Incidence and impact of hyperviscosity on sperm parameters of Malawian men seeking assisted reproduction.

BACKGROUND: Seminal hyperviscosity has been shown to be associated with male infertility. The aim of this study was to assess the prevalence of hyperviscosity in semen of Malawian males seeking infertility treatment. METHODS: A total of 120 men visiting our laboratory for fertility assessment donated semen samples. The semen samples were assessed for hyperviscosity, volume, concentration, total motility, progressive motility, viability, and morphology. RESULTS: Out of the 120 samples analyzed, 34 samples were hyperviscous representing 28.3%. No significant statistical difference in semen volume between samples with normal viscosity compared to those with hyperviscosity (p>0.05). Sperm concentration, progressive motility, total motility, viability, and normal morphology were significantly higher in the normal viscosity group when compared to the abnormal viscocity group (p<0.05). CONCLUSION: Hyperviscosity affects a significant number of men in Malawi and may be the cause of decreased fertility as it was associated with poor sperm concentration, total motility, progressive motility, viability, and morphology.

Communication Between Traditional Medical Practitioners and Western Medical Professionals.

The high burden of disease in Malawi is exacerbated by a lack of healthcare professionals, and the inaccessibility of healthcare services to many Malawians, due to geographical and financial barriers. The World Health Organization commends the contribution that traditional and complementary medicine could make to achieve such coverage through its integration into health systems. This study aimed to evaluate the barriers that exist between traditional healers and biomedical practitioners for them to collaborate with each other. Semi-structured interviews were conducted with traditional healers and biomedical practitioners. Results showed that the two groups were willing to collaborate with each other, but to differing degrees. Traditional healers were more enthusiastic than biomedical practitioners, who had several reservations about traditional healers, and placed certain conditions on prospective collaboration. While traditional healers clearly had confidence in biomedical practitioners' competencies and respect for their practice, biomedical practitioners lacked trust in traditional healers and would not refer patients to them due to several reservations, such as the lack of scientific basis for traditional medicine. This study points out barriers that affects collaboration between traditional healers and biomedical practitioners and it suggests possible solutions.

Assessing bed net damage: comparisons of three measurement methods for estimating the size, shape, and distribution of holes on bed nets.

BACKGROUND: Measuring the physical condition of long-lasting insecticidal nets (LLINs) under field conditions is of great importance for malaria control programmes to guide decisions on how frequently to replace LLINs. Current guidelines by the World Health Organization Pesticide Evaluation Scheme (WHOPES) propose a proportionate hole index (pHI) for assessing LLIN condition by counting the number of holes the size of a thumb, fist, head, and larger than a head. However, this method does not account for irregular hole shapes or exact hole sizes which could result in inaccurate decisions about when to replace LLINs. METHODS: LLINs were collected during a 2013 health facility-based malaria case control study in Machinga District, Malawi. To evaluate the accuracy of the pHI, the physical condition of 277 LLINs was estimated by the WHOPES method and then compared with two more thorough measurement methods: image analysis of digital photographs of each LLIN side; and for 10 nets, ruler measurements of the length, width, and location of each hole. Total hole counts and areas per net were estimated by each method, and detailed results of hole shapes and composite pictures of hole locations were generated using image analysis. RESULTS: The WHOPES method and image analysis resulted in similar estimates of total hole counts, each with a median of 10 (inter-quartile range (IQR) 4-24 and 4-23, respectively; p = 0.004); however, estimated hole areas were significantly larger using the WHOPES method (median 162 cm2, IQR 28-793) than image analysis (median 13 cm2, IQR 3-101; p < 0.0001). The WHOPES method classified fewer LLINs in 'good condition' compared to image analysis (42% vs 74%). The ruler method detected significantly more holes than image analysis did (p = 0.002) in 10 LLINs; however, total hole area was not significantly different (p = 0.16). Most holes were not circular but roughly 2-5 times longer in one direction. The lower quarter of LLIN sides was found to have the most holes. CONCLUSIONS: The WHOPES method overestimated total hole area, likely because holes are elongated rather than circular, suggesting further adjustments to the pHI formula may be warranted when considering LLIN replacement strategies.

The effect of holes in long-lasting insecticidal nets on malaria in Malawi: results from a case-control study.

