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Background:
Reactive focal mass drug administration (rfMDA), or presumptive treatment without malaria testing of household members and neighbours of a passively identified malaria case, is currently being explored as a possible malaria elimination strategy in low transmission settings. One of the primary factors determining the effectiveness of rf...
Citations
... Full-text not available (n = 6) [29,45,48,[52][53][54][55][56][57] implemented a design using only qualitative methods such as focus group discussions and in-depth interviews. The remaining studies utilized a mixed-methods approach, which most commonly included a combination of cross-sectional surveys and in-depth interviews, focus group discussions, or qualitative observations with a subset of the survey sample. ...
... Evidence from the reviewed studies suggests that individuals with a high level of perceived susceptibility to malaria are more likely to practice preventive or treatment behaviours [53,54,81,82]. Studies focusing on child caregivers also frequently measured this variable with questions assessing the caretaker's perception of whether they or the child were at risk for severe malaria. ...
Background
Recent estimates show progress toward malaria elimination is slowing in many settings, underscoring the need for tailored approaches to fight the disease. In addition to essential structural changes, human behaviour plays an important role in elimination. Engagement in malaria behaviours depends in part on psychosocial determinants such as knowledge, perceived risk, and community norms. Understanding the state of research on psychosocial determinants in low malaria transmission settings is important to augment social and behaviour change practice. This review synthesizes research on psychosocial factors and malaria behaviours in low-transmission settings.
Methods
A systematic search of peer-reviewed literature and supplemental manual search of grey literature was conducted using key terms and eligibility criteria defined a priori. Publications from 2000–2020 in the English language were identified, screened, and analysed using inductive methods to determine the relationship between the measured psychosocial factors and malaria behaviours.
Results
Screening of 961 publications yielded 96 for inclusion. Nineteen articles collected data among subpopulations that are at increased risk of malaria exposure in low-transmission settings. Purposive and cluster randomized sampling were common sampling approaches. Quantitative, qualitative, and mixed-methods study designs were used. Knowledge, attitudes, and perceived risk were commonly measured psychosocial factors. Perceived response-efficacy, perceived self-efficacy, and community norms were rarely measured. Results indicate positive associations between malaria knowledge and attitudes, and preventive and care-seeking behaviour. Studies generally report high rates of correct knowledge, although it is comparatively lower among studies of high-risk groups. There does not appear to be sufficient extant evidence to determine the relationship between other psychosocial variables and behaviour.
Conclusions
The review highlights the need to deploy more consistent, comprehensive measures of psychosocial factors and the importance of reaching subpopulations at higher risk of transmission in low transmission contexts. Malaria-related knowledge is generally high, even in settings of low transmission. Programmes and research should work to better understand the psychosocial factors that have been positively associated with prevention and care-seeking behaviours, such as norms, perceived response efficacy, perceived self-efficacy, and interpersonal communication. These factors are not necessarily distinct from that which research has shown are important in settings of high malaria transmission. However, the importance of each factor and application to malaria behaviour change programming in low-transmission settings is an area in need of further research. Existing instruments and approaches are available to support more systematic collection of psychosocial determinants and improved sampling approaches and should be applied more widely. Finally, while human behaviour is critical, health systems strengthening, and structural interventions are essential to achieve malaria elimination goals.
... Targeted mass antimalarial drug administration pilots in the Greater Mekong Subregion highlight the importance of understanding target communities to provide appropriate information in suitable ways [11]. Some evidence exists on the acceptability and operational feasibility of RDA in a low transmission P. falciparum settings, [6,7,12,13]. Although these findings have relevance in all settings, P. vivax predominant settings have unique challenges due to the treatment. ...
... Interview guides for FGDs and KIIs were adapted from previous RDA trials, [12,13] and modified based on this study context and reviewed by in-country study and program staff. Guides were developed in English and translated into Thai then reviewed and confirmed by study and program staff to confirm that the translations were accurate. ...
