Assessing the efficacy of an integrated intervention to create demand for fishermen’s schistosomiasis and HIV services (FISH) in Mangochi, Malawi: Study protocol for a cluster randomized control trial

Background Both HIV and schistosomiasis are major public health problems worldwide with 1.8 million new HIV infections, and up to 110 million untreated schistosomiasis cases globally. Although a causal link has not been established, there are strong suggestions that having schistosomiasis increases onward transmission of HIV from co-infected men to women. With both HIV and schistosomiasis treatment readily available in Malawi, there is a need to investigate the feasibility, acceptability and health impacts of joint management of these two hazards, with special focus on health education and demand-creation for fishermen. The aim of this project is to identify optimal models of delivering integrated HIV and schistosomiasis services for fishermen, particularly investigating the effect of using social networks, HIV self-test kits and beach clinic services in Mangochi, Malawi. Methods We have mapped 45 boat teams or landing sites for a 3-arm cluster randomized trial using “boat team” as the unit of randomization. The three arms are: 1) Standard of care (SOC) with leaflets explaining the importance of receiving presumptive treatment for schistosomiasis (praziquantel) and HIV services for fishermen, and two intervention arms of 2) SOC + a peer explaining the leaflet to his fellow fishermen in a boat team; and 3) arm 2 with HIV self-test kits delivered to the boat team fishermen by the peer. The primary outcomes measured at 9 months of trial delivery will compare differences between arms in the proportions of boat-team fishermen: 1) who self-report starting antiretroviral therapy or undergoing voluntary medical male circumcision; and 2) who have ≥1 S. haematobium egg seen on light microscopy of the filtrate from 10mls urine (“egg-positive”). Discussion This is the first evaluation of an integrated HIV and schistosomiasis services intervention for fishermen, particularly investigating the effect of using social networks, HIVST kits and beach clinic services. The findings will support future efforts to integrate HIVST with other health services for fishermen in similar settings if found to be efficacious. Trial registration This trial is registered in the ISRCTN registry: ISRCTN14354324; date of registration: 05 October 2020. https://www.isrctn.com/ISRCTN14354324?q=ISRCTN14354324&filters=&sort=&offset=1&totalResults=1&page=1&pageSize=10&searchType=basic-search. Linked to protocol version number 1.4 of 11 January 2021.

Feature Selection Approach to Improve Malaria Diagnosis Model for High and Low Endemic Areas of Tanzania

Malaria remains an important cause of death, especially in sub-Saharan Africa with about 228 million malaria cases worldwide and an estimated 405,000 deaths in 2019. Currently, malaria is diagnosed in the health facility using a microscope (BS) or rapid malaria diagnostic test (MRDT) and with area where these tools are inadequate the presumptive treatment is performed. Apart from that self-diagnosis and treatment is also practiced in some of the households. With the high-rate self-medication on malaria drugs, this study aimed at computing the most significant features using feature selection methods for best prediction of malaria in Tanzania that can be used in developing a machine learning model for malaria diagnosis. A malaria symptoms and clinical diagnosis dataset were extracted from patients’ files from four (4) identified health facilities in the regions of Kilimanjaro and Morogoro. These regions were selected to represent the high endemic areas (Morogoro) and low endemic areas (Kilimanjaro) in the country. The dataset contained 2556 instances and 36 variables. The random forest classifier a tree based was used to select the most important features for malaria prediction. Regional based features were obtained to facilitate accurate prediction. The feature ranking as indicated that fever is universally the most influential feature for predicting malaria followed by general body malaise, vomiting and headache. However, these features are ranked differently across the regional datasets. Subsequently, six predictive models, using important features selected by feature selection method, were used to evaluate the features performance. The features identified complies with malaria diagnosis and treatment guideline provided with WHO and Tanzania Mainland. The compliance is observed so as to produce a prediction model that will fit in the current health care provision system in Tanzania.

