Last data update: May 06, 2024. (Total: 46732 publications since 2009)
Records 1-28 (of 28 Records) |
Query Trace: Zulliger R[original query] |
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Contextual factors to improve implementation of malaria chemoprevention in children: A systematic review
Gatiba P , Laury J , Steinhardt L , Hwang J , Thwing JI , Zulliger R , Emerson C , Gutman JR . Am J Trop Med Hyg 2023 110 (1) 69-78 Malaria remains a leading cause of childhood morbidity and mortality in sub-Saharan Africa, particularly among children under 5 years of age. To help address this challenge, the WHO recommends chemoprevention for certain populations. For children and infants, the WHO recommends seasonal malaria chemoprevention (SMC), perennial malaria chemoprevention (PMC; formerly intermittent preventive treatment in infants [IPTi]), and, more recently, intermittent preventive treatment in school children (IPTsc). This review describes the contextual factors, including feasibility, acceptability, health equity, financial considerations, and values and preferences, that impact implementation of these strategies. A systematic search was conducted on July 5, 2022, and repeated April 13, 2023, to identify relevant literature. Two reviewers independently screened titles for eligibility, extracted data from eligible articles, and identified and summarized themes. Of 6,295 unique titles identified, 65 were included. The most frequently evaluated strategy was SMC (n = 40), followed by IPTi (n = 18) and then IPTsc (n = 6). Overall, these strategies were highly acceptable, although with IPTsc, there were community concerns with providing drugs to girls of reproductive age and the use of nonmedical staff for drug distribution. For SMC, door-to-door delivery resulted in higher coverage, improved caregiver acceptance, and reduced cost. Lower adherence was noted when caregivers were charged with giving doses 2 and 3 unsupervised. For SMC and IPTi, travel distances and inclement weather limited accessibility. Sensitization and caregiver education efforts, retention of high-quality drug distributors, and improved transportation were key to improving coverage. Additional research is needed to understand the role of community values and preferences in chemoprevention implementation. |
Interpersonal communication, cultural norms, and community perceptions associated with care-seeking for fever among children under age five in Mago district, Mozambique
Hutchinson P , Zulliger R , Butts JK , Candrinho B , Saifodine A , Eisele TP , Yukich J . Malar J 2023 22 (1) 279 BACKGROUND: Malaria is endemic throughout Mozambique, contributing significantly to the country's burden of disease. Prompt and effective treatment for fevers in children can limit the mortality and morbidity impacts of the disease but many children in the country are not taken for formal care when ill. Using an ideational model of behaviour, this study assesses the magnitude of the relationships for potential drivers of care-seeking, including interpersonal communication, malaria messaging, and knowledge and attitudes about malaria, with actual care-seeking behaviours for under-five children with fever in Magoé district, Mozambique. METHODS: Data on the care-seeking behaviours for fever come from a 2019 household malaria survey in Magoé district. Households were randomly selected for interview from among those with at least one child under age five and one net for every two household members. From 1621 mother-child dyads, the analytical sample consists of 300 children under age five with a fever in the 2 weeks prior to the survey. Multilevel random effects logistic regression models are estimated to test for associations between care-seeking behaviours and hypothesized behavioural determinants, including interpersonal communication (IPC), malaria messaging, ideational factors (e.g., norms, attitudes, beliefs, risk perceptions), and community characteristics. RESULTS: Overall, 18.5% of children under age five (N = 300) were reported to have fever in the previous 2 weeks and, of these, 68.5% were taken to a formal sector health care provider. Multivariate models highlight significant roles for interpersonal communication; care-seeking was highest among mothers who spoke only with friends/community members about malaria (94.0%, p < 0.001), followed by those who spoke only with their husband (78.6%, p = 0.015), relative to 63.3% who spoke with no one. Care-seeking decisions made by a child's grandmother were associated with a 25.0% point (p = 0.001) greater likelihood of seeking care relative to decisions made by the mother alone. Exposure to any malaria messaging was also positively associated with care-seeking (90.5% versus 62.7%, p < 0.001). In contrast, among all individual- and community-level ideational factors, only perceptions of self-efficacy to seek care were related to care-seeking behaviours. CONCLUSIONS: These results suggest that social and behaviour change interventions that focus on encouraging families and community members to talk about malaria and the need to promptly seek treatment for fevers in children may be particularly effective at increasing this behaviour in this and similar settings. Such messaging and IPC should consider grandmothers as a target audience, as they appear to be perceived as highly influential in care-seeking decision-making in this community. |
Mask use in public places in Maputo City, Mozambique: Cross-sectional survey
Balate D , Afai G , Sallé F , Simone T , Baltazar CS , Zulliger R , Rossetto É V . PLoS One 2023 18 (8) e0288957 INTRODUCTION: The use of face masks is one of the preventive measures that Mozambique adopted in order to limit the spread of COVID-19. A study carried out from May 25 to June 6, 2020 found that although many wore masks, incorrect use was observed in 27.5% of the population observed. This data collection aimed to measure the degree of mask use compliance during a more protracted, higher second wave of transmission. METHODOLOGY: A cross-sectional study was conducted in the City of Maputo from 19 to 28 October 2020 through direct observation of mask use of all individuals present in markets, supermarkets and bus terminals. The data were collected using mobile phones with the Open Data Kit Collect (ODK) data collection program. Sociodemographic characteristics, mask use, and type of mask used were documented. Factors associated with incorrect mask use were evaluated considering sex, age, observation period and location. RESULTS: A total of 49,404 individuals were observed, of whom 24,977(50.6%) were male, 46,484 (94.1%) were adults and 17,549 (35.5%) were observed in the markets. An observed 41,786 (84.6%) wore a mask, of whom 33,851 (81.0%) used it correctly. Not covering the mouth and nose was common; observed in 4,649 (58.5%) of those using incorrectly. Of different types of masks, fabric masks were most often used incorrectly 7,225 (21.4%). The factors associated with incorrect mask use were female gender (OR = 1.2 [1.1-1.3], p <0.001), observation in peri-urban versus urban areas (OR = 1.9 [1.8-2.1], p <0.001) and observation during the afternoon (OR = 1.5 [1.5-1.6], p <0. 001). CONCLUSION: A high proportion of observed individuals wore a mask in the context of prevention of COVID-19, however some non-use and incorrect use persists. Intensified public awareness of the correct use of the mask is recommended, especially in peri-urban areas and at the end of the day. |
Targeted and whole-genome sequencing reveal a north-south divide in P. falciparum drug resistance markers and genetic structure in Mozambique
da Silva C , Boene S , Datta D , Rovira-Vallbona E , Aranda-Díaz A , Cisteró P , Hathaway N , Tessema S , Chidimatembue A , Matambisso G , Nhama A , Macete E , Pujol A , Nhamussua L , Galatas B , Guinovart C , Enosse S , De Carvalho E , Rogier E , Plucinski MM , Colborn J , Zulliger R , Saifodine A , Alonso PL , Candrinho B , Greenhouse B , Aide P , Saute F , Mayor A . Commun Biol 2023 6 (1) 619 Mozambique is one of the four African countries which account for over half of all malaria deaths worldwide, yet little is known about the parasite genetic structure in that country. We performed P. falciparum amplicon and whole genome sequencing on 2251 malaria-infected blood samples collected in 2015 and 2018 in seven provinces of Mozambique to genotype antimalarial resistance markers and interrogate parasite population structure using genome-wide microhaplotyes. Here we show that the only resistance-associated markers observed at frequencies above 5% were pfmdr1-184F (59%), pfdhfr-51I/59 R/108 N (99%) and pfdhps-437G/540E (89%). The frequency of pfdhfr/pfdhps quintuple mutants associated with sulfadoxine-pyrimethamine resistance increased from 80% in 2015 to 89% in 2018 (p < 0.001), with a lower expected heterozygosity and higher relatedness of microhaplotypes surrounding pfdhps mutants than wild-type parasites suggestive of recent selection. pfdhfr/pfdhps quintuple mutants also increased from 72% in the north to 95% in the south (2018; p < 0.001). This resistance gradient was accompanied by a concentration of mutations at pfdhps-436 (17%) in the north, a south-to-north increase in the genetic complexity of P. falciparum infections (p = 0.001) and a microhaplotype signature of regional differentiation. The parasite population structure identified here offers insights to guide antimalarial interventions and epidemiological surveys. |
