Malaria epidemics and interventions, Kenya, Burundi, southern Sudan, and Ethiopia, 1999-2004.Quantitative data on the onset and evolution of malaria malaria, infectious parasitic disease that can be either acute or chronic and is frequently recurrent. Malaria is common in Africa, Central and South America, the Mediterranean countries, Asia, and many of the Pacific islands. epidemics are scarce. We review case studies from recent African Plasmodium falciparum Plasmodium fal·cip·a·rum
A protozoan that causes falciparum malaria. epidemics (Kisii and Gucha Districts Gucha District is a district in Nyanza Province, western Kenya. It is also known by the name: South Kisii District or Ogembo District. Its population is approximately 461,000 (as of 1999) . , Kenya, 1999; Kayanza Province, Burundi, 2000-2001; Aweil East, southern Sudan Southern Sudan is a region of Sudan, comprising ten of that country's provinces. The Sudanese government agreed to give autonomy to the region in the Comprehensive Peace Agreement , 2003; Gutten and Damot Gale Damot Gale is one of the 77 woredas in the Southern Nations, Nationalities and Peoples' Region of Ethiopia. Part of the Semien Omo Zone, Damot Gale is bordered on the south by Sodo Zuria, on the west by Boloso Sore, on the north by the Hadiya Zone, and on the east by Damot Weyde. , Ethiopia, 2003-2004). We highlight possible epidemic risk factors and review delays in epidemic detection and response (up to 20 weeks), essentially due to poor case reporting and analysis or low use of public facilities. Epidemics lasted 15-36 weeks, and patients' age profiles suggested departures from classical notions of epidemic malaria everywhere but Burundi. Although emergency interventions were mounted to expand inpatient and outpatient treatment access, we believe their effects were lessened because of delays, insufficient evaluation of disease burden, lack of evidence on how to increase treatment coverage in emergencies, and use of ineffective drugs.
Plasmodium falciparum malaria epidemics were detected in 41 African sites from 1997 through 2002 (1). A total of 125 million persons are considered at risk for malaria epidemics, with an estimated yearly death rate of 155,000 to 310,000 (2).
Research on malaria epidemics mostly concerns long-range forecasting, early warning, and early detection (improved understanding of the role of temperature, rainfall, and El Nino-Southern Oscillation Oscillation
Any effect that varies in a back-and-forth or reciprocating manner. Examples of oscillation include the variations of pressure in a sound wave and the fluctuations in a mathematical function whose value repeatedly alternates above and below some events [3-6], development of epidemic detection thresholds ). Malaria epidemics evolve rapidly and most often occur in remote, underresourced settings without proper surveillance. Data on their evolution may thus go unrecorded, which prevents the development of evidence-based recommendations on effective epidemic control.
Recently, Medecins Sans Frontieres (MSF MSF Manufacturing, Science, and Finance (Union) ) intervened in several P. falciparum malaria fal·cip·a·rum malaria
Malaria caused by Plasmodium falciparum and characterized by severe malarial paroxysms that recur about every 48 hours and often by acute cerebral, renal, or gastrointestinal manifestations. epidemics in remote or conflict-affected sub-Saharan African settings. We present case studies from these interventions (Kisii and Gucha Districts, Kenya, 1999; Kayanza Province, Burundi, 2000-2001; Gutten and Damot Gale, Ethiopia, 2003-2004; Aweil East County, southern Sudan, 2003). We also describe the epidemics and possible factors that explain their occurrence, review challenges encountered in their detection and control, and make recommendations for epidemic prevention and control policies. This article reports health facility-based morbidity and mortality Morbidity and Mortality can refer to:
We reviewed MSF program reports; unpublished assessments (8-12); and available morbidity, mortality, diagnostic, and treatment data from each of the 5 interventions. We also consulted archives of the United Nations humanitarian data clearinghouse (www.reliefweb.int) for general situation reports for each epidemic period epidemic period Epidemiology A timespan when the number of cases of a disease reported is greater than expected and extracted meteorologic me·te·or·ol·o·gy
The science that deals with the phenomena of the atmosphere, especially weather and weather conditions.