Screening for Parasitic Infection and Tuberculosis in Immunosuppressed and Pre-Immunosuppressed Patients: An Observational Study

Reactivation of latent tuberculosis infection (LTBI) or latent parasitic infection (LPI) during drug-induced immunosuppression can have serious consequences. The Division of tropical and humanitarian medicine of the Geneva University Hospitals runs a specific consultation for parasitic screening of immunosuppressed or pre-immunosuppressed patients. We sought to determine the seroprevalence of LTBI and LPI in such patients and explore its relationship with country of origin or previous travel in a retrospective, single-centre observational study from 2016 to 2019. Demographic data, travel history, ongoing treatments and results of the parasitological (Strongyloides stercoralis, Trypanosoma cruzi, Echinococcus multilocularis, Entamoeba histolytica and Leishmania spp.) and TB screening were collected to calculate LPI or LTBI prevalence. Risk factors for LTBI and strongyloidiasis were analysed using Poisson regression with robust variance. Among 406 eligible patients, 24/353 (6.8%) had LTBI, 8/368 (2.2%) were positive for Strongyloides stercoralis infection, 1/32 (3.1%) was positive for Entamoeba histolytica and 1/299 (0.3%) was positive for Leishmaniasis. No cases of Trypanosoma cruzi (0/274) or Echinococcus multilocularis (0/56) infection were detected. Previous travel to or originating from high-prevalence countries was a risk factor for LTBI (PR = 3.4, CI 95%: 1.4–8.2 and 4.0, CI 95%: 1.8–8.9, respectively). The prevalence of serological Strongyloidiasis in immunosuppressed patients is lower in comparison to those without immunosuppression (PR = 0.1, CI 95%: 0.01–0.8). In conclusion, screening before immunosuppression needs to be individualized, and LTBI and LPI need to be ruled out in patients who originate from or have travelled to high-prevalence countries. The sensitivity of strongyloidiasis serology is reduced following immunosuppression, so an algorithm combining different tests or presumptive treatment should be considered.

Malaria and dengue in Hodeidah city, Yemen: High proportion of febrile outpatients with dengue or malaria, but low proportion co-infected

Background The emergence of dengue in malaria-endemic countries with limited diagnostic resources, such as Yemen, can be problematic because presumptive treatment of febrile cases as being malaria is a common practice. Co-infections with dengue and malaria are often overlooked and misdiagnosed as being a mono-infection because of clinical similarities. In Hodeidah city, Yemen, the capacity to conduct the diagnosis can be aggravated by the war context. To assess the magnitude of the problem, we determined the proportions of malaria, dengue and co-infection in relation to clinical characteristics among febrile outpatients. Methods This cross-sectional study included 355 febrile outpatients from Hodeidah city during the malaria transmission season (September 2018 –February 2019). Sociodemographic and clinical characteristics were collected using a pre-designed, structured questionnaire. Malaria was confirmed using microscopy and rapid diagnostic tests (RDTs), while dengue was confirmed using RDTs. Results Mono-infection proportions of 32.4% for falciparum malaria and 35.2% for dengue were found, where about two-thirds of dengue patients had a recent probable infection. However, co-infection with falciparum malaria and dengue was detected among 4.8% of cases. There was no statistically significant difference between having co-infection and mono-infection with malaria or dengue in relation to the sociodemographic characteristics. On the other hand, the odds of co-infection were significantly lower than the odds of malaria among patients presenting with sweating (OR = 0.1, 95% CI: 0.05–0.45; p <0.001), while the odds of co-infection were 3.5 times significantly higher than the odds of dengue among patients presenting with vomiting (OR = 3.5, 95% CI: 1.20–10.04; p <0.021). However, there were no statistically significant differences between having co-infection and mono-infection (malaria or dengue) in relation to other clinical characteristics. Conclusions Mono-infection with malaria or dengue can be detected among about one-third of febrile outpatients in Hodeidah, while almost 5.0% of cases can be co-infected. Sociodemographic and clinical characteristics cannot easily distinguish malaria patients from dengue-infected or co-infected ones, reinforcing the necessity of laboratory confirmation and avoidance of treating febrile patients as being presumed malaria cases.

OMNIGEN KIT ACCURACY FOR PLASMODIUM FALCIPARU

Malaria is a serious public health burden in Senegal. Accurate diagnosis is essential to avoided unnecessary presumptive treatment. Malaria diagnosis currently relies on identifying malaria parasite using microscopy and detecting soluble parasite antigens by Rapid Diagnostic Tests (RDT). These techniques do not detect low-level, sub-patent malaria infections and are inherently hazardous and invasive. To overcome these obstacles, alternatives diagnostics method were explored. In contrast to blood, saliva presents a reduced biohazard and can be painlessly collected in relatively large quantities by individuals with moderate training. The objective of this study was to use saliva collected in OmnIGEN Kits as an alternative sample for malaria detection. Methods: A total of 77 febril patients tested malaria positive by mRDT were enrolled in this study. From each patient, blood sample was collected for dried blood spot and blood smear; and saliva sample on OMNIGEN kit. Parasite density was determined from smear and Plasmodium falciparum DNA was extracted from both dried blood spot and saliva samples collected from the same patients. Extracted DNA was amplied by qPCR machine. Results: Malaria prevalence using qPCR was 98,7% and 60% respectively with blood and saliva. Compared to blood, saliva showed a sensitivity; specicity; positive predictive value of 60%; 100 %; and 100 %. The concordance between parasites detection from saliva and blood was (p = 0.45). In addition, no difference was found between these two methods and the microscopy counting. Conclusions:Saliva could be a non-invasive alternative method for P. falciparum detection and epidemiological surveillance in country with limited ressources.

