi-level analysis related 37% of this decrease to the distribution of bed net treatment kits initiated in May of 2001. Children of the Fulani (Peuhl) ethnicity had significantly lower odds of a presumptive malaria diagnosis when compared to children of other ethnic groups. CONCLUSIONS: Presumptive malaria diagnostic rates have decreased between 1998-2006 among health care-seeking children under five in Mopti and Svar. A bed net treatment kit intervention conducted in 2001 is likely to have contributed to this decline. The results corroborate previous findings that suggest that the Fulani ethnicity is protective against malaria. The findings are useful to encourage dialogue around the urban malaria situation in Mali, particularly in the context of achieving the target of reducing malaria morbidity in children younger than five by 50% by 2011 as compared to levels in 2000. PMCID: PMC2993732 PMID: 21067615 [PubMed - indexed for MEDLINE] 128. Malar J. 2010 Nov 1;9:309. doi: 10.1186/1475-2875-9-309. Fairness and legitimacy of decisions during delivery of malaria services and ITN interventions in Zambia.

Tuba M, Sandoy IF, Bloch P, Byskov J. Center for International Health, University of Bergen, PO Box 7804, N5020 Bergen, Norway. mary_tuba2004@yahoo.co.uk BACKGROUND: Malaria is the leading cause of morbidity and the second leading cause of mortality in Zambia. Perceptions of fairness and legitimacy of decisions relating to treatment of malaria cases within public health facilities and distribution of ITNs were assessed in a district in Zambia. The study was conducted within the framework of REsponse to ACcountable priority setting for Trust in health systems (REACT), a north-south collaborative action research study, which evaluates the Accountability for Reasonableness (AFR) approach to priority setting in Zambia, Tanzania and Kenya. METHODS: This paper is based on baseline in-depth interviews (IDIs) conducted with 38 decision-makers, who were involved in prioritization of malaria services and ITN distribution at district, facility and community levels in Zambia, one Focus Group Discussion (FGD) with District Health Management Team managers and eight FGDs with outpatients' attendees. Perceptions and attitudes of providers and users and practices of providers were systematized according to the four AFR conditions relevance, publicity, appeals and leadership. RESULTS: Conflicting criteria for judging fairness were used by decisionmakers and patients. Decision-makers argued that there was fairness in delivery of malaria treatment and distribution of ITNs based on alleged excessive supply of free malaria medicines, subsidized ITNs, and presence of a qualified health-provider in every facility. Patients argued that there was unfairness due to differences in waiting time, distances to health facilities, erratic supply of ITNs, no responsive appeal mechanisms, inadequate access to malaria medicines, ITNs and health providers, and uncaring providers. Decision-makers only perceived government bodies and donors/NGOs to be legitimate stakeholders to involve during delivery. Patients found government bodies, patients, indigenous healers, chiefs and politicians to be legitimate stakeholders during both planning and delivery. CONCLUSION: Poor status of the AFR conditions of relevance, publicity, appeals

and leadership corresponds well to the differing perceptions of fairness and unfairness among outpatient attendees and decision-makers. This may have been re-enforced by existing disagreements between the two groups regarding who the legitimate stakeholders to involve during service delivery were. Conflicts identified in this study could be resolved by promoting application of approaches such as AFR during priority setting in the district. PMCID: PMC2988042 PMID: 21040552 [PubMed - indexed for MEDLINE] 129. Am J Trop Med Hyg. 2010 Nov;83(5):1014-9. doi: 10.4269/ajtmh.2010.09-0599. Rapid scale-up of long-lasting insecticide-treated bed nets through integration into the national immunization program during child health week in Togo, 2004. Wolkon A, Vanden Eng JL, Morgah K, Eliades MJ, Thwing J, Terlouw DJ, Takpa V, Dare A, Sodahlon YK, Doumanou Y, Hightower AW, Lama M, Thawani N, Slutsker L, Hawley WA. National Center for Infectious Diseases, Division of Parasitic Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia 30341, USA. aow5@cdc.gov In December 2004, Togo was the first country to conduct a nationwide free insecticide-treated net (ITN) distribution as part of its National Integrated Child Health Campaign. Community-based cross-sectional surveys were conducted one and nine months post-campaign as part of a multidisciplinary evaluation of the nationwide distribution of ITNs to children 9-59 months of age to evaluate ITN ownership, equity, and use. Our results demonstrated that at one month post-campaign, 93.1% of all eligible children received an ITN. Household ITN ownership and equity increased significantly post-campaign. Nine months post-campaign, 78.6% of households with a child eligible to participate in the campaign retained at least one campaign net. Use by eligible children was 43.5% at one month post-campaign (during the dry season) and 52.9% at nine months post-campaign (during the rainy season). Household ownership of at least one ITN

increased from 8.0% pre-campaign to 62.5% one month post-campaign. Together, these findings demonstrate that in this setting, increased household ITN ownership, equity, and retention can be achieved on a national scale through free ITN distribution during an integrated campaign. PMCID: PMC2963961 PMID: 21036829 [PubMed - indexed for MEDLINE] 130. Trans R Soc Trop Med Hyg. 2010 Dec;104(12):758-65. doi: 10.1016/j.trstmh.2010.08.008. Epub 2010 Oct 16. An experimental hut evaluation of PermaNet() 3.0, a deltamethrinpiperonyl butoxide combination net, against pyrethroid-resistant Anopheles gambiae and Culex quinquefasciatus mosquitoes in southern Benin. N'Guessan R, Asidi A, Boko P, Odjo A, Akogbeto M, Pigeon O, Rowland M. London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E7HT, UK. raphael.n'guessan@lshtm.ac.uk PermaNet 3.0 is a long-lasting combination net with deltamethrin present on the sides and a mixture of deltamethrin and piperonyl butoxide (PBO), an oxidase synergist, on the top panel. An experimental hut trial comparing unwashed and 20 times washed PermaNet 3.0 and PermaNet 2.0, Olyset Net and a conventional deltamethrin-treated net washed three times was conducted in southern Benin. Anopheles gambiae and Culex quinquefasciatus from this area are highly resistant to pyrethroids through kdr and cytochrome P450 mechanisms. The unwashed PermaNet 3.0 killed slightly more A. gambiae (52%) than the unwashed PermaNet 2.0 (44%) (P=0.036), indicating only partial synergism of resistance. After washing there was significant loss of activity to a similar level, with PermaNet 3.0 killing 31%, PermaNet 2.0 killing 29% and the conventional net killing 26%. Blood-feeding rates were partially inhibited for unwashed PermaNet 3.0 and Olyset Net (27% inhibition). Personal protection against A. gambiae derived from PermaNet 3.0 was similar to that from PermaNet 2.0 before washing (50% vs. 47%), and after 20 washes it decreased to 30%. Against C. quinquefasciatus, no treatment killed >24% entering the huts. The synergism from unwashed PermaNet 3.0 was lower than

expected, probably due to an unidentified resistance mechanism unaffected by PBO. Copyright 2010 Royal Society of Tropical Medicine and Hygiene. All rights reserved. PMID: 20956008 [PubMed - indexed for MEDLINE]

131. Trans R Soc Trop Med Hyg. 2010 Dec;104(12):777-81. doi: 10.1016/j.trstmh.2010.09.001. Epub 2010 Oct 16. Towards eradication: three years after the tsunami of 2004, has malaria transmission been eliminated from the island of Simeulue? Sudomo M, Arianti Y, Wahid I, Safruddin D, Pedersen EM, Charlwood JD. Health Ecology Research and Development Centre, National Institute of Health Research and Development, Ministry of Health, Jl. Percetakan Negara 29, Jakarta Pusat, Jakarta 10560, Indonesia. The island of Simeulue was the first landfall of the tsunami of December 2004. The tsunami destroyed many villages on the island, leaving one third of the population homeless. Malaria is endemic in Simeulue and an epidemic was reported to have occurred three months prior to the tsunami. Information concerning malaria was, however, not easily available. The earthquakes related to the tsunami may have created extensive potential breeding sites of Anopheles sundaicus, the probable vector, and increased vulnerability of the human population; a possibility of increased transmission made a further outbreak possible. Consequently, subsequent to the tsunami, considerable amounts of aid, including anti-malarial measures such as insecticide treated mosquitonets, were deployed on the island. A series of island-wide cross-sectional surveys were conducted in 2005-2007 to determine whether these had had any effect on malaria prevalence. Larval sampling, and CDC light-trap and landing collections of hungry mosquitoes were also undertaken. The results indicate that despite the continuing presence of potential vectors in some places the anti-malaria measures introduced following the tsunami have controlled, and may be close to eliminating, malaria from the island.

Copyright 2010 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved. PMID: 20952042 [PubMed - indexed for MEDLINE]

132. Malar J. 2010 Sep 29;9:264. doi: 10.1186/1475-2875-9-264. Potential threat of malaria epidemics in a low transmission area, as exemplified by So Tom and Prncipe. Lee PW, Liu CT, do Rosario VE, de Sousa B, Rampao HS, Shaio MF. The Anti-Malaria Team of Taiwan in So Tom and Prncipe, Democratic Republic of So Tom and Prncipe. BACKGROUND: Plasmodium falciparum is the major cause of malaria infection in the island of So Tom, in the Republic of So Tom and Prncipe (STP), with an incidence of 40 - 50% before 2004. Since 2004, through the coordination of the Ministry of Health of STP and their Centro Nacional de Endemias (CNE), an integrated malaria control programme has been intensively deployed on the island of So Tom. Malaria morbidity and mortality decreased by 95% after three years of effective intervention. In the low transmission settings, however, malaria seasonal fluctuation can be a potential problem directly related to epidemics if ongoing control measures are interrupted. Studies on a number of associated factors with malaria epidemics and the measures taken to respond to outbreaks are presented. METHODS: The integrated malaria control programme included indoor residual spraying (IRS), long-lasting insecticidal nets (LLINs), intermittent preventive therapy for pregnant women, as well as early diagnosis and prompt treatment with artemisinin-based combination therapy (ACT). Regular implementation of an island-wide IRS programme was carried out yearly in 2004-2007, and enhanced throughout the island in 2009. Malaria incidence and prevalence were estimated based on passive case detection and mass screening, respectively. Slide positivity rates were used for monitoring the beginning of a malaria epidemic or a seasonal peak. RESULTS: A steep decline of ca. 95% of malaria morbidity and mortality was

observed between 2004 and 2008 with use of the combined control methods. Malaria incidence was 2.0%, 1.5%, and 3.0% for 2007, 2008, and 2009, respectively. In April 2008, a cross-sectional country-wide surveillance showed malaria prevalence of 3.5%, of which 95% cases were asymptomatic carriers. Only 50% of asymptomatic carriers were cured with ACT treatment, while 90% of the symptomatic patients were cured by ACT treatment as confirmed with a follow up study. Malaria morbidity increased by three-fold during the first half of 2009 as compared to the same period in 2008. Over this period of six months, severe malaria was also noted in all age groups and malaria mortality increased by two-fold in children less than five years old. After an emergency IRS was deployed, with increased use of LLINs, and an active search of asymptomatic carriers was followed and given complete ACT treatment, malaria incidence decreased to less than 1% in the second half of 2009. CONCLUSION: At the initial stage of the integrated malaria control programme, IRS contributed to the visible effect on the rapid reduction of malaria morbidity and mortality, while this programme highlights an urgent demand for the improvement of other measures, particularly promotion of LLINs usage, with close monitoring of asymptomatic carriers and with ACT treatment in malaria transmission hotspots. In addition, both daily reports and a regular active surveillance to prevent malaria outbreaks should be established permanently, so that a fast response to epidemics can be effectively made when necessary. PMCID: PMC2955676 PMID: 20920216 [PubMed - indexed for MEDLINE] 133. Am J Trop Med Hyg. 2010 Oct;83(4):854-60. doi: 10.4269/ajtmh.2010.10-0331. Predicting the unmet need for biologically targeted coverage of insecticide-treated nets in Kenya. Noor AM, Alegana VA, Patil AP, Snow RW. Malaria Public Health and Epidemiology Group, Centre for Geographic Medicine, Kenya Medical Research Institute/University of Oxford-Wellcome Trust Research Programme, Kenyatta National Hospital Grounds, Nairobi, Kenya.

anoor@nairobi.kemri-wellcome.org In some countries the biological targeting of universal malaria prevention may offer optimal impact on disease and significant cost-savings compared with approaches that presume universal risk. Spatially defined data on coverage of treated nets from recent national household surveys in Kenya were used within a Bayesian geostatistical framework to predict treated net coverage nationally. When combined with the distributions of malaria risk and population an estimated 8.1 million people were not protected with treated nets in 2010 in biologically defined priority areas. After adjusting for the proportion of nets in use that were not long lasting, an estimated 5.5 to 6.3 million long-lasting treated nets would be required to achieve universal coverage in 2010 in Kenya in atrisk areas compared with 16.4 to 18.1 million nets if not restricted to areas of greatest malaria risk. In Kenya, this evidence-based approach could save the national program at least 55 million US dollars. PMCID: PMC2946756 PMID: 20889879 [PubMed - indexed for MEDLINE] 134. PLoS One. 2010 Sep 10;5(9). pii: e12660. doi: 10.1371/journal.pone.0012660. Possession and usage of insecticidal bed nets among the people of Uganda: is BRAC Uganda Health Programme pursuing a pro-poor path? Ahmed SM, Zerihun A. Research and Evaluation Division, BRAC, Dhaka, Bangladesh. ahmed.sm@brac.net BACKGROUND: The use of insecticidal bed nets is found to be an effective public health tool for control of malaria, especially for under-five children and pregnant women. BRAC, an indigenous Bangladeshi non-governmental development organization, started working in the East African state of Uganda in June 2006. As part of its efforts to improve the health and well-being of its participants, BRAC Uganda has been distributing long lasting insecticide-treated bed nets

(LLIN) at a subsidized price through health volunteers since February 2008. This study was conducted in March-April 2009 to examine how equitable the programme had been in consistence with BRAC Uganda's pro-poor policy. METHODOLOGY/PRINCIPAL FINDINGS: Information on possession of LLINs and relevant knowledge on its proper use and maintenance was collected from households either with an under-five child and/or a pregnant woman. The sample included three villages from each of the 10 branch offices where BRAC Uganda's community-based health programme was operating. Data were collected by trained enumerators through face-to-face interviews using a hand-held personal digital assistant (PDA). Findings reveal that the study population had superficial knowledge on malaria and its transmission, including the use and maintenance of LLINs. The households' rate of possession of bed nets (41-59%), and the proportion of under-five children (17-19%) and pregnant women (25-27%) who reported sleeping under an LLIN were not encouraging. Inequity was observed in the number of LLINs possessed by the households, in the knowledge on its use and maintenance, and between the two programme areas. CONCLUSIONS/SIGNIFICANCE: The BRAC Uganda's LLINs distribution at a subsidized price appeared to be inadequate and inequitable, and BRAC's knowledge dissemination is insufficient for initiating preventive actions such as proper use of LLINs to interrupt malaria transmission. Findings contribute to the on-going debate on LLINs distribution in Africa and make a strong case for its free distribution. PMCID: PMC2937018 PMID: 20844749 [PubMed - indexed for MEDLINE] 135. Malar J. 2010 Sep 15;9:256. doi: 10.1186/1475-2875-9-256. The potential role of the educational system in addressing the effect of inadequate knowledge of mosquitoes on use of insecticide-treated nets in Ghana. Kudom AA, Mensah BA. Department of Entomology and Wildlife, School of Biological Sciences, University of Cape Coast, Ghana. adusandy@yahoo.co.uk

BACKGROUND: Since 2001, there has been a tremendous increase in number of households protected by ITN and IRS in Ghana. However, there has not been evidence of a reduction in malaria cases as expected and reported deaths have rather increased since 2007. As a result, this study was undertaken to get a better understanding of perceptions of malaria, knowledge on mosquitoes and the value attached to ITNs among secondary and tertiary students in Cape Coast. METHODS: Structured questionnaires were administered randomly to gather data on demographic characteristics of students, knowledge of mosquitoes and ITNs and attitude towards the use of ITN in seven public high schools and four tertiary institutions in Cape Coast metropolis. In addition, curriculums of science courses common to all students from junior high school to the university were carefully examined. RESULTS: A total of 492 students took part in this study and more than 90% of them had high knowledge of malaria transmission and ITN, but little knowledge of mosquito life history. Only 1% in secondary and 2.1% in tertiary institutions had seen or knew about all the development stages of mosquitoes. In high school and tertiary institutions, 24.2% and 10.8% of respondents, respectively, were able to mention other genera of mosquitoes, apart from Anopheles. Though 93.9% in senior high school and 86.7% in the tertiary institutions knew that ITNs are either used to protect oneself from mosquito bites or to prevent malaria, 32.7% of the respondents in secondary and 21.9% in tertiary institutions who owned ITN did not use them. CONCLUSIONS: The study reveals that respondents did not have adequate knowledge on the biology and behaviour of mosquitoes. This appears to weaken their knowledge of the link between the use of ITN and malaria control; the effect of this is that a significant number owned ITNs but did not use them. The implication is that if people will really accept and use ITN or other mosquito control interventions, then just creating awareness of those interventions is not enough but people should also be educated on the life history of mosquitoes and on the mechanism of the control strategies. This can be effectively done through the formal education system. PMCID: PMC2949741

PMID: 20843345

[PubMed - indexed for MEDLINE]

