Mapping internal connectivity through human migration in malaria endemic countries.

The launch of Roll Back Malaria (RBM) initiative in the early 2000s marked the first serious international efforts to control, prevent and treat malaria in endemic countries of sub-Sahara Africa unparalleled since the demise of the global malaria eradication campaign in the 1960s. These efforts have led to accelerated scale-up of highly proven malaria interventions, that is, insecticide-treated nets, indoor residual spraying, and case management with artemisinin-based combination therapies. This has been followed by a decline of malaria morbidity and mortality in high endemic countries including Uganda which is ranked in the top six high-burden countries. Despite these achievements, malaria remains a major global public health problem and a leading cause of hospitalization and death in Uganda. The RBM support in Uganda has been extended to malaria surveillance specifically to strengthen the national Health Management Information System (HMIS), and periodical implementation of nationally representative household surveys such as Malaria Indicator Survey (MIS) and Demographic Health Surveys (DHS), and facility assessment surveys. The availability of these large datasets notwithstanding, their utilization remains low and the information extracted is limited to national averages that neither take into account subnational heterogeneities and disparities nor evaluate the effects of interventions and other important confounders on malaria burden changes in space and time. In this thesis, we developed Bayesian hierarchical geostatistical and spatio-temporal models for malaria surveillance data collected in Uganda during 2009-2017 to estimate malaria burden, assess interventions and health system-related effects on its changes, and forecast malaria cases to support early warning systems. These models fitted via Markov Chain Monte Carlo (MCMC) simulations offer the flexibility to incorporate correlation of malaria in space and time and can easily be extended to capture complex relationships.

Preventable diseases still cause huge mortality in low- and middle-income countries. Research in spatial epidemiology and earth observation is helping academics to understand and prioritise how mortality could be reduced and generates spatial data that are used at a global and national level, to inform disease control policy. These data could also inform operational decision making at a more local level, for example to help officials target efforts at a local/regional level. To be usable for local decision-making, data needs to be presented in a way that is relevant to and understandable by local decision makers. We demonstrate an approach and prototype web application to make spatial outputs from disease modelling more useful for local decision making. Key to our approach is: (1) we focus on a handful of important data layers to maintain simplicity; (2) data are summarised at scales relevant to decision making (administrative units); (3) the application has the ability to rank and compare administrative units; (4) open-source code that can be modified and re-used by others, to target specific user-needs. Our prototype application allows visualisation of a handful of key layers from the Malaria Atlas Project. Data can be summarised by administrative unit for any malaria endemic African country, ranked and compared; e.g. to answer questions such as, ‘does the district with the highest malaria prevalence also have the lowest coverage of insecticide treated nets?’. The application is developed in R and the code is open-source. It would be relatively easy for others to change the source code to incorporate different data layers, administrative boundaries or other data visualisations. We suggest such open-source web application development can facilitate the use of data for public health decision making in low resource settings.

To provide information about preventive measures and treatment seeking behaviour as well as an estimate of the malaria burden in different epidemiological settings for effective monitoring and evaluation of the ongoing efforts. Cross-sectional survey carried out in four areas representing different levels of transmission to explore the use of preventive measures, care-seeking behaviour and accessibility in addition to point prevalence was followed by a follow-up phase in which the health workers registered and reported all fever cases including malaria. The relation between the reported malaria incidence, the product of symptomatic/asymptomatic ratio and the prevalence of confirmed malaria cases was used to develop the equation that could predict the true malaria incidence. Thousand households and 3628 individuals were surveyed. The presence of any net varied between 6.6% and 40%; the percentage of people who reportedly slept under mosquito nets in the previous night varied between 35 and 80. Prompt use of medications ranged between 14 and 48% with a delay of more than 24 h noticed in different areas. The mean number of individuals per household who reported use of anti-malarial drugs in the last 2 weeks ranged between 0.6 (SD = 0.92) and 1.2 (SD = 1.1), with variable cost per treatment and affordability. The prevalence of asymptomatic parasitaemia, fever and confirmed malaria at time of the survey differed by area. The incidence of malaria during the follow-up period was estimated to be 8.5, 178.6, 23.7 and 10.3 episodes per 1000 population in Malakal, Elrank, Elhosh and El Matama, respectively. Based on this, a prediction equation was developed. We found suboptimal health care seeking behaviour, coverage and use of preventive measures with a high malaria burden. We developed a model for future estimation of malaria episodes.