[French météorologie, from Greek indexes to explore the possible contribution of climate to epidemic onset (online Appendix, available from http://www.cdc.gov/ncidod/ EID/vol12no10/06-0540_app.htm).
Description of Intervention Sites
Four interventions (Table 1) took place in highland environments, where peaks and valleys create a complex, climate-affected altitude gradient of malaria transmission and age-acquired immunity. Kisii and Gucha Districts are located in the southern highlands The Southern Highlands could refer to:
In Burundi's northern Kayanza Province, a 3-year time series up to September 2000 showed constant monthly caseloads of [approximately equal to] 10,000 outpatients/month. In 2000, MSF operated 7 of the province's 22 outpatient facilities. The September 2000-May 2001 epidemic, the largest ever recorded in Burundi, affected 9 of 16 provinces, and 3.5 million cases were reported (18).
The Ethiopian highlands Ethiopian Highlands, rugged plateau region of E Africa, covering about two thirds of Ethiopia. It is divided into two massifs by the Great Rift Valley; the Amhara, or Ethiopian Plateau, is the larger of the two. experience 2 moderate transmission seasons every year (after rains in March through April and August through September). Epidemics occur in 5- to 8-year cycles; >1 million cases were recorded in 1998 (1). The 2003-2004 epidemic affected 15 million persons in 3 federal regions (19).
Finally, malaria is considered endemic in low-altitude Aweil East County (Bahr el Ghazal Bahr el Gha·zal
A river of southwest Sudan flowing about 805 km (500 mi) east to Lake No, where it joins the Bahr el Jebel. state, southern Sudan), although no data are available. Most cases occur from July through January after spring rains.
Possible Epidemic Determinants
Findings on possible epidemic determinants are summarized in Table 1. Factors noted at all sites were drought in preepidemic years followed by above-average rainfall in the preepidemic months and elevated drug resistance. Individual sites also experienced temperature abnormalities, land pattern changes, and high malnutrition malnutrition, insufficiency of one or more nutritional elements necessary for health and well-being. Primary malnutrition is caused by the lack of essential foodstuffs—usually vitamins, minerals, or proteins—in the diet. rates. Further detail on these findings is provided in the online Appendix.
Epidemic Alert and Detection
No early warnings were issued. In Kisii, the alert came from the media in epidemic week 5 (when the district hospital was overwhelmed o·ver·whelm
tr.v. o·ver·whelmed, o·ver·whelm·ing, o·ver·whelms
1. To surge over and submerge; engulf: waves overwhelming the rocky shoreline.
a. with malaria cases). MSF issued alerts in Kayanza (doubling of fever cases in epidemic week 2, early exhaustion of antimalarial antimalarial /an·ti·ma·lar·i·al/ (-mah-lar´e-al) therapeutically effective against malaria, or an agent with this quality.
Preventing or relieving the symptoms of malaria. stocks), Aweil East (quadrupled inpatient and outpatient malaria after epidemic week 1), and Damot Gale (increased proportion of P. falciparum-positive test results among children admitted to feeding centers, Figure 1). No alert information was found for Gutten.
[FIGURE 1 OMITTED]
Formal epidemic declaration was hampered by missing data. Time series for historical comparisons were available in Kisii (12 years) and Kayanza (3 years), where, however, authorities initially suspected a typhus typhus, any of a group of infectious diseases caused by microorganisms classified between bacteria and viruses, known as rickettsias. Typhus diseases are characterized by high fever and an early onset of rash and headache. outbreak, until the 80% seroprevalence seroprevalence Immunology The proportion of a population that is seropositive–ie, has been exposed to a particular pathogen or immunogen; the seropositivity of a population is calculated as the number of individuals who produce a particular antibody divided detected among febrile febrile /feb·rile/ (feb´ril) pertaining to or characterized by fever.