136. PLoS Med. 2010 Aug 17;7(8):e1000328. doi: 10.1371/journal.pmed.1000328. Rapid scaling up of insecticide-treated bed net coverage in Africa and its relationship with development assistance for health: a systematic synthesis of supply, distribution, and household survey data. Flaxman AD, Fullman N, Otten MW Jr, Menon M, Cibulskis RE, Ng M, Murray CJ, Lim SS. Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States of America. BACKGROUND: Development assistance for health (DAH) targeted at malaria has risen exponentially over the last 10 years, with a large fraction of these resources directed toward the distribution of insecticide-treated bed nets (ITNs). Identifying countries that have been successful in scaling up ITN coverage and understanding the role of DAH is critical for making progress in countries where coverage remains low. Sparse and inconsistent sources of data have prevented robust estimates of the coverage of ITNs over time. METHODS AND PRINCIPAL FINDINGS: We combined data from manufacturer reports of ITN deliveries to countries, National Malaria Control Program (NMCP) reports of ITNs distributed to health facilities and operational partners, and household survey data using Bayesian inference on a deterministic compartmental model of ITN distribution. For 44 countries in Africa, we calculated (1) ITN ownership coverage, defined as the proportion of households that own at least one ITN, and (2) ITN use in children under 5 coverage, defined as the proportion of children under the age of 5 years who slept under an ITN. Using regression, we examined the relationship between cumulative DAH targeted at malaria between 2000 and 2008 and the change in national-level ITN coverage over the same time period. In 1999, assuming that all ITNs are owned and used in populations at risk of malaria, mean coverage of ITN ownership and use in children under 5 among populations at risk of malaria were 2.2% and 1.5%, respectively, and were uniformly low across all 44

countries. In 2003, coverage of ITN ownership and use in children under 5 was 5.1% (95% uncertainty interval 4.6% to 5.7%) and 3.7% (2.9% to 4.9%); in 2006 it was 17.5% (16.4% to 18.8%) and 12.9% (10.8% to 15.4%); and by 2008 it was 32.8% (31.4% to 34.4%) and 26.6% (22.3% to 30.9%), respectively. In 2008, four countries had ITN ownership coverage of 80% or greater; six countries were between 60% and 80%; nine countries were between 40% and 60%; 12 countries were between 20% and 40%; and 13 countries had coverage below 20%. Excluding four outlier countries, each US$1 per capita in malaria DAH was associated with a significant increase in ITN household coverage and ITN use in children under 5 coverage of 5.3 percentage points (3.7 to 6.9) and 4.6 percentage points (2.5 to 6.7), respectively. CONCLUSIONS: Rapid increases in ITN coverage have occurred in some of the poorest countries, but coverage remains low in large populations at risk. DAH targeted at malaria can lead to improvements in ITN coverage; inadequate financing may be a reason for lack of progress in some countries. Please see later in the article for the Editors' Summary. PMCID: PMC2923089 PMID: 20808957 [PubMed - indexed for MEDLINE] 137. East Afr J Public Health. 2009 Dec;6(3):317-25. Social marketing and the fight against malaria in Africa: population services international (PSI) and insecticide treated nets (ITNS). Omona J. omonaj@yahoo.co.uk This textual analyses on Social marketing, Insecticide Treated Nets (ITNs) and Population Services International (PSI) were undertaken to achieve two objectives: (a) to contribute to the continuing debate and search for a better strategy for combating malaria in sub-Saharan Africa; and (b) to contribute to theory building on social marketing. The analyses revealed that Malaria has reached an epidemic proportion and despite major inroads by PSI in combating malaria on the principles of social marketing, the strategies of pricing and

segmentation of the clients are not appropriate for Sub-Saharan African countries that are mired in absolute poverty where majority of the rural communities eke a living on less than a dollar per day and the health sector does not receive priority attention from policy makers and politicians. The descriptive statistics and a one sample t test for the sampled countries suggest that subSaharan countries have not even met the hypothesized 5% investment of their GDP on health, compared to their counterparts, the developed countries, who are all above this figure. The null hypothesis that there is no significant different between the population and the sample means of both developed and a developing country in their investments in the health sector was also tested and rejected. Though the elements in some of the existent models and theories of social marketing such as Health Belief Model, Theory of Reasoned Action, Social Cognitive Theory and Trans-theoretical Models all attempt to advocate for elimination of constraints and barriers to effective access to a service or product, PSI is adamant to these and try to generalize these principles in all contexts, including in Sub-Saharan Africa. The African scenario, where about 90% of Malaria related deaths cases in the world occur, demands more than what these theories present. Accordingly, it was concluded that however good intentioned social marketing is, in the case of ITNs in this region, it is counter productive as the pricing de-motivates clients who usually have other pressing needs to address and segmentation limits coverage. Social marketing is thus more relevant to developed economies where absolute poverty no longer exist and people can afford to pay for health services. Malaria in sub-Saharan Africa needs a "carpet bombing" strategy. It was also concluded that for Sub-Saharan countries to effectively address the MDG six on malaria, and implement the Abuja Summit and the Roll Back Malaria partnership declarations, it requires a high degree of political commitment, amongst others, to enable the vulnerable communities have access to free malaria treatment related drugs. Partners in the fight against malaria such as PSI should adopt a more eclectic intervention strategy, and be cognizant of the fact that the strategy that works for Africa should be that

which is based on strict equity and stimulates demand for ITNs. The paper concludes by agreeing with Professors Curtis and Sachs that comprehensive malaria control in Africa is achievable by 2010, at the minimal cost if sound principles of public health and economics are observed. Millions of lives can be saved and Africa will be given vital help in escaping from the viscous circle of poverty and diseases that continue to grip the continent. The target for all intervention efforts should be to eliminate the cost factor and ensure free distribution of all malaria related treatment products. PMID: 20803927 [PubMed - indexed for MEDLINE]

138. Med Trop (Mars). 2010 Jun;70(3):249-54. [Operation to promote use of long-lasting insecticidal nets (LLIN) in French Guiana in 2006: design, implementation and results]. [Article in French] Mansotte F, Ravachol F, Carlisi R, Caudal J, Pinchon S, Maison D. Direction de la Sant et du Dveloppement Social de la Guyane, Cayenne. francois.mansotte@ars.sante.fr In 2006, the Regional Health Office (DSDS) in French Guiana undertook a major operation involving importation and distribution of long-lasting insecticide treated nets (LLIN/ITN). In collaboration with the WHO, a Vietnamese manufacturer of LLINs suited to the requirements of French Guiana was sourced. With the help of a dynamic local importer and dealer, a sales network was developed through chemist shops located all over French Guiana. This network provided wide coverage since these outlets can be found in all large communities. The selling price ranged from 15 to 23 euros depending on the model, i.e., hammock or bed size. In addition, LLINs were distributed within the framework of two special programs. First they are given to women giving birth in French Guiana and undergoing medical surveillance as part of the Mother and Child Protection program by public healthcare system. Second they are distributed in case of natural disaster or other events that could lead to an increased risk of vector-borne outbreaks.

Thanks to this operation, a total of 13,882 LLINs were delivered in French Guiana from July 2006 to December 2008. This milestone operation in the fight against malaria was made possible thanks to funding granted on a one-time basis after the outbreak of dengue in 2005-2006. The structure of this operation and its survival will depend on the continued goodwill and determination of a small group of local partners who created this successful distribution campaign with no specific guidance or program from the national authorities. PMID: 20734592 [PubMed - indexed for MEDLINE]

139. Afr J Reprod Health. 2010 Mar;14(1):117-28. Perceptions on the use of insecticide treated nets in parts of the Imo River Basin, Nigeria: implications for preventing malaria in pregnancy. Chukwuocha UM, Dozie IN, Onwuliri CO, Ukaga CN, Nwoke BE, Nwankwo BO, Nwoke EA, Nwaokoro JC, Nwoga KS, Udujih OG, Iwuala CC, Ohaji ET, Morakinyo OM, Adindu BC. Department of Public Health Technology, Federal University of Technology, Owerri, Imo state Nigeria. chukwuochauchem@yahoo.com This study aimed at assessing perceptions on use of ITNs in parts of the Imo River Basin, Nigeria and its implications in preventing malaria in pregnancy. Data was collected using focus group discussions, key informant interviews and structured questionnaires. Results showed high awareness on the benefits of ITNs. Factors affecting use of ITNs included its high cost, perceptions of chemicals used to treat them as having dangerous effects on pregnancy, low utilization of antenatal care, husband's lack of interest in malaria prevention and perceptions that adolescent girls are at low risk of getting malaria. The implications of these findings include demystifying the negative perceptions on the chemicals used for net treatment and subsidizing the cost of ITNs to increase access. These findings provide important lessons for malaria programmes that aim at increasing access to ITNs by pregnant women in developing countries. PMID: 20695144 [PubMed - indexed for MEDLINE]

140. Malar J. 2010 Aug 4;9:222. doi: 10.1186/1475-2875-9-222. Ownership and usage of insecticide-treated bed nets after free distribution via a voucher system in two provinces of Mozambique. Macedo de Oliveira A, Wolkon A, Krishnamurthy R, Erskine M, Crenshaw DP, Roberts J, Sate F. Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, USA. BACKGROUND: Insecticide-treated bed nets (ITNs) are an efficacious intervention for malaria prevention. During a national immunization campaign in Mozambique, vouchers, which were to be redeemed at a later date for free ITNs, were distributed in Manica and Sofala provinces. A survey to evaluate ITN ownership and usage post-campaign was conducted. METHODS: Four districts in each province and four enumeration areas (EAs) in each district were selected using probability proportional to size. Within each EA, 32 households (HHs) were selected using a simple random sample. Interviews to assess ownership and usage were conducted in each of the selected HHs using personal digital assistants. RESULTS: Valid interviews were completed for 947 (92.5%) (440 in Manica and 507 in Sofala) of the 1,024 selected HHs. Among participating HHs, 65.0% in Manica and 63.1% in Sofala reported that at least one child under five years of age slept in the house the previous night. HH ownership of at least one bed net of any kind was 20.6% (95% confidence interval [CI]: 7.9%-43.6%) and 35.6% (95% CI: 27.8%-44.3%) pre-campaign; and 55.1% (95% CI: 43.6%-66.1%) and 59.6 (95% CI: 42.4%-74.7%) post-campaign in Manica and Sofala, respectively. Postcampaign HH ownership of at least one ITN was 50.2% (95% CI: 41.8%-58.5%) for both provinces combined. In addition, 60.3% (95% CI: 50.6%-69.2%) of children under five years of age slept under an ITN the previous night. CONCLUSIONS: This ITN distribution increased bed net ownership and usage rates. Integration of ITN distribution with immunization campaigns presents an opportunity for reaching malaria control targets and should continue to be

considered. PMCID: PMC2925365 PMID: 20684764 [PubMed - indexed for MEDLINE]

141. Malar J. 2010 Jul 22;9:211. doi: 10.1186/1475-2875-9-211. Which family members use the best nets? An analysis of the condition of mosquito nets and their distribution within households in Tanzania. Tsuang A, Lines J, Hanson K. London School of Hygiene and Tropical Medicine, London, UK. ajtsuang@gmail.com BACKGROUND: Household ownership of insecticide-treated mosquito nets (ITNs) is increasing, and coverage targets have been revised to address universal coverage with ITNs. However, many households do not have enough nets to cover everyone, and the nets available vary in physical condition and insecticide treatment status. Since 2004, the Government of Tanzania has been implementing the Tanzania National Voucher Scheme (TNVS), which distributes vouchers for ITNs through antenatal clinics to target pregnant women and their infants. This analysis aimed to determine the following: (1) coverage patterns of bed nets within households according to physical condition and treatment status; (2) who might be at risk if mosquitoes were diverted from occupants of untreated nets to those not using nets? (3) the degree to which those at highest risk of malaria use the most protective nets. METHODS: Data from the 2006 TNVS household survey were analysed to assess within-household distribution of net use. The associations between net characteristics and net user were also evaluated. Multivariate analysis was applied to the relationship between the number of holes per net and user characteristics while adjusting for confounders. RESULTS: In households with a net:person ratio better than 1:4 (one net for every four household members), more than 80% of the people in such households reported using a net the previous night. ITNs were most likely to be used by infants,

young children (1-4 y), and women of childbearing age; they were least likely to be used by older women (>or=50 y), older children (5-14 y), and adult men. The nets used by infants and women of childbearing age were in better-thanaverage physical condition; the nets used by older women and older children were in worse-than-average condition; while young children and adult men used nets in intermediate (average) condition. When adjusted for confounders, the nets used by young and older children had more holes than nets used by infants. CONCLUSIONS: Infants and other vulnerable groups were most likely to sleep under the most protective nets. Nevertheless, more communication efforts are needed to increase use of intact ITNs within households for children. Further research is necessary to fully understand motivations influencing within-household net distribution. PMCID: PMC2918626 PMID: 20663143 [PubMed - indexed for MEDLINE] 142. Health Policy Plan. 2011 Mar;26(2):133-41. doi: 10.1093/heapol/czq027. Epub 2010 Jul 21. Household demand for insecticide-treated bednets in Tanzania and policy options for increasing uptake. Gingrich CD, Hanson KG, Marchant TJ, Mulligan JA, Mponda H. Department of Business and Economics, Eastern Mennonite University, Harrisonburg, VA 22802, USA. chris.gingrich@emu.edu There has been considerable controversy about the most appropriate means of delivering insecticide-treated nets (ITNs) to prevent malaria. Household demand for ITNs is a key factor influencing the choice of delivery strategy, but evidence to date about price and income elasticities comes either from studies of hypothetical willingness to pay or small-scale policy experiments. This study estimates the price and income elasticities of demand for ITNs using nationally representative household survey data and actual consumer choices, in the context of a national scheme to provide vouchers for subsidized nets to pregnant women in

Tanzania. Under this distribution system, the estimated price elasticity of demand for subsidized ITNs equals -0.12 and the income elasticity estimates range from zero to 0.47, depending on household socio-economic status. The model also shows a substantial decline in short-term ITN purchases for women whose household received a free ITN. These findings suggest that if the Tanzanian government continues to use a mixed public-private model to distribute ITNs, increasing the consumer subsidy alone will not dramatically improve ITN coverage. A concerted effort is required including an increase in the subsidy amount, attention to income growth for poor households, increases in women's and girls' education levels, and expansion of the retail ITN distribution network. Use of a catch-up campaign to distribute free ITNs would increase coverage but raises questions about the effect of households' long-term purchase decisions for ITNs. PMID: 20660208 [PubMed - indexed for MEDLINE]

143. Bull Soc Pathol Exot. 2010 Oct;103(4):223-9. doi: 10.1007/s13149010-0068-6. Epub 2010 Jul 20. [A mosquito net for everyone in 2010]. [Article in French] Pays JF. CHU Necker-EM, Paris, France. pays@necker.fr At less than two hundred days of the 2010 deadline for the "Roll Back Malaria" initiative which committed itself to reduce by half, before that date, mortality due to malaria in the world and relying on the latest WHO reports pointing out, in Africa, major shortcomings concerning the accessibility to treatment combinations consisting of artemisinin and on the acknowledged fact that an insufficient number of pregnant women receive an intermittent treatment, the author notes that a coverage, so-called universal, with the use of long action insecticide treated mosquito nets has become the Grail of the battle against malaria, with the perverse effects entailed, namely that of blinding realities or throwing discredit on other types of possible interventions that are not

consistent with an accounting logic. He also notes that the average figure of estimated deaths due to malaria was at a quasi stagnation in 2008 and that the lives of 34,000 African children of less than 5 years of age saved between 2006 and 2008 was achieved in the context of the reduction in infant mortality resulting from a series of causes among which it is impossible to individualise malaria with certainty. He finally points out that Eritrea, Rwanda, Zambia, So Tome y Principe and the Tanzanian island of Zanzibar which quite regularly serve as showcases to RBM and UNICEF and which report spectacular progress in the field of prevention of malaria accompanied by a parallel reduction in its mortality, are, for different reasons, far from being representative of the totality of African countries and that they should be considered as exceptions rather than examples to be exploited without restraint. On the other hand, the author considers that deluding the grand public into thinking that a few watchwords, slogans and simple, even simplistic, ideas would enable eradicating malaria given that large sums of money are made available, is not quite honest and may finally prove to be dangerous. He warns against the false hopes concerning the impact of coming discoveries on the antimalarial battle often conjured up to take over today's actions, by recalling that a century of scientific, technological and medical progress has not positively translated into any decisive progress in the prevention or treatment of this disease, in spite of the issue of scientific publications on the subject at every 20 minute interval since more than thirty years. Although the author willingly agrees that huge financial means are essential and for a long time to come, he however believes that they would not suffice to enable, in countries with high rates of transmission, the elimination of a disease that is not solely linked to biological, ecological and entomological parameters, but that is also anchored to the economic, societal, social and cultural contexts that are quite often forgotten and on which it is difficult, but essential, to act in order to obtain long lasting results. He recalls, on this occasion, that man, as an individual in relationship with his surroundings, should also be at the heart of the battle on the same footing as

the anopheles and the plasmodium, even if this, at times, leads to clashes between medical logic and native social, traditional, popular, scholarly or religious logics. He regrets, similarly and within the spirit of the Abuja declaration, that the educational systems of African countries having a high transmission rate do not play the role they had to assume in the battle against malaria and are not mobilised much better than they are, by including, for example, in the primary and secondary curriculum of public and private schools, on the same footing as the learning of the alphabet or of the multiplication tables, a compulsory adapted instruction in malaria, so that children not only become victims but also "actors in the battle against malaria". The author finally underlines the absolute necessity to rapidly strengthen health care facilities of the most affected countries, particularly in the rural area, and plead that this intensification becomes a true priority financed on its own merits. The Global Malaria Action Plan, that will take over from the RBM and would have the advantage of masking the insufficient results obtained by the latter, would have to face two huge challenges: an ancient but recurring one that concerns, in the context of a world economic crisis, the financing of the battle against malaria and the other one, new and associated with the development of resistance by Plasmodium falciparum to artemisinin, a first- and lastline antimalaria drug. PMID: 20652477 [PubMed - indexed for MEDLINE]