Using antenatal care as a platform for malaria surveillance data collection: study protocol
Gutman JR , Mwesigwa JN , Arnett K , Kangale C , Aaron S , Babarinde D , Buekens J , Candrinho B , Debe S , Digre P , Drake M , Gansané A , Gogue C , Griffith KS , Hicks J , Kinda R , Koenker H , Lemwayi R , Munsey A , Obi E , Ogouyèmi-Hounto A , Okoko OO , Onikpo F , Onoja A , Porter T , Savaio B , Tynuv K , Uhomoibhi P , Wagman J , Wolf K , Zulliger R , Walker P , Miller JM , Robertson M . Malar J 2023 22 (1) 99 BACKGROUND: While many malaria-endemic countries have health management information systems that can measure and report malaria trends in a timely manner, these routine systems have limitations. Periodic community cross-sectional household surveys are used to estimate malaria prevalence and intervention coverage but lack geographic granularity and are resource intensive. Incorporating malaria testing for all women at their first antenatal care (ANC) visit (i.e., ANC1) could provide a more timely and granular source of data for monitoring trends in malaria burden and intervention coverage. This article describes a protocol designed to assess if ANC-based surveillance could be a pragmatic tool to monitor malaria. METHODS: This is an observational, cross-sectional study conducted in Benin, Burkina Faso, Mozambique, Nigeria, Tanzania, and Zambia. Pregnant women attending ANC1 in selected health facilities will be tested for malaria infection by rapid diagnostic test and administered a brief questionnaire to capture key indicators of malaria control intervention coverage and care-seeking behaviour. In each location, contemporaneous cross-sectional household surveys will be leveraged to assess correlations between estimates obtained using each method, and the use of ANC data as a tool to track trends in malaria burden and intervention coverage will be validated. RESULTS: This study will assess malaria prevalence at ANC1 aggregated at health facility and district levels, and by gravidity relative to current pregnancy (i.e., gravida 1, gravida 2, and gravida 3 +). ANC1 malaria prevalence will be presented as monthly trends. Additionally, correlation between ANC1 and household survey-derived estimates of malaria prevalence, bed net ownership and use, and care-seeking will be assessed. CONCLUSION: ANC1-based surveillance has the potential to provide a cost-effective, localized measure of malaria prevalence that is representative of the general population and useful for tracking monthly changes in parasite prevalence, as well as providing population-representative estimates of intervention coverage and care-seeking behavior. This study will evaluate the representativeness of these measures and collect information on operational feasibility, usefulness for programmatic decision-making, and potential for scale-up of malaria ANC1 surveillance. |
Ideational factors and their association with insecticide treated net use in Magoe District, Mozambique
Yukich JO , Hutchinson P , Candrinho B , Butts J , Murimirgua F , Eisele TP , Zulliger R . Malar J 2022 21 (1) 387 BACKGROUND: Insecticide treated bed nets (ITN) are considered a core malaria vector control tool by the WHO and are the main contributor to the large decline in malaria burden in sub-Saharan Africa over the past 20 years, but they are less effective if they are not broadly and regularly used. ITN use may depend on factors including temperature, relative humidity, mosquito density, seasonality, as well as ideational or psychosocial factors including perceptions of nets and perceptions of net use behaviours. METHODS: A cross-sectional household survey was conducted as part of a planned randomized controlled trial in Magoe District, Mozambique. Interviewers captured data on general malaria and ITN perceptions including ideational factors related to perceived ITN response efficacy, self-efficacy to use an ITN, and community norms around ITN using a standardized questionnaire. Only households with sufficient ITNs present for all children to sleep under (at least one ITN for every two children under the age of five years) were eligible for inclusion in the study. Additional questions were added about seasonality and frequency of ITN use. RESULTS: One-thousand six hundred sixteen mother-child dyads were interviewed. Responses indicated gaps in use of existing nets and net use was largely independent of ideational factors related to ITNs. Self-reported ITN use varied little by season nor meaningfully when different methods were used to solicit responses on net use behaviour. Mothers' perceived response efficacy of ITNS was negatively associated with net use (high perceived response efficacy reduced the log-odds of net use by 0.27 (95% CI - 0.04 to - 0.51), implying that stronger beliefs in the effectiveness of ITNs might result in reduced net use among their children. CONCLUSIONS: In this context, ITN use among children was not clearly related to mothers' ideational factors measured in the study. Scales used in solicitation of ideation around ITN use and beliefs need careful design and testing across a broader range of populations in order to identify ideational factors related to ITN use among those with access. |
Adaptation to a multiplex bead assay and seroprevalence to Rift Valley Fever N protein: Nampula Province, Mozambique, 2013-2014
Rogier E , Plucinski M , Candrinho B , Moss DM , Gibbons A , Colborn J , Higgins J , Chambe G , Muchanga J , Muguande O , Matsinhe G , Mathe G , Doyle T , Zulliger R , Saifodine A , Montgomery JM , Klena JD , Priest JW . J Virol 2022 96 (16) e0067222 Rift Valley fever virus (RVFV) is endemic in sub-Saharan Africa (SSA), with outbreaks reported in the Arabian Peninsula and throughout SSA. The natural reservoir for RVFV are ruminants, with livestock populations exceeding 50% exposure rates in some areas of SSA. Transmission to humans can occur through exposure to infected livestock products or multiple species of mosquito vectors. In 2013 and 2014, cross-sectional surveys occurred in two districts of Nacala-a-Velha and Mecubri in northern Mozambique, and participants provided blood samples for later serological assays. IgG against the N protein of RVFV was detected through multiplex bead assay (MBA). Of the 2,278 persons enrolled between the two surveys and study sites, 181 (7.9%, 95% confidence interval (CI): 6.9%-9.1%) were found to be IgG seropositive with increasing seroprevalence with older age and significantly higher seroprevalence in Nacala-a-Velha (10.5%, 8.8%-12.5%) versus Mecubri (5.7%, 4.5%-7.1%). Seroprevalence estimates were not significantly different between the 2013 and 2014 surveys. Significant spatial clustering of IgG positive persons were consistent among surveys and within the two districts, pointing toward the consistency of serology data for making population-level assumptions regarding RVFV seroprevalence. A subset of persons (n=539) provided samples for both the 2013 and 2014 surveys, and a low percentage (0.81%) of these were found to seroconvert between these two surveys. Including the RVFV N protein in an MBA antigen panel could assist elucidate RVFV exposure in SSA. IMPORTANCE Due to sporadic transmission, human contact with Rift Valley Fever Virus (RVFV) is difficult to ascertain at a population level. Detection of antibodies against RVFV antigens assist in estimating exposure as antibodies remain in the host long after the virus has been cleared. In this study, we show that antibodies against RVFV N protein can be detected from dried blood spot (DBS) samples being assayed by multiplex bead assay. DBS from two districts in northern Mozambique were tested for IgG against the N protein, and 7.9% of all enrolled persons were seropositive. Older persons, males, and persons residing closer to the coast had higher RVFV N protein seroprevalence. Spatial clustering of IgG positive persons was noted in both districts. These results show low exposure rates to RVFV in these two northern districts in Mozambique, and the ability to perform serology for the RVFV N protein from dried blood samples. |
Missed plasmodium ovale infections among symptomatic persons in Angola, Mozambique, and Ethiopia