Background:
Reactive case detection (RACD) or testing and treatment of close contacts of recent malaria cases, is commonly practiced in settings approaching malaria elimination, but standard diagnostics have limited sensitivity to detect low level infections. Reactive drug administration (RDA), or presumptive treatment without testing, is an alternative approach, but better understanding regarding community acceptability and operational feasibility are needed.
Methods:
A qualitative study was conducted as part of a two-arm cluster randomized-controlled trial evaluating the effectiveness of RDA targeting high-risk villages and forest workers for reducing Plasmodium vivax and P. falciparum malaria in Thailand. Key informant interviews (KIIs) and focus group discussions (FGDs) were conducted virtually among key public health staff, village health volunteers (VHVs), and household members that implemented or received RDA activities. Transcriptions were reviewed, coded, and managed manually using Dedoose qualitative data analysis software, then underwent qualitative content analysis to identify key themes.
Results:
RDA was well accepted by household members and public health staff that implemented it. RDA participation was driven by fear of contracting malaria, eagerness to receive protection provided by malaria medicines, and the increased access to health care. Concerns were raised about the safety of taking malaria medicines without having an illness, particularly if underlying health conditions existed. Health promotion hospital (HPH) staff implementing RDA noted its operational feasibility, but highlighted difficulty in traveling to remote areas, and requested additional travel resources and hiring more VHVs. Other challenges were highlighted including the need for additional training for VHVs on malaria activities and the inability of HPH staff to conduct RDA due to other health priorities (e.g., Covid-19). More training and practice for VHVs were noted as ways to improve implementation of RDA.
Conclusions:
To maximize uptake of RDA, regular education and sensitization campaigns in collaboration with village leaders on the purpose and rationale of RDA will be critical. To alleviate safety concerns and increase participant safety, a rigorous pharmacovigilance program will be important. To accelerate uptake of RDA, trust between HPH staff and VHVs and the communities they serve must continue to be strengthened to ensure acceptance of the intervention.
Trial registration:
This study was approved by the Committee on Human Research at the University of California San Francisco (19-28,060) and the local Ethics Committee for Research in Human Subjects at Tak Provincial Health office (009/63) and Kanchanaburi Provincial health office (Kor Chor 0032.002/2185). Local authorities and health officers in the provinces, districts, and villages agreed upon and coordinated the implementation of the study. All methods in this study were carried out in accordance with relevant guidelines and regulations.
... In particular, these previous studies found that high acceptability of MDA was influenced by the perception of malaria as a main health problem [9] and by the community engagement campaign [7]. Moreover, others studies undertaken in Tanzania [17], Eswatini [18] and Cambodia [19] showed that perceived risk for malaria influenced acceptability of malaria treatment. ...
... Moreover, participants had experience of previous antimalarial pills, and they were concerned about drug adverse reactions, and others were reluctant to take drugs without malaria symptoms. These barriers have also been documented in previous studies [18,[21][22][23][24]. Furthermore, like previous studies [25] have reported, lack of access to accurate information, spread of misinformation about malaria intervention, being unable to drink alcohol while taking DHAp [7], lack of trust of fieldworkers, and the demand of food as precondition to take DHAp are potentials barriers to rfMDA. ...
This study analysed acceptability and perceived barriers to reactive focal mass drug administration (rfMDA) among community members exposed to community engagement campaigns and malaria elimination interventions in Magude district, following mass drug administration (MDA) in the same district. The study used a formative qualitative study design, consisting of 56 semi-structured interviews with community members, including community leaders, household heads, women of reproductive age, members of the community and adolescents, 4 semi-structured interviews with community health workers, 9 semi-structured interviews with healthcare professionals; and 16 focus group discussions with the general adult population. Data were collected between June and September 2017. A content thematic analysis approach was used to analyse the data. The results of this study showed that rfMDA was accepted due to awareness about the intervention, experience of a previous similar programme, the MDA campaign, and due to favourable perceptions built on the believe that rfMDA would help to prevent, treat and eliminate malaria in the community. Perceived barriers to rfMDA include lack of access to accurate information, reluctance to take a pregnancy test, concern on drug adverse reactions, and reluctance to take antimalarial drugs without any symptom. In conclusion, the community found rfMDA acceptable for malaria intervention. But more community engagement is needed to foster community involvement and self-appropriation of the malaria programme elimination.