BACKGROUND: Long-lasting insecticidal nets (LLINs) are a cornerstone of malaria prevention. Holes develop in LLINs over time and compromise their physical integrity, but how holes affect malaria transmission risk is not well known. METHODS: After a nationwide mass LLIN distribution in July 2012, a study was conducted to assess the relationship between LLIN damage and malaria. From March to September 2013, febrile children ages 6-59 months who consistently slept under LLINs (every night for 2 weeks before illness onset) were enrolled in a case-control study at Machinga District Hospital outpatient department. Cases were positive for Plasmodium falciparum asexual parasites by microscopy while controls were negative. Digital photographs of participants' LLINs were analysed using an image-processing programme to measure holes. Total hole area was classified by quartiles and according to the World Health Organization's proportionate hole index (pHI) cut-offs [< 79 cm2 (good), 80-789 cm2 (damaged), and > 790 cm2 (too torn)]. Number of holes by location and size, and total hole area, were compared between case and control LLINs using non-parametric analyses and logistic regression. RESULTS: Of 248 LLINs analysed, 97 (39%) were from cases. Overall, 86% of LLINs had at least one hole. The median number of holes of any size was 9 [interquartile range (IQR) 3, 22], and most holes were located in the lower halves of the nets [median 7 (IQR 2, 16)]. There were no differences in number or location of holes between LLINs used by cases and controls. The median total hole area was 10 cm2 (IQR 2, 125) for control LLINs and 8 cm2 (IQR 2, 47) for case LLINs (p = 0.10). Based on pHI, 109 (72%) control LLINs and 83 (86%) case LLINs were in "good" condition. Multivariable modeling showed no association between total hole area and malaria, controlling for child age, caregiver education, and iron versus thatched roof houses. CONCLUSIONS: LLIN holes were not associated with increased odds of malaria in this study. However, most of the LLINs were in relatively good condition 1 year after distribution. Future studies should examine associations between LLIN holes and malaria risk with more damaged nets.

Clinical outcomes among febrile children aged 2 to 59 months with negative malaria rapid diagnostic test results in Mchinji District, Malawi.

BACKGROUND: Malawi malaria treatment guidelines recommend a definitive diagnosis, using a malaria rapid diagnostic test (mRDT), for all patients with fever or history of fever. Improving the management and outcomes of febrile children with negative mRDT results should be a priority. METHODS: Through a prospective cohort study designed to investigate clinical outcomes of children treated at the community level, we followed, for 7 days, children aged 2 to 59 months, who had negative mRDT results and were treated with antipyretic medication. Clinical outcomes were assessed on days 3 and 7 post-recruitment. RESULTS: The median age of recruited children was 19 months. Of the 285 children enrolled, 139 (48.8%) were females. Of the children for whom data were available for analysis, 95/236 (40.3%) had fever (temperature ≥ 37.5°C) at enrolment, and almost half of the sick children (125/268; 46.6%) had symptoms of upper respiratory tract infection. Most sick children (89.6%; 95% confidence interval, CI = 84.2 to 93.3) recovered, while 10.4% (95% CI: 6.7 to 15.8) were still sick by day 7 of follow-up. There were no deaths reported during the 7 days of follow-up. Being afebrile at enrolment (odds ratio, OR = 2.5; 95% CI = 1.1 to 6.0; P = 0.027) and sleeping under an insecticide-treated net (ITN) (OR = 2.7; 95% CI = 1.2 to 6.2; P = 0.011) were associated with recovery by day 7. In multivariable analysis, sleeping under an ITN the previous night was the only factor associated with recovery by day 7. Microscopy did not detect any malaria parasites in the blood of recruited children, at recruitment or on day 7. CONCLUSIONS: In this community-level study, the majority of febrile children with negative mRDT results recovered within 7 days of health worker consultation for a febrile illness, having only taken antipyretics.

The effectiveness of long-lasting, insecticide-treated nets in a setting of pyrethroid resistance: a case-control study among febrile children 6 to 59 months of age in Machinga District, Malawi.

BACKGROUND: The escalating level of mosquito resistance to pyrethroid insecticides threatens the effectiveness of insecticide-treated nets (ITNs) for malaria control in Malawi. An evaluation of the effectiveness of ITNs for preventing malaria in children aged 6-59 months old, after 1 year of mass distribution of LLINs was conducted in Machinga District, Malawi, an area of moderate pyrethroid resistance. METHODS: A facility-based, case-control study among children 6-59 months was conducted in an area of pyrethroid resistance between March and September 2013 in Machinga District. Cases and controls were children with fever who sought care from the same hospital and tested positive and negative, respectively, for malaria parasites by microscopy. RESULTS: A high proportion of both cases (354 of 404 or 87.6 %) and controls (660 of 778 or 84.8 %) slept under an ITN the night before the survey. In univariable logistic regression, older age (24-59 months versus 6-23 months, p < 0.001), sleeping on the floor versus a mattress (p < 0.001), and open versus closed house eaves (p = 0.001) were associated with increased odds of malaria, whilst secondary education of the caretaker, having windows on multiple walls, and being in the least poor wealth quintile (p < 0.001 for each) reduced the odds of malaria; ITN use was not associated with malaria (p = 0.181). In multivariable analysis, older age (p < 0.001) and secondary education of the caregiver (p = 0.011) were the only factors significantly associated with malaria. CONCLUSION: This study did not find a significant personal protective effect of ITNs. However, high use of ITNs in the community and recent findings of lower malaria incidence in ITN users compared to bed net non-users from a cohort study in the same area suggest that ITNs provide community protection to both users and non-users alike in this area.