144. BMC Health Serv Res. 2010 Jul 2;10 Suppl 1:S8. doi: 10.1186/14726963-10-S1-S8. Methods for evaluating delivery systems for scaling-up malaria control intervention. Webster J, Chandramohan D, Hanson K. Disease Control and Vector Biology Unit, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK. Jayne.Webster@lshtm.ac.uk BACKGROUND: Despite increased resources over the past few years the coverage of

malaria control interventions is still inadequate to reach national and international targets and achieve the full potential of the interventions to improve population health. One of the reasons for this inadequate coverage of efficacious interventions is the limited understanding of the optimum delivery systems of the interventions in different contexts. Although there have been debates about how to deliver interventions, the methods for evaluating the effectiveness of different delivery systems have rarely been discussed. Delivery of interventions is relatively complex and a thorough evaluation would need to look holistically at multiple steps in the delivery process and at multiple factors influencing the process. A better understanding of the strength of the evidence on delivery system effectiveness is needed in order to optimise delivery of efficacious interventions. METHODS: A literature review was conducted of methods used to evaluate delivery systems for insecticide treated nets, intermittent preventive treatment in pregnant women, and treatment for malaria in children. RESULTS: The methodology of delivery system evaluations varied. There were inconsistencies between objectives and methods of the evaluations including inappropriate outcome measures and unnecessary controls. There were few examples where the delivery processes were adequately described, or measured. We propose a cross sectional observational study design with attribution of the outcomes to a specific delivery system as an appropriate method for evaluating delivery systems at scale. CONCLUSIONS: The proposed evaluation framework is adaptable to natural experiments at scale, and can be applied using data from routine surveys such as the Demographic and Health Surveys, modified by the addition of one to two questions for each intervention. This framework has the potential to enable wider application of rigorous evaluations and thereby improve the evidence base on which decisions about delivery systems for malaria control and other public health interventions are taken. PMCID: PMC2895752 PMID: 20594374 [PubMed - indexed for MEDLINE]

145. Malar J. 2010 Jul 12;9:199. doi: 10.1186/1475-2875-9-199. Impact of mass distribution of free long-lasting insecticidal nets on childhood malaria morbidity: the Togo National Integrated Child Health Campaign. Terlouw DJ, Morgah K, Wolkon A, Dare A, Dorkenoo A, Eliades MJ, Vanden Eng J, Sodahlon YK, ter Kuile FO, Hawley WA. Child and Reproductive Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK. d.j.terlouw@liv.ac.uk BACKGROUND: An evaluation of the short-term impact on childhood malaria morbidity of mass distribution of free long-lasting insecticidal nets (LLINs) to households with children aged 9-59 months as part of the Togo National Integrated Child Health Campaign. METHODS: The prevalence of anaemia and malaria in children aged zero to 59 months was measured during two cross-sectional household cluster-sample surveys conducted during the peak malaria transmission, three months before (Sept 2004, n=2521) and nine months after the campaign (Sept 2005, n=2813) in three districts representative of Togo's three epidemiological malaria transmission regions: southern tropical coastal plains (Yoto), central fertile highlands (Ogou) and northern semi-arid savannah (Tone). RESULTS: In households with children<5 years of age, insecticide-treated net (ITN) ownership increased from <1% to >65% in all 3 districts. Reported ITN use by children during the previous night was 35.9%, 43.8% and 80.6% in Yoto, Ogou and Tone, respectively. Rainfall patterns were comparable in both years. The overall prevalence of moderate to severe anaemia (Hb<8.0 g/dL) was reduced by 28% (prevalence ratio [PR] 0.72, 95% CI 0.62-0.84) and mean haemoglobin was increased by 0.35 g/dL (95% CI 0.25-0.45).The effect was predominantly seen in children aged 18-59 months and in the two southern districts: PR (95% CI) for moderate to severe anaemia and clinical malaria: Yoto 0.62 (0.44-0.88) and 0.49 (0.35-0.75); Ogou 0.54 (0.37-0.79) and 0.85 (0.57-1.27), respectively. Similar reductions occurred in children<18 months in Ogou, but not in Yoto. No effect was seen in the semi-arid northern district despite a high malaria burden and ITN coverage.

CONCLUSIONS: A marked reduction in childhood malaria associated morbidity was observed in the year following mass distribution of free LLINs in two of the three districts in Togo. Sub-national level impact evaluations will contribute to a better understanding of the impact of expanding national malaria control efforts. PMCID: PMC2914062 PMID: 20624305 [PubMed - indexed for MEDLINE] 146. Bull World Health Organ. 2010 Jul 1;88(7):509-18. doi: 10.2471/BLT.09.069203. Epub 2009 Dec 1. Community-directed interventions for priority health problems in Africa: results of a multicountry study. CDI Study Group. Collaborators: Amazigo U, Diarra T, Wanji S, Enyong P, Tendongfor N, Njoumemi Z, Nana C, Moukam LV, Longang YT, Njie T, Datchoua F, Molioum I, Abia LK, Takougang I, Wabo JP, Darios TM, Henriette N, Ndeffo LN, Innocent F, Keuzeta JJ, Medard D, Tatah P, Amayunzu M, Oladepo O, Oshiname F, Ajuwon A, Jaiyeoba A, Alaba O, Olayinwola K, Otusanya S, Oyeyemi A, Titloye M, Adeniyi JD, Arulogun OS, Soyibo D, Lawanson OA, Adeniyi BA, Babalola CP, Elemile TT, Ndekwu OS, Oso JA, Andah L, Aiyede AI, Afolabi N, Kale OO, ElHassan E, Isyaku S, Sanda S, Enwezor FN, Adekeye O, Agbo F, Ogungbemi MK, Lawong D, Folurunsho F, Ibrahim F, Gwom A, Akogun O, Badaki JA, Echeta DO, Adesina AO, Njobdi S, Manabete J, Shitta K, Ahmed U, Okeibunor J, Homeida M, Ndyomugyenyi R, Kabali AT, Kiberu B, Mugaba Z, Sommerfeld J, Remme JH, Brieger W, Zimicki S. Special Programme for Research and Training in Tropical Diseases, World Health Organization, 20 avenue Appia, 1211 Geneva 27, Switzerland. hansremme@gmail.com OBJECTIVE: To determine the extent to which the community-directed approach used in onchocerciasis control in Africa could effectively and efficiently provide integrated delivery of other health interventions.

METHODS: A three-year experimental study was undertaken in 35 health districts from 2005 to 2007 in seven research sites in Cameroon, Nigeria and Uganda. Four trial districts and one comparison district were randomly selected in each site. All districts had established ivermectin treatment programmes, and in the trial districts four other established interventions - vitamin A supplementation, use of insecticide-treated nets, home management of malaria and short-course, directly-observed treatment for tuberculosis patients - were progressively incorporated into a community-directed intervention (CDI) process. At the end of each of the three study years, we performed quantitative evaluations of intervention coverage and provider costs, as well as qualitative assessments of the CDI process. FINDINGS: With the CDI strategy, significantly higher coverage was achieved than with other delivery approaches for all interventions except for shortcourse, directly-observed treatment. The coverage of malaria interventions more than doubled. The district-level costs of delivering all five interventions were lower in the CDI districts, but no cost difference was found at the first-line health facility level. Process evaluation showed that: (i) participatory processes were important; (ii) recurrent problems with the supply of intervention materials were a major constraint to implementation; (iii) the communities and community implementers were deeply committed to the CDI process; (iv) community implementers were more motivated by intangible incentives than by external financial incentives. CONCLUSION: The CDI strategy, which builds upon the core principles of primary health care, is an effective and efficient model for integrated delivery of appropriate health interventions at the community level in Africa. PMCID: PMC2897985 PMID: 20616970 [PubMed - indexed for MEDLINE] 147. Am J Trop Med Hyg. 2010 Jul;83(1):115-21. doi: 10.4269/ajtmh.2010.09-0684. Human antibody response to Anopheles gambiae saliva: an immunoepidemiological biomarker to evaluate the efficacy of insecticide-treated nets in malaria vector control.

Drame PM, Poinsignon A, Besnard P, Le Mire J, Dos-Santos MA, Sow CS, Cornelie S, Foumane V, Toto JC, Sembene M, Boulanger D, Simondon F, Fortes F, Carnevale P, Remoue F. Institut de Recherche pour le Dveloppement (IRD), UR024 "Epidmiologie et Prvention" Unit, Dakar, Senegal. papa-makhtar.drame@ird.fr For the fight against malaria, the World Health Organization (WHO) has emphasized the need for indicators to evaluate the efficacy of vector-control strategies. This study investigates a potential immunological marker, based on human antibody responses to Anopheles saliva, as a new indicator to evaluate the efficacy of insecticide-treated nets (ITNs). Parasitological, entomological, and immunological assessments were carried out in children and adults from a malaria-endemic region of Angola before and after the introduction of ITNs. Immunoglobulin G (IgG) levels to An. gambiae saliva were positively associated with the intensity of An. gambiae exposure and malaria infection. A significant decrease in the anti-saliva IgG response was observed after the introduction of ITNs, and this was associated with a drop in parasite load. This study represents the first stage in the development of a new indicator to evaluate the efficacy of malaria vector-control strategies, which could apply in other arthropod vector-borne diseases. PMCID: PMC2912587 PMID: 20595489 [PubMed - indexed for MEDLINE] 148. Malar J. 2010 Jun 28;9:187. doi: 10.1186/1475-2875-9-187. Impact of promoting longer-lasting insecticide treatment of bed nets upon malaria transmission in a rural Tanzanian setting with pre-existing high coverage of untreated nets. Russell TL, Lwetoijera DW, Maliti D, Chipwaza B, Kihonda J, Charlwood JD, Smith TA, Lengeler C, Mwanyangala MA, Nathan R, Knols BG, Takken W, Killeen GF. Biomedical and Environmental Thematic Group, Ifakara Health Institute, P.O. Box 53, Ifakara, Tanzania. t.russell2@uq.edu.au BACKGROUND: The communities of Namawala and Idete villages in southern Tanzania

experienced extremely high malaria transmission in the 1990s. By 2001-03, following high usage rates (75% of all age groups) of untreated bed nets, a 4.2-fold reduction in malaria transmission intensity was achieved. Since 2006, a national-scale programme has promoted the use of longer-lasting insecticide treatment kits (consisting of an insecticide plus binder) co-packaged with all bed nets manufactured in the country. METHODS: The entomological inoculation rate (EIR) was estimated through monthly surveys in 72 houses randomly selected in each of the two villages. Mosquitoes were caught using CDC light traps placed beside occupied bed nets between January and December 2008 (n = 1,648 trap nights). Sub-samples of mosquitoes were taken from each trap to determine parity status, sporozoite infection and Anopheles gambiae complex sibling species identity. RESULTS: Compared with a historical mean EIR of approximately 1400 infectious bites/person/year (ib/p/y) in 1990-94; the 2008 estimate of 81 ib/p/y represents an 18-fold reduction for an unprotected person without a net. The combined impact of longer-lasting insecticide treatments as well as high bed net coverage was associated with a 4.6-fold reduction in EIR, on top of the impact from the use of untreated nets alone. The scale-up of bed nets and subsequent insecticidal treatment has reduced the density of the anthropophagic, endophagic primary vector species, Anopheles gambiae sensu stricto, by 79%. In contrast, the reduction in density of the zoophagic, exophagic sibling species Anopheles arabiensis was only 38%. CONCLUSION: Insecticide treatment of nets reduced the intensity of malaria transmission in addition to that achieved by the untreated nets alone. Impacts were most pronounced against the highly anthropophagic, endophagic primary vector, leading to a shift in the sibling species composition of the A. gambiae complex. PMCID: PMC2902500 PMID: 20579399 [PubMed - indexed for MEDLINE] 149. Malar J. 2010 Jun 24;9:183. doi: 10.1186/1475-2875-9-183. Bed net ownership in Kenya: the impact of 3.4 million free bed nets.

Hightower A, Kiptui R, Manya A, Wolkon A, Vanden Eng JL, Hamel M, Noor A, Sharif SK, Buluma R, Vulule J, Laserson K, Slutsker L, Akhwale W. Division of Parasitic Diseases and Malaria, Centers for Disease Control, Center for Global Health, Mailstop F22, 4770 Buford Highway, Atlanta, GA 30341, USA. awh1@cdc.gov BACKGROUND: In July and September 2006, 3.4 million long-lasting insecticide-treated bed nets (LLINs) were distributed free in a campaign targeting children 0-59 months old (CU5s) in the 46 districts with malaria in Kenya. A survey was conducted one month after the distribution to evaluate who received campaign LLINs, who owned insecticide-treated bed nets and other bed nets received through other channels, and how these nets were being used. The feasibility of a distribution strategy aimed at a high-risk target group to meet bed net ownership and usage targets is evaluated. METHODS: A stratified, two-stage cluster survey sampled districts and enumeration areas with probability proportional to size. Handheld computers (PDAs) with attached global positioning systems (GPS) were used to develop the sampling frame, guide interviewers back to chosen households, and collect survey data. RESULTS: In targeted areas, 67.5% (95% CI: 64.6, 70.3%) of all households with CU5s received campaign LLINs. Including previously owned nets, 74.4% (95% CI: 71.8, 77.0%) of all households with CU5s had an ITN. Over half of CU5s (51.7%, 95% CI: 48.8, 54.7%) slept under an ITN during the previous evening. Nearly forty percent (39.1%) of all households received a campaign net, elevating overall household ownership of ITNs to 50.7% (95% CI: 48.4, 52.9%). CONCLUSIONS: The campaign was successful in reaching the target population, families with CU5s, the risk group most vulnerable to malaria. Targeted distribution strategies will help Kenya approach indicator targets, but will need to be combined with other strategies to achieve desired population coverage levels. PMCID: PMC2912322 PMID: 20576145 [PubMed - indexed for MEDLINE] 150. Malar J. 2010 Jun 23;9:177. doi: 10.1186/1475-2875-9-177.

Effect of trimethoprim-sulphamethoxazole on the risk of malaria in HIVinfected Ugandan children living in an area of widespread antifolate resistance. Gasasira AF, Kamya MR, Ochong EO, Vora N, Achan J, Charlebois E, Ruel T, Kateera F, Meya DN, Havlir D, Rosenthal PJ, Dorsey G. School of Medicine, Makerere University Kampala, Uganda. agasasira@gmail.com BACKGROUND: Daily trimethoprim-sulfamethoxazole (TS) protects against malaria, but efficacy may be diminished as anti-folate resistance increases. This study assessed the incidence of falciparum malaria and the prevalence of resistance-conferring Plasmodium falciparum mutations in HIV-infected children receiving daily TS and HIV-uninfected children not taking TS. MATERIALS AND METHODS: Subjects were 292 HIV-infected and 517 uninfected children from two cohort studies in Kampala, Uganda observed from August 2006 to December 2008. Daily TS was given to HIV-infected, but not HIV-uninfected children and all participants were provided an insecticide-treated bed net. Standardized protocols were used to measure the incidence of malaria and identify markers of antifolate resistance. RESULTS: Sixty-five episodes of falciparum malaria occurred in HIVinfected and 491 episodes in uninfected children during the observation period. TS was associated with a protective efficacy of 80% (0.10 vs. 0.45 episodes per person year, p < 0.001), and efficacy did not vary over three consecutive 9.5 month periods (81%, 74%, 80% respectively, p = 0.506). The prevalences of dhfr 51I, 108N, and 59R and dhps 437G and 540E mutations were each over 90% among parasites infecting both HIV-infected and uninfected children. Prevalence of the dhfr 164L mutation, which is associated with high-level resistance, was significantly higher in parasites from HIV-infected compared to uninfected children (8% vs. 1%, p = 0.001). Sequencing of the dhfr and dhps genes identified only one additional polymorphism, dhps 581G, in 2 of 30 samples from HIV-infected and 0 of 54 samples from uninfected children. CONCLUSION: Despite high prevalence of known anti-folate resistancemediating mutations, TS prophylaxis was highly effective against malaria, but was associated with presence of dhfr 164L mutation.