Dexamethasone and COVID-19: Strategies in Low- and Middle-Income Countries to Tackle Steroid-Related Strongyloides Hyperinfection

COVID-19 can trigger a systemic inflammatory response that in some cases leads to severe lung involvement, multisystem dysfunction, and death. Dexamethasone therapy, because of its potent anti-inflammatory effects, has been proposed for the management of hospitalized patients with severe COVID-19. The subject of this article is to discuss potential strategies to tackle Strongyloides hyperinfection in hospitalized patients with COVID-19 receiving dexamethasone therapy in low- and middle-income countries. In this context, dexamethasone treatment has been found to be generally safe. However, its use in people coinfected with undetected Strongyloides stercoralis increases the risk for Strongyloides hyperinfection/dissemination a potentially fatal complication. Infection caused by S. stercoralis may remain asymptomatic or with mild symptoms in humans for several years. Early detection and specific treatment prevent a fatal evolution of this complication, but the challenge is to screen before corticosteroid therapy. In some cases, presumptive treatment may be justified. Ivermectin is the gold standard for treatment.

What is the yield of malaria reactive case detection in the Greater Mekong Sub-region? A review of published data and meta-analysis

Background Reactive malaria case detection involves the screening of those in contact with index cases and is used in countries in the Greater Mekong Sub-region. The yield of reactive case detection, defined here as the percentage of positive malaria cases among potential contacts who were screened, was assessed. Methods A literature search was conducted on PubMed to identify studies on reactive case detection in the Greater Mekong Sub-region. Eligible published articles were reviewed and pooled estimates from the studies were calculated, by type of malaria test used. Results Eighty-five publications were retrieved, of which 8 (9.4%) eligible articles were included in the analysis. The yield from reactive case detection ranged from 0.1 to 4.2%, with higher rates from PCR testing compared with microscopy and/or rapid diagnostic test. The overall yield from microscopy and/or rapid diagnostic test was 0.56% (95% CI 0.31–0.88%), while that from PCR was 2.35% (95% CI 1.19–3.87%). The two studies comparing different target groups showed higher yield from co-workers/co-travellers, compared with household contacts. Conclusion In low malaria transmission settings, the effectiveness of reactive case detection is diminishing. In the Greater Mekong Sub-region, modifying reactive case detection from household contacts to co-workers/co-travellers and from testing to presumptive treatment of targeted contacts, could increase the impact of this approach.

Evaluation of the adhesion of pregnant women to intermittent presumptive treatment with Sulfadoxine-Pyrimethamine in a rural area of Gabon.

Background: Gestational malaria remains one of the most complex forms of malaria. To fight it, several African countries adopted intermittent presumptive treatment with Sulfadoxine-Pyrimethamine (IPT-SP) and the use of preventive measures such as insecticide-treated bed nets (ITNs), indoor residual sprays (IRS) and popular education on good practices to fight against malaria. In Gabon a country of central Africa, no study has investigated the use of IPT-SP in rural areas since its implementation. The aim of this study was to investigate the adhesion level of pregnant women to IPT-SP, coverage of ITNs and IRS, and knowledge on the good practices about malaria in a rural area of Gabon. Using a questionnaire, we led a retrospective study including pregnant women from January 5th 2016 to January 31st 2018 and a cross-sectional survey including women seen for antenatal care and all febrile patients in consultation from February 2nd to May 31st 2018. Malaria was diagnosed using rapid diagnostic tests. Statistical analyses were done. Results: We included 607 pregnant women before their delivery. Women between 20 and 25 years old were the most prevalent (37.26%, n=229). Among them, 74.53% were unemployed and 47.21% living in the villages surrounding the rural town of Fougamou. The rate of adhesion to IPT-SP was 94.37% (n=573). Among them, 47.8% (n=274) had received 3 doses of IPT. Among the pregnant women included during the cross-sectional survey, only 8.7% (n=14) were infected with Plasmodium. Bed nets were used by 80.12% (n=129) of women. Conclusion: Data showed a near complete adhesion of IPT-SP in the rural area of Fougamou. Clinical trials are needed to investigate the efficacy of IPT-SP and antimalarial drug markers.

