Comprehensive case management of malaria: Operational research informing policy.

In 2013, the Odisha state Vector Borne Disease Control Programme led a five year operational research project, under programmatic conditions, in close collaboration with several partners. This Comprehensive Case Management Project covered a population of 900,000 across paired control and intervention blocks in four districts, each with different transmission intensities. Key gaps in access to malaria services were identified through household surveys and a detailed situation analysis. The interventions included ensuring adequate stocks of rapid diagnostic tests and antimalarial drugs at the village level, the capacity building of health workers and ASHAs, setting up microscopy centres at the primary health care level, and conducting mass screening and treatment in poorly accessible areas. The programme strengthened the routine health system, and improved malaria surveillance as well as the access to and quality of care. Initially, the programme led to increased case reporting due to improved detection, followed by a decline in malaria incidence. Lessons from the project were then scaled up statewide in the form of a new initiative-Durgama Anchalare Malaria Nirakaran (DAMaN).

Malaria and HIV co-infection: available evidence, gaps and possible interventions.

OBJECTIVES: To review the evidence of association between malaria and HIV/AIDS co-infection for purposes of developing strategies for malaria control. DESIGN: Desktop review of literature. SETTING: Harare, Zimbabwe. MAIN OUTCOME MEASURES: Response to treatment, development of severe malaria, malarial immunological response in HIV/AIDS positive people and incidence of malaria in HIV/AIDS positive individuals. RESULTS: HIV-1 infection increases the incidence of Plasmodium falciparum parasitaemia and is associated with the development of severe malaria, commonly anaemia, cerebral malaria and high parasite density (OR = 2.56; 95% CI = 1.53 to 4.29; p < 0.001). The efficacy of chloroquine and sulphadoxine-pyrimethamine in reducing placental malaria in HIV-1 positive pregnant women was impaired compared to HIV-1 negative pregnant women. However, the situation in non-gravid HIV-1 positive people as regards efficacy of chloroquine and sulphadoxine-pyrimethamine prophylaxis is not known. Also not known is the relationship between malaria parasitaemia without symptoms and HIV-1 infection, the results of which may provide useful information regarding malaria control and prevention in HIV-1 positive people. CONCLUSIONS: HIV-1 positive people staying in malaria endemic areas are at risk of developing severe malaria. Malaria prevention using insecticide-treated bednets and indoor residual house spraying may be the best available options for these people. Chloroquine and sulphadoxine-pyrimethamine prophylaxis require further studies to verify their efficacy, in the presence of HIV-1/AIDS infection.

Factors associated with measles complications in Gweru, Zimbabwe.

OBJECTIVE: To investigate factors associated with complications or death among measles cases. DESIGN: A cross-sectional study. SETTING: Health facilities in the city of Gweru, Zimbabwe. SUBJECTS: Six hundred and thirty seven measles cases randomly selected from measles surveillance data. MAIN OUTCOME MEASURES: (a) Associations of respiratory complications and diarrhoea with death among complicated cases; (b) associations of age at infection, gender of cases and vaccination status of cases with occurrence of either respiratory complications or diarrhoea or death among measles cases. RESULTS: Among cases with respiratory complications, twenty two (29%) had died, while five (5%) had died among those with diarrhoea (OR=7.06,95% CI=2.55-22.35, p<0.001). On rates of respiratory complications among cases, age groups 24-59 and 60+ months were protective by 57% (95% CI=11-79%) and 76% (95% CI=52-88%) respectively compared to the age group <24 months, and vaccination was protective by 42% (95% CI=2-65%) compared to those unvaccinated. Concerning rates of diarrhoea among cases, the age group 60+ months was protective by 80% (95% CI=62-89%) compared to age group <60 months, while vaccination was protective by 64% (95% CI=42-77%) compared to those unvaccinated. With respect to rates of mortality among cases, age was protective by six per cent (95% CI=3-9 %) for every year older. CONCLUSION: It was concluded that: (a) the risk of death was higher in cases with respiratory complications than diarrhoea; (b) the risk of complications and death was inversely related to age at infection and older age groups were protective against occurrence of complications or death; (c) the risk of complications was higher in unvaccinated cases and vaccination was protective against occurrence of complications.

Measles complications: the importance of their management in reducing mortality attributed to measles.

OBJECTIVE: To determine the effect of rates of complications among cases and management of complicated cases on measles case fatality rates. DESIGN: Measles disease surveillance. SETTING: City of Gweru, Department of Health. SUBJECTS: Children aged zero to 15 years. MAIN OUTCOME MEASURES: Case fatality rates. RESULTS: Measles case fatality rates declined from 47.6 in 1967 to zero in 1989. Between 1967 and 1978 respiratory infections were the predominant complications (66.5%), while after 1979 diarrhoea was the predominant complications (60.6%). A significant partial correlation coefficient was observed between rates of mortality among complicated cases and case fatality rates (r = 0.89, df = 20, p < 0.001). CONCLUSION: Good management of complicated cases may have contributed towards the decline in measles case fatality rates.

PIP: A measles surveillance study conducted in 1967-89 among children 0-15 years of age in Gweru, Zimbabwe, sought to determine the effect of measles complications and their management on measles case fatality rates. The surveillance system in Gweru records measles cases and deaths reported from the city's health centers as well as those detected through active case searches in the community. Complicated measles cases are managed at the city's infectious disease hospital. In the period under review, the median case fatality rate was 4.2% and the median rate of complications was 25.5%. The measles case fatality rate declined from 47.6% in 1967 to zero in 1989. Between 1967 and 1978, respiratory infections were the predominant complication (66.5% of cases); after 1979, diarrhea was the most common complication (60.6% of cases). A significant partial correlation coefficient was observed between rates of mortality among complicated cases and case fatality rates (p 0.001). The dramatic improvements detected in this study are presumed due to improved case management and treatment (especially vitamin A administration) of measles cases admitted to the infectious disease hospital.

Comparison of protection afforded by single measles vaccination and late revaccination schedules.

An intervention study compared the protection afforded vaccinees by single measles vaccination and late revaccination schedules in 1990-94. During the intervention a single revaccination (after initial vaccination at nine months of age) was applied to children at any point in time between 12 and 23 months of age. Cases of measles aged 10-23 months were identified through an active surveillance system and in this period 5, 11 and 11 cases of revaccinated, single vaccination and unvaccinated children were identified. Measles incidence rates were 392.2-415.6 (mean = 405.6, SD = 6.7), 75.4-112.1 (median = 91.7, SD = 13.3) and 12.8-15.2 (mean = 13.9, DS = 0.99) per 100,000 population in children who were unvaccinated, with single vaccination and revaccinated respectively. Relative risk of contracting measles in children who were unvaccinated or with single vaccination was 26.5-32.5 (mean = 29.4, SD = 2.3) and 5.8-8.8 (mean = 6.8, SD = 1.2) respectively compared with revaccinated children. Vaccine efficacies that were determined were 73-81% (mean = 77.2, SD = 2.9) and 96.2-96.9% (mean = 96.6, SD = 0.27) for single vaccination and late revaccination schedules respectively. It was concluded that late revaccination affords vaccinees better protection than single vaccination through improvement in vaccine.