Insecticide Treated Net Projects: A Handbook for Managers by D. Chevasse, C. Reed and K. Attawell

Malaria remains an important health problem in Bangladesh, with approximately 14 million people at risk. Antimalarial drug resistance is a major obstacle to the control of malaria in endemic countries. In 2012, Bangladesh reported an estimated 29 522 malaria episodes, of which 94% were reported as being caused by Plasmodium falciparum. In this study, we reviewed and summarized antimalarial drug resistance data from Bangladesh published until June 2013. We searched published sources for data referring to any type of P. falciparum drug resistance (in vivo, in vitro, or molecular) and found 169 articles published in peer-reviewed journals. Of these, 143 articles were excluded because they did not meet our inclusion criteria. After detailed review of the remaining 26 articles, 14 were selected for evaluation. Published studies indicate that P. falciparum shows varying levels of resistance to chloroquine, mefloquine and sulfadoxine-pyrimethamine. Combination therapy of chloroquine and primaquine has proven ineffective and combinations of sulfadoxine-pyrimethamine with either quinine or chloroquine have also shown poor efficacy. Recent studies indicate that artemisinin derivatives, such as artesunate, remain highly efficacious in treating P. falciparum malaria. Available data suggest that artemisinins, quinine, doxycyline, mefloquine-artesunate and azithromycin-artesunate combination therapy remain efficacious in the treatment of P. falciparum malaria in Bangladesh.

Malaria infection during pregnancy, although preventable and treatable, still has adverse effects on both the mother and fetus in Nigeria. These adverse effects; intrauterine growth retardation, low birth weight and maternal anemia are significant risk factors for neonatal and infant mortality. The 2014 national guidelines and strategies for control of malaria during pregnancy recommend administration of at least 3 doses of Sulphadoxine-Pyrimethamine (SP) as Intermittent Preventive Treatment in pregnancy (IPTp) to pregnant women attending Antenatal Care Clinic (ANC). However, implementation of the guidelines is still sub-optimal. The objective of the study was to assess the effect of scaled implementation of prevention of malaria in pregnancy (MiP) with IPTp on birth weight of babies born in states supported by the US President’s Malaria Initiative. The study used secondary data collected from July 2013 to June 2015 in 7 states where routine ANC data from all the health facilities are reported through the National District Health Information System to analyze trend and differences in reported birth weight following implementation of IPTp with SP. The interventions provided by the project include capacity building on control of malaria in pregnancy; strengthening of logistics management systems for SP, monitoring and supportive supervision. Between July 2014 and June 2015, 636,600 health facility ANC visits and 191,104 births were reported. The observed trend in the available data showed that the birth weight of babies improved as the IPTp uptake increased. Mean percentage of ANC revisits who received IPTp2 increased from 29% to 38%; the mean percentage of babies with low birth weight decreased from 14% to 10%; while the mean percentage of babies with birth weight higher than 2,500g increased from 86% to 90% between the previous year and the intervention period. Though many confounders might contribute to the improved birth weight of babies reported within the period, however the contribution of the scaled implementation of IPTp is significant as previously documented in other malaria endemic countries. Concerted efforts are needed to scale up this intervention nationwide and strengthen health system in order to improve the birth weight of babies and consequently reducing neonatal and infant mortality.