Leonard CM , Hwang J , Assefa A , Zulliger R , Candrinho B , Dimbu PR , Saifodine A , Plucinski M , Rogier E . Open Forum Infect Dis 2022 9 (7) ofac261 The majority of symptomatic malaria in sub-Saharan Africa is caused by Plasmodium falciparum. Infection with Plasmodium ovale is often not recorded and not considered clinically relevant. Here, we describe 8 cases of P ovale infection from 3 African countries-all of which were misdiagnosed at the presenting health facility. |
Factors associated with knowledge about malaria prevention among women of reproductive age, Tete Province, Mozambique, 2019-2020
Afai G , Rossetto EV , Baltazar CS , Candrinho B , Saifodine A , Zulliger R . Malar J 2022 21 (1) 76 BACKGROUND: Mozambique is a malaria endemic country with an estimated prevalence of malaria in children 6-59 months old that is twice as high in rural areas (46.0%) as in urban areas (18.0%). However, only 46.0% of women aged 15-49 years had complete knowledge about malaria in 2018. This study aimed to identify the factors associated with malaria knowledge among women of reproductive age in a high malaria burden district. METHODS: Data from a cross-sectional study, using a population-based malaria research study in Mágoe District, 2019, were analysed. This analysis included women aged 15-49 years. A multivariate logistic regression model was developed to determine factors associated with complete knowledge of malaria that calculated adjusted odds ratio (aOR) and 95% confidence interval (CI) at a p < 0.05 significance level. Complete malaria knowledge was defined as when a woman correctly identified: fever as a malaria symptom, mosquito bites as the means of malaria transmission, mosquito nets as a tool for malaria prevention, malaria as curable, and were able to name an anti-malarial. RESULTS: A total of 1899 women were included in this analysis. There was complete malaria knowledge among 49% of the respondents. Seventy one percent mentioned fever as one of malaria symptoms, 92% mentioned mosquito bite as the cause of malaria infection, 94% identified that mosquito nets prevent malaria, 92% agreed that malaria has cure, and 76% were able to name at least one anti-malarial medicine. In the multivariate analysis, the following characteristics were associated with significantly higher odds of having complete malaria knowledge: having a secondary school or above education level (adjusted Odds Ratio, aOR = 2.5 CI [1.3-4.6] p = 0.005), being from the middle socioeconomic status group (aOR = 1.5 CI [1.1-2.1] p = 0.005), being from older age group of 35-39 (aOR = 1.9; CI [1.1-3.1] p < 0.001), having 1-2 children (aOR = 1.8; CI [1.2-2.6] p = 0.003), and having interviews completed in Portuguese or Cinyungwe (aOR = 2.3; CI [1.3-4.1] p = 0.004 and aOR = 2.1; CI [1.5-2.8] p < 0.001, respectively). CONCLUSION: Most women in this study had some malaria knowledge, but gaps in complete knowledge remained. In order to broaden knowledge, educational messages about malaria prevention should be more effectively targeted to reach younger, less-educated women and in non-dominant languages. |
Molecular surveillance for polymorphisms associated with artemisinin-based combination therapy resistance in Plasmodium falciparum isolates collected in Mozambique, 2018.
Chidimatembue A , Svigel SS , Mayor A , Aíde P , Nhama A , Nhamussua L , Nhacolo A , Bassat Q , Salvador C , Enosse S , Saifodine A , De Carvalho E , Candrinho B , Zulliger R , Goldman I , Udhayakumar V , Lucchi NW , Halsey ES , Macete E . Malar J 2021 20 (1) 398 BACKGROUND: Due to the threat of emerging anti-malarial resistance, the World Health Organization recommends incorporating surveillance for molecular markers of anti-malarial resistance into routine therapeutic efficacy studies (TESs). In 2018, a TES of artemether-lumefantrine (AL) and artesunate-amodiaquine (ASAQ) was conducted in Mozambique, and the prevalence of polymorphisms in the pfk13, pfcrt, and pfmdr1 genes associated with drug resistance was investigated. METHODS: Children aged 6-59 months were enrolled in four study sites. Blood was collected and dried on filter paper from participants who developed fever within 28 days of initial malaria treatment. All samples were first screened for Plasmodium falciparum using a multiplex real-time PCR assay, and polymorphisms in the pfk13, pfcrt, and pfmdr1 genes were investigated by Sanger sequencing. RESULTS: No pfk13 mutations, associated with artemisinin partial resistance, were observed. The only pfcrt haplotype observed was the wild type CVMNK (codons 72-76), associated with chloroquine sensitivity. Polymorphisms in pfmdr1 were only observed at codon 184, with the mutant 184F in 43/109 (39.4%) of the samples, wild type Y184 in 42/109 (38.5%), and mixed 184F/Y in 24/109 (22.0%). All samples possessed N86 and D1246 at these two codons. CONCLUSION: In 2018, no markers of artemisinin resistance were documented. Molecular surveillance should continue to monitor the prevalence of these markers to inform decisions on malaria treatment in Mozambique. |
In vivo efficacy and safety of artemether-lumefantrine and amodiaquine-artesunate for uncomplicated Plasmodium falciparum malaria in Mozambique, 2018.
Nhama A , Nhamússua L , Macete E , Bassat Q , Salvador C , Enosse S , Candrinho B , Carvalho E , Nhacolo A , Chidimatembue A , Saifodine A , Zulliger R , Lucchi N , Svigel SS , Moriarty LF , Halsey ES , Mayor A , Aide P . Malar J 2021 20 (1) 390 BACKGROUND: Artemisinin-based combination therapy (ACT) has been the recommended first-line treatment for uncomplicated malaria in Mozambique since 2006, with artemether-lumefantrine (AL) and amodiaquine-artesunate (AS-AQ) as the first choice. To assess efficacy of currently used ACT, an in vivo therapeutic efficacy study was conducted. METHODS: The study was conducted in four sentinel sites: Montepuez, Moatize, Mopeia and Massinga. Patients between 6 and 59 months old with uncomplicated Plasmodium falciparum malaria (2000-200,000 parasites/µl) were enrolled between February and September of 2018, assigned to either an AL or AS-AQ treatment arm, and monitored for 28 days. A Bayesian algorithm was applied to differentiate recrudescence from new infection using genotyping data of seven neutral microsatellites. Uncorrected and PCR-corrected efficacy results at day 28 were calculated. RESULTS: Totals of 368 and 273 patients were enrolled in the AL and AS-AQ arms, respectively. Of these, 9.5% (35/368) and 5.1% (14/273) were lost to follow-up in the AL and AS-AQ arms, respectively. There were 48 and 3 recurrent malaria infections (late clinical and late parasitological failures) in the AL and AS-AQ arms, respectively. The day 28 uncorrected efficacy was 85.6% (95% confidence interval (CI) 81.3-89.2%) for AL and 98.8% (95% CI 96.7-99.8%) for AS-AQ, whereas day 28 PCR-corrected efficacy was 97.9% (95% CI 95.6-99.2%) for AL and 99.6% (95% CI 97.9-100%) for AS-AQ. Molecular testing confirmed that 87.4% (42/48) and 33.3% (1/3) of participants with a recurrent malaria infection in the AL and AS-AQ arms were new infections; an expected finding in a high malaria transmission area. Adverse events were documented in less than 2% of participants for both drugs. CONCLUSION: Both AL and AS-AQ have therapeutic efficacies well above the 90% WHO recommended threshold and remain well-tolerated in Mozambique. Routine monitoring of therapeutic efficacy should continue to ensure the treatments remain efficacious. Trial registration Clinicaltrials.gov: NCT04370977. |
Cost and cost-effectiveness of indoor residual spraying with pirimiphos-methyl in a high malaria transmission district of Mozambique with high access to standard insecticide-treated nets