Of, relating to, or characterized by fever; feverish. patients (epidemic week 7) pointed to P. falciparum. In Aweil East, comparison with the 2 past years was confounded by 1) a change in diagnostic strategy (from presumptive pre·sump·tive
1. Providing a reasonable basis for belief or acceptance.
2. Founded on probability or presumption.
pre·sump in 2001 to rapid test-based in 2002 and 2003) and 2) decreased access to treatment in 2003 because of flooding.
In Ethiopia, a malaria-specific surveillance system aimed for early outbreak detection at both the village (positivity >25% detected among slides collected by field workers in the community was considered an outbreak and theoretically led to village-level mass treatment and vector control Vector control is any method to limit or eradicate the vectors of vector born diseases, for which the pathogen (e.g. virusor parasite) is transmitted by a vector which can be mammals, birds or arthropods, especially insects, and more specifically mosquitoes. ) and woreda or zone (where weekly reports from health facilities were compiled) levels. A malaria epidemic was declared in August 2003 (6-10 weeks after probable onset) by East Wollega Zone, including Gutten. Data from this surveillance system were difficult to interpret. Only some of the reports reached the zone bureau, with a delay of 4 to 6 weeks. In Damot Gale, despite incomplete reporting, a massive increase in caseload case·load
The number of cases handled in a given period, as by an attorney or by a clinic or social services agency.
Noun was evident at the province level (6,500 from July through October 2003 vs. 1,233 from July through October 2002); however, by early July (epidemic onset), only reports up to April were available. Furthermore, clinics aggregated mass fever treatment and outpatient data, causing artificial incidence spikes when the former took place. Conversely con·verse 1
intr.v. con·versed, con·vers·ing, con·vers·es
1. To engage in a spoken exchange of thoughts, ideas, or feelings; talk. See Synonyms at speak.
2. , drug shortages in August gave a false impression of declining incidence. MSF had only been present in Damot Gale since April 2003 and only operated feeding centers.
Interventions occurred 3-20 weeks late (Table 2). In Kisii and Gucha, numerous agencies, including Merlin Merlin, in Arthurian legend, magician, seer, and teacher at the court of King Vortigern and later at the court of King Arthur. He was a bard and culture hero in early Celtic folklore. In Arthurian legend he is famous as a magician and as the counselor of King Arthur. , African Medical and Research Foundation (AMREF AMREF African Medical & Research Foundation, Inc. ), Cooperative for Assistance and Relief Everywhere, Inc. (CARE), World Vision, the Kenyan Army, and medical staff of Kenyatta National Hospital supported health structures. Elsewhere, MSF was the sole external agency. Everywhere, facilities were initially overwhelmed. In Kisii Hospital, bed occupancy reached 300% in the first 3 weeks. Hospitalization hospitalization /hos·pi·tal·iza·tion/ (hos?pi-t'l-i-za´shun)
1. the placing of a patient in a hospital for treatment.
2. the term of confinement in a hospital. capacity was 0.45 beds per 10,000 people in Gutten and 0.53 beds per 10,000 in Damot Gale, where, in June and July 2003 (epidemic onset), the rate of outpatient consultations per person per year was 0.03-0.09 (0.5-1.0 is expected in such settings if access is good) (20). Although waived once epidemics were officially recognized, user fees were initially charged in Kenya, Burundi, and Ethiopia. In Aweil East, non-MSF clinics had run out of chloroquine chloroquine /chlo·ro·quine/ (klor´o-kwin) an antiamebic and anti-inflammatory used in the treatment of malaria, giardiasis, extraintestinal amebiasis, lupus erythematosus, and rheumatoid arthritis; used also as the hydrochloride and 3 weeks into the outbreak.