... The primary outcome of the trial was the cluster-level cumulative incidence of all passively detected malaria cases per person years at risk over 2 years of follow-up. Secondary outcomes include safety and adherence (acceptability has been reported elsewhere 23 ). Infection prevalence and seroprevalence were originally also secondary outcomes but the endline cross-sectional survey was not conducted due to a shift in priorities within the Ministry of Health. ...
... Adherence to presumptive treatment with DP was high, and as reported elsewhere, acceptability was high. 23 There were no serious adverse events (SAEs). ...
... To elicit ongoing feedback regarding the conduct and burden of the study intervention, patients and the public were engaged in an ongoing basis through focus group discussions, the results of which are published elsewhere. (23) Patient consent for publication Not required. ...
Introduction
To reduce malaria transmission in very low-endemic settings, screening and treatment near index cases (reactive case detection (RACD)), is widely practised, but the rapid diagnostic tests (RDTs) used miss low-density infections. Reactive focal mass drug administration (rfMDA) may be safe and more effective.
Methods
We conducted a pragmatic cluster randomised controlled trial in Eswatini, a very low-endemic setting. 77 clusters were randomised to rfMDA using dihydroartemisin–piperaquine (DP) or RACD involving RDTs and artemether–lumefantrine. Interventions were delivered by the local programme. An intention-to-treat analysis was used to compare cluster-level cumulative confirmed malaria incidence among clusters with cases. Secondary outcomes included safety and adherence.
Results
From September 2015 to August 2017, 222 index cases from 47 clusters triggered 46 RACD events and 64 rfMDA events. RACD and rfMDA were delivered to 1455 and 1776 individuals, respectively. Index case coverage was 69.5% and 62.4% for RACD and rfMDA, respectively. Adherence to DP was 98.7%. No serious adverse events occurred. For rfMDA versus RACD, cumulative incidences (per 1000 person-years) of all malaria were 2.11 (95% CI 1.73 to 2.59) and 1.97 (95% CI 1.57 to 2.47), respectively; and of locally acquired malaria, they were 1.29 (95% CI 1.00 to 1.67) and 0.97 (95% CI 0.71 to 1.34), respectively. Adjusting for imbalance in baseline incidence, incidence rate ratio for rfMDA versus RACD was 0.95 (95% CI 0.55 to 1.65) for all malaria and 0.82 (95% CI 0.40 to 1.71) for locally acquired malaria. Similar results were obtained in a per-protocol analysis that excluded clusters with <80% index case coverage.
Conclusion
In a very low-endemic, real-world setting, rfMDA using DP was safe, but did not lower incidence compared with RACD, potentially due to insufficient coverage and/or power. To assess impact of interventions in very low-endemic settings, improved coverage, complementary interventions and adaptive ring trial designs may be needed.
Trial registration number
NCT02315690 .
... This strategy is supported by the fact that malaria transmission in Nigeria is largely seasonal and there is global decline in the burden of malaria in general [12] as it is reported that between 2000 and 2015, 17 countries successfully eliminated malaria and an additional 10 countries were expected to eliminate malaria by 2020 [13]. Based on these successes, malaria eradication is being explored as a feasible global goal [14]. ...
