Malaria Elimination in Africa: Rethinking Strategies for Plasmodium vivax and Lessons from Botswana.

The global malaria community has picked up the theme of malaria elimination in more than 90% of the world's population in the next decade. Recent reports of Plasmodium vivax (P. vivax) in sub-Saharan Africa, including in Duffy-negative individuals, threaten the efforts aimed at achieving elimination. This is not only in view of strategies that are tailored only to P. falciparum elimination but also due to currently revealed biological characteristics of P. vivax concerning the relapse patterns of hypnozoites and conservation of large biomasses in cryptic sites in the bone marrow and spleen. A typical scenario was observed in Botswana between 2008 and 2018, which palpably projects how P. vivax could endanger malaria elimination efforts where the two parasites co-exist. The need for the global malaria community, national malaria programs (NMPs), funding agencies and relevant stakeholders to engage in a forum to discuss and recommend clear pathways for elimination of malaria, including P. vivax, in sub-Saharan Africa is warranted.

Acceptance of the District Health Information System Version 2 Platform for Malaria Case-Based Surveillance By Health Care Workers in Botswana: Web-Based Survey.

BACKGROUND: Similar to many low- and middle-income countries, Botswana has identified eHealth as a means of improving health care service provision and delivery. The National Malaria Programme (NMP) in Botswana has implemented the District Health Information System version 2 (DHIS2) to support timely malaria case reporting across its 27 health districts; however, the implementation of an eHealth system is never without challenges. Barriers to the implementation of eHealth innovations within health care settings may arise at the individual or organizational levels. As such, the evaluation of user perceptions of the technology is an important step that can inform its sustainable implementation. The DHIS2 was implemented without evaluating user perceptions beforehand; therefore, the Botswana Ministry of Health and Wellness was uncertain about the likelihood of acceptance and use of the platform. OBJECTIVE: We aimed to determine the acceptance of the DHIS2 platform by the NMP in Botswana to gauge whether adoption would be successful. METHODS: The study's design was informed by constructs of the technology acceptance model. A survey, with items assessed using a 7-point Likert scale, and focus group discussions were undertaken with DHIS2 core users from 27 health districts and NMP personnel at the Ministry of Health and Wellness. The web-based survey was administered from August 3, 2020 to September 30, 2020. RESULTS: Survey participants were core users (n=27). Focus group participants were NMP personnel (n=5). Overall, participants' survey responses (frequently occurring scores of 7) showed their confidence in the DHIS2 platform for case-based surveillance of malaria; however, participants also noted some organizational issues that could compromise user acceptance of the DHIS2 platform. CONCLUSIONS: Participants' responses indicated their acceptance of the DHIS2 platform; however, the consideration of factors related to organizational readiness could further enhance successful acceptance, and consequently, successful adoption of the platform by the malaria program in Botswana.

Recent Molecular Assessment of Plasmodium vivax and Plasmodium falciparum Asymptomatic Infections in Botswana.

In 2016, we reported the presence of Plasmodium vivax in Botswana through active case detection. A real-time PCR was used during a similar study in 10 districts to assess changes in the P. vivax prevalence. We assessed 1,614 children (2-13 years of age) for hemoglobin (Hb; g/dL) and Plasmodium parasites. The median age of all participants was 5.0 years (25th percentile, 3 years; 75th percentile, 8 years). The median Hb (g/dL) level was 12.1, but 18.3% of the participants had anemia (Hb < 11.0 g/dL); these participants were clustered in the younger than 5 years age group in all districts (P < 0.001). The risk of anemia decreased with age 5 years or older (odds ratio [OR], 0.26; 95% confidence interval [CI], 0.197-0.34; P < 0.001). The prevalence rates of Plasmodium parasites were as follows: P. vivax, 12.7%; P. falciparum, 12.7%; P. malariae, 0.74%; and P. ovale (P. ovale curtisi), 0.68%. Mixed infection rates were as follows: P. falciparum and P. vivax, 2.35%; P. falciparum and P. ovale curtisi, 0.56%; P. vivax and P. malariae, 0.06%; and P. falciparum and P. malariae, 0.68%. The infections were largely asymptomatic (99.6%). Using logistic regression, the risk of infection with P. vivax was highest in Kweneng East (OR, 6.2; 95% CI, 2.9-13.1), followed by South East (OR, 5.6; 95% CI, 2.5-12.3) and Ngami (OR, 5.1; 95% CI, 2.2-12.0). Compared to the risk of infection for children younger than 5 years, the risk of infection decreased for children 5 years or older in regions with high rates of P. vivax and P. falciparum infections. P. vivax and P. falciparum have expanded within the asymptomatic population in Botswana; therefore, careful attention is required for their elimination.