All interventions included inpatient components with blood transfusion blood transfusion, transfer of blood from one person to another, or from one animal to another of the same species. Transfusions are performed to replace a substantial loss of blood and as supportive treatment in certain diseases and blood disorders. . Conversion of existing MSF nutritional structures enabled expansion of care in Aweil East and Damot Gale. To reach isolated communities, mobile clinics, consisting of teams of nurses or nursing assistants working with simple treatment algorithms, were established at each site. However, this intervention occurred late (10 weeks late in Kisii and Gucha, 7 in Kayanza, 8 in Aweil East, 13 in Gutten, and 27 in Damot Gale) and, apart from in Kayanza, after the epidemic peak (Table 2). Choice of location depended on results of a cross-sectional prevalence survey (Kisii and Gucha), distance from the nearest health center or proximity to swampy swamp
a. A seasonally flooded bottomland with more woody plants than a marsh and better drainage than a bog.
b. A lowland region saturated with water.
2. areas (Kayanza), known gathering point and greatest distance to the outpatient department (Aweil East), known gathering point near existing health posts (Gutten), and village morbidity/mortality surveillance results (Damot Gale). Diagnosis was presumptive everywhere except Ethiopia, where the P. falciparum-specific rapid diagnostic test (RDT RDT 1. Renal dialysis treatment 2. Retinal damage threshold ) Paracheck (Orchid Biomedical bi·o·med·i·cal
1. Of or relating to biomedicine.
2. Of, relating to, or involving biological, medical, and physical sciences. Systems, Verna, Goa, India) was used systematically (Table 2). In Aweil East, mobile teams traveled on bicycle and canoe canoe (kən`), long, narrow watercraft with sharp ends originally used by most peoples. , spending 3-4 days in each location; because transporting patients with severe cases was impossible, more experienced teams carried injectable in·ject·a·ble
Capable of being injected. Used of a drug.
A drug or medicine that can be injected. artemether and anticonvulsant drugs Anticonvulsant Drugs Definition
Anticonvulsant drugs are medicines used to prevent or treat convulsions (seizures).
Anticonvulsant drugs are used to control seizures in people with epilepsy. and treated 110 patients on a semi-inpatient basis (no outcome was recorded for these patients). At other sites, mobile clinics remained on site for 1 day and provided an ambulance service. Mobile teams were present in each targeted village for no more than 1-2 days a week on average and as little as once a month in Kenya and Damot Gale (Table 2). Mobile clinics treated 46,541 (9.3%) of 501,214 reported cases in Kayanza, 34,749 (68.3%) of 50,863 in Aweil East, 7,258 (19.4%) of 37,457 in Gutten, and 467 (2.8%) of 16,621 in Damot Gale (Table 3). In Damot Gale, active severe case finding was organized (no data available).
Artemisinin-based combination therapy (ACT) was deployed in Aweil East and in mobile clinics in Kenya (Table 2). Its use was not officially authorized au·thor·ize
tr.v. au·thor·ized, au·thor·iz·ing, au·thor·iz·es
1. To grant authority or power to.
2. To give permission for; sanction: in Burundi and in Ethiopia, where empiric evidence of poor sulfadoxine-pyrimethamine efficacy, later confirmed by in vivo in vivo /in vi·vo/ (ve´vo) [L.] within the living body.
Within a living organism.
in vivo adv. studies (15), led clinicians to use quinine quinine (kwī`nīn', kwĭnēn`), white crystalline alkaloid with a bitter taste. Before the development of more effective synthetic drugs such as quinacrine, chloroquine, and primaquine, quinine was the specific agent in the treatment of as first-line treatment A first-line treatment or first-line therapy is a medical therapy recommended for the initial treatment of a disease, sign or symptom, usually on the basis of empirical evidence for its efficacy. . To ensure adherence to the 7-day regimen, high-risk patients were treated intrarectally under observation (Table 3).
Surveillance and Epidemic Evolution
In Burundi, Sudan, and Ethiopia, surveillance data were analyzed weekly. In Kayanza, RDT testing was carried out every 2-3 weeks among outpatients to monitor epidemic trends. In Aweil East and Gutten, an automated surveillance spreadsheet generated key indicators and graphs (caseload, proportionate morbidity and mortality, case-fatality, RDT confirmation of diagnosis).