PMCID: PMC2903607 PMID: 20573194 [PubMed - indexed for MEDLINE] 151. Malar J. 2010 Jun 18;9:173. doi: 10.1186/1475-2875-9-173. System effectiveness of a targeted free mass distribution of long lasting insecticidal nets in Zanzibar, Tanzania. Beer N, Ali AS, de Savigny D, Al-Mafazy AW, Ramsan M, Abass AK, Omari RS, Bjrkman A, Kllander K. Division of Global Health IHCAR, Department of Public Health Sciences, Karolinska Institutet, 171 77 Stockholm, Sweden. netta.beer@gmail.com BACKGROUND: Insecticide-treated nets (ITN) and long-lasting insecticidal treated nets (LLIN) are important means of malaria prevention. Although there is consensus regarding their importance, there is uncertainty as to which delivery strategies are optimal for dispensing these life saving interventions. A targeted mass distribution of free LLINs to children under five and pregnant women was implemented in Zanzibar between August 2005 and January 2006. The outcomes of this distribution among children under five were evaluated, four to nine months after implementation. METHODS: Two cross-sectional surveys were conducted in May 2006 in two districts of Zanzibar: Micheweni (MI) on Pemba Island and North A (NA) on Unguja Island. Household interviews were conducted with 509 caretakers of under-five children, who were surveyed for socio-economic status, the net distribution process, perceptions and use of bed nets. Each step in the distribution process was assessed in all children one to five years of age for unconditional and conditional proportion of success. System effectiveness (the accumulated proportion of success) and equity effectiveness were calculated, and predictors for LLIN use were identified. RESULTS: The overall proportion of children under five sleeping under any type of treated net was 83.7% (318/380) in MI and 91.8% (357/389) in NA. The LLIN usage was 56.8% (216/380) in MI and 86.9% (338/389) in NA. Overall system effectiveness was 49% in MI and 87% in NA, and equity was found in the distribution scale-up in NA. In both districts, the predicting factor of a child sleeping under an LLIN was caretakers thinking that LLINs are better than conventional nets (OR = 2.8, p

= 0.005 in MI and 2.5, p = 0.041 in NA), in addition to receiving an LLIN (OR = 4.9, p < 0.001 in MI and in OR = 30.1, p = 0.001 in NA). CONCLUSIONS: Targeted free mass distribution of LLINs can result in high and equitable bed net coverage among children under five. However, in order to sustain high effective coverage, there is need for complimentary distribution strategies between mass distribution campaigns. Considering the community's preferences prior to a mass distribution and addressing the communities concerns through information, education and communication, may improve the LLIN usage. PMCID: PMC2911471 PMID: 20565860 [PubMed - indexed for MEDLINE] 152. Malar J. 2010 Jun 10;9:156. doi: 10.1186/1475-2875-9-156. Progress and challenges to control malaria in a remote area of Chittagong hill tracts, Bangladesh. Haque U, Hashizume M, Sunahara T, Hossain S, Ahmed SM, Haque R, Yamamoto T, Glass GE. International Center for Diarrhoeal Disease Research Bangladesh, Mohakhali, Dhaka 1212, Bangladesh. ubydul@icddrb.org BACKGROUND: Malaria is endemic in 13 eastern districts where the overall infection prevalence is 3.97%. In 2006, Bangladesh received US$ 36.9 million from the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) to support the national malaria control programme of Bangladesh. OBJECTIVES: The objective of this study was to i) clarify factors associated with treatment seeking behaviours of malaria ii) distribution of LLIN, and iii) re-treatment of ITN in remote area of a CHT district of Bangladesh two years after implementation of national control programme. METHODS: All households of Rajasthali sub-district of Rangamati district (households about 5,322, population about 24,097), all BRAC health workers (n = 15), health facilities and drug vendors' locations were mapped. Distances from households to health facilities, BRAC health workers and drug vendors were calculated. Logistic regression analysis was performed to assess the associations between the choice of the treatment and the distance to various treatment

sources, education, occupation and ethnicity. SaTScan was used to detect clustering of treatment-seeking approaches. FINDINGS: LLIN distribution and the re-treatment of ITN exceeded target goals. The most common treatment facility for malaria-associated fever was malaria control programme led by BRAC and government (66.6%) followed by the drug vendor (48.8%). CONCLUSION: Closeness to health facilities run by the malaria control programme and drug vendors were significantly associated with the choice of treatment. A high proportion of people preferred drug vendors without having a proper diagnosis. Drug vendors are highly patronized and thus there is a need to improve their services for public health good. Otherwise it may cause incomplete treatment, misuse of anti-malarial drugs that will contribute to the risk of drug resistance and jeopardize the present malaria control efforts in Bangladesh. PMCID: PMC2910016 PMID: 20537127 [PubMed - indexed for MEDLINE] 153. East Afr Med J. 2009 Jul;86(7):314-22. Use of insecticide treated bed nets among pregnant women in Kilifi District, Kenya. Njoroge FK, Kimani VN, Ongore D, Akwale WS. Department of Community Health, College of Health Sciences, University of Nairobi, P.O. Box 19676-0202 Nairobi, Kenya. BACKGROUND: Malaria is one of the most serious public health problems in Kenya. Pregnant women are among the groups with the highest risk of malaria. Use of insecticide treated bed nets (ITNs) is a cost-effective method of controlling malaria. Despite this, there is low utilisation of ITNs among pregnant women in Kilifi district which is an endemic malaria zone. OBJECTIVE: To determine knowledge, attitude and practice on the use of ITNs in the prevention of malaria among pregnant women in Kilifi district. DESIGN: A descriptive cross-sectional study. SETTING: The district hospital and the five health centres in Kilifi district SUBJECTS: Two hundred and twenty pregnant women attending antenatal clinics (ANC) between October and December 2007. RESULTS: Knowledge on malaria illness and ITNs was high with majority of pregnant

women having adequate level of knowledge (86.9%). There was significant association between level of education and adequate knowledge (P-value = 0.010). Good attitude on ITNs use was low. There was no association between good attitude and any of the socio-demographic variables. The majority of pregnant women attending ANC owned ITNs (75.4%). ITNs usage was high (70.5%). There was significant association between religion and good practice (p-value = 0.050). Although adequate level of knowledge on malaria and protective role of ITNs was high, there was no association between knowledge with practice and attitude. CONCLUSION: Before any malaria preventive intervention is implemented in an area, different socio-cultural factors must be considered when behavioural interventions for malaria control are designed and implemented. Targeted health education should be disseminated to the community to remove stigma and misconceptions associated with ITNs. Community concerns and fears should be addressed. PMID: 20499780 [PubMed - indexed for MEDLINE]

154. East Afr Med J. 2009 Jul;86(7):308-13. Use of insecticide treated nets among caregivers of children under five years in Makueni District, Kenya. Malusha JM, Mwanzo I, Yitambe A, Mbugi JP. Ministry of Public Health and Sanitation, P.O. Box 172-01100, Kajiado, Kenya. BACKGROUND: Insecticide treated nets (ITNs) have been identified as a key strategy in addressing malaria problem among young children and pregnant women. Their utilisation among under fives, however, have been found to be low in some areas. OBJECTIVE: To identify factors affecting net utilisation (sleeping under insecticide treated net) among caregivers of under fives in Makueni District in Kenya. DESIGN: A cross-sectional, descriptive study. SETTING: Eight sub-locations in Wote division Makueni district. SUBJECTS: Four hundred caregivers of children aged five years and below. RESULTS: The results indicated that 88.5% of caregivers were aware of ITNs. The proportion of households with children below five years that owned mosquito net were found to be 46.2%, and only 32.0% had at least a treated net. Slightly more

than half of treated nets were used by under fives (52.2%) compared to 47.8% used by children over five years including adults. The main reason cited by majority of caregivers as a hindrance to net utilisation was lack of treated nets in households (72.3%). Utilisation of ITNs by under five children was found to be positively associated with knowledge of ITNs (p = 0.024), marital status (p = 0.018) and occupation (p = 0.043). CONCLUSION: Utilisation of ITNs by under fives was low despite high level of awareness among caregivers. Factors such as awareness of ITNs, marital status and occupation significantly affected ITNs utilisation. Although the government with support from other stakeholders has recently embarked on large scale distribution of nets in high risky districts, more interventions from various stakeholders are needed to increase availability and accessibility of subsidised permanently treated nets, including interventions to address non-compliance to proper utilisation of nets. There is also need for intensive education emphasising on their proper and consistent use. Scaling up proper use of ITNs along with other initiatives can contribute significantly in reducing malaria. PMID: 20499779 [PubMed - indexed for MEDLINE]

155. Niger J Clin Pract. 2010 Jun;13(2):144-8. ITN utilization among pregnant women attending ANC in Etsako West Lga, Edo State, Nigeria. Wagbatsoma VA, Aigbe EE. Department of Community Health, School of Medicine, College of Medical Sciences, University of Benin, Benin City, Nigeria. OBJECTIVE: To determine the factors affecting utilization of ITN by pregnant women in Etsako West LGA, Edo State. METHODOLOGY: A descriptive cross-sectional study design was employed. Using a systematic sampling method, a total of 385 respondents were selected from all ANC facilities in the LGA following a verbally obtained consent. Tool for data collection was a semi-structured, researcher administered questionnaire. RESULT: The respondents' knowledge of cause of malaria was good, as 269 (69%) had

good knowledge but only 9 (2.3%) knew its effects on the foetus. Meanwhile, ownership of ITN and its use were very low, 36 (9.3%) and 31 (8.0) respectively. The main factor affecting the use of the commodity in the LGA was unavailability of ITNs. Other factors included belief of the women on the effectiveness of the commodity, level of education, marital status and family sizes ofrespondents. CONCLUSION: Use of Insecticide treated bed net has been hampered by unavailability of the commodity. It is therefore recommended that efforts should be made to make the commodity available to reduce morbidity and mortality among this vulnerable group. PMID: 20499745 [PubMed - indexed for MEDLINE]

156. Malar J. 2010 May 18;9:133. doi: 10.1186/1475-2875-9-133. Assessing bed net use and non-use after long-lasting insecticidal net distribution: a simple framework to guide programmatic strategies. Vanden Eng JL, Thwing J, Wolkon A, Kulkarni MA, Manya A, Erskine M, Hightower A, Slutsker L. Centers for Disease Control and Prevention, Center for Global Health, Division of Parasitic Diseases and Malaria, 4770 Buford Hwy MS F-22, Atlanta, GA 30341, USA. jev8@cdc.gov BACKGROUND: Insecticide-treated nets (ITNs) are becoming increasingly available to vulnerable populations at risk for malaria. Their appropriate and consistent use is essential to preventing malaria, but ITN use often lags behind ITN ownership. In order to increase ITN use, it is necessary to devise strategies that accurately identify, differentiate, and target the reasons and types of non-use. METHODS: A simple method based on the end-user as the denominator was employed to classify each individual into one of four ITN use categories: 1) living in households not owning an ITN; 2) living in households owning, but not hanging an ITN; 3) living in households owning and hanging an ITN, but who are not sleeping under one; and 4) sleeping under an ITN. This framework was applied to survey data designed to evaluate long-lasting insecticidal nets (LLINs) distributions

following integrated campaigns in five countries: Togo, Sierra Leone, Madagascar, Kenya and Niger. RESULTS: The percentage of children <5 years of age sleeping under an ITN ranged from 51.5% in Kenya to 81.1% in Madagascar. Among the three categories of non-use, children living in households without an ITN make up largest group (range: 9.4%-30.0%), despite the efforts of the integrated child health campaigns. The percentage of children who live in households that own but do not hang an ITN ranged from 5.1% to 16.1%. The percentage of children living in households where an ITN was suspended, but who were not sleeping under it ranged from 4.3% to 16.4%. Use by all household members in Sierra Leone (39.9%) and Madagascar (60.4%) indicate that integrated campaigns reach beyond their desired target populations. CONCLUSIONS: The framework outlined in this paper provides a helpful tool to examine the deficiencies in ITN use. Monitoring and evaluation strategies designed to assess ITN ownership and use can easily incorporate this approach using existing data collection instruments that measure the standard indicators. PMCID: PMC2890673 PMID: 20482776 [PubMed - indexed for MEDLINE] 157. Acta Trop. 2010 Oct;116(1):24-30. doi: 10.1016/j.actatropica.2010.05.002. Epub 2010 May 11. Wash-resistance and field evaluation of alphacypermethrin treated longlasting insecticidal net (Interceptor) against malaria vectors Anopheles culicifacies and Anopheles fluviatilis in a tribal area of Orissa, India. Sharma SK, Upadhyay AK, Haque MA, Tyagi PK, Raghavendra K, Dash AP. National Institute of Malaria Research, Field Station, Sector-5, Rourkela 769 002, Orissa, India. suryaksharma@gmail.com A field trial was conducted on the efficacy of Interceptor nets-a longlasting insecticidal net (LLN) factory treated with alphacypermethrin 0.667% (w/w) corresponding to 200mg/m(2), against malaria vectors Anopheles culicifacies and Anopheles fluviatilis in one of the highly endemic areas of Orissa. The study area comprised 19 villages which were randomized into three clusters and

designated as Interceptor net cluster, untreated net cluster, and no net cluster. Baseline studies showed that both the vector species An. culicifacies and An. fluviatilis were 100% susceptible to alphacypermethrin. Results of wash-resistance and bio-efficacy of Interceptor nets showed 100% mortality in An. culicifacies and An. fluviatilis even after 20 washings. Bioassays on the Interceptor nets while in use in the field conditions showed a knockdown effect on 70-90% mosquitoes during different months of intervention after 3 min of exposure and 100% mortality was recorded after 24h of recovery period. The median knockdown time for these species ranged between 4.10-5.25 min and 4.005.00 min respectively during intervention period. In Interceptor net study area, there was a significant reduction of 88.9, 96.3 and 90.6% in the entry rate of An. culicifacies, An. fluviatilis and other anopheline species respectively with an over all reduction of 87.5% in total mosquitoes. The overall feeding success rate of mosquitoes in the trial villages was only 12.8% in comparison to 35.0 and 78.8% in villages with untreated nets and no nets respectively. A significant reduction was also recorded in parity rate and human blood index of vector species in Interceptor net area. The results of the study showed that Interceptor nets are effective against the malaria vectors and may be used as a suitable intervention strategy in high-risk areas. Copyright 2010 Elsevier B.V. All rights reserved. PMID: 20465990 [PubMed - indexed for MEDLINE]

158. Malar J. 2010 May 10;9:121. doi: 10.1186/1475-2875-9-121. Effect of training on the use of long-lasting insecticide-treated bed nets on the burden of malaria among vulnerable groups, south-west Ethiopia: baseline results of a cluster randomized trial. Deribew A, Alemseged F, Birhanu Z, Sena L, Tegegn A, Zeynudin A, Dejene T, Sudhakar M, Abdo N, Tessema F. Department of Epidemiology, Jimma University, Jimma, Ethiopia. amare_deribew@yahoo.com BACKGROUND: In Ethiopia, the utilization of long-lasting insecticidetreated bed

nets (LLITN) is hampered by behavioural factors such as low awareness and negative attitude of the community. The aim of this study was to present the design and baseline results of a cluster randomized trial on the effect of training of household heads on the use of LLITN. METHODS: This baseline survey was undertaken from February to March, 2009 as part of a randomized cluster trial. A total of 11 intervention and 11 control Gots (villages) were included in the Gilgel Gibe Field Research Centre, southwest Ethiopia. House to house visit was done in 4135 households to collect information about the use of LLITN and socio-demographic variables. For the diagnosis of malaria and anaemia, blood samples were collected from 2410 under-five children and 242 pregnant women. RESULTS: One fourth of the households in the intervention and control Gots had functional LLITN. Only 30% of the observed LLITN in the intervention and 28% in the control Gots were hanged properly. Adults were more likely to utilize LLITN than under-five children in the control and intervention Gots. The prevalence of malaria in under-five children in the intervention and control Gots was 10.5% and 8.3% respectively. The intervention and control Gots had no significant difference concerning the prevalence of malaria in under-five children, [OR = 1.28, (95%CI: 0.97, 1.69)]. Eight (6.1%) pregnant women in the intervention and eight (7.2%) in the control Gots were positive for malaria (P = 0.9). Children in the intervention Gots were less likely to have anaemia than children in the control Gots, [OR = 0.75, (95%CI: 0.62, 0.85)]. CONCLUSION: The availability and utilization of LLITN was low in the study area. The prevalence of malaria and anaemia was high. Intervention strategies of malaria should focus on high risk population and vulnerable groups. PMCID: PMC2891814 PMID: 20459742 [PubMed - indexed for MEDLINE] 159. BMC Infect Dis. 2010 Apr 30;10:109. doi: 10.1186/1471-2334-10-109. Lives saved by Global Fund-supported HIV/AIDS, tuberculosis and malaria programs: estimation approach and results between 2003 and end-2007. Komatsu R, Korenromp EL, Low-Beer D, Watt C, Dye C, Steketee RW, Nahlen BL,