This study qualitatively compared the acceptability of intermittent preventive therapy with an alternative intervention - intermittent screening and treatment for prevention of malaria in pregnancy (MiP) among postpartum women in Edo State, Nigeria. Four focused group discussions were held with postpartum women who participated in a multi-center clinical trial that compared intermittent preventive therapy and intermittent screening and treatment for malaria in pregnancy between 2014 and 2015. The focus group discussions were guided by semi-structured open ended questions covering topics related to their experiences and choice of either interventions. Discussions were analyzed inductively based on emerged themes. Intermittent screening and treatment was most preferred and acceptable by the study participants compared to the intermittent preventive treatment approached. The quest to know their health status through the investigations was a motivation for their choice of the intervention. The rejection of intermittent preventive therapy was due to the general fear of medication use during pregnancy without apparent indication considering theside effects experienced with SP-based intermittent preventive therapy by women who considered themselves healthy. A properly designed and implemented intermittent screening and treatment programme could therefore be more effective in reducing the burden of malaria in pregnancy in the country. Keywords: Acceptability; Focus group discussions; Malaria prevention; Pregnant women
... Awareness of and concern about malaria Participants from Burkina Faso, Eswatini, Ghana, Laos, Mozambique and Nigeria described malaria as one of the most common and important health problems in their communities Baltzell et al., 2019;Chatio et al., 2019;Miaffo et al., 2004;Pell et al., 2019;Portugaliza et al., 2019;Strachan et al., 2016). Past experience of malaria compounded concerns about the disease in South-East Asia and Eswatini, though there were few contemporaneous clinical cases (Baltzell et al., 2019;Pell et al., 2017;Pell et al., 2019). ...
... Awareness of and concern about malaria Participants from Burkina Faso, Eswatini, Ghana, Laos, Mozambique and Nigeria described malaria as one of the most common and important health problems in their communities Baltzell et al., 2019;Chatio et al., 2019;Miaffo et al., 2004;Pell et al., 2019;Portugaliza et al., 2019;Strachan et al., 2016). Past experience of malaria compounded concerns about the disease in South-East Asia and Eswatini, though there were few contemporaneous clinical cases (Baltzell et al., 2019;Pell et al., 2017;Pell et al., 2019). Community members from South-East Asia were worried about malaria infection because of the personal economic consequences Pell et al., 2019). ...
... 'Hidden malaria' was also mentioned in Zambia to make sense of receiving an antimalarial when asymptomatic (Silumbe et al., 2020). Most participants from Eswatini were unaware that MDA treats sub-clinical infections and gives short-term protection against malaria (Baltzell et al., 2019). In Cambodia, MDA was associated with malaria elimination, understood on an individual basis, with the antimalarials clearing the parasite from their bodies . ...
Antimalarials have been administered widely to prevent clinical malaria and researchers have explored how end-users’ perspectives influence uptake and adherence. Drawing on a systematic search, this review aims to synthesise qualitative research on end-user perceptions of antimalarials for disease prevention. Searches were undertaken in PubMed and ISI Web of Knowledge. After applying exclusion criteria, identified sources underwent thematic analysis. Identified sources were published between 2000 and 2020 and drew on studies undertaken across Africa, Asia, Europe, Oceania and America. The sources revealed end-user concerns about the potential benefits and harms of preventive treatment that are entwined with broader understandings of the disease, the intervention, its implementation, accompanying information, and how it is embedded in wider healthcare and social relationships. The implications for antimalarials as preventive therapy encompass the need to build trust, including interpersonal trust, engage diverse stakeholders and to address broader health and wellbeing concerns during implementation.
... Previous studies have evaluated the effect of adding reactive targeted interventions, including IRS and drug administration, to routine population-wide measures, to further reduce or eliminate malaria. 13,14,[45][46][47] A trial in Namibia showed effective reduction of malaria incidence through reactive focal mass drug administration and reactive focal IRS, alone and in combination, when added to standard IRS. 14 Our trial is unique in using a non-inferiority design to assess whether replacing annual IRS campaigns with reactive IRS targeting at-risk neighbourhoods would be safe and prevent malaria from surging out of control. ...
Background
Increasing insecticide costs and constrained malaria budgets could make universal vector control strategies, such as indoor residual spraying (IRS), unsustainable in low-transmission settings. We investigated the effectiveness and cost-effectiveness of a reactive, targeted IRS strategy.