Dear Sir: The article, “Compliance with Antimalaria Chemoprophylaxis in a Combat Zone,” confirmed the limited adherence to such preventive measures among military service members. The authors analyzed the reasons for noncompliance while presenting measures undertaken to address them. These measures include education and training, supply of medicines before departure, directly observed therapy, and an established discipline policy with consequences rarely applied but supported by the laws of the Uniform Code of Military Justice.1 Given the importance of malaria chemoprophylaxis, solutions are needed urgently to address this critical weakness in malaria prevention and control systems, not just for troops but all other non-immune travelers and residents. Poor compliance affects the health of individuals improperly taking the medications. It has the potential to roll back the current gains in malaria control efforts in endemic countries by creating resistance and allowing the re-emergence of parasites in areas that have seen an impressive decline in parasitemia. For more than a decade, ExxonMobil has assigned thousands of non-immune workers in malaria-endemic countries. They face the same compliance challenges as the United States military service members and other long-term travelers2. In 2003, at the inception of our operations in malaria-endemic locations, more than 200 malaria cases were reported. Our strategic response to this was the implementation of a comprehensive malaria program and its integration into the health and safety procedures of our company organizations. As a result, malaria cases decreased to < 15 per year. The workplace malaria program measures are targeted at individual employees and contractors; they are also embedded into the verification and reporting systems of company operations. They include: 1. A comprehensive awareness program that communicates and confirms the risk of malaria, the program requirements, and each individual's commitment to chemoprophylaxis with their willingness to be tested for compliance verification. Education begins before departure, with consistent reinforcement of key messages upon arrival, during site induction, and safety meetings. Training completion is verified before travel, at arrival in the country, and at specific check points such as company air transportation sites or camp offices. For company providers, malaria program requirements are specified in contractor agreements and subject to review at contractor mobilization. 2. Provision of chemoprophylaxis medicines recommended by the World Health Organization (WHO)3 and the U.S. Center for Control of Infectious Diseases.4 They include Atovaquone-Proguanil, Mefloquine, and doxycycline, which can be adopted for long-term use,5 expand workers' choices, personalize their prescription, enable them to switch medications when needed while representing a panel of medicines with reported equal efficacy and side-effect occurrence.6 Medical services are available on site to ensure that medications are tolerated or changed. The costs of medicines are reimbursed by the company for employees and for contractors, through company policies and agreements. 3. Monitoring chemoprophylaxis compliance through random testing of workers. The laboratory test method was developed with a United States-based company.7 Between 5,000 and 10,000 tests were performed annually from 20038 to 2011. Non-detect rate of malaria medicines in urine samples tested during this time frame decreased from 2.5% to 0.5%. The urine tests verify the use of malaria chemoprophylaxis, although their protective levels can only be assessed through blood tests. In early 2012, a field test developed with the French Army9 for Proguanil and Mefloquine was implemented. It provides results in 10 minutes and enables more practical on-site verification and immediate feedback. 4. A “show-me process” at arrival and departure from work sites. This process requires workers to verify that they are in possession of their malaria chemoprophylaxis and are practicing bite protection (wearing factory-treated permethrin clothing, carrying insect repellent, and documentation of malaria awareness training). 5. Engagement of Senior Management for a malaria control program. Malaria cases, cases of non-detects for urine malaria drug tests, and periodic assessments of the malaria control program elements performed through Operations Integrity Management Systems are reported up line to senior company executives from affiliates. These reports are a part of the site performances in malaria locations. They are stewarded by a Corporate Malaria Steering Committee responsible for guidance and sponsor of program activities. Contractor companies are also assessed and notified of health expectations, including malaria program requirements through various mechanisms before, during, and after mobilization. Successful programs, including malaria chemoprophylaxis compliance, rely on clear expectations, personal and organizational engagement with effective verification of expectations, and application of corrective action when indicated. Like any behavior required from population groups (observance of speed limits, proper harnessing while working at heights, or adherence to required health practices), repeated training and awareness, individual and leadership commitment, verification of observance, and application of consequences for noncompliance are key enabling factors.

BackgroundThe spatial and temporal variability inherent in malaria transmission within countries implies that targeted interventions for malaria control in high-burden settings and subnational elimination are a practical necessity. Identifying the spatio-temporal incidence, risk, and trends at different administrative geographies within malaria-endemic countries and monitoring them in near real-time as change occurs is crucial for developing and introducing cost-effective, subnational control and elimination intervention strategies.MethodsThis study developed intelligent data analytics incorporating Bayesian trend and spatio-temporal Integrated Laplace Approximation models to analyse high-burden over 32 million reported malaria cases from 1743 health facilities in Zambia between 2009 and 2015.ResultsThe results show that at least 5.4 million people live in catchment areas with increasing trends of malaria, covering over 47% of all health facilities, while 5.7 million people live in areas with a declining trend (95% CI), covering 27% of health facilities. A two-scale spatio-temporal trend comparison identified significant differences between health facilities and higher-level districts, and the pattern observed in the southeastern region of Zambia provides the first evidence of the impact of recently implemented localised interventions.ConclusionsThe results support our recommendation for an adaptive scaling approach when implementing national malaria monitoring, control and elimination strategies and a particular need for stratified subnational approaches targeting high-burden regions with increasing disease trends. Strong clusters along borders with highly endemic countries in the north and south of Zambia underscore the need for coordinated cross-border malaria initiatives and strategies.