Lyerla R, Garcia-Calleja JM, Cutler J, Schwartlnder B. The Global Fund to Fight AIDS, Tuberculosis and Malaria, Chemin Blandonnet 8, 1214 Vernier, Geneva, Switzerland. ryuichi.komatsu@theglobalfund.org BACKGROUND: Since 2003, the Global Fund has supported the scale-up of HIV/AIDS, tuberculosis and malaria control in low- and middle-income countries. This paper presents and discusses a methodology for estimating the lives saved through selected service deliveries reported to the Global Fund. METHODS: Global Fund-supported programs reported, by end-2007, 1.4 million HIV-infected persons on antiretroviral treatment (ARV), 3.3 million new smear-positive tuberculosis cases detected in DOTS (directly observed TB treatment, short course) programs, and 46 million insecticide-treated mosquito nets (ITNs) delivered. We estimated the corresponding lives saved using adaptations of existing epidemiological estimation models. RESULTS: By end-2007, an estimated 681,000 lives (95% uncertainty range 619,000-774,000) were saved and 1,097,000 (993,000-1,249,000) life-years gained by ARV. DOTS treatment would have saved 1.63 million lives (1.09-2.17 million) when compared against no treatment, or 408,000 lives (265,000-551,000) when compared against non-DOTS treatment. ITN distributions in countries with stable endemic falciparum malaria were estimated to have achieved protection from malaria for 26 million of child-years at risk cumulatively, resulting in 130,000 (27,000-232,000) under-5 deaths prevented. CONCLUSIONS: These results illustrate the scale of mortality effects that supported programs may have achieved in recent years, despite margins of uncertainty and covering only selected intervention components. Evidencebased evaluation of disease impact of the programs supported by the Global Fund with international and in-country partners must be strengthened using population-level data on intervention coverage and demographic outcomes, information on quality of services, and trends in disease burdens recorded in national health information systems. PMCID: PMC2876166 PMID: 20433714 [PubMed - indexed for MEDLINE] 160. Malar J. 2010 Apr 27;9:113. doi: 10.1186/1475-2875-9-113. Field efficacy of a new mosaic long-lasting mosquito net (PermaNet 3.0) against

pyrethroid-resistant malaria vectors: a multi centre study in Western and Central Africa. Corbel V, Chabi J, Dabir RK, Etang J, Nwane P, Pigeon O, Akogbeto M, Hougard JM. Institut de Recherche pour le Dveloppement, UR016, Caractrisation et Contrle des Populations de Vecteurs, 01 BP 4414 RP Cotonou, Rpublique du Bnin. vincent.corbel@ird.fr BACKGROUND: Due to the spread of pyrethroid-resistance in malaria vectors in Africa, new strategies and tools are urgently needed to better control malaria transmission. The aim of this study was to evaluate the performances of a new mosaic long-lasting insecticidal net (LLIN), i.e. PermaNet 3.0, against wild pyrethroid-resistant Anopheles gambiae s.l. in West and Central Africa. METHODS: A multi centre experimental hut trial was conducted in Malanville (Benin), Valle du Kou (Burkina Faso) and Pitoa (Cameroon) to investigate the exophily, blood feeding inhibition and mortality induced by PermaNet 3.0 (i.e. a mosaic net containing piperonyl butoxide and deltamethrin on the roof) comparatively to the WHO recommended PermaNet 2.0 (unwashed and washed 20-times) and a conventionally deltamethrin-treated net (CTN). RESULTS: The personal protection and insecticidal activity of PermaNet 3.0 and PermaNet 2.0 were excellent (>80%) in the "pyrethroid-tolerant" area of Malanville. In the pyrethroid-resistance areas of Pitoa (metabolic resistance) and Valle du Kou (presence of the L1014F kdr mutation), PermaNet 3.0 showed equal or better performances than PermaNet 2.0. It should be noted however that the deltamethrin content on PermaNet 3.0 was up to twice higher than that of PermaNet 2.0. Significant reduction of efficacy of both LLIN was noted after 20 washes although PermaNet 3.0 still fulfilled the WHO requirement for LLIN. CONCLUSION: The use of combination nets for malaria control offers promising prospects. However, further investigations are needed to demonstrate the benefits of using PermaNet 3.0 for the control of pyrethroid resistant mosquito populations in Africa. PMCID: PMC2877060 PMID: 20423479 [PubMed - indexed for MEDLINE]

161. Indian J Pediatr. 2010 Apr;77(4):425-30. doi: 10.1007/s12098-0100051-z. Epub 2010 Mar 19. Insecticide treated nets, antimalarials and child survival in India. Lal S, Lahariya C, Saxena VK. National Centre for Disease Control (National Institute of Communicable Diseases), Sham Nath Marg, Delhi, India. Malaria has been a complex public health problem affecting mainly the poor and the rural communities in India. Insecticide treated nets (ITN) and antimalarials are the two proven interventions for prevention and control of malaria. ITN has been amply demonstrated to be an effective intervention to protect children from malaria, and in preventing deaths due to falciparum malaria. Antimalarials are a therapeutic intervention for management of malaria, and prevention of complications due to Plasmodium falciparum infection. However, implementation of these interventions is fraught with problems of complex and multidimensional nature at the periphery. These can be addressed by optimizing the use of the 2 interventions, the insecticide treated nets and antimalarials, for area specific application and country specific needs, determined by the ecoepidemiological diversity of malaria in India. This article reviews the significant role of ITN in reducing child mortality, and the judicious use of antimalarials in the management of malaria patient, and the problems associated with the use of these interventions in protecting children against malaria in India. PMID: 20422322 [PubMed - indexed for MEDLINE]

162. Malar J. 2010 Apr 21;9:107. doi: 10.1186/1475-2875-9-107. Comparison of anaemia and parasitaemia as indicators of malaria control in household and EPI-health facility surveys in Malawi. Mathanga DP, Campbell CH Jr, Vanden Eng J, Wolkon A, Bronzan RN, Malenga GJ, Ali D, Desai M. Malaria Alert Centre, College of Medicine, University of Malawi, P/Bag 360,

Blantyre 3, Malawi. dmathang@mac.medcol.mw BACKGROUND: The World Health Organization has recommended that anaemia be used as an additional indicator to monitor malaria burden at the community level as malaria interventions are nationally scaled up. To date, there are no published evaluations of this recommendation. METHODS: To evaluate this recommendation, a comparison of anaemia and parasitaemia among 6-30 month old children was made during two repeated cross-sectional household (HH) and health facility (HF) surveys in six districts across Malawi at baseline (2005) and in a follow-up survey (2008) after a scale up of malaria control interventions. RESULTS: HH net ownership did not increase between the years (50.5% vs. 49.8%), but insecticide treated net (ITN) ownership increased modestly from 41.5% (95% CI: 37.2%-45.8%) in 2005 to 45.3% (95% CI: 42.6%-48.0%) in 2008. ITN use by children 6-30 months old, who were living in HH with at least one net, increased from 73.6% (95% CI:68.2%-79.1%) to 80.0% (95% CI:75.9%-84.1%) over the three-year period. This modest increase in ITN use was associated with a decrease in moderate to severe anaemia (Hb <8 g/dl) from 18.4% (95% CI:14.9%-21.8%) in 2005 to 15.4% (13.2%-17.7%) in 2008, while parasitaemia, measured as positiveslide microscopy, decreased from 18.9% (95% CI:14.7%-23.2%) to 16.9% (95% CI:13.8%-20.0%), a relative reduction of 16% and 11%, respectively. In HF surveys, anaemia prevalence decreased from 18.3% (95% CI: 14.9%-21.7%) to 15.4% (95% CI: 12.7%-18.2%), while parasitaemia decreased from 30.6% (95% CI: 25.7%-35.5%) to 13.2% (95% CI: 10.6%-15.8%), a relative reduction of 15% and 57%, respectively. CONCLUSION: Increasing access to effective malaria prevention was associated with a reduced burden of malaria in young Malawian children. Anaemia measured at the HF level at time of routine vaccination may be a good surrogate indicator for its measurement at the HH level in evaluating national malaria control programmes. PMCID: PMC2864286 PMID: 20409342 [PubMed - indexed for MEDLINE] 163. Malar J. 2010 Apr 20;9:102. doi: 10.1186/1475-2875-9-102. Costs and effects of two public sector delivery channels for long-lasting insecticidal nets in Uganda.

Kolaczinski JH, Kolaczinski K, Kyabayinze D, Strachan D, Temperley M, Wijayanandana N, Kilian A. Malaria Consortium - Africa Regional Office, PO Box 8045, Plot 2, Sturrock Road, Kampala, Uganda. jan.kolaczinski@lshtm.ac.uk BACKGROUND: In Uganda, long-lasting insecticidal nets (LLIN) have been predominantly delivered through two public sector channels: targeted campaigns or routine antenatal care (ANC) services. Their combination in a mixed-model strategy is being advocated to quickly increase LLIN coverage and maintain it over time, but there is little evidence on the efficiency of each system. This study evaluated the two delivery channels regarding LLIN retention and use, and estimated the associated costs, to contribute towards the evidence-base on LLIN delivery channels in Uganda. METHODS: Household surveys were conducted 5-7 months after LLIN distribution, combining questionnaires with visual verification of LLIN presence. Focus groups and interviews were conducted to further investigate determinants of LLIN retention and use. Campaign distribution was evaluated in Jinja and Adjumani while ANC distribution was evaluated only in the latter district. Costs were calculated from the provider perspective through retrospective analysis of expenditure data, and effects were estimated as cost per LLIN delivered and cost per treated-net-year (TNY). These effects were calculated for the total number of LLINs delivered and for those retained and used. RESULTS: After 5-7 months, over 90% of LLINs were still owned by recipients, and between 74% (Jinja) and 99% (ANC Adjumani) were being used. Costing results showed that delivery was cheapest for the campaign in Jinja and highest for the ANC channel, with economic delivery cost per net retained and used of USD 1.10 and USD 2.31, respectively. Financial delivery costs for the two channels were similar in the same location, USD 1.04 for campaign or USD 1.07 for ANC delivery in Adjumani, but differed between locations (USD 0.67 for campaign delivery in Jinja). Economic cost for ANC distribution were considerably higher (USD 2.27) compared to campaign costs (USD 1.23) in Adjumani. CONCLUSIONS: Targeted campaigns and routine ANC services can both achieve high LLIN retention and use among the target population. The comparatively higher

economic cost of delivery through ANC facilities was at least partially due to the relatively short time this system had been in existence. Further studies comparing the cost of well-established ANC delivery with LLIN campaigns and other delivery channels are thus encouraged. PMCID: PMC2868859 PMID: 20406448 [PubMed - indexed for MEDLINE] 164. Cochrane Database Syst Rev. 2010 Apr 14;(4):CD006657. doi: 10.1002/14651858.CD006657.pub2. Indoor residual spraying for preventing malaria. Pluess B, Tanser FC, Lengeler C, Sharp BL. Public Health and Epidemiology, Swiss Tropical and Public Health Institute, Basel, Switzerland, 4002. BACKGROUND: Primary malaria prevention on a large scale depends on two vector control interventions: indoor residual spraying (IRS) and insecticidetreated mosquito nets (ITNs). Historically, IRS has reduced malaria transmission in many settings in the world, but the health effects of IRS have never been properly quantified. This is important, and will help compare IRS with other vector control interventions. OBJECTIVES: To quantify the impact of IRS alone, and to compare the relative impacts of IRS and ITNs, on key malariological parameters. SEARCH STRATEGY: We searched the Cochrane Infectious Diseases Group Specialized Register (September 2009), CENTRAL (The Cochrane Library 2009, Issue 3), MEDLINE (1966 to September 2009), EMBASE (1974 to September 2009), LILACS (1982 to September 2009), mRCT (September 2009), reference lists, and conference abstracts. We also contacted researchers in the field, organizations, and manufacturers of insecticides (June 2007). SELECTION CRITERIA: Cluster randomized controlled trials (RCTs), controlled before-and-after studies (CBA) and interrupted time series (ITS) of IRS compared to no IRS or ITNs. Studies examining the impact of IRS on special groups not representative of the general population, or using insecticides and dosages not recommended by the World Health Organization (WHO) were excluded. DATA COLLECTION AND ANALYSIS: Two authors independently reviewed trials for

inclusion. Two authors extracted data, assessed risk of bias and analysed the data. Where possible, we adjusted confidence intervals (CIs) for clustering. Studies were grouped into those comparing IRS with no IRS, and IRS compared with ITNs, and then stratified by malaria endemicity. MAIN RESULTS: IRS versus no IRSStable malaria (entomological inoculation rate (EIR) > 1): In one RCT in Tanzania IRS reduced re-infection with malaria parasites detected by active surveillance in children following treatment; protective efficacy (PE) 54%. In the same setting, malaria case incidence assessed by passive surveillance was marginally reduced in children aged one to five years; PE 14%, but not in children older than five years (PE -2%). In the IRS group, malaria prevalence was slightly lower but this was not significant (PE 6%), but mean haemoglobin was higher (mean difference 0.85 g/dL).In one CBA trial in Nigeria, IRS showed protection against malaria prevalence during the wet season (PE 26%; 95% CI 20 to 32%) but not in the dry season (PE 6%; 95% CI -4 to 15%). In one ITS in Mozambique, the prevalence was reduced substantially over a period of 7 years (from 60 to 65% prevalence to 4 to 8% prevalence; the weighted PE before-after was 74% (95% CI 72 to 76%).Unstable malaria (EIR < 1): In two RCTs, IRS reduced the incidence rate of all malaria infections;PE 31% in India, and 88% (95% CI 69 to 96%) in Pakistan. By malaria species, IRS also reduced the incidence of P. falciparum (PE 93%, 95% CI 61 to 98% in Pakistan) and P. vivax (PE 79%, 95% CI 45 to 90% in Pakistan); There were similar impacts on malaria prevalence for any infection: PE 76% in Pakistan; PE 28% in India. When looking separately by parasite species, for P. falciparum there was a PE of 92% in Pakistan and 34% in India; for P. vivax there was a PE of 68% in Pakistan and no impact demonstrated in India (PE of -2%).IRS versus Insecticide Treated Nets (ITNs)Stable malaria (EIR > 1): Only one RCT was done in an area of stable transmission (in Tanzania). When comparing parasitological re-infection by active surveillance after treatment in short-term cohorts, ITNs appeared better, but it was likely not to be significant as the unadjusted CIs approached 1 (risk ratio IRS:ITN = 1.22). When the incidence of malaria episodes was measured by passive

case detection, no difference was found in children aged one to five years (risk ratio = 0.88, direction in favour of IRS). No difference was found for malaria prevalence or haemoglobin.Unstable malaria (EIR < 1): Two studies; for incidence and prevalence, the malaria rates were higher in the IRS group compared to the ITN group in one study. Malaria incidence was higher in the IRS arm in India (risk ratio IRS:ITN = 1.48) and in South Africa (risk ratio 1.34 but the cluster unadjusted CIs included 1). For malaria prevalence, ITNs appeared to give better protection against any infection compared to IRS in India (risk ratio IRS:ITN = 1.70) and also for both P. falciparum (risk ratio IRS:ITN = 1.78) and P. vivax (risk ratio IRS:ITN = 1.37). AUTHORS' CONCLUSIONS: Historical and programme documentation has clearly established the impact of IRS. However, the number of high-quality trials are too few to quantify the size of effect in different transmission settings. The evidence from randomized comparisons of IRS versus no IRS confirms that IRS reduces malaria incidence in unstable malaria settings, but randomized trial data from stable malaria settings is very limited. Some limited data suggest that ITN give better protection than IRS in unstable areas, but more trials are needed to compare the effects of ITNs with IRS, as well as to quantify their combined effects. PMID: 20393950 [PubMed - indexed for MEDLINE]

165. Am J Trop Med Hyg. 2010 Apr;82(4):525-8. doi: 10.4269/ajtmh.2010.090188. Syndromic diagnosis of malaria in rural Sierra Leone and proposed additions to the national integrated management of childhood illness guidelines for fever. Nnedu ON, Rimel B, Terry C, Jalloh-Vos H, Baryon B, Bausch DG. Tulane University Health Sciences Center, New Orleans, Louisiana, USA. onnedu@u.washington.edu Many countries in Africa, including Sierra Leone, have adopted artemisinin-based combination therapy as first-line therapy for treatment of patients with malaria.

Because laboratory testing is often unavailable in rural areas, the costbenefit and viability of this approach may depend on accurately diagnosing malaria by using clinical criteria. We assessed the accuracy of syndromic diagnosis for malaria in three peripheral health units in rural Sierra Leone and determined factors that were associated with an accurate malaria diagnosis. Of 175 children diagnosed with malaria on syndromic grounds, 143 (82%) were confirmed by the Paracheck-Pf test. In a multivariate analysis, splenomegaly (P = 0.04) was the only clinical sign significantly associated with laboratory-confirmed malaria, and sleeping under a bed net was protective (P = 0.05). Our findings show that clinical malaria is diagnosed relatively accurately in rural Sierra Leone. Incorporating bed net use and splenomegaly into the national Integrated Management of Childhood Illness guidelines for evaluation of fever may further enhance diagnostic accuracy for malaria. PMCID: PMC2844576 PMID: 20348493 [PubMed - indexed for MEDLINE] 166. Malar J. 2010 Mar 24;9:84. doi: 10.1186/1475-2875-9-84. Evaluation of Interceptor long-lasting insecticidal nets in eight communities in Liberia. Banek K, Kilian A, Allan R. Uganda Malaria Surveillance Project, PO Box 7475, Kampala, Uganda. kebanek@yahoo.com BACKGROUND: By 2008, the WHO Pesticide Evaluation Scheme (WHOPES) recommended five long-lasting insecticidal nets (LLINs) for the prevention of malaria: Olyset((R)), PermaNet 2.0((R)), Netprotect((R)), Duranet((R)) and Interceptor((R)). Field information is available for both Olyset(R) and PermaNet((R)), with limited data on the newer LLINs. To address this gap, a field evaluation was carried out to determine the acceptability and durability of Interceptor((R)) LLINs. METHODS: A one-year prospective field study was conducted in eight rural returnee villages in Liberia. Households were randomized to receive Interceptor((R)) LLINs or conventionally treated nets (CTNs). Primary outcomes were levels of residual

alpha-cypermethrin measured by HPLC and participant utilization/acceptability of the ITNs. RESULTS: A total of 398 nets were analysed for residual alphacypermethrin. The median baseline concentrations of insecticide were 175.5 mg/m2 for the Interceptor((R)) LLIN and 21.8 mg/m2 for the CTN. Chemical residue loss after a one year follow-up period was 22% and 93% respectively. Retention and utilization of nets remained high (94%) after one year, irrespective of type, while parasitaemia prevalence decreased from 29.7% at baseline to 13.6% during the follow up survey (p = < 0.001). Interview and survey data show perceived effectiveness of ITNs was just as important as other physical attributes in influencing net utilization. CONCLUSION: Interceptor((R)) LLINs are effective and desirable in rural communities in Liberia. Consideration for end user preferences should be incorporated into product development of all LLINs in the future, in order to achieve optimum retention and utilization. PMCID: PMC2858215 PMID: 20334677 [PubMed - indexed for MEDLINE] 167. Am J Trop Med Hyg. 2010 Mar;82(3):420-5. doi: 10.4269/ajtmh.2010.090597. Contribution of integrated campaign distribution of long-lasting insecticidal nets to coverage of target groups and total populations in malariaendemic areas in Madagascar. Kulkarni MA, Vanden Eng J, Desrochers RE, Cotte AH, Goodson JL, Johnston A, Wolkon A, Erskine M, Berti P, Rakotoarisoa A, Ranaivo L, Peat J. HealthBridge, Ottawa, Ontario, Canada. mkulkarni@healthbridge.ca In October 2007, Madagascar conducted a nationwide integrated campaign to deliver measles vaccination, mebendazole, and vitamin A to children six months to five years of age. In 59 of the 111 districts, long-lasting insecticidal nets (LLINs) were delivered to children less than five years of age in combination with the other interventions. A community-based, cross-sectional survey assessed LLIN ownership and use six months post-campaign during the rainy season. LLIN ownership was analyzed by wealth quintile to assess equity. In the 59 districts, 76.8% of households possessed at least one LLIN from any source and 56.4% of

households possessed a campaign net. Equity of campaign net ownership was evident. Post-campaign, the LLIN use target of > or = 80% by children less than five years of age and a high level of LLIN use (69%) by pregnant women were attained. Targeted LLIN distribution further contributed to total population coverage (60%) through use of campaign nets by all age groups. PMCID: PMC2829903 PMID: 20207867 [PubMed - indexed for MEDLINE] 168. Am J Trop Med Hyg. 2010 Mar;82(3):415-9. doi: 10.4269/ajtmh.2010.090579. Insecticide-treated nets can reduce malaria transmission by mosquitoes which feed outdoors. Govella NJ, Okumu FO, Killeen GF. Ifakara Health Institute, Dar es Salaam, Tanzania. govella@ihi.or.tz Insecticide treated nets (ITNs) represent a powerful means for controlling malaria in Africa because the mosquito vectors feed primarily indoors at night. The proportion of human exposure that occurs indoors, when people are asleep and can conveniently use ITNs, is therefore very high. Recent evidence suggests behavioral changes by malaria mosquito populations to avoid contact with ITNs by feeding outdoors in the early evening. We adapt an established mathematical model of mosquito behavior and malaria transmission to illustrate how ITNs can achieve communal suppression of malaria transmission exposure, even where mosquito evade them and personal protection is modest. We also review recent reports from Tanzania to show that conventional mosquito behavior measures can underestimate the potential of ITNs because they ignore the importance of human movements. PMCID: PMC2829902 PMID: 20207866 [PubMed - indexed for MEDLINE] 169. Acta Trop. 2010 Jul-Aug;115(1-2):131-6. doi: 10.1016/j.actatropica.2010.02.014. Epub 2010 Mar 3. Anopheline fauna and malaria transmission in four ecologically distinct zones in