Alonso S , Chaccour CJ , Wagman J , Candrinho B , Muthoni R , Saifodine A , Saute F , Robertson M , Zulliger R . Malar J 2021 20 (1) 143 BACKGROUND: As malaria cases increase in some of the highest burden countries, more strategic deployment of new and proven interventions must be evaluated to meet global malaria reduction goals. METHODS: The cost and cost-effectiveness of indoor residual spraying (IRS) with pirimiphos-methyl (Actellic®300 CS) were assessed in a high transmission district (Mopeia) with high access to pyrethroid insecticide-treated nets (ITNs), compared to ITNs alone. The major mosquito vectors in the area were susceptible to primiphos-methyl, but resistant to pyrethoids. A decision analysis approach was followed to conduct deterministic and probabilistic sensitivity analyses in a theoretical cohort of 10,000 children under five years of age (U5) and 10,000 individuals of all ages, separately. Model parameters and distributions were based on prospectively collected cost and epidemiological data from a cluster-randomized control trial and a literature review. The primary analysis used health facility-malaria incidence, while community cohort incidence and cross-sectional prevalence rates were used in sensitivity analyses. Lifetime costs, malaria cases, deaths and disability-adjusted life-years (DALYs) were calculated to determine the incremental costs per DALY averted through IRS. RESULTS: The average IRS cost per person protected was US$8.26 and 51% of the cost was insecticide. IRS averted 46,609 (95% CI 46,570-46,646) uncomplicated and 242 (95% CI 241-243) severe lifetime cases in a theoretical children U5 cohort, yielding an incremental cost-effectiveness ratio (ICER) of US$400 (95% CI 399-402) per DALY averted. In the all-age cohort, the ICER was higher: US$1,860 (95% CI 1,852-1,868) per DALY averted. Deterministic and probabilistic results were consistent. When adding the community protective effect of IRS, the cost per person protected decreased (US$7.06) and IRS was highly cost-effective in children U5 (ICER = US$312) and cost-effective in individuals of all ages (ICER = US$1,431), compared to ITNs alone. CONCLUSION: This study provides robust evidence that IRS with pirimiphos-methyl can be cost-effective in high transmission regions with high pyrethroid ITN coverage where the major vector is susceptible to pirimiphos-methyl but resistant to pyrethroids. The finding that insecticide cost is the main driver of IRS costs highlights the need to reduce the insecticide price without jeopardizing effectiveness. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT02910934 (Registered 22 September 2016). https://clinicaltrials.gov/ct2/show/NCT02910934?term=NCT02910934&draw=2&rank=1. |
Incremental impact on malaria incidence following indoor residual spraying in a highly endemic area with high standard ITN access in Mozambique: results from a cluster-randomized study
Chaccour C , Zulliger R , Wagman J , Casellas A , Nacima A , Elobolobo E , Savaio B , Saifodine A , Fornadel C , Richardson J , Candrinho B , Robertson M , Saute F . Malar J 2021 20 (1) 84 BACKGROUND: Attaining the goal of reducing the global malaria burden is threatened by recent setbacks in maintaining the effectiveness of vector control interventions partly due to the emergence of pyrethroid resistant vectors. One potential strategy to address these setbacks could be combining indoor residual spraying (IRS) with non-pyrethroids and standard insecticide-treated nets (ITNs). This study aimed to provide evidence on the incremental epidemiological benefit of using third-generation IRS product in a highly endemic area with high ITN ownership. METHODS: A cluster-randomized, open-label, parallel-arms, superiority trial was conducted in the Mopeia district in Zambezia, Mozambique from 2016 to 2018. The district had received mass distribution of alphacypermethrin ITNs two years before the trial and again mid-way. 86 clusters were defined, stratified and randomized to receive or not receive IRS with pirimiphos-methyl (Actellic®300 CS). Efficacy of adding IRS was assessed through malaria incidence in a cohort of children under five followed prospectively for two years, enhanced passive surveillance at health facilities and by community health workers, and yearly cross-sectional surveys at the peak of the transmission season. FINDINGS: A total of 1536 children were enrolled in the cohort. Children in the IRS arm experienced 4,801 cases (incidence rate of 3,532 per 10,000 children-month at risk) versus 5,758 cases in the no-IRS arm (incidence rate of 4,297 per 10,000 children-month at risk), resulting in a crude risk reduction of 18% and an incidence risk ratio of 0.82 (95% CI 0.79-0.86, p-value < 0.001). Facility and community passive surveillance showed a malaria incidence of 278 per 10,000 person-month in the IRS group (43,974 cases over 22 months) versus 358 (95% CI 355-360) per 10,000 person-month at risk in the no-IRS group (58,030 cases over 22 months), resulting in an incidence rate ratio of 0.65 (95% CI 0.60-0.71, p < 0.001). In the 2018 survey, prevalence in children under five in the IRS arm was significantly lower than in the no-IRS arm (OR 0.54, 95% CI, 0.31-0.92, p = 0.0241). CONCLUSION: In a highly endemic area with high ITN access and emerging pyrethroid resistance, adding IRS with pirimiphos-methyl resulted in significant additional protection for children under five years of age. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT02910934, registered 22 September 2016, https://clinicaltrials.gov/ct2/show/NCT02910934?term=NCT02910934&draw=2&rank=1 . |
Reduced exposure to malaria vectors following indoor residual spraying of pirimiphos-methyl in a high-burden district of rural Mozambique with high ownership of long-lasting insecticidal nets: entomological surveillance results from a cluster-randomized trial
Wagman JM , Varela K , Zulliger R , Saifodine A , Muthoni R , Magesa S , Chaccour C , Gogue C , Tynuv K , Seyoum A , Dengela D , Saúte F , Richardson JH , Fornadel C , Linton YM , Slutsker L , Candrinho B , Robertson M . Malar J 2021 20 (1) 54 BACKGROUND: The need to develop new products and novel approaches for malaria vector control is recognized as a global health priority. One approach to meeting this need has been the development of new products for indoor residual spraying (IRS) with novel active ingredients for public health. While initial results showing the impact of several of these next-generation IRS products have been encouraging, questions remain about how to best deploy them for maximum impact. To help address these questions, a 2-year cluster-randomized controlled trial to measure the impact of IRS with a microencapsulated formulation of pirimiphos-methyl (PM) in an area with high ownership of long-lasting insecticidal nets (LLINs) was conducted in a high-transmission district of central Mozambique with pyrethroid resistant vectors. Presented here are the results of the vector surveillance component of the trial. METHODS: The 2 year, two-armed trial was conducted in Mopeia District, Zambezia Province, Mozambique. In ten sentinel villages, five that received IRS with PM in October-November 2016 and again in October-November 2017 and five that received no IRS, indoor light trap collections and paired indoor-outdoor human landing collections catches (HLCs) were conducted monthly from September 2016 through October 2018. A universal coverage campaign in June 2017, just prior to the second spray round, distributed 131,540 standard alpha-cypermethrin LLINs across all study villages and increased overall net usage rates in children under 5 years old to over 90%. RESULTS: The primary malaria vector during the trial was Anopheles funestus sensu lato (s.l.), and standard World Health Organization (WHO) tube tests with this population indicated variable but increasing resistance to pyrethroids (including alpha-cypermethrin, from > 85% mortality in 2017 to 7% mortality in 2018) and uniform susceptibility to PM (100% mortality in both years). Over the entire duration of the study, IRS reduced An. funestus s.l. densities by 48% (CI(95) 33-59%; p < 0.001) in indoor light traps and by 74% (CI(95) 38-90%; p = 0.010) during indoor and outdoor HLC, though in each study year reductions in vector density were consistently greatest in those months immediately following the IRS campaigns and waned over time. Overall there was no strong preference for An. funestus to feed indoors or outdoors, and these biting behaviours did not differ significantly across study arms: observed indoor-outdoor biting ratios were 1.10 (CI(95) 1.00-1.21) in no-IRS villages and 0.88 (CI(95) 0.67-1.15) in IRS villages. The impact of IRS was consistent in reducing HLC exposures both indoors (75% reduction: CI(95) 47-88%; p = 0. < 0.001) and outdoors (68% reduction: CI(95) 22-87%; p = 0.012). While substantially fewer Anopheles gambiae s.l. were collected during the study, trends show a similar impact of IRS on this key vector group as well, with a 33% (CI(95) 7-53%; p = 0.019) reduction in mosquitoes collected in light traps and a non-statistically significant 39% reduction (p = 0.249) in HLC landing rates. CONCLUSION: IRS with PM used in addition to pyrethroid-only LLINs substantially reduced human exposures to malaria vectors during both years of the cluster-randomized controlled trial in Mopeia-a high-burden district where the primary vector, An. funestus s.l., was equally likely to feed indoors or outdoors and demonstrated increasing resistance to pyrethroids. Findings suggest that IRS with PM can provide effective vector control, including in some settings where pyrethroid-only ITNs are widely used. Trial registration clinicaltrials.gov , NCT02910934. Registered 22 September 2016, https://www.clinicaltrials.gov/ct2/show/NCT02910934. |
Monitoring the durability of the long-lasting insecticidal nets MAGNet and Royal Sentry in three ecological zones of Mozambique