Methods
This cluster-randomised, open-label, non-inferiority trial compared reactive, targeted IRS with standard IRS practice in northeastern South Africa over two malaria seasons (2015–17). In standard IRS clusters, programme managers conducted annual mass spray campaigns prioritising areas using historical data, expert opinion, and other factors. In targeted IRS clusters, only houses of index cases (identified through passive surveillance) and their immediate neighbours were sprayed. The non-inferiority margin was 1 case per 1000 person-years. Health service costs of real-world implementation were modelled from primary and secondary data. Incremental costs per disability-adjusted life-year (DALY) were estimated and deterministic and probabilistic sensitivity analyses conducted. This study is registered with ClinicalTrials.gov, NCT02556242.
Findings
Malaria incidence was 0·95 per 1000 person-years (95% CI 0·58 to 1·32) in the standard IRS group and 1·05 per 1000 person-years (0·72 to 1·38) in the targeted IRS group, corresponding to a rate difference of 0·10 per 1000 person-years (–0·38 to 0·59), demonstrating non-inferiority for targeted IRS (p<0·0001). Per additional DALY incurred, targeted IRS saved US$7845 (2902 to 64 907), giving a 94–98% probability that switching to targeted IRS would be cost-effective relative to plausible cost-effectiveness thresholds for South Africa ($2637 to $3557 per DALY averted). Depending on the threshold used, targeted IRS would remain cost-effective at incidences of less than 2·0–2·7 per 1000 person-years. Findings were robust to plausible variation in other parameters.
Interpretation
Targeted IRS was non-inferior, safe, less costly, and cost-effective compared with standard IRS in this very-low-transmission setting. Saved resources could be reallocated to other malaria control and elimination activities.
Funding
Joint Global Health Trials.
... High coverage and acceptability could have been due to effective community sensitisation activities before the study, 10 ongoing engagement by staff during pharmacovigilance and follow-up visits, and high motivation for individuals to participate because of the perceived threat of malaria when there was a recent case in their neighbourhood. 34 Our study has some limitations. First, the large differences in crude and adjusted incidence and prevalence estimates were due to an imbalance of factors in the study arms that were associated with the trial outcomes. ...
Background
In low malaria-endemic settings, screening and treatment of individuals in close proximity to index cases, also known as reactive case detection (RACD), is practised for surveillance and response. However, other approaches could be more effective for reducing transmission. We aimed to evaluate the effectiveness of reactive focal mass drug administration (rfMDA) and reactive focal vector control (RAVC) in the low malaria-endemic setting of Zambezi (Namibia).
Methods
We did a cluster-randomised controlled, open-label trial using a two-by-two factorial design of 56 enumeration area clusters in the low malaria-endemic setting of Zambezi (Namibia). We randomly assigned these clusters using restricted randomisation to four groups: RACD only, rfMDA only, RAVC plus RACD, or rfMDA plus RAVC. RACD involved rapid diagnostic testing and treatment with artemether-lumefantrine and single-dose primaquine, rfMDA involved presumptive treatment with artemether-lumefantrine, and RAVC involved indoor residual spraying with pirimiphos-methyl. Interventions were administered within 500 m of index cases. To evaluate the effectiveness of interventions targeting the parasite reservoir in humans (rfMDA vs RACD), in mosquitoes (RAVC vs no RAVC), and in both humans and mosquitoes (rfMDA plus RAVC vs RACD only), an intention-to-treat analysis was done. For each of the three comparisons, the primary outcome was the cumulative incidence of locally acquired malaria cases. This trial is registered with ClinicalTrials.gov, number NCT02610400.