The Kisii and Gucha epidemic followed a historical pattern of short dramatic peaks (Figure 2). Kisii Hospital records showed that, during the first 12 epidemic weeks, 2,669 (22.2%) of children <5 years of age in Kisii municipality MUNICIPALITY. The body of officers, taken collectively, belonging to a city, who are appointed to manage its affairs and defend its interests. ([approximately equal to] 12,000) were hospitalized for malaria (Table 3).
[FIGURE 2 OMITTED]
The Kayanza epidemic lasted 36 weeks and roughly followed a normal distribution (Figure 3). A total of 501,214 cases were reported, for a minimum attack rate of 86.5%.
[FIGURE 3 OMITTED]
In Aweil East, a peak was reached by epidemic week 2, and a steady decline followed, which reflected percentage of confirmed malaria cases among women who came to the clinic for antenatal an·te·na·tal
before parturition. Called also prenatal, antepartal. visits (Figure 4). Children <5 years of age (assumed to be 20% of the population) experienced attack rates of [greater than or equal to] 41.2% (all malaria) and 1.1% (complicated).
[FIGURE 4 OMITTED]
In Ethiopia, the epidemic's evolution can partly be reconstructed by plotting available microscopy microscopy /mi·cros·co·py/ (mi-kros´kah-pe) examination under or observation by means of the microscope.
1. The study of microscopes.
2. results from the Gutten government clinic, which yields a normal distribution (Figure 5), and percentage P. falciparum positivity among malnourished mal·nour·ished
Affected by improper nutrition or an insufficient diet. children admitted to feeding centers in Damot Gale (Figure 1). Results showed a steady rise from June, a plateau in August and September, and a new peak in late November after heavy rains.
[FIGURE 5 OMITTED]
Profile of Patients
Among uncomplicated cases, the proportion of patients <5 years of age exceeded the expected levels of 15% to 20% in southern Sudan and Ethiopia but not Kenya, where only presumptive diagnosis was used (Table 3). Patients <5 years made up half of all complicated cases in Kisii, Gucha, Gutten, and Damot Gale and almost 80% in Aweil East. Case-fatality rates were comparable across ages and sites except Gutten (footnote, Table 3). Convenience samples of outpatients or household surveys suggested high P. falciparum prevalences at or near caseload peaks (Table 3). Where MSF was involved in both outpatient and inpatient care inpatient care Managed care Services delivered to a Pt who needs physician care for > 24 hrs in a hospital (Kayanza, Aweil East, and Gutten), comparable proportions of patients were hospitalized (1.2%, 1.9%, and 1.4% respectively).
In sub-Saharan Africa, malaria epidemics arise suddenly in mostly remote, disadvantaged settings without effective alert systems. Our case studies show that large-scale interventions can be organized in such epidemics, and that these interventions can considerably increase diagnostic and treatment output. Both preparedness pre·par·ed·ness
The state of being prepared, especially military readiness for combat.
Noun 1. preparedness - the state of having been made ready or prepared for use or action (especially military action); "putting them and control, however, were seriously deficient. Epidemic detection was late everywhere, and additional delays occurred before external intervention to support overwhelmed local health structures.
Experiences in Kisii, Gucha, Kayanza, Gutten, and Damot Gale probably reflect conditions in neighboring neigh·bor
1. One who lives near or next to another.
2. A person, place, or thing adjacent to or located near another.
3. A fellow human.
4. Used as a form of familiar address.
v. regions affected by the corresponding epidemics, although scarcity Scarcity
The basic economic problem which arises from people having unlimited wants while there are and always will be limited resources. Because of scarcity, various economic decisions must be made to allocate resources efficiently. of published records makes comparisons difficult. This analysis relies on programmatic pro·gram·mat·ic
1. Of, relating to, or having a program.
2. Following an overall plan or schedule: a step-by-step, programmatic approach to problem solving.
3. data, the limitations of which are apparent.
Epidemic Risk and Vulnerability Factors
Our analysis did not include controls (i.e., sites where no epidemics occurred). Nevertheless, remotely sensed climate data suggest rainfall abnormalities during key preepidemic periods: relative drought in the 2 or 3 preepidemic years (with the exception of Kayanza) and above-average rainfall 1-2 months before epidemic onset. No consistent temperature pattern emerged.