Abilio AP , Obi E , Koenker H , Babalola S , Saifodine A , Zulliger R , Swamidoss I , Ponce de Leon G , Alfai E , Blaufuss S , Olapeju B , Harig H , Kilian A . Malar J 2020 19 (1) 209 BACKGROUND: Malaria prevention with long-lasting insecticidal nets (LLINs) has seen a tremendous scale-up in sub-Saharan Africa in the last decade. To sustain this success, it is important to understand how long LLINs remain in the households and continue to protect net users, which is termed durability. This information is needed to decide the appropriate timing of LLIN distribution and also to identify product(s) that may be underperforming relative to expectations. Following guidance from the U.S. President's Malaria Initiative, durability monitoring of polyethylene 150-denier LLIN (Royal Sentry((R)) and MAGNet((R))) distributed during a 2017 mass campaign in Mozambique was implemented in three ecologically different sites: Inhambane, Tete, and Nampula. METHODS: This was a prospective cohort study in which representative samples of households from each district were recruited at baseline, 1 to 6 months after the mass campaign. All campaign LLINs in these households were labelled and followed up over a period of 36 months. The primary outcome was the "proportion of LLINs surviving in serviceable condition" based on attrition and integrity measures and the median survival in years. The outcome for insecticidal durability was determined by bio-assay from subsamples of campaign LLINs. RESULTS: A total of 998 households (98% of target) and 1998 campaign LLIN (85% of target) were included in the study. Definite outcomes could be determined for 80% of the cohort LLIN in Inhambane, 45% in Tete, and 72% in Nampula. The highest all-cause attrition was seen in Nampula with 74% followed by Inhambane at 56% and Tete at 50%. Overall, only 2% of campaign LLINs were used for other purposes. Estimated survival in serviceable condition of campaign LLINs after 36 months was 57% in Inhambane, 43% in Tete, and 33% in Nampula, corresponding to median survival of 3.0, 2.8, and 2.4 years, respectively. Factors that were associated with better survival were exposure to social and behavioural change communication, a positive net care attitude, and folding up the net during the day. Larger household size negatively impacted survival. Insecticidal performance was optimal up to 24 months follow-up, but declined at 36 months when only 3% of samples showed optimal effectiveness in Inhambane, 11% in Tete and 29% in Nampula. However, 96% of LLIN still had minimal effectiveness at 36 months. CONCLUSIONS: Differences in median survival could be attributed at least in part to household environment and net care and repair behaviours. This means that in two of the three sites the assumption of a three-year cycle of campaign distributions holds, while in the Nampula site either continuous distribution channels could be expanded or more intense or targeted social and behaviour change activities to encourage net care and retention could be considered. |
Quality of malaria data in public health facilities in three provinces of Mozambique
Colborn JM , Zulliger R , Da Silva M , Mathe G , Chico AR , Castel-Branco AC , Brito F , Andela M , de Leon GP , Saifodine A , Candrinho B , Plucinski MM . PLoS One 2020 15 (4) e0231358 BACKGROUND: Malaria data reported through Mozambique's routine health information system are used to guide the implementation of prevention and control activities. Although previous studies have identified issues with the quality of aggregated data reported from public health facilities in the country, no studies have evaluated the quality of routine indicators recorded in health facility registries. This study addresses this issue by comparing indicators calculated from data from exit interviews and re-examinations of patients with data based on registry records from health facilities in order to measure the quality of registry data and data reporting in three provinces in Mozambique. METHODS: Data were collected from 1,840 outpatients from 117 health facilities in Maputo, Zambezia, and Cabo Delgado Provinces interviewed and examined as part of a malaria-specific health facility survey. Key indicators based on exit interview / re-examination data were compared to the same indicators based on records from health facility registries. Multivariable regression was performed to identify factors associated with indicators matching in re-examination / exit interview data and health facility registries. Aggregated indicators abstracted from facility registries were compared to those reported through the routine health management information system (HMIS) for the same time period. RESULTS: Sensitivity of exit interview / re-examination data compared with those recorded in facility registries was low for all indicators in all facilities. The lowest sensitivities were in Maputo, where the sensitivity for recording negative RDT results was 9.7%. The highest sensitivity was for recording positive RDT results in Cabo Delgado, at 75%. Multivariable analysis of factors associated with agreement between gold standard and registry data showed patients were less likely to be asked about having a fever in the triage ward in Maputo and Cabo Delgado (adjusted Odds Ratio 0.75 and 0.39 respectively), and in the outpatient ward in Cabo Delgado (aOR = 0.37), compared with the emergency department. Patients with positive RDT were also more likely to have RDT results recorded in all three provinces when patients had been managed according to national treatment guidelines during initial examination. Comparison of retrospective data abstracted from facility registries to HMIS data showed discrepancies in all three provinces. The proportion of outpatient cases with suspected and confirmed malaria were similar in registry and HMIS data across all provinces (a relatively low difference between registry and HMIS data of 3% in Maputo and Zambezia), though the total number of all-cause outpatient cases was consistently higher in the HMIS. The largest difference was in Maputo, where a total of 87,992 all-cause outpatient cases were reported in HMIS, compared with a total of 42,431 abstracted from facility registries. CONCLUSION: This study shows that care should be taken in interpreting trends based solely on routine data due to data quality issues, though the discrepancy in all-cause outpatient cases may be indicative that register availability and storage are important factors. As such, simple steps such as providing consistent access and storage of registers that include reporting of patient fever symptoms might improve the quality of routine data recorded at health facilities. |
"We have this, with my husband, we live in harmony": exploring the gendered decision-making matrix for malaria prevention and treatment in Nampula Province, Mozambique
Hildon ZJ , Escorcio-Ymayo M , Zulliger R , Arias de Aramburu R , Lewicky N , Harig H , Chidassicua JB , Underwood C , Pinto L , Figueroa ME . Malar J 2020 19 (1) 133 BACKGROUND: Conceptualizing gender dynamics and ways of bridging entrenched gender roles will contribute to better health promotion, policy and planning. Such processes are explored in relation to malaria in Mozambique. METHODS: A multi-method, qualitative study using focus group discussions (FGDs) and in-depth interviews (IDIs) explored the perspectives of community members, leaders and stakeholders on malaria. The study was conducted in Nampula Province, in an intervention district for the Tchova Tchova Stop Malaria (TTSM) gender-sensitive community dialogues, and in a non-intervention district. RESULTS: Participants (n = 106) took part in six FGDs and five IDIs in each district. Those exposed to TTSM commonly stated that the programme influenced more equalitarian gender roles, attitudes and uptake of protective malaria-related practices. These positive changes occurred within the context of an observed, gendered decision-making matrix, which aligns inward- or outward-facing decisions with malaria prevention or treatment. Decisions more dependent on male or elder sanctioning at community level are outward-facing decisions, while decisions falling within women's domain at household level are inward-facing decisions. Related to prevention, using bed nets was largely an inward-facing prevention decision for women, who were generally tasked with hanging, washing and making nets usable. Net purchase and appropriation for malaria prevention (rather than for instance for fishing) was men's prerogative. Regular net use was associated with sleeping together more regularly, bringing couples closer. Attending antenatal care to access intermittent preventive treatment during pregnancy was often an outward-facing prevention decision, under the purview of older, influential women and ultimately needing sanctioning by men. With respect to seeking care for malaria symptoms, women typically sought help from traditional healers first. This inward-facing treatment decision was within their control, in contrast to the frequently transport-dependent, outward-facing decision to attend a health facility. Sharing decisions was described as a feature of a "harmonious household," something that was said to be encouraged by the TTSM intervention and that was both lived and aspirational. CONCLUSIONS: TTSM community dialogues helped communication on both interpersonal (couple) and community levels, ultimately encouraging malaria-related behaviours. Leveraging ways of bringing men and women together to share decision making will improve malaria intervention success. |