Cameroon. Atangana J, Bigoga JD, Patchok S, Ndjema MN, Tabue RN, Nem TE, Fondjo E. National Malaria Control Programme, Ministry of Public Health, Cameroon, P.O. Box: 14386, Yaounde, Cameroon. Knowledge of baseline malaria transmission intensity in a given environment is important to guide malaria control interventions. In Cameroon, recent information on malaria transmission intensity is insufficient. Therefore, an entomological study was conducted in four ecologically different sites throughout the country to assess the seasonal patterns in malaria transmission intensity. Anopheles arabiensis was the main vector in six of the nine study sites, while An. gambiae sensu stricto was the most important vector in the other three sites. Clear differences in entomological inoculation rates (EIR) were observed between the study sites, ranging from 0.1 infective bites per person per night in the sahelian zone of the country to 5.5 infective bites per person per night in the forest zone. Based on the observed behaviour of the vectors, insecticidetreated bed nets will be highly effective in controlling malaria. However, in the high transmission areas, additional measures will be needed to reduce the malaria burden to acceptable levels. 2010 Elsevier B.V. All rights reserved. PMID: 20206111 [PubMed - indexed for MEDLINE]

170. Malar J. 2010 Feb 24;9:58. doi: 10.1186/1475-2875-9-58. Malaria indicator survey 2007, Ethiopia: coverage and use of major malaria prevention and control interventions. Jima D, Getachew A, Bilak H, Steketee RW, Emerson PM, Graves PM, Gebre T, Reithinger R, Hwang J; Ethiopia Malaria Indicator Survey Working Group. Collaborators: Amena M, Bergeron L, Bilak H, Chirwa B, Demeke F, Dinkessa W, Ejigsemahu Y, Emerson PM, Endeshaw T, Etana K, Fente G, Filler S, Frolov A, Gausi K, Gebre T, Gebreyesus TA, Getachew A, Getachew A, Graves PM, HaileGiorgis Z,

Hailemariam A, Hwang J, Jima D, Kebede H, Lilay A, Lungu C, Medhin A, Mekasha A, Miller J, Mosher AW, Muhamed H, Mulatu S, Nefdt R, Ngondi J, Olana D, Reithinger R, Richards FO Jr, Seid A, Shargie EB, Steketee R, Tadesse Z, Teferri T, Tekalegne A, Tenaw E, Tilahun A, Wolkon A, Yigezu B, Yohannes G. Diseases Prevention and Control Department, Federal Ministry of Health, Addis Ababa, Ethiopia. BACKGROUND: In 2005, a nationwide survey estimated that 6.5% of households in Ethiopia owned an insecticide-treated net (ITN), 17% of households had been sprayed with insecticide, and 4% of children under five years of age with a fever were taking an anti-malarial drug. Similar to other sub-Saharan African countries scaling-up malaria interventions, the Government of Ethiopia set an ambitious national goal in 2005 to (i) provide 100% ITN coverage in malarious areas, with a mean of two ITNs per household; (ii) to scale-up indoor residual spraying of households with insecticide (IRS) to cover 30% of households targeted for IRS; and (iii) scale-up the provision of case management with rapid diagnostic tests (RDTs) and artemisinin-based combination therapy (ACT), particularly at the peripheral level. METHODS: A nationally representative malaria indicator survey (MIS) was conducted in Ethiopia between September and December 2007 to determine parasite and anaemia prevalence in the population at risk and to assess coverage, use and access to scaled-up malaria prevention and control interventions. The survey used a two-stage random cluster sample of 7,621 households in 319 census enumeration areas. A total of 32,380 people participated in the survey. Data was collected using standardized Roll Back Malaria Monitoring and Evaluation Reference Group MIS household and women's questionnaires, which were adapted to the local context. RESULTS: Data presented is for households in malarious areas, which according to the Ethiopian Federal Ministry of Health are defined as being located <2,000 m altitude. Of 5,083 surveyed households, 3,282 (65.6%) owned at least one ITN. In ITN-owning households, 53.2% of all persons had slept under an ITN the prior night, including 1,564/2,496 (60.1%) children <5 years of age, 1,891/3,009

(60.9%) of women 15 - 49 years of age, and 166/266 (65.7%) of pregnant women. Overall, 906 (20.0%) households reported to have had IRS in the past 12 months. Of 747 children with reported fever in the two weeks preceding the survey, 131 (16.3%) sought medical attention within 24 hours. Of those with fever, 86 (11.9%) took an anti-malarial drug and 41 (4.7%) took it within 24 hours of fever onset. Among 7,167 surveyed individuals of all ages, parasitaemia as estimated by microscopy was 1.0% (95% CI 0.5 - 1.5), with 0.7% and 0.3% due to Plasmodium falciparum and Plasmodium vivax, respectively. Moderate-severe anaemia (haemoglobin <8 g/dl) was observed in 239/3,366 (6.6%, 95% CI 4.9-8.3) children <5 years of age. CONCLUSIONS: Since mid-2005, the Ethiopian National Malaria Control Programme has considerably scaled-up its malaria prevention and control interventions, demonstrating the impact of strong political will and a committed partnership. The MIS showed, however, that besides sustaining and expanding malaria intervention coverage, efforts will have to be made to increase intervention access and use. With ongoing efforts to sustain and expand malaria intervention coverage, to increase intervention access and use, and with strong involvement of the community, Ethiopia expects to achieve its targets in terms of coverage and uptake of interventions in the coming years and move towards eliminating malaria. PMCID: PMC2841196 PMID: 20178654 [PubMed - indexed for MEDLINE] 171. Trans R Soc Trop Med Hyg. 2010 Jun;104(6):423-8. doi: 10.1016/j.trstmh.2010.01.001. Epub 2010 Feb 11. Increased financial accessibility and targeted education messages could increase ownership and use of mosquito nets in Purulia District, West Bengal, India. Biswas AK, Hutin YJ, Ramakrishnan R, Patra B, Gupte MD. West Bengal Directorate of Public Health, Kolkata, West Bengal, India; Master of Applied Epidemiology (MAE)-Field Epidemiology Training Programme (FETP), National Institute of Epidemiology (NIE), Chennai, Tamil Nadu, India. Insecticide-treated mosquito nets are effective in reducing malaria transmission

and mortality, yet they are underused for prevention. In this study, 561 households in 33 clusters were surveyed to estimate the coverage of net ownership and the frequency of use according to selected characteristics. Of the 540 participating household heads, 247 (46%) owned mosquito nets. Of 1681 individuals in households with mosquito nets, 1359 (81%) used the nets. A household monthly income > or =2000 Indian rupees (US$45) was strongly associated with mosquito net ownership (prevalence ratio=12, 95% CI 7.8-82). Factors independently associated with net use in multivariate analysis included age < 35 years (P<0.001), sleeping inside (P<0.001), use of repellent (P=0.03) as well as knowledge that mosquitoes cause malaria (P=0.002) and that malaria is severe in children (P<0.001). Whilst household income is the strongest determinant of mosquito net ownership, selected knowledge elements are associated with net use. It is necessary to improve financial accessibility to nets and to communicate that malaria is a disease transmitted by mosquitoes that could be fatal in children. 2010 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved. PMID: 20153006 [PubMed - indexed for MEDLINE]

172. Trop Med Int Health. 2010 Apr;15(4):480-8. doi: 10.1111/j.13653156.2010.02478.x. Epub 2010 Feb 9. Long-lasting insecticide-treated net usage in eastern Sierra Leone - the success of free distribution. Gerstl S, Dunkley S, Mukhtar A, Maes P, De Smet M, Baker S, Maikere J. Mdecins Sans Frontires-United Kingdom, London, UK. sgerstl@aol.com <sgerstl@aol.com> OBJECTIVE: Mdecins Sans Frontires (MSF) runs a malaria control project in Bo and Pujehun districts (population 158 000) that includes the mass distribution, routine delivery and demonstration of correct use of free, long-lasting insecticide-treated nets (LLINs). In 2006/2007, around 65 000 LLINs were distributed. The aim of this follow-up study was to measure LLIN usage and ownership in the project area. METHODS: Heads of 900 randomly selected households in 30 clusters were

interviewed, using a standardized questionnaire, about household use of LLINs. The condition of any LLIN was physically assessed. RESULTS: Of the 900 households reported, 83.4% owning at least one LLIN. Of the 16.6% without an LLIN, 91.9% had not participated in the MSF mass distribution. In 94.1% of the households reporting LLINs, the nets were observed hanging correctly over the beds. Of the 1135 hanging LLINs, 75.2% had no holes or 10 or fewer finger-size holes. The most common source of LLINs was MSF (75.2%). Of the 4997 household members, 67.2% reported sleeping under an LLIN the night before the study, including 76.8% of children under 5 years and 73.0% of pregnant women. CONCLUSION: Our results show that MSF achieved good usage with freely distributed LLINs. It is one of the few areas where results almost achieve the new targets set in 2005 by Roll Back Malaria to have at least 80% of pregnant women and children under 5 years using LLINs by 2010. PMID: 20149163 [PubMed - indexed for MEDLINE]

173. PLoS One. 2010 Feb 4;5(2):e9047. doi: 10.1371/journal.pone.0009047. Differential patterns of infection and disease with P. falciparum and P. vivax in young Papua New Guinean children. Lin E, Kiniboro B, Gray L, Dobbie S, Robinson L, Laumaea A, Schpflin S, Stanisic D, Betuela I, Blood-Zikursh M, Siba P, Felger I, Schofield L, Zimmerman P, Mueller I. PNG Institute of Medical Research, Madang, Papua New Guinea. BACKGROUND: Where P. vivax and P. falciparum occur in the same population, the peak burden of P. vivax infection and illness is often concentrated in younger age groups. Experiences from malaria therapy patients indicate that immunity is acquired faster to P. vivax than to P. falciparum challenge. There is however little prospective data on the comparative risk of infection and disease from both species in young children living in co-endemic areas. METHODOLOGY/PRINCIPAL FINDINGS: A cohort of 264 Papua New Guinean children aged 1-3 years (at enrolment) were actively followed-up for Plasmodium infection and

febrile illness for 16 months. Infection status was determined by light microscopy and PCR every 8 weeks and at each febrile episode. A generalised estimating equation (GEE) approach was used to analyse both prevalence of infection and incidence of clinical episodes. A more pronounced rise in prevalence of P. falciparum compared to P. vivax infection was evident with increasing age. Although the overall incidence of clinical episodes was comparable (P. falciparum: 2.56, P. vivax 2.46 episodes / child / yr), P. falciparum and P. vivax infectious episodes showed strong but opposing age trends: P. falciparum incidence increased until the age of 30 months with little change thereafter, but incidence of P. vivax decreased significantly with age throughout the entire age range. For P. falciparum, both prevalence and incidence of P. falciparum showed marked seasonality, whereas only P. vivax incidence but not prevalence decreased in the dry season. CONCLUSIONS/SIGNIFICANCE: Under high, perennial exposure, children in PNG begin acquiring significant clinical immunity, characterized by an increasing ability to control parasite densities below the pyrogenic threshold to P. vivax, but not to P. falciparum, in the 2(nd) and 3(rd) year of life. The ability to relapse from long-lasting liver-stages restricts the seasonal variation in prevalence of P. vivax infections. PMCID: PMC2816213 PMID: 20140220 [PubMed - indexed for MEDLINE] 174. Int J Epidemiol. 2010 Feb;39(1):72-9. doi: 10.1093/ije/dyp363. An assessment of Lot Quality Assurance Sampling to evaluate malaria outcome indicators: extending malaria indicator surveys. Biedron C, Pagano M, Hedt BL, Kilian A, Ratcliffe A, Mabunda S, Valadez JJ. Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA. BACKGROUND: Large investments and increased global prioritization of malaria prevention and treatment have resulted in greater emphasis on programme monitoring and evaluation (M&E) in many countries. Many countries currently use large multistage cluster sample surveys to monitor malaria outcome indicators on

a regional and national level. However, these surveys often mask locallevel variability important to programme management. Lot Quality Assurance Sampling (LQAS) has played a valuable role for local-level programme M&E. If incorporated into these larger surveys, it would provide a comprehensive M&E plan at little, if any, extra cost. METHODS: The Mozambique Ministry of Health conducted a Malaria Indicator Survey (MIS) in June and July 2007. We applied LQAS classification rules to the 345 sampled enumeration areas to demonstrate identifying high- and lowperforming areas with respect to two malaria program indicators-'household possession of any bednet' and 'household possession of any insecticide-treated bednet (ITN)'. RESULTS: As shown by the MIS, no province in Mozambique achieved the 70% coverage target for household possession of bednets or ITNs. By applying LQAS classification rules to the data, we identify 266 of the 345 enumeration areas as having bednet coverage severely below the 70% target. An additional 73 were identified with low ITN coverage. CONCLUSIONS: This article demonstrates the feasibility of integrating LQAS into multistage cluster sampling surveys and using these results to support a comprehensive national, regional and local programme M&E system. Furthermore, in the recommendations we outlined how to integrate the Large Country-LQAS design into macro-surveys while still obtaining results available through current sampling practices. PMCID: PMC2912491 PMID: 20139435 [PubMed - indexed for MEDLINE] 175. Acta Trop. 2010 Jun;114(3):177-83. doi: 10.1016/j.actatropica.2010.01.012. Epub 2010 Feb 2. A community-directed strategy for sustainable malaria elimination on islands: short-term MDA integrated with ITNs and robust surveillance. Kaneko A. Karolinska Institutet, Island Malaria Group, Scheeles labo B2, Stockholm, Sweden. akirakaneko555@gmail.com

In the Asia Pacific sites with low and unstable transmission, elimination should be feasible with existing tools. On Aneityum island, Vanuatu, both Plasmodium falciparum and Plasmodium vivax malaria were eliminated in 1991 after implementation of a combined intervention package, including mass drug administration (MDA) and insecticide-treated bed nets (ITNs), with high degree of community involvement. Subsequently, community-based surveillance and vector control measures have kept. By reviewing the experiences of the Aneityum project, I intended to examine the roles of community in malaria elimination. To be successful, the program should transfer major intervention components from the external donor-directed initiative to the community-directed approach. Scaling up of community involvement from simple participation to social participation, where communities involve in health planning functions is necessary from malaria control to malaria elimination. Copyright (c) 2010 Elsevier B.V. All rights reserved. PMID: 20132788 [PubMed - indexed for MEDLINE]

176. CMAJ. 2010 Feb 9;182(2):152-6. doi: 10.1503/cmaj.090268. Epub 2010 Jan 11. Assessment of a national voucher scheme to deliver insecticide-treated mosquito nets to pregnant women. Marchant T, Schellenberg D, Nathan R, Armstrong-Schellenberg J, Mponda H, Jones C, Sedekia Y, Bruce J, Hanson K. London School of Hygiene and Tropical Medicine, London, UK. tanya.marchant@lshtm.ac.uk BACKGROUND: The benefits of a health-related intervention may be compromised by the challenges of delivering the intervention on a large scale. We analyzed the process involved in the Tanzania National Voucher Scheme, a system for delivering insecticide-treated mosquito nets to pregnant women. We aimed to identify potential ways to equitably improve overall coverage of the intervention. METHODS: We defined five steps in the process. We collected data from a multistage cluster survey of nationally representative households conducted in 2007 across 21 districts in Tanzania. Using these data, we multiplied the rate of

success of each step cumulatively to estimate the overall success of the system. RESULTS: The rate of coverage for use of insecticide-treated nets among pregnant women was 23% (95% confidence interval [CI] 19%-27%). We observed large differences in coverage by socio-economic status, from 7% (95% CI 4%-13%) among participants in the poorest households to 48% (95% CI 38%-59%) among those in the richest households. The rate of success of each step in the process was high (60%-98%). However, the cumulative rate of success for the process as a whole was low (30%). The largest and most inequitable reduction in coverage occurred in the step involving treatment of nets with insecticide. INTERPRETATION: The cumulative effect of modest attrition at several steps in the process substantially diminished the overall rate of coverage for all women, but most markedly among the poorest participants. Analysis of the process suggests that delivery of nets treated with long-lasting insecticide rather than untreated nets packaged with an insecticide-treatment kit could result in an improvement in coverage of 22 percentage points, from 30% to 52%. PMCID: PMC2817322 PMID: 20064944 [PubMed - indexed for MEDLINE] 177. Malar J. 2010 Jan 6;9:7. doi: 10.1186/1475-2875-9-7. Malaria control under the Taliban regime: insecticide-treated net purchasing, coverage, and usage among men and women in eastern Afghanistan. Howard N, Shafi A, Jones C, Rowland M. London School of Hygiene and Tropical Medicine, London, UK. natasha.howard@lshtm.ac.uk BACKGROUND: Scaling up insecticide-treated mosquito net (ITN) coverage is a key malaria control strategy even in conflict-affected countries 12. Socioeconomic factors influence access to ITNs whether subsidized or provided free to users. This study examines reported ITN purchasing, coverage, and usage in eastern Afghanistan and explores women's access to health information during the Taliban regime (1996-2001). This strengthens the knowledge base on householdlevel health choices in complex-emergency settings.