BackgroundThe proportion of individuals who seek treatment for fever is an important quantity in understanding access to and use of health systems, as well as for interpreting data on disease incidence from routine surveillance systems. For many malaria endemic countries (MECs), treatment-seeking information is available from national household surveys. The aim of this paper was to assemble sub-national estimates of treatment-seeking behaviours and to predict national treatment-seeking measures for all MECs lacking household survey data.MethodsData on treatment seeking for fever were obtained from Demographic and Health Surveys, Malaria Indicator Surveys and Multiple Cluster Indicator Surveys for every MEC and year that data were available. National-level social, economic and health-related variables were gathered from the World Bank as putative covariates of treatment-seeking rates. A generalized additive mixed model (GAMM) was used to estimate treatment-seeking behaviours for countries where survey data were unavailable. Two separate models were developed to predict the proportion of fever cases that would seek treatment at (1) a public health facility or (2) from any kind of treatment provider.ResultsTreatment-seeking data were available for 74 MECs and modelled for the remaining 24. GAMMs found that the percentage of pregnant women receiving prenatal care, vaccination rates, education level, government health expenditure, and GDP growth were important predictors for both categories of treatment-seeking outcomes. Treatment-seeking rates, which varied both within and among regions, revealed that public facilities were not always the primary facility type used.ConclusionsEstimates of treatment-seeking rates show how health services are utilized and help correct reported malaria case numbers to obtain more accurate measures of disease burden. The assembled and modelled data demonstrated that while treatment-seeking rates have overall increased over time, access remains low in some malaria endemic regions and utilization of government services is in some areas limited.Electronic supplementary materialThe online version of this article (doi:10.1186/s12936-015-1048-x) contains supplementary material, which is available to authorized users.

Artemisinin-based combination therapies (ACTs): Best hope for malaria treatment but inaccessible to the needy!

I merge publicly available data on CO2 emissions, with patterns of human movement, to analyze the anticipated effects of human migration on the abilities of nations to attain 2030 UNFCCC CO2 emission targets. I do so at both global (175 countries) and national (Canada and the USA) scales. The analyses reveal that mean per capita CO2 emissions are nearly three times higher in countries with net immigration than in countries with net emigration. Those differences project a cumulative migration-induced annual increase in global emissions of approximately 1.7 billion tonnes. For Canada and the United States, the projected total emissions attributable to migration from 2021 to 2030 vary between 0.7 and 0.9 billion tonnes. Although staggering, the annual and total emissions represent a small fraction of current global emissions totalling 36 billion tonnes per annum. Even so, the projected decadal immigration of nearly 4 million humans to Canada, and 10 million to the USA, represent significant additional challenges in reducing CO2 emissions. The challenges pale in comparison with poor nations that are minor contributors to climate change. Such nations face the incomprehensible burden of improving the quality of their citizens’ lives without increasing global CO2 emissions. National and international strategies aimed at lowering emissions must thus acknowledge, and cooperatively address, consumptive inequities and expected increases in human population size and migration.

BackgroundWhile substantial gains have been made in the fight against malaria over the past 20 years, malaria morbidity and mortality are marked by inequality. The equitable elimination of malaria within countries will be determined in part by greater spending on malaria interventions, and how those investments are allocated. This study aims to identify potential drivers of malaria outcome inequality and to demonstrate how spending through different mechanisms might lead to greater health equity.MethodsUsing the Gini index, subnational estimates of malaria incidence and mortality rates from 2010 to 2020 were used to quantify the degree of inequality in malaria burden within countries with incidence rates above 5000 cases per 100,000 people in 2020. Estimates of Gini indices represent within-country distributions of disease burden, with high values corresponding to inequitable distributions of malaria burden within a country. Time series analyses were used to quantify associations of malaria inequality with malaria spending, controlling for country socioeconomic and population characteristics.ResultsBetween 2010 and 2020, varying levels of inequality in malaria burden within malaria-endemic countries was found. In 2020, values of the Gini index ranged from 0.06 to 0.73 for incidence, 0.07 to 0.73 for mortality, and 0.00 to 0.36 for case fatality. Greater total malaria spending, spending on health systems strengthening for malaria, healthcare access and quality, and national malaria incidence were associated with reductions in malaria outcomes inequality within countries. In addition, government expenditure on malaria, aggregated government and donor spending on treatment, and maternal educational attainment were also associated with changes in malaria outcome inequality among countries with the greatest malaria burden.ConclusionsThe findings from this study suggest that prioritizing health systems strengthening in malaria spending and malaria spending in general especially from governments will help to reduce inequality of the malaria burden within countries. Given heterogeneity in outcomes in countries currently fighting to control malaria, and the challenges in increasing both domestic and international funding allocated to control and eliminate malaria, the efficient targeting of limited resources is critical to attain global malaria eradication goals.