Findings
Between Jan 1, 2017, and Dec 31, 2017, 55 enumeration area clusters had 1118 eligible index cases that led to 342 interventions covering 8948 individuals. The cumulative incidence of locally acquired malaria was 30·8 per 1000 person-years (95% CI 12·8–48·7) in the clusters that received rfMDA versus 38·3 per 1000 person-years (23·0–53·6) in the clusters that received RACD; 30·2 per 1000 person-years (15·0–45·5) in the clusters that received RAVC versus 38·9 per 1000 person-years (20·7–57·1) in the clusters that did not receive RAVC; and 25·0 per 1000 person-years (5·2–44·7) in the clusters that received rfMDA plus RAVC versus 41·4 per 1000 person-years (21·5–61·2) in the clusters that received RACD only. After adjusting for imbalances in baseline and implementation factors, the incidence of malaria was lower in clusters receiving rfMDA than in those receiving RACD (adjusted incidence rate ratio 0·52 [95% CI 0·16–0·88], p=0·009), lower in clusters receiving RAVC than in those that did not (0·48 [0·16–0·80], p=0·002), and lower in clusters that received rfMDA plus RAVC than in those receiving RACD only (0·26 [0·10–0·68], p=0·006). No serious adverse events were reported.
Interpretation
In a low malaria-endemic setting, rfMDA and RAVC, implemented alone and in combination, reduced malaria transmission and should be considered as alternatives to RACD for elimination of malaria.
Funding
Novartis Foundation, Bill & Melinda Gates Foundation, and Horchow Family Fund.
Introducción: A pesar de ser una enfermedad prevenible y curable, la malaria continúa siendo un problema para la salud pública. Objetivo: Identificar las barreras y facilitadores para la eliminación de la malaria. Material y Método: Entre 2019 y 2020 se revisó literatura disponible en las bases de datos Pubmed y LILACS; se realizó una matriz para la organización y posterior análisis de la información. Resultados: En total, 57 artículos fueron seleccionados evidenciando como barreras, la falta de recurso humano, técnico y económico, la resistencia del vector al manejo farmacológico, la diversidad parasitaria y de vectores y la movilidad humana entre en regiones endémicas. Estrategias como el manejo integrado de vectores, la estratificación dinámica de la enfermedad, la detección y manejo oportuno y la adecuada vigilancia epidemiológica, fueron repetidamente enunciadas como facilitadores. Conclusión: Es necesario identificar la realidad social, epidemiológica y política en el nivel regional y así poder personalizar y sostener las estrategias de eliminación.
Background:
Malaria is a significant cause of morbidity and mortality in children aged under 5 years in Mozambique. The World Health Organization recommends seasonal malaria chemoprevention (SMC), the administration of four monthly courses of sulfadoxine-pyrimethamine (SP) and amodiaquine (AQ), to children aged 3-59 months during rainy season. However, as resistance to SP is widespread in East and Southern Africa, SMC has so far only been implemented across the Sahel in West Africa.
Objective:
This protocol describes the first phase of a pilot project that aims to assess the protective effect of SP and AQ when used for SMC and investigate the levels of molecular markers of resistance of Plasmodium falciparum to antimalarial medicines in the study districts. In addition, it is important to understand whether SMC is a feasible and acceptable intervention in the context of Nampula Province, Mozambique.
Methods:
This study will adopt a hybrid effectiveness-implementation design to conduct a mixed methods evaluation with six objectives: a molecular marker study, a nonrandomized controlled trial, an analysis of reported malaria morbidity indicators, a documentation exercise of the contextual SMC adaptation, an acceptability and feasibility assessment, and a coverage and quality assessment.
Results:
Ethical approval for this study was granted by the Mozambican Ministry of Health National Bioethics Committee on September 15, 2020. Data collection began in October 2020, and data analysis is expected to be completed by August 2021.
Conclusions:
This research will make a unique contribution to our understanding of whether the combination of SP and AQ, when used for SMC, can confer a protective effect against malaria in children aged 3-59 months in a region where malaria transmission is seasonal and SP resistance is expected to be high. If the project is successful, subsequent phases are expected to provide a more comprehensive assessment of the effectiveness and sustainability of SMCs.
International registered report identifier (irrid):
DERR1-10.2196/27855.