Factors impacting test-based management of suspected malaria among caregivers of febrile children and private medicine retailers within rural communities of Fanteakwa North District, Ghana.

Background Prompt diagnosis and treatment prevents a mild case of malaria from developing into severe disease and death. Unfortunately, parasitological testing of febrile children is greater in the public and formal private sector than in the informal private sector in sub-Saharan Africa. Methods A mixed method study was carried out to determine factors limiting test-based management of suspected malaria cases among caregivers of febrile children and Over-the-Counter medicine sellers (OTCMS) in eight rural communities in Ghana. Structured questionnaires were used to interview 254 adult caregivers. Fourteen in-depth interviews were conducted with OTCMS. The interviews were audio-recorded, transcribed verbatim, and analysed thematically. Results The most frequently sought health providers by caregivers of febrile children in descending order were Community Health-Based Planning Services (CHPS) compounds; drug vendors; and OTCMS. Malaria parasitological testing rate of febrile children was highest (94.9%) at the CHPS compound and lowest (10.5%) at the OTCMS shops. Proportion of febrile children not subjected to malaria blood test is below average (28.3%). Among caregivers who did not ask for malaria blood test, 15.2% reported that healthcare provider did not offer a malaria blood test; 21.7% were financially handicapped to visit the Health Centre; and 63% lacked knowledge of malaria blood test and where to get it. From OTCMS point of view, clients’ inability to pay for malaria blood test, community perception that OTCMS are unqualified to perform malaria blood test, clients’ adherence to presumptive treatment, financial loss when unused RDT kits expires, clients’ demand for half dose of ACT, and activities of drug peddlers are factors limiting adherence to WHO recommended policy on testing before treating uncomplicated malaria cases. Conclusion The study results suggest the need to implement community friendly interventions aimed at improving test-based management of suspected malaria in febrile children. These may include educating caregivers and community members on the need to test and confirm malaria in febrile children before treating them, and supply of subsidized RDT kits to OTCMS and re-training them to provide testing services to their clients. Further studies pertaining to influence of gender roles on healthcare seeking attitude for febrile children is also suggested.

Transition of radical, preventive and presumptive treatment regimens for malaria in China: a systematic review

Background Globally, malaria is still a major public health challenge. Drug-based treatment is the primary intervention in malaria control and elimination. However, optimal use of mass or targeted treatments remains unclear. A variety of radical, preventive and presumptive treatment regimens have been administrated in China and a systematic review was conducted to evaluate effectiveness, and discuss experiences, limitations, and lessons learnt in relation to the use of these regimens. Methods The search for information includes both paper documents, such as books, malaria control annals and guidelines for malaria prevention and treatment, as well as three computer-based databases in Chinese (CNKI, WanFangdata and Xueshu.baidu) and two databases in English (PubMed and Google Scholar), to identify original articles and reports associated with drug administration for malaria in China. Results Starting from hyperendemicity to elimination of malaria in China, a large number of radical, preventive and presumptive treatment regimens had been tried. Those effective regimens were scaled up for malaria control and elimination programmes in China. Between 1949 and 1959, presumptive treatment with available anti-malarial drugs was given to people with enlarged spleens and those who had symptoms suggestive of malaria within the last 6 months. Between 1960 and 1999, mass drug administration (MDA) was given for preventive and radical treatment. Between 2000 and 2009, the approach was more targeted, and drugs were administed only to prevent malaria infection in those at high risk of exposure and those who needed radical treatment for suspected malaria. Presumptive therapy was only given to febrile patients. From 2010, the malaria programme changed into elimination phase, radical treatment changed to target individuals with confirmed either Plasmodium vivax or Plasmodium ovale within the last year. Preventive treatment was given to those who will travel to other endemic countries. Presumptive treatment was normally not given during this elimination phase. All cases of suspected were confirmed by either microscopy or rapid diagnosis tests for malaria antigens before drugs were administered. The engagement of the broader community ensured high coverage of these drug-based interventions, and the directly-observed therapy improved patient safety during drug administration. Conclusion A large number of radical, preventive and presumptive treatment regimens for malaria had been tried in China with reported success, but the impact of drug-based interventions has been difficult to quantify because they are just a part of an integrated malaria control strategy. The historical experiences of China suggest that intervention trials should be done by the local health facilities with community involvement, and a local decision is made according to their own trial results.