In May 1981, the Thirty-fourth World Health Assembly adopted the global strategy for “Health for All by the Year 2000” and decided to monitor the progress and evaluate the effectiveness of the strategy at regular intervals. A plan of action for the implementation, monitoring and evaluation of the strategy was prepared and in September 1981, the WHO Regional Committee for South-East Asia endorsed the global strategy and the plan of action resulting from it. This plan envisaged, inter-alia, that the progress in implementing the national, regional and global strategies will be monitored every two years and their effectiveness evaluated every six years.

This book chapter focuses on a programme on improving human health through livestock research in three areas: (i) animal-source foods for nutrition; (ii) zoonoses (diseases transmitted between animals and people); and (iii) FBD. This was the first CGIAR group with an explicit food safety mandate (rather than focusing on specific hazards) and with expertise in using research methods for food safety rather than diseases in general. ILRI was also one of the first groups to focus on food safety in the 'informal markets' of developing countries, and by the 2010s, had become the lead research institute globally in this emerging area. ILRI research on FBD has resulted in many science outputs, including some genuinely innovative tools and approaches, and has already demonstrated outcomes at community, national and regional levels. These include substantial inputs into global, regional and national strategies and national training programmes. The major development-oriented approach - the triple-path for training, motivating and enabling of informal market agents - has been shown to be both scalable and sustainable. While questions remain about its lasting effects on food safety and its application outside those few countries where its success has been demonstrated, the next few years should bring further evidence about this, with benefits lasting for many decades to come.

&amp;lt;p&amp;gt;High spatial resolution (&amp;lt;100m) mapping of NO&amp;lt;sub&amp;gt;2&amp;lt;/sub&amp;gt; at various temporal scales (e.g., hours of the week, month, or year) provides opportunities to study the relationship between personal air pollution exposure and health over large populations. Statistical modelling of NO&amp;lt;sub&amp;gt;2&amp;lt;/sub&amp;gt; at the global scale provides high-resolution estimations for countries with deficient ground station measurements and provides air pollution maps and human exposures with consistent uncertainties for global health studies. Our objective is to develop spatiotemporally-resolved statistical learning models, understand the temporal dynamics of NO&amp;lt;sub&amp;gt;2&amp;lt;/sub&amp;gt; and the contributing sources, and open-source our global NO&amp;lt;sub&amp;gt;2&amp;lt;/sub&amp;gt; prediction maps at 100 m resolution. The global maps are provided at various temporal aggregations (e.g. separating between weekdays and weekends, day and night) and spatial aggregations (e.g. multiple gridded resolutions, administrative units) to facilitate global exposure assessment. To create these maps, we compiled from multiple sources a dataset of hourly NO&amp;lt;sub&amp;gt;2&amp;lt;/sub&amp;gt; measurements from more than 7000 ground stations over the globe, considerably larger in size and spatiotemporal coverage than used in recent high-resolution NO&amp;lt;sub&amp;gt;2 &amp;lt;/sub&amp;gt;mapping studies. For statistical modelling, geospatial predictors include Sentinel-5 satellite (Tropomi instrument) measurements, variables relating to the emission sources (e.g., road network), dispersion processes (e.g., meteorological variables), elevation and Earth nightlights (from VIIRS nightlight data). We evaluate various statistical models including linear models, ensemble tree-based models, deep convolution models, stacked models with regularisation, and hierarchical modelling strategies and select the optimal model for mapping. Evaluation of models included uncertainty assessment as well as spatial validation methods.&amp;lt;/p&amp;gt;