The full role of such abnormalities as epidemic determinants is unclear. Furthermore, although remotely sensed environmental variables provide relatively robust and accurate estimates (21) and are becoming more publicly accessible (22), they remain only proxies for ground-based measurements. Nonetheless, we believe that our findings implicate im·pli·cate
tr.v. im·pli·cat·ed, im·pli·cat·ing, im·pli·cates
1. To involve or connect intimately or incriminatingly: evidence that implicates others in the plot.
2. climate abnormalities to a varying extent in all 5 epidemics and support strengthened monitoring of climate variables for early warning.
Land cover changes in Aweil East (flooding) and in Kayanza (rice paddy creation) probably favored vector breeding. Malnutrition, displacement, and drug resistance may not in themselves cause epidemics, but in our settings these factors probably exacerbated the epidemics' magnitude, duration, and case-fatality ratios case-fatality ratio Epidemiology A value calculated as 100 cases of a disease 'X', divided by the number of persons with the disease who died in a given period of time; the resulting ratio is equal to the rate of a disease's occurrence. See Cause-fatality ratio. . The effects of past drought and malnutrition are difficult to extricate: they are related causally, and either could result in impaired immunity (respectively, through reduced exposure to infection and nutrient nutrient /nu·tri·ent/ (noo´tre-int)
1. nourishing; providing nutrition.
2. a food or other substance that provides energy or building material for the survival and growth of a living organism. deficiencies).
To our knowledge, no entomologic en·to·mol·o·gy
The scientific study of insects.
ento·mo·log data were collected during any of these epidemics, which limits the strength of our findings; changes in vector species or breeding habitats could have had a major role, but these factors can only be imputed Attributed vicariously.
In the legal sense, the term imputed is used to describe an action, fact, or quality, the knowledge of which is charged to an individual based upon the actions of another for whom the individual is responsible rather than on the individual's from observed land pattern or climate alterations. Future studies on malaria epidemics should include detailed entomologic profiling, even during the epidemics.
In short, we believe that, given available evidence, to predicate In programming, a statement that evaluates an expression and provides a true or false answer based on the condition of the data. epidemic prevention activities solely on the basis of individual risk factors (meteorologic or other) would be imprudent im·pru·dent
Unwise or indiscreet; not prudent.
im·prudent·ly adv. . Instead, appropriate decision support systems should be built that integrate all relevant data (e.g., environmental variables, food security and nutritional status nutritional status,
n the assessment of the state of nourishment of a patient or subject. , drug efficacy, health coverage, vector characteristics, population at risk) into a risk profile for each epidemic-prone population, to be updated regularly; in such a scenario, warning flags (23) resulting from detected environmental anomalies or other risk factors would result in enhanced surveillance activity and increased emergency preparedness (e.g., stockpiling stock·pile
A supply stored for future use, usually carefully accrued and maintained.
tr.v. stock·piled, stock·pil·ing, stock·piles
To accumulate and maintain a supply of for future use. drugs, ensuring insecticides insecticides, chemical, biological, or other agents used to destroy insect pests; the term commonly refers to chemical agents only. Chemical Insecticides
and spray teams are in place), rather than leading directly to control activities.
Difficulties in Detection
Even without early warning, detecting epidemics within 2 weeks of onset should be possible (24), provided that weekly reporting and analysis are complete and timely and that caseload data reflect community incidence trends. In most case studies described here, epidemics were detected after substantial delay and by agencies other than local authorities with unconventional methods, such as RDT monitoring among malnourished children. An exception was Aweil East, where weekly reporting and analysis took place. Several formal definitions of a malaria epidemic have been proposed. Most, like the C-Sum or Cullen methods (22), rely on comparison with past caseloads. These methods cannot be effective unless surveillance is greatly improved. Experience from the Highland Malaria Project (HIMAL) (7) shows that meeting the requirements of epidemic early detection requires supplementing existing routine surveillance systems with networks of representative sentinel sentinel /sen·ti·nel/ (sen´ti-n'l) one who gives a warning or indicates danger.