Vector control for malaria elimination in Botswana: progress, gaps and opportunities.

Botswana has in the recent past 10 years made tremendous progress in the control of malaria and this informed re-orientation from malaria control to malaria elimination by the year 2020. This progress is attributed to improved case management, and scale-up of key vector control interventions; indoor residual spraying (IRS) and long-lasting insecticidal nets (LLINs). However, insecticide resistance, outdoor biting and resting, and predisposing human behaviour, such as staying outdoors or sleeping outdoors without the use of protective measures, pose a challenge to the realization of the full impact of LLINs and IRS. This, together with the paucity of entomological data, inadequate resources and weak community participation for vector control programme implementation delayed attainment of Botswana's goal of malaria elimination. Also, the Botswana National Malaria Programme (NMP) experiences the lack of intersectoral collaborations and operational research for evidence-based decision making. This case study focuses on the vector control aspect of malaria elimination by identifying challenges and explores opportunities that could be taken advantage of to benefit the NMP to optimize and augment the current vector control interventions to achieve malaria elimination by the year 2030 as per the Global Technical Strategy for Malaria 2016-2030 targets. The authors emphasize the need for timely and quality entomological surveillance, operational research and integrated vector management.

Prevalence of G6PD deficiency and associated haematological parameters in children from Botswana.

Glucose-6-Phosphate Dehydrogenase (G6PD) deficiency is commonly seen in malaria endemic areas as it is known to confer a selective advantage against malaria. Recently, we reported a high proportion of asymptomatic reservoir of Plasmodium vivax in Botswana, that calls for intervention with primaquine to achieve radical cure of vivax malaria. Considering that individuals with this enzyme deficiency are at risk of haemolysis following primaquine treatment, assessment of the population for the relative frequency of G6PD deficiency is imperative. Samples from 3019 children from all the districts of Botswana were successfully genotyped for polymorphisms at positions 202 and 376 of the G6PD gene. Haematological parameters were also measured. The overall population allele frequency (based on the hemizygous male frequency) was 2.30% (95% CI, 1.77-2.83), while the overall frequency of G6PD-deficient genotypes A- (hemizygote and homozygote genotypes only) was 1.26% (95% CI, 0.86-1.66). G6PD deficiency is spread in Botswana according to the historical prevalence of malaria with a North-West to South-East decreasing gradient trend. There was no association between G6PD status and P. vivax infection. G6PD A- form was found to be associated with decreased RBC count and haemoglobin levels without a known cause or illness. In conclusion, we report for the first time the prevalence of G6PD deficiency in Botswana which is relevant for strategies in the malaria elimination campaign. Further work to examine the activities of the enzyme in the Botswana population at risk for malaria is warranted.

Malaria control in Botswana, 2008-2012: the path towards elimination.

BACKGROUND: Botswana has made substantial progress towards malaria elimination across the country. This work assessed interventions and epidemiological characteristics of malaria in Botswana, during a period of decreasing transmission intensity. METHODS: National passive malaria surveillance data for five years (2008-2012) were analysed. A district-level, random effects model with Poisson regression was used to explore the association between malaria cases and coverage with long-lasting insecticide-treated nets (LLINs) and indoor residual spraying (IRS). Malaria cases were mapped to visualize spatio-temporal variation in malaria for each year. RESULTS: Within five years, a reduction in malaria prevalence (approximately 98%) and number of deaths (12 to three) was observed. Between 2008 and 2012, 237,050 LLINs were distributed and 596,979 rooms were sprayed with insecticides. Coverage with LLINs and IRS was not uniformly distributed over the study period and only targeted the northern districts with a high malaria burden. The coverage of IRS was associated with a reduction in malaria cases. CONCLUSIONS: Botswana has made significant strides towards its goal of country-wide elimination of malaria. A major challenge in the future will be prevention and management of imported malaria infections from neighbouring countries. In order to accurately monitor progress towards the elimination goal, the malaria control programme (NMP) should strengthen the reporting and capturing of data at household and individual level. Systematic, periodic operational research to feedback the NMP will help to guide and achieve elimination.