A robust estimator of malaria incidence from routine health facility data
Thwing J , Camara A , Candrinho B , Zulliger R , Colborn J , Painter J , Plucinski MM . Am J Trop Med Hyg 2019 102 (4) 811-820 Routine incident malaria case data have become a pillar of malaria surveillance in sub-Saharan Africa. These data provide granular, timely information to track malaria burden. However, incidence data are sensitive to changes in care seeking rates, rates of testing of suspect cases, and reporting completeness. Based on a set of assumptions, we derived a simple algebraic formula to convert crude incidence rates to a corrected estimation of incidence, adjusting for biases in variable and suboptimal rates of care seeking, testing of suspect cases, and reporting completeness. We applied the correction to routine incidence data from Guinea and Mozambique, and aggregate data for sub-Saharan African countries from the World Malaria Report. We calculated continent-wide needs for malaria tests and treatments, assuming universal testing but current care seeking rates. Countries in southern and eastern Africa reporting recent increases in malaria incidence generally had lower overall corrected incidence than countries in Central and West Africa. Under current care seeking rates, the unmet need for malaria tests was estimated to be 160 million (M) (interquartile range [IQR]: 139-188) and for malaria treatments to be 37 M (IQR: 29-51). Maps of corrected incidence were more consistent with maps of community survey prevalence than was crude incidence in Guinea and Mozambique. Crude malaria incidence rates need to be interpreted in the context of suboptimal testing and care seeking rates, which vary over space and time. Adjusting for these factors can provide an insight into the spatiotemporal trends of malaria burden. |
The economic burden of malaria on households and the health system in a high transmission district of Mozambique
Alonso S , Chaccour CJ , Elobolobo E , Nacima A , Candrinho B , Saifodine A , Saute F , Robertson M , Zulliger R . Malar J 2019 18 (1) 360 BACKGROUND: Malaria remains a leading cause of morbidity and mortality in Mozambique. Increased investments in malaria control have reduced the burden, but few studies have estimated the costs of malaria in the country. This paper estimates the economic costs associated with malaria care to households and to the health system in the high burden district of Mopeia in central Mozambique. METHODS: Malaria care-seeking and morbidity costs were routinely collected among 1373 households with at least one child enrolled in an active case detection (ACD) cohort in Mopeia, and through cross-sectional surveys with 824 families in 2017 and 805 families in 2018. Household costs included direct medical expenses, transportation and opportunity costs of the time lost due to illness. Structured questionnaires were used to estimate the health system costs associated with malaria care in all 13 district health facilities. Cost estimations followed an ingredient-based approach with a top-down allocation approach for health system expenses. RESULTS: Among participants in cross-sectional studies, households sought care for nine severe malaria cases requiring hospital admission and for 679 uncomplicated malaria cases. Median household costs associated with uncomplicated malaria among individuals of all ages were US$ 3.46 (IQR US$ 0.07-22.41) and US$ 81.08 (IQR US$ 39.34-88.38) per severe case. Median household costs were lower among children under five (ACD cohort): US$ 1.63 (IQR US$ 0.00-7.79) per uncomplicated case and US$ 64.90 (IQR US$ 49.76-80.96) per severe case. Opportunity costs were the main source of household costs. Median health system costs associated with malaria among patients of all ages were US$ 4.34 (IQR US$ 4.32-4.35) per uncomplicated case and US$ 26.56 (IQR US$ 18.03-44.09) per severe case. Considering household and health system costs, the overall cost of malaria care to society was US$ 7.80 per uncomplicated case and US$ 107.64 per severe case, representing an economic malaria burden of US$ 332,286.24 (IQR US$ 186,355.84-1,091,212.90) per year only in Mopeia. CONCLUSIONS: Despite the provision of free malaria services, households in Mopeia incur significant direct and indirect costs associated with the disease. Furthermore, the high malaria cost on the Mozambican health system underscores the need to strengthen malaria prevention to reduce the high burden and improve productivity in the region. |
Estimation of malaria-attributable fever in malaria test-positive febrile outpatients in three provinces of Mozambique, 2018
Plucinski MM , Candrinho B , Dimene M , Smith T , Thwing J , Colborn J , Rogier E , Zulliger R . Am J Trop Med Hyg 2019 102 (1) 151-155 Like most malaria-endemic countries, Mozambique relies on tabulation of confirmed malaria test-positive febrile patients to track incidence of malaria. However, this approach is potentially biased by incidental malaria parasitemia in patients with fever of another etiology. We compared pan-Plasmodium aldolase and lactate dehydrogenase and Plasmodium falciparum HRP2 antigen concentrations measured using a laboratory bead-based assay of samples collected from 1,712 febrile and afebrile patients of all ages in Maputo, Zambezia, and Cabo Delgado provinces. We used a Bayesian latent class model to estimate the proportion of malaria-attributable fevers in malaria test-positive febrile patients. Depending on the antigen, estimated rates of malaria-attributable fever in malaria test-positive febrile patients were 100% in Maputo, 33-58% in Zambezia, and 63-74% in Cabo Delgado. Our findings indicate that most malaria test-positive febrile patients in the three provinces of Mozambique had a fever that was likely caused by the concurrent malaria infection. Counting malaria test-positive febrile patients for estimation of malaria incidence appears to be appropriate in this setting. |
Assessing performance of HRP2 antigen detection for malaria diagnosis in Mozambique
Plucinski MM , Candrinho B , Dimene M , Colborn J , Lu A , Nace D , Zulliger R , Rogier E . J Clin Microbiol 2019 57 (9) Background: Rapid diagnostic tests (RDTs) that detect the Plasmodium falciparum-specific histidine-rich protein 2 (PfHRP2) antigen are the primary method for malaria diagnosis in Mozambique. However, these tests do not detect infections with non-falciparum malaria or Pfhrp2/3-deleted P. falciparum parasites.Methods: To assess the appropriateness of conventional PfHRP2-only RDTs for malaria diagnosis in Mozambique, samples collected during a health facility survey conducted in three provinces of Mozambique were screened using antigen detection methods and further characterized by molecular techniques. Samples from 1861 outpatients of all ages and symptoms attending 117 randomly-selected public health facilities in 2018 were analyzed with an ultra-sensitive bead-based immunoassay for the presence of PfHRP2, pan-Plasmodium Aldolase (pAldo), and pan-Plasmodium lactate dehydrogenase (pLDH). Presence of PfHRP2 in patient blood detected using the bead-based assay was compared to the results of PfHRP2-based RDTs performed during the routine health facility consult and during the survey re-examination at exit interview. Samples with discordant antigen profiles (negative for PfHRP2 but positive for pAldo and/or pLDH) were further characterized by photo-induced electron transfer (PET)-PCR.Results: Using the bead-based laboratory assay as the gold standard, the sensitivity of the conventional RDTs administered during the routine health facility consult and the exit interview was 90% and 83%, respectively, and specificity was 91% and 97%. Of 710 samples positive for at least one antigen, 704 (99.2%) were positive for PfHRP2. Six (0.8% of total) discordant samples lacked PfHRP2 but were positive for pAldo and/or pLDH; 3 of these (0.4% of total) were P. ovale mono-infections or co-infections where P. ovale was the dominant species. The remaining 3 discordant samples were negative by PET-PCR.Conclusions: The sensitivity and specificity of the conventional RDTs performed in the routine health facility consults and survey exit interviews were acceptable, and there was no evidence of Pfhrp2/3-deleted parasites. Mono-infections with non-falciparum malaria species comprised <1% of total malaria infections. Nearly all malaria antigen-positive patients had detectable PfHRP2, confirming this antigen remains an appropriate malaria diagnostic target in the surveyed provinces. |