METHODS: Fifteen focus group discussions (FGDs) and thirty in-depth interviews were conducted with men and women from ITN-owning and non-owning households. FGDs included rank ordering, pile sorting and focused discussion of malaria knowledge and ITN purchasing. Interviews explored general health issues, prevention and treatment practices, and women's malaria knowledge and concerns. Seven key informant interviews with health-related workers and a concurrent survey of 200 ITN-owning and 214 non-owning households were used to clarify or quantify findings. RESULTS: Malaria knowledge was similar among men and women and ITN owners and non-owners. Women reported obtaining health information through a variety of sources including clinic staff, their husbands who had easier access to information, and particularly female peers. Most participants considered ITNs very desirable, though not usually household necessities. ITN owners reported more household assets than non-owners. Male ITN owners and non-owners ranked rugs and ITNs as most desired, while women ranked personal assets such as jewellery highest. While men were primarily responsible for household decisionmaking and purchasing, older women exerted considerable influence. Widow-led and landless households reported most difficulties purchasing ITNs. Most participants wanted to buy ITNs only if they could cover all household members. When not possible, preferential usage was given to women and children. CONCLUSIONS: Despite restricted access to health facilities and formal education, Afghan women were surprisingly knowledgeable about the causes of malaria and the value of ITNs in prevention. Inequities in ITN usage were noted between rather than within households, with some unable to afford even one ITN and others not wanting ITNs unless all household members could be protected. Malaria knowledge thus appears a lesser barrier to ITN purchasing and coverage in eastern Afghanistan than are pricing and distribution strategies. PMCID: PMC2817706 PMID: 20053281 [PubMed - indexed for MEDLINE] 178. PLoS One. 2009 Dec 23;4(12):e8321. doi: 10.1371/journal.pone.0008321.

Interactions between age and ITN use determine the risk of febrile malaria in children. Bejon P, Ogada E, Peshu N, Marsh K. Kenyan Medical Research Institute (KEMRI), Centre for Geographic Medicine Research (Coast), Kilifi, Kenya. pbejon@well.ox.ac.uk Erratum in PLoS One. 2011;6(2). doi: 10.1371/annotation/73a096b6-934c-4bc7-b0b1-de1f11231350. BACKGROUND: Control measures which reduce individual exposure to malaria are expected to reduce disease, but also to eventually reduce immunity. Reassuringly, long term data following community wide ITN distribution show sustained benefits at a population level. However, the more common practice in Sub-Saharan Africa is to target ITN distribution on young children. There are few data on the long term outcomes of this practice. METHODOLOGY/PRINCIPAL FINDINGS: Episodes of febrile malaria were identified by active surveillance in 383 children over 18 months of follow up. In order to compare the short and long term outcomes of ITN use, we examined interactions between ITN use and age (12-42 months of age versus 42-80 months) in determining the risk of febrile malaria. ITN use and older age protected against the first or only episode of malaria (Hazard Ratio [HR] = 0.33, 95%CI 0.17-0.65 and HR = 0.30, 95%CI 0.17-0.51, respectively). The interaction term between ITN use and older age was HR = 2.91, 95%CI 1.02-8.3, p = 0.045, indicating that ITNs did not protect older children. When multiple episodes were included in analysis, ITN use and older age were again protective against malaria episodes (Incident Rate Ratio [IRR] = 0.43 95%CI 0.27-0.7) and IRR = 0.23, 95%CI 0.13-0.42, respectively) and the interaction term indicated that ITNs did not protect older children (IRR = 2.71, 95%CI 1.3-5.7, p = 0.008). CONCLUSIONS/SIGNIFICANCE: These data on age interactions with ITN use suggest that larger scale studies on the long term individual outcomes should be undertaken if the policy of targeted ITN use for vulnerable groups is to continue. PMCID: PMC2792723 PMID: 20037643 [PubMed - indexed for MEDLINE]

179. PLoS One. 2009 Dec 22;4(12):e8409. doi: 10.1371/journal.pone.0008409. Is the scale up of malaria intervention coverage also achieving equity? Steketee RW, Eisele TP. Malaria Control and Evaluation Partnership in Africa (MACEPA)-PATH, Ferney-Voltaire, France. rsteketee@path.org BACKGROUND AND METHODS: Malaria in Africa is most severe in young children and pregnant women, particularly in rural and poor households. In many countries, malaria intervention coverage rates have increased as a result of scale up; but this may mask limited coverage in these highest-risk populations. Reports were reviewed from nationally representative surveys in African malariaendemic countries from 2006 through 2008 to understand how reported intervention coverage rates reflect access by the most at-risk populations. RESULTS: Reports were available from 27 Demographic and Health Surveys (DHSs), Multiple Indicator Cluster Surveys (MICSs), and Malaria Indicator Surveys (MISs) during this interval with data on household intervention coverage by urban or rural setting, wealth quintile, and sex. Household ownership of insecticide-treated mosquito nets (ITNs) varied from 5% to greater than 60%, and was equitable by urban/rural and wealth quintile status among 13 (52%) of 25 countries. Malaria treatment rates for febrile children under five years of age varied from less than 10% to greater than 70%, and while equitable coverage was achieved in 8 (30%) of 27 countries, rates were generally higher in urban and richest quintile households. Use of intermittent preventive treatment in pregnant women varied from 2% to more than 60%, and again tended to be higher in urban and richest quintile households. Across all countries, there were no significant male/female inequalities seen for children sleeping under ITNs or receiving antimalarial treatment for febrile illness. Parasitemia and anemia rates from eight national surveys showed predominance in poor and rural populations. CONCLUSIONS/SIGNIFICANCE: Recent efforts to scale up malaria intervention coverage have achieved equity in some countries (especially with ITNs), but delivery methods in other countries are not addressing the most at-risk

populations. As countries seek universal malaria intervention coverage, their delivery systems must reach the rural and poor populations; this is not a small task, but it has been achieved in some countries. PMCID: PMC2791860 PMID: 20027289 [PubMed - indexed for MEDLINE] 180. Malar J. 2009 Dec 16;8:298. doi: 10.1186/1475-2875-8-298. A cluster randomized controlled cross-over bed net acceptability and preference trial in Solomon Islands: community participation in shaping policy for malaria elimination. Atkinson JA, Bobogare A, Vallely A, Boaz L, Kelly G, Basifiri W, Forsyth S, Baker P, Appleyard B, Toaliu H, Williams G. Pacific Malaria Initiative Support Centre, Australian Centre for International and Tropical Health, School of Population Health, University of Queensland, Brisbane, Australia. joan.atkinson@uq.edu.au BACKGROUND: A key component of the malaria elimination strategy in Solomon Islands (SI) is widespread coverage of long-lasting insecticidal nets (LLINs). The success of this strategy is dependent on LLIN acceptability and compliance. There has been unresolved debate among policy makers and donors as to which type of LLIN would be most appropriate for large-scale distribution in SI, and anecdotal reports of a lack of acceptability of certain brands of LLINs. A cluster randomized controlled crossover bed net acceptability and preference trial was therefore carried out from July to September, 2008 to inform policy and to facilitate community engagement and participation in the selection of the most appropriate LLIN for use in SI. METHOD: A three-stage sampling method was used to randomly select the study population from Malaita Province, SI. Three brands of LLINs were assessed in this study: Olyset, PermaNet and DuraNet. Bed net acceptability and preference were evaluated through surveys at three defined time points after short and longer-term trial of each LLIN. RESULTS: The acceptability of PermaNet after short-term use (96.5%) was significantly greater than Olyset (67.3%, p < 0.001) and DuraNet (69.8%, p <

0.001). The acceptability of DuraNet and Olyset after short-term use was not significantly different at the 5% level. LLINs that were perceived not to prevent mosquito bites were significantly less acceptable than LLINs that were perceived to prevent mosquito bites (OR 0.15; 95%CI 0.03 to 0.6). LLINs that allow a pleasant night's sleep (OR 6.3; 95%CI:3.3-12.3) and have a soft texture (OR 5.7; 95%CI:1.9-20.5) were considered more acceptable than those that did not. Olyset's acceptability decreased over time and this was due to net wrinkling/shrinkage after washing resulting in reduced efficiency in preventing mosquito bites. The increase in DuraNet acceptability was a result of a reduction in minor adverse events following longer-term use. CONCLUSION: This research was conducted to inform LLIN procurement as part of the national malaria control and elimination programme in SI. The success of malaria elimination in the Pacific and elsewhere relies on provision of acceptable interventions, consideration of local-level realities and engagement of communities in strategy development. TRIAL REGISTRATIONS: Clinical trials ACTRN12608000322336. PMCID: PMC2803192 PMID: 20015402 [PubMed - indexed for MEDLINE]

181. Malar J. 2009 Dec 9;8:283. doi: 10.1186/1475-2875-8-283. The effects of zooprophylaxis and other mosquito control measures against malaria in Nouna, Burkina Faso. Yamamoto SS, Louis VR, Si A, Sauerborn R. Institute of Public Health, University of Heidelberg, Im Neuenheimer Feld 324, 69120 Heidelberg, Germany. shelby.yamamoto@urz.uni-heidelberg.de BACKGROUND: In the absence of large scale, organized vector control programmes, individual protective measures against mosquitoes are essential for reducing the transmission of diseases like malaria. Knowledge of the types and effectiveness of mosquito control methods used by households can aid in the development and promotion of preventive measures.

METHODS: A matched, population-based case control study was carried out in the semi-urban region of Nouna, Burkina Faso. Surveys and mosquito captures were conducted for each participating household. Data were analysed using conditional logistic regression and Pearson's product-moment correlations. RESULTS: In Nouna, Burkina Faso, the main types of reported mosquito control measures used included sleeping under bed nets (insecticide-treated and untreated) and burning mosquito coils. Most of the study households kept animals within the compound or house at night. Insecticide house sprays, donkeys, rabbits and pigs were significantly associated with a reduced risk of malaria only in univariate analyses. CONCLUSION: Given the conflicting results of the effects of zooprophylaxis from previous studies, other community-based preventive measures, such as bed nets, coils and insecticide house-spraying, may be of more benefit. PMCID: PMC2799429 PMID: 20003189 [PubMed - indexed for MEDLINE] 182. East Afr J Public Health. 2009 Aug;6(2):205-10. Knowledge, attitudes and practices of local inhabitants about insecticide treated nets (ITNs) for malaria control in an endemic area of Ethiopia. Kaliyaperumal K, Yesuf D. Jimma University, School of Environmental Health Sciences, Jimma, Ethiopia. k_karnamoorthi@yahoo.com OBJECTIVE: The present study was conducted to assess the knowledge, attitudes and practices of local residents about insecticide treated nets (ITNs) for malaria control in an endemic area of Ethiopia. METHODS: A descriptive cross-survey was conducted from July 2008 to September 2008. A structured questionnaire collecting sociodemographic, ITNs and malaria-related KAP information was administered to the representatives of households. SETTINGS: Azendabo town, Ethiopia. RESULTS: 84% of the inhabitants had awareness about malaria transmission; mosquito bites were identified correctly as the cause of malaria. 85.2% respondents indicated that mosquitoes bite at night. ITNs awareness level of inhabitants was 92.4%; however, just 57.8% of them own ITNs. 96.2% and 91.5% of

the inhabitants indicated the foremost reasons for nonpossession of ITNs were due to unaffordability and nonavailability. Inhabitants average monthly income significantly associated with the ITNs ownership at p<0.05 and, however educational status of the respondents and ITNs ownership was not significant (p=0.1). CONCLUSION: Indeed, respondents had adequate knowledge regarding ITNs and malaria related information. However, inhabitants had poor attitude and practice towards the ITNs utilization due to lack of availability and affordability. Therefore, besides health education campaign, distribution and promotion of ITNs to entire rural residents at free of charge may possibly bring constructive outcome in the near future. PMID: 20000031 [PubMed - indexed for MEDLINE]

183. J Infect Dis. 2010 Jan 1;201(1):123-31. doi: 10.1086/648595. The effect of intermittent preventive treatment during pregnancy on malarial antibodies depends on HIV status and is not associated with poor delivery outcomes. Serra-Casas E, Menndez C, Bardaj A, Quint L, Dobao C, Sigauque B, Jimnez A, Mandomando I, Chauhan VS, Chitnis CE, Alonso PL, Mayor A. Barcelona Centre for International Health Research, Hospital Clnic/Institut d'Investigacions Biomdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain. BACKGROUND: Intermittent preventive treatment during pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is recommended for malaria prevention in sub-Saharan Africa. However, studies reporting the effect of IPTp on malaria-specific immunity are scarce and are based on findings in human immunodeficiency virus (HIV)-negative primigravidae. METHODS: Plasma samples obtained from 302 pregnant women (177 who were HIV negative, 88 who were HIV positive, and 37 who were of unknown HIV status) participating in a placebo-controlled trial of IPTp with SP (IPTp-SP) were analyzed for the presence of antibodies against merozoite antigens, whole asexual parasites, and variant surface antigens from chondroitin sulfate Abinding and

nonbinding lines. Antibody levels were compared between intervention groups, and their association with morbidity outcomes was assessed. RESULTS: HIV-positive mothers receiving SP had lower levels of peripheral antibodies against apical membrane antigen-1 and variant surface antigens, as well as lower levels of cord antibodies against erythrocyte-binding antigen-175 and parasite lysate, than did HIV-positive placebo recipients. No difference between intervention groups was observed among HIV-negative mothers. High antibody levels were associated with maternal infection and an increased risk of a first malaria episode in infants. Antibody responses were not consistently associated with reduced maternal anemia, prematurity, or low birth weight. CONCLUSIONS: The IPTp-associated reduction in antibodies in HIV-infected women, but not in HIV-uninfected women, may reflect a higher efficacy of the intervention in preventing malaria among HIV-positive mothers. This reduction did not translate into an enhanced risk of malaria-associated morbidity in mothers and infants. Trial registration. Clinicaltrials.gov identifier NCT00209781. PMID: 19954383 [PubMed - indexed for MEDLINE]

184. Malar J. 2009 Nov 16;8:256. doi: 10.1186/1475-2875-8-256. Predicting the impact of insecticide-treated bed nets on malaria transmission: the devil is in the detail. Gu W, Novak RJ. Division of Infectious Diseases, University of Alabama, Birmingham, Alabama 35294, USA. wgu@uab.edu BACKGROUND: Insecticide-treated bed nets (ITNs), including long-lasting insecticidal nets (LLINs), play a primary role in global campaigns to roll back malaria in tropical Africa. Effectiveness of treated nets depends on direct impacts on individual mosquitoes including killing and excite-repellency, which vary considerably among vector species due to variations in host-seeking behaviours. While monitoring and evaluation programmes of ITNs have focuses on morbidity and all-cause mortality in humans, local entomological context receives little attention. Without knowing the dynamics of local vector species and their

responses to treated nets, it is difficult to predict clinical outcomes when ITN applications are scaled up across African continent. Sound model frameworks incorporating intricate interactions between mosquitoes and treated nets are needed to develop the predictive capacity for scale-up applications of ITNs. METHODS: An established agent-based model was extended to incorporate the direct outcomes, e.g. killing and avoidance, of individual mosquitoes exposing to ITNs in a hypothetical village setting with 50 houses and 90 aquatic habitats. Individual mosquitoes were tracked throughout the life cycle across the landscape. Four levels of coverage, i.e. 40, 60, 80 and 100%, were applied at the household level with treated houses having only one bed net. By using Latin hypercube sampling scheme, parameters governing killing, diverting and personal protection of net users were evaluated for their relative roles in containing mosquito populations, entomological inoculation rates (EIRs) and malaria incidence. RESULTS: There were substantial gaps in coverage between households and individual persons, and 100% household coverage resulted in circa 50% coverage of the population. The results show that applications of ITNs could give rise to varying impacts on population-level metrics depending on values of parameters governing interactions of mosquitoes and treated nets at the individual level. The most significant factor in determining effectiveness was killing capability of treated nets. Strong excito-repellent effect of impregnated nets might lead to higher risk exposure to non-bed net users. CONCLUSION: With variabilities of vector mosquitoes in host-seeking behaviours and the responses to treated nets, it is anticipated that scale-up applications of INTs might produce varying degrees of success dependent on local entomological and epidemiological contexts. This study highlights that increased ITN coverage led to significant reduction in risk exposure and malaria incidence only when treated nets yielded high killing effects. It is necessary to test efficacy of treated nets on local dominant vector mosquitoes, at least in laboratory, for monitoring and evaluation of ITN programmes. PMCID: PMC2780451 PMID: 19917119 [PubMed - indexed for MEDLINE]