a recording mechanism, such as an animal, a farm or a veterinarian, posted explicitly to record a possible occurrence or series of health facilities, new data collection forms, procedures for rapid exchange of data between different levels of the health system, and tools for the collation COLLATION, descents. A term used in the laws of Louisiana. Collation -of goods is the supposed or real return to the mass of the succession, which an heir makes of the property he received in advance of his share or otherwise, in order that such property may be divided, together with the , analysis, and interpretation of incoming data. However, the apparent success of HIMAL's pilot early detection systems in selected districts of Uganda Uganda is divided into 80 districts across four administrative regions. Most districts are named after their main commercial and administrative towns. Eleven new districts came into being on 1 July 2006. and Kenya suggests that these efforts are viable, given requisite resources and motivation (J. Cox and Y. Abeku, pers. comm.).
Free treatment and steady drug supplies probably favored early detection in Aweil East. Conversely, in Ethiopia, facility use was too low to reflect the magnitude of the emergency, and irregular drug distributions confounded epidemiologic monitoring. User fee systems may have long-term benefits, but cost barriers hamper treatment access (25). In impoverished populations at risk for malaria epidemics, a free care policy may encourage early treatment seeking and thus facilitate early epidemic detection and monitoring, in addition to minimizing deaths. Conversely, user fee systems may result in "silent" public health disasters.
Expansion of Access
By the time interventions were implemented, their potential effects were reduced. Mobile clinics were deployed to expand health access and detect severe cases. Implementation of clinics understandably varied according to according to
1. As stated or indicated by; on the authority of: according to historians.
2. In keeping with: according to instructions.
3. local conditions, but apart from in Aweil East, probably had limited impact. Mobile clinic programs should be designed on the basis of clearly identified catchment areas catchment area or drainage basin, area drained by a stream or other body of water. The limits of a given catchment area are the heights of land—often called drainage divides, or watersheds—separating it from neighboring drainage and set frequencies with which communities should be visited. Although various criteria were used in our case studies, we believe that actual access to healthcare should be a key indicator for selecting target populations. Rapid methods to assess antimalarial treatment coverage thus need to be developed. How frequently communities are visited determines both the improvement in treatment coverage and the probability of preventing progression to severe disease through prompt treatment, which is likely to increase exponentially ex·po·nen·tial
1. Of or relating to an exponent.
a. Containing, involving, or expressed as an exponent.
b. with frequency of mobile team visits; we hypothesize hy·poth·e·size
v. hy·poth·e·sized, hy·poth·e·siz·ing, hy·poth·e·siz·es
To assert as a hypothesis.
To form a hypothesis. that frequent visits to selected sites may be more efficient than infrequent in·fre·quent
1. Not occurring regularly; occasional or rare: an infrequent guest.
2. visits to a wider area. Impact monitoring should be included in future mobile clinic interventions to adjust their strategy as the situation evolves, and they should be evaluated after the fact. More generally, alternative modes of rapidly decentralizing de·cen·tral·ize
v. de·cen·tral·ized, de·cen·tral·iz·ing, de·cen·tral·iz·es
1. To distribute the administrative functions or powers of (a central authority) among several local authorities. care, such as fixed temporary health posts or training of resident community health workers (possibly equipped with artesunate suppositories Artesunate suppositories are used for the treatment of malaria. Artesunate is an antimalarial water-soluble derivative of dihydroartemisinin. Artemisinins are sesquiterpene lactones isolated from Artemisia annua, a Chinese traditional medicine. to treat severely ill patients), merit further exploration. Where no clear indications exist that local health structures can cope with a large malaria epidemic, mobile clinics or other temporary treatment programs should be implemented immediately.
Reduction of Case-fatality Ratio
Case-fatality ratio among patients with complicated cases was lower than current best estimates of 10% (2) and 13% (26); however, whether all cases were severe depends on the case definition used. Treatment of uncomplicated cases relied on failing drugs everywhere but Sudan, and sulfadoxine-pyrimethamine monotherapy monotherapy /mono·ther·a·py/ (-ther´ah-pe) treatment of a condition by means of a single drug.