Quality of malaria services offered in public health facilities in three provinces of Mozambique: a cross-sectional study
Candrinho B , Plucinski MM , Colborn JM , da Silva M , Mathe G , Dimene M , Chico AR , Castel-Branco AC , Brito F , Andela M , Ponce de Leon G , Saifodine A , Zulliger R . Malar J 2019 18 (1) 162 BACKGROUND: Fever associated with malaria is the leading cause of health care-seeking in Mozambique, yet there is limited evidence on the quality of malaria case management. This study evaluated the quality of malaria service provision offered in public health facilities in Mozambique. METHODS: A cross-sectional assessment was conducted in April-May 2018 in three provinces of Mozambique: Maputo Province (low malaria burden), Cabo Delgado (high), and Zambezia (high). The study included all secondary and tertiary facilities and a random sample of primary facilities in each province. Data collection included exit interviews and re-examinations of 20 randomly selected outpatient service patients, interviews with up to five health care providers and the health facility director, a stockroom inventory and routine data abstraction. RESULTS: A total of 319 health care providers and 1840 patients from 117 health facilities were included. Of these, 1325 patients (72%) had suspected malaria (fever/history of fever) and 550 (30%) had febrile, confirmed malaria with the highest burden in Cabo Delgado (43%), followed by Zambezia (34%) and Maputo Province (2%). Appropriate management of malaria cases, defined as testing malaria suspects and treating confirmed cases with the correct dose of anti-malarial, was highest in Zambezia and Cabo Delgado where 52% (95% CI 42-62) and 49% (42-57) of febrile malaria cases were appropriately managed, respectively. Only 14% (5-34) of febrile cases in Maputo Province were appropriately managed. The biggest gap in the malaria case management pathway was failure to test febrile patients, with only 46% of patients with this indication tested for malaria in Maputo Province. Additionally, anti-malarial treatment of patients with a negative malaria test result was common, ranging from 8% (2-23) in Maputo Province to 22% (14-32) of patients with a negative test in Zambezia. Only 58-62% of patients prescribed an anti-malarial correctly recited dosing instructions. Provider training and malaria knowledge was low outside of Zambezia and supervision rates were low in all provinces. Factors associated with correct case management varied by province and included patient age, facility type, treatment and testing availability, supervision, and training. CONCLUSION: These findings underscore the need to strengthen provider testing of all patients with fever, provider adherence to negative test results, and effective counselling of patients across epidemiological settings in Mozambique. |
Malaria case management commodity supply and use by community health workers in Mozambique, 2017
Davlantes E , Salomao C , Wate F , Sarmento D , Rodrigues H , Halsey ES , Lewis L , Candrinho B , Zulliger R . Malar J 2019 18 (1) 47 BACKGROUND: Community health workers (CHWs) provide preventive care and integrated community case management (iCCM) to people with low healthcare access worldwide. CHW programmes have helped reduce mortality in myriad countries, but little data on malaria supply chain management has been shared. This project evaluated the current composition, use, and delivery of malaria iCCM kit commodities in Mozambique-rapid diagnostic tests (RDTs) and artemether-lumefantrine (AL) treatments-to better tailor existing resources to the needs of CHWs in diverse practice settings. METHODS: Health facilities in Maputo (low malaria burden), Inhambane (moderate), and Nampula (high) Provinces were selected using probability proportionate to the number of CHWs at each facility. All CHWs and their supervisors at selected facilities were interviewed using a structured questionnaire to document experiences with kit commodities. Data were analysed to assess CHW commodity stock levels by province and season. RESULTS: In total, 216 CHWs and 56 supervisors were interviewed at 56 health facilities. CHWs reported receiving an average of 6.7 kits in the last year, although they are intended to receive kits monthly. One-tenth of CHWs reported receiving kits with missing RDTs, and 28% reported lacking some AL treatments. Commodity use was highest in the rainy season. Stockouts were reported by CHWs in all provinces, more commonly in the rainy season. Facility-level stockouts of RDTs or some AL formulation in the past year were reported by 66% of supervisors. Use of CHW kit materials by health facilities was reported by 43% of supervisors; this was most common at facilities experiencing stockouts. CONCLUSIONS: Variations in geographic and seasonal malaria commodity needs should be considered in CHW kit distribution planning in Mozambique. Improvements in provision of complete, monthly CHW kits are needed in parallel with improvements in the broader commodity system strengthening. The findings of this evaluation can help other CHW programmes determine best practices for management of iCCM supply chains. |
Mozambique's Community Antiretroviral Therapy Support Group Program: The role of social relationships in facilitating HIV/AIDS treatment retention
Kun KE , Couto A , Jobarteh K , Zulliger R , Pedro E , Malimane I , Auld A , Meldonian M . AIDS Behav 2019 23 (9) 2477-2485 The Community Antiretroviral (ARV) Therapy Support Group (CASG) program aims to address low retention rates in Mozambique's HIV treatment program and the absorptive capacity of the country's health facilities. CASG provides patients with the opportunity to form groups, whose members provide peer support and collect ARV medications on a rotating basis for one another. Based on the promising results in one province, a multi-site level evaluation followed. We report on qualitative findings from this evaluation from the patient perspective on the role of social relationships (as facilitated through CASG) in conferring time, financial, educational and psychosocial benefits that contribute to improved patient retention. These findings may be helpful in informing what aspects of social relationships are critical to foster as CASG is implemented within a greater number of Mozambican health facilities, and as other countries design and implement related models of care and treatment with a support group component. |
Community knowledge and acceptance of indoor residual spraying for malaria prevention in Mozambique: a qualitative study
Magaco A , Botao C , Nhassengo P , Saide M , Ubisse A , Chicumbe S , Zulliger R . Malar J 2019 18 (1) 27 BACKGROUND: Malaria control remains a leading health challenge in Mozambique. Indoor residual spraying (IRS) is an effective strategy to control malaria transmission, but there are often barriers to reaching the coverage necessary for attaining maximum community protective effect of IRS. Mozambique recorded a high number of household refusals during the 2016 IRS campaign. This study sought to evaluate household and community factors related to the acceptability of IRS to inform strategies for future campaigns in Mozambique and the region. METHODS: A cross-sectional, qualitative study was conducted in eight urban and rural communities in two high malaria burden provinces in Mozambique. Data were collected through in-depth interviews with community members, leaders, sprayers, and representatives of district health directorates; focus group discussions with community members who accepted and who refused IRS during the 2016 campaign; systematic field observations; and informal conversations. Data were systematically coded and analysed using NVIVO-11((R)). RESULTS: A total of 61 interviews and 12 discussions were conducted. Community participants predominantly described IRS as safe, but many felt that it had limited efficacy. The main factors that participants mentioned as having influenced their IRS acceptance or refusal were: understanding of IRS; community leader level of support; characteristics of IRS programmatic implementation; environmental, political and historical factors. Specifically, IRS acceptance was higher when there was perceived community solidarity through IRS acceptance, desire to reduce the insect population in homes, trust in government and community satisfaction with past IRS campaign effectiveness. Participants who refused were mainly from urban districts and were more educated. The main barriers to acceptance were associated with selection and performance of spray operators, negative experiences from previous campaigns, political-partisan conflicts, difficulty in removing heavy or numerous household assets, and preference for insecticide-treated nets over IRS. CONCLUSIONS: Acceptance of IRS was influenced by diverse operational and contextual factors. As such, future IRS communications in targeted communities should emphasize the importance of high IRS coverage for promoting both familial and community health. Additionally, clear communications and engagement with community leaders during spray operator selection and spray implementation may help reduce barriers to IRS acceptance. |