185. Malar J. 2009 Nov 11;8:252. doi: 10.1186/1475-2875-8-252. Spatial risk profiling of Plasmodium falciparum parasitaemia in a high endemicity area in Cte d'Ivoire. Raso G, Silu KD, Vounatsou P, Singer BH, Yapi A, Tanner M, Utzinger J, N'Goran EK. Dpartement Environnement et Sant, Centre Suisse de Recherches Scientifiques, Abidjan, Cte d'Ivoire. giovanna.raso@gmail.com BACKGROUND: The objective of this study was to identify demographic, environmental and socioeconomic risk factors and spatial patterns of Plasmodium falciparum parasitaemia in a high endemicity area of Africa, and to specify how this information can facilitate improved malaria control at the district level. METHODS: A questionnaire was administered to about 4,000 schoolchildren in 55 schools in western Cte d'Ivoire to determine children's socioeconomic status and their habit of sleeping under bed nets. Environmental data were obtained from satellite images, digitized ground maps and a second questionnaire addressed to school directors. Finger prick blood samples were collected and P. falciparum parasitaemia determined under a microscope using standardized, qualitycontrolled methods. Bayesian variogram models were utilized for spatial risk modelling and mapping of P. falciparum parasitaemia at non-sampled locations, assuming stationary and non-stationary underlying spatial dependence. RESULTS: Two-thirds of the schoolchildren were infected with P. falciparum and the mean parasitaemia among infected children was 959 parasites/microl of blood. Age, socioeconomic status, not sleeping under a bed net, coverage rate with bed nets and environmental factors (e.g., normalized difference vegetation index, rainfall, land surface temperature and living in close proximity to standing water) were significantly associated with the risk of P. falciparum parasitaemia. After accounting for spatial correlation, age, bed net coverage, rainfall during the main malaria transmission season and distance to rivers remained significant covariates. CONCLUSION: It is argued that a massive increase in bed net coverage,

particularly in villages in close proximity to rivers, in concert with other control measures, is necessary to bring malaria endemicity down to intermediate or low levels. PMCID: PMC2783037 PMID: 19906295 [PubMed - indexed for MEDLINE] 186. J Epidemiol Community Health. 2011 Jan;65(1):78-82. doi: 10.1136/jech.2008.085449. Epub 2009 Nov 5. Timing of delivery of malaria preventive interventions in pregnancy: results from the Tanzania national voucher programme. Marchant T, Hanson K, Nathan R, Mponda H, Bruce J, Jones C, Sedekia Y, Mshinda H, Schellenberg J. London School of Hygiene and Tropical Medicine, London, UK. tanya.marchant@lshtm.ac.uk BACKGROUND: Across sub-Saharan Africa, pregnant women attend routine health services around the 20th week of gestation. OBJECTIVE: To investigate, with a view to maximising effectiveness of malaria control tools delivered via routine services, coverage of an antenatal clinic insecticide-treated net (ITN) voucher scheme in Tanzania by gestational age. METHODS: Household and antenatal clinic survey data from 21 districts in Tanzania were collected and analysed annually 2005-2007. Optimal voucher protection was defined as giving women access to vouchers for 24 weeks of pregnancy (weeks 16 and 40 gestation). The relationship between gestational age and use of ITNs throughout pregnancy was explored. RESULTS: Coverage of the ITN voucher was high (84% in 2007), but only 61% of optimal voucher protection was achieved. It was reduced by a combination of late attendance at clinic and staff not distributing vouchers at first visit. An increasing trend by gestational age in ITN use was observed each survey year, rising in 2007 from 23% of first-trimester women to 30% of women post partum ((2)=5.9, p=0.01). CONCLUSION: Uptake of malaria interventions is not evenly distributed throughout pregnancy. Including gestational age in pregnancy coverage indicators can enhance

understanding of the public health potential available from pregnancy interventions. PMID: 19897468 [PubMed - indexed for MEDLINE]

187. Malar J. 2009 Oct 29;8:248. doi: 10.1186/1475-2875-8-248. Impact of insecticide-treated nets on wild pyrethroid resistant Anopheles epiroticus population from southern Vietnam tested in experimental huts. Van Bortel W, Chinh VD, Berkvens D, Speybroeck N, Trung HD, Coosemans M. Institute of Tropical Medicine, Dept Parasitology, Nationalestraat 155, B-2000 Antwerpen, Belgium. wvbortel@itg.be BACKGROUND: In this study, the efficacy of insecticide-treated nets was evaluated in terms of deterrence, blood-feeding inhibition, induced exophily and mortality on a wild resistant population of Anopheles epiroticus in southern Vietnam, in order to gain insight into the operational consequences of the insecticide resistance observed in this malaria vector in the Mekong delta. METHOD: An experimental station, based on the model of West Africa and adapted to the behaviour of the target species, was built in southern Vietnam. The study design was adapted from the WHO phase 2 guidelines. The study arms included a conventionally treated polyester net (CTN) with deltamethrin washed just before exhaustion, the WHO recommended long-lasting insecticidal net (LLIN) PermaNet 2.0 unwashed and 20 times washed and PermaNet 3.0, designed for the control of pyrethroid resistant vectors, unwashed and 20 times washed. RESULTS: The nets still provided personal protection against the resistant An. epiroticus population. The personal protection ranged from 67% for deltamethrin CTN to 85% for unwashed PermaNet 3.0. Insecticide resistance in the An. epiroticus mosquitoes did not seem to alter the deterrent effect of pyrethroids. A significant higher mortality was still observed among the treatment arms despite the fact that the An. epiroticus population is resistant against the tested insecticides. CONCLUSION: This study shows that CTN and LLINs still protect individuals against a pyrethroid resistant malaria vector from the Mekong region, where insecticide resistance is caused by a metabolic mechanism. In the light of a possible

elimination of malaria from the Mekong region these insights in operational consequences of the insecticide resistance on control tools is of upmost importance. PMCID: PMC2781025 PMID: 19874581 [PubMed - indexed for MEDLINE] 188. Vector Borne Zoonotic Dis. 2010 May;10(4):403-10. doi: 10.1089/vbz.2008.0191. Wash-resistance and field efficacy of Olyset net, a permethrinincorporated long-lasting insecticidal netting, against Anopheles minimus-transmitted malaria in Assam, Northeastern India. Dev V, Raghavendra K, Barman K, Phookan S, Dash AP. National Institute of Malaria Research (Field Station), Chachal, Guwahati, India. mrcassam@hotmail.com INTRODUCTION: The long-lasting insecticidal nets are ready-to-use, pretreated nets, which do not require retreatment for 4-5 years. Olyset nets that are made of high-density polyethylene monofilament yarn with 2% w/w permethrin incorporated (corresponding to 1 g/m(2)) are type-2 in which insecticide is incorporated into the polymers and are wash resistant. In these, insecticide migrates to the surface of the netting fiber to be bioavailable against mosquitoes and other insect pests. STUDY SITE AND OBJECTIVES: The present study was a village scale, field-based trial that was conducted in Plasmodium falciparum predominant area of Assam to assess feasibility, acceptability, and sustainability of this intervention against vector populations and disease transmission. We here report the research findings of Olyset net as an intervention against Anopheles minimus-transmitted malaria in foothill area of Assam for the first year of observations beginning July 2005 till June 2006. RESULTS: An. minimus, the mosquito vector species, was observed to be fully susceptible to permethrin. Follow-up investigations revealed that An. minimus mosquitoes had virtually disappeared in Olyset net villages, which was corroborated by data on human bait mosquito-landing catches. There was a consistent decline in the malarial incidence in Olyset net intervention villages, and the overall impact on the malarial transmission was significant compared to

untreated net and no-net control villages for the corresponding study period. The bioavailability of insecticide on Olyset netting fiber was consistent (100% kill effect) up to 10 months of monitoring, and was observed to be wash resistant even after the 20th wash at fortnightly intervals. CONCLUSIONS: The Olyset nets were safe to use, wash resistant, and assessed to be operationally feasible, community-based intervention for sustainable management of disease vectors against malaria. Community compliance and acceptance was high, and users reported decreased nuisance due to biting mosquitoes. PMID: 19874188 [PubMed - indexed for MEDLINE]

189. Ann Afr Med. 2009 Apr-Jun;8(2):85-9. doi: 10.4103/1596-3519.56234. Insecticide-treated nets usage and malaria episodes among boarding students in Zaria, northern Nigeria. Aliyu AA, Alti-Mu'azu M. Department of Community Medicine, A.B.U., Zaria, Nigeria. draaaliyu@yahoo.com BACKGROUND: Despite malaria being the largest public health problem in Africa South of Sahara with over one million associated deaths each year, there has been little progress in its prevention/control during the past decades. Therefore, this study was conducted to determine the knowledge, attitude, use of insecticide-treated nets (ITNs), and the prevalence of malaria episodes among boarding secondary school pupils in Zaria, Nigeria. METHODS: A multi-stage sampling technique was used to sample five (5) secondary schools within Zaria, from which six classes (JSS 1 - 3 and SS 1- 3) of respondents were then randomly selected. Structured, closed-ended self-administered questionnaires were used to collect information on demographic characteristics, knowledge, attitude, and use of ITNs, reasons for nonuse and malaria episodes in last 12 months. RESULTS: A total of 150 students from the five (5) boarding secondary schools were interviewed, majority were in the age group 15-17 (53.3%) with a mean (x) SD of 16.8 0.8 years. Males were 60% and females 40% of respondents. Majority of the respondents (87.3%) knew about and had actually seen an ITN; only 43.3% were

current users. Most of the current users of ITN noticed a significant reduction in malaria episodes in the last 12 months. This was statistically significant (P=0.004). Cost and availability were reasons sited by non-ITN users. CONCLUSION: There is urgent need on the part of all the three tiers of Government for public health awareness campaigns through information, education and communication (IEC) to create positive ITN culture and usage. It is also suggested that ITN usage among boarding school pupils should be incorporated into school health service. PMID: 19805937 [PubMed - indexed for MEDLINE]

190. BMC Public Health. 2009 Oct 1;9:369. doi: 10.1186/1471-2458-9-369. The use of insecticide treated nets by age: implications for universal coverage in Africa. Noor AM, Kirui VC, Brooker SJ, Snow RW. Malaria Public Health and Epidemiology Group, Centre for Geographic Medicine, KEMRI-University of Oxford-Wellcome Trust Collaborative Programme, Kenyatta National Hospital Grounds, Nairobi, Kenya. anoor@nairobi.kemriwellcome.org BACKGROUND: The scaling of malaria control to achieve universal coverage requires a better understanding of the population sub-groups that are least protected and provide barriers to interrupted transmission. Here we examine the age pattern of use of insecticide treated nets (ITNs) in Africa in relation to biological vulnerabilities and the implications for future prospects for universal coverage. METHODS: Recent national household survey data for 18 malaria endemic countries in Africa were assembled to identify information on use of ITNs by age and sex. Age-structured medium variant projected population estimates for the midpoint year of the earliest and most recent national surveys were derived to compute the population by age protected by ITNs. RESULTS: All surveys were undertaken between 2005 and 2009, either as demographic health surveys (n = 12) or malaria indicator surveys (n = 6). Countries were categorized into three ITN use groups: <10%; 10 to <20%; and > or =20% and

projected population estimates for the mid-point year of 2007 were computed. In general, the pattern of overall ITNs use with age was similar by country and across the three country groups with ITNs use initially high among children <5 years of age, sharply declining among the population aged 5-19 years, before rising again across the ages 20-44 years and finally decreasing gradually in older ages. For all groups of countries, the highest proportion of the population not protected by ITNs (38% - 42%) was among those aged 5-19 years. CONCLUSION: In malaria-endemic Africa, school-aged children are the least protected with ITNs but represent the greatest reservoir of infections. With increasing school enrollment rates, school-delivery of ITNs should be considered as an approach to reach universal ITNs coverage and improve the likelihood of impacting upon parasite transmission. PMCID: PMC2761895 PMID: 19796380 [PubMed - indexed for MEDLINE] 191. Trends Parasitol. 2009 Nov;25(11):511-6. doi: 10.1016/j.pt.2009.08.002. Epub 2009 Sep 9. Predicting changing malaria risk after expanded insecticide-treated net coverage in Africa. Smith DL, Hay SI, Noor AM, Snow RW. Department of Biology and Emerging Pathogens Institute, University of Florida, P.O. Box 100009, Gainesville, Florida 32610, USA. smitdave@gmail.com The Roll Back Malaria (RBM) partnership has established goals for protecting vulnerable populations with locally appropriate vector control. In many places, these goals will be achieved by the mass distribution of insecticide treated bednets (ITNs). Mathematical models can forecast an ITN-driven realignment of malaria endemicity, defined by the Plasmodium falciparum parasite rate (PfPR) in children, to predict PfPR endpoints and appropriate program timelines for this change in Africa. The relative ease of measuring PfPR and its widespread use make it particularly suitable for monitoring and evaluation. This theory provides a

method for context-dependent evaluation of ITN programs and a basis for setting rational ITN coverage targets over the next decade. PMCID: PMC2768685 PMID: 19744887 [PubMed - indexed for MEDLINE] 192. J Pak Med Assoc. 2009 Jun;59(6):354-8. Awareness and use of insecticide treated nets among women attending antenatal clinic in a northern state of Nigeria. Musa OI, Salaudeen GA, Jimoh RO. Dept of Epidemiology & Community Health, College of Health Sciences, University of Ilorin, Ilorin, Nigeria. OBJECTIVE: To determine the awareness, accessibility and use of ITN by pregnant women attending ante-natal clinic (ANC) at the Primary Health Care (PHC) level considering the Government commitment of ensuring that at least 60% of pregnant women benefit from ITN by year 2010. METHODS: This descriptive cross sectional study was carried out in all 78 PHC centres in the state. Four hundred and fifty-five (455) pregnant women that consented to the study where interviewed during their ANC sessions using semi-structured questionnaires. Data entry and analysis was done on a micro computer; frequency tables and cross tabulations of important variables were done; and Chi-square test was used for the test of significance. RESULTS: About one-third 164 (36%) of the respondents were aware of ITN in malaria prevention, but less than a third 124 (27%) had ever used it and only 88 (19%) were currently using it, while 104 (23%) of the total respondents had a member of their household using ITN. Some of the difficulties encountered or experienced by respondents currently using ITN were scarcity of new nets, difficulty in getting chemicals for re-treatment of nets, non availability of quality ITN for sale. Three hundred and thirty-one (73%) respondents have never used ITN before because of lack of awareness 136 (41%), price of ITN is too costly 26 (8%) and non-availability of ITN for purchase 67 (20%). Respondents' age, educational level, parity and source of information or awareness on ITN have

no significant influence on ITN use (P > 0.05); however, the frequency of malaria attack among respondents using ITN was lower than those not using it and this was significant (P > 0.0043). CONCLUSION: Awareness and utilization of ITN among pregnant women and their household members is still low despite Government policy of free ITN for vulnerable groups and subsidized nets for other people. There is need to focus on creating demand for ITNs through all available health information channels including social marketing. PMID: 19534367 [PubMed - indexed for MEDLINE]

193. Trans R Soc Trop Med Hyg. 2009 Nov;103(11):1098-104. doi: 10.1016/j.trstmh.2009.03.003. Epub 2009 Apr 5. Preliminary examination of integrated vector management in a tropical rainforest area of Cameroon. Matthews GA, Dobson HM, Nkot PB, Wiles TL, Birchmore M. The Yaound Initiative Foundation, c/o IPARC, Imperial College London, Silwood Park, Ascot SL5 7PY, UK. g.matthews@imperial.ac.uk In the tropical rainforest area of Cameroon, people are affected by blackflies (Simulium spp.) and mosquitoes (Anopheles spp). Use of insecticidetreated bed nets (ITNs) has been promoted to protect vulnerable groups from mosquito bites, whereas historically indoor residual spraying (IRS) was the primary intervention. In a malaria-endemic area, a pilot study examined different mosquito control interventions applied to entire villages to assess their impact on vectors, malaria incidence and the quality of life of the communities. The Sanaga River near these villages was treated with insecticide to kill blackfly larvae. A medical survey of the six villages had shown that 20% of the population suffered from malaria, while 50% were infected with onchocerciasis and 5% with Loa loa. IRS+ITN using ICON CS (lambda-cyhalothrin capsule suspension formulation) or improved screening of houses combined with outdoor misting reduced the numbers of mosquitoes collected from exit traps compared to the other treatments. More

sporozoites were detected in mosquitoes sampled in exit traps in the untreated village than in the treated villages. Malaria incidence several months after treatments was not significantly different from pre-treatment levels. Blackfly adult populations were reduced for several weeks following larvicide application but recovered when treatment was halted. PMID: 19345969 [PubMed - indexed for MEDLINE]