Combination of indoor residual spraying with long-lasting insecticide-treated nets for malaria control in Zambezia, Mozambique: a cluster randomised trial and cost-effectiveness study protocol
Chaccour CJ , Alonso S , Zulliger R , Wagman J , Saifodine A , Candrinho B , Macete E , Brew J , Fornadel C , Kassim H , Loch L , Sacoor C , Varela K , Carty CL , Robertson M , Saute F . BMJ Glob Health 2018 3 (1) e000610 Background: Most of the reduction in malaria prevalence seen in Africa since 2000 has been attributed to vector control interventions. Yet increases in the distribution and intensity of insecticide resistance and higher costs of newer insecticides pose a challenge to sustaining these gains. Thus, endemic countries face challenging decisions regarding the choice of vector control interventions. Methods: A cluster randomised trial is being carried out in Mopeia District in the Zambezia Province of Mozambique, where malaria prevalence in children under 5 is high (68% in 2015), despite continuous and campaign distribution of long-lasting insecticide-treated nets (LLINs). Study arm 1 will continue to use the standard, LLIN-based National Malaria Control Programme vector control strategy (LLINs only), while study arm 2 will receive indoor residual spraying (IRS) once a year for 2 years with a microencapsulated formulation of pirimiphos-methyl (Actellic 300 CS), in addition to the standard LLIN strategy (LLINs+IRS). Prior to the 2016 IRS implementation (the first of two IRS campaigns in this study), 146 clusters were defined and stratified per number of households. Clusters were then randomised 1:1 into the two study arms. The public health impact and cost-effectiveness of IRS intervention will be evaluated over 2 years using multiple methods: (1) monthly active malaria case detection in a cohort of 1548 total children aged 6-59 months; (2) enhanced passive surveillance at health facilities and with community health workers; (3) annual cross-sectional surveys; and (4) entomological surveillance. Prospective microcosting of the intervention and provider and societal costs will be conducted. Insecticide resistance status pattern and changes in local Anopheline populations will be included as important supportive outcomes. Discussion: By evaluating the public health impact and cost-effectiveness of IRS with a non-pyrethroid insecticide in a high-transmission setting with high LLIN ownership, it is expected that this study will provide programmatic and policy-relevant data to guide national and global vector control strategies. Trial registration number: NCT02910934. |
Multiplex serology for impact evaluation of bed net distribution on burden of lymphatic filariasis and four species of human malaria in northern Mozambique
Plucinski MM , Candrinho B , Chambe G , Muchanga J , Muguande O , Matsinhe G , Mathe G , Rogier E , Doyle T , Zulliger R , Colborn J , Saifodine A , Lammie P , Priest JW . PLoS Negl Trop Dis 2018 12 (2) e0006278 BACKGROUND: Universal coverage with long-lasting insecticidal nets (LLINs) is a primary control strategy against Plasmodium falciparum malaria. However, its impact on the three other main species of human malaria and lymphatic filariasis (LF), which share the same vectors in many co-endemic areas, is not as well characterized. The recent development of multiplex antibody detection provides the opportunity for simultaneous evaluation of the impact of control measures on the burden of multiple diseases. METHODOLOGY/PRINCIPAL FINDINGS: Two cross-sectional household surveys at baseline and one year after a LLIN distribution campaign were implemented in Mecuburi and Nacala-a-Velha Districts in Nampula Province, Mozambique. Both districts were known to be endemic for LF; both received mass drug administration (MDA) with antifilarial drugs during the evaluation period. Access to and use of LLINs was recorded, and household members were tested with P. falciparum rapid diagnostic tests (RDTs). Dried blood spots were collected and analyzed for presence of antibodies to three P. falciparum antigens, P. vivax MSP-119, P. ovale MSP-119, P. malariae MSP-119, and three LF antigens. Seroconversion rates were calculated and the association between LLIN use and post-campaign seropositivity was estimated using multivariate regression. The campaign covered 68% (95% CI: 58-77) of the population in Nacala-a-Velha and 46% (37-56) in Mecuburi. There was no statistically significant change in P. falciparum RDT positivity between the two surveys. Population seropositivity at baseline ranged from 31-81% for the P. falciparum antigens, 3-4% for P. vivax MSP-119, 41-43% for P. ovale MSP-119, 46-56% for P. malariae MSP-119, and 37-76% for the LF antigens. The seroconversion rate to the LF Bm33 antigen decreased significantly in both districts. The seroconversion rate to P. malariae MSP-119 and the LF Wb123 and Bm14 antigens each decreased significantly in one of the two districts. Community LLIN use was associated with a decreased risk of P. falciparum RDT positivity, P. falciparum CSP and LSA-1 seropositivity, and P. malariae MSP-119 seropositivity, but not LF antigen seropositivity. CONCLUSIONS/SIGNIFICANCE: The study area noted significant declines in LF seropositivity, but these were not associated with LLIN use. The MDA could have masked any impact of the LLINs on population LF seropositivity. The LLIN campaign did not reach adequately high coverage to decrease P. falciparum RDT positivity, the most common measure of P. falciparum burden. However, the significant decreases in the seroconversion rate to the P. malariae antigen, coupled with an association between community LLIN use and individual-level decreases in seropositivity to P. falciparum and P. malariae antigens show evidence of impact of the LLIN campaign and highlight the utility of using multiantigenic serological approaches for measuring intervention impact. |
Cost-utility of HIV testing programs among men who have sex with men in the United States
Zulliger R , Maulsby C , Solomon L , Baytop C , Orr A , Nasrullah M , Shouse L , DiNenno E , Holtgrave D . AIDS Behav 2016 21 (3) 619-625 Few groups in the United States (US) are as heavily affected by HIV as men who have sex with men (MSM), yet many MSM remain unaware of their infection. HIV diagnosis is important for decreasing onward transmission and promoting effective treatment for HIV, but the cost-effectiveness of testing programs is not well-established. This study reports on the costs and cost-utility of the MSM Testing Initiative (MTI) to newly diagnose HIV among MSM and link them to medical care. Cost and testing data in 15 US cities from January 2013 to March 2014 were prospectively collected and combined to determine the cost-utility of MTI in each city in terms of the cost per Quality Adjusted Life Years (QALY) saved from payer and societal perspectives. The total venue-based HIV testing costs ranged from $18,759 to $564,284 for nine to fifteen months of MTI implementation. The cost-saving threshold for HIV testing of MSM was $20,645 per new HIV diagnosis. Overall, 27,475 men were tested through venue-based MTI, of whom 807 (3 %) were newly diagnosed with HIV. These new diagnoses were associated with approximately 47 averted HIV infections. The cost per QALY saved by implementation of MTI in each city was negative, indicating that MTI venue-based testing was cost-saving in all cities. The cost-utility of social network and couples testing strategies was, however, dependent on whether the programs newly diagnosed MSM. The cost per new HIV diagnosis varied considerably across cities and was influenced by both the local cost of MSM testing implementation and by the seropositivity rate of those reached by the HIV testing program. While the cost-saving threshold for HIV testing is highly achievable, testing programs must successfully reach undiagnosed HIV-positive individuals in order to be cost-effective. This underscores the need for HIV testing programs which target and engage populations such as MSM who are most likely to have undiagnosed HIV to maximize programmatic benefit and cost-utility. |
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