Treatment of a disorder with a single drug. was probably counterproductive coun·ter·pro·duc·tive
Tending to hinder rather than serve one's purpose: "Violation of the court order would be counterproductive" Philip H. Lee. because the drug stimulates gametocytogenesis (27) and thus transmission. Ineffective drug use in Burundi probably limited the effect on mortality; in Ethiopia, quinine first-line administration proved challenging because of vomiting vomiting, ejection of food and other matter from the stomach through the mouth, often preceded by nausea. The process is initiated by stimulation of the vomiting center of the brain by nerve impulses from the gastrointestinal tract or other part of the body. and required impractical patient monitoring.
Effect on Public Health
Kayanza excluded, the increased proportion of children <5 years of age among inpatients, as previously observed in Kenya (28), suggests that children were more susceptible to symptomatic disease, which challenges classical notions of unstable, epidemic malaria. In Aweil East, the predominance pre·dom·i·nance also pre·dom·i·nan·cy
The state or quality of being predominant; preponderance.
Noun 1. predominance - the state of being predominant over others
predomination, prepotency of children is consistent with stable, mesoendemic to hyperendemic transmission, and this situation is probably better characterized as a severe seasonal outbreak.
Clinic-based attack rates approach 100% for all age groups when extrapolated to the entire epidemic period (Kayanza and Gutten) and are even more alarming among children <5 years of age in Kisii. Even after overdiagnosis from presumptive treatment is accounted for, these rates are likely to be gross underestimates. The vast gap in treatment coverage was evident in Aweil East, where large-scale deployment of mobile clinics greatly increased output, and in Ethiopia, where despite capturing only the declining phase of the epidemic, uninterrupted provision of free care with effective drugs resulted in far higher outpatient and inpatient department attendance. The true community incidence in these epidemics is probably much greater than represented by regular reporting systems and higher than current estimates of 0.5 episodes of malaria per person per epidemic (29). Only population-based studies can yield realistic estimates of this incidence.
Malaria epidemics create daunting daunt
tr.v. daunt·ed, daunt·ing, daunts
To abate the courage of; discourage. See Synonyms at dismay.
[Middle English daunten, from Old French danter, from Latin medical emergencies. In addition to ongoing research on alert systems, much greater donor investment is necessary to prevent and control them. All 4 countries in this study are moving to ACT combinations for outpatient treatment, a major improvement that is still insufficient unless 1) simple but valid surveillance data are transmitted and analyzed on a weekly basis, maximizing the chance of early epidemic detection, and 2) treatment coverage of uncomplicated and complicated cases truly reflects community needs. Further research is needed on methods to rapidly estimate needs (incidence) and coverage and on strategies to efficiently expand treatment access. Arguably ar·gu·a·ble
1. Open to argument: an arguable question, still unresolved.
2. That can be argued plausibly; defensible in argument: three arguable points of law. , focusing resources only on how to predict and respond to epidemics might lead policymakers to overlook basic problems with access to effective treatment and tools for prevention that are common to both epidemic and stable malaria settings and that probably merit similar solutions. Donors and policymakers should thus aim for a balanced approach: improved capacity for epidemic prediction and response is needed, but long-term improvements in access to proper care and vector control by all members of the community, even before epidemics strike, must not be neglected, as they could be the most relevant determinants of decreased epidemic severity.
Because malaria epidemics are difficult to predict and multifactorial multifactorial /mul·ti·fac·to·ri·al/ (mul?te-fak-tor´e-al)
1. of or pertaining to, or arising through the action of many factors.
2. , setting up controlled studies to formally demonstrate the benefit of any single intervention will be difficult. Properly documenting the cost, feasibility, and output of these interventions and measuring the true extent of malaria epidemics are nevertheless crucial to inform the choice of future prevention and control strategies and must be included in the research agenda.
We thank MSF staff and local health authorities for their work on these malaria interventions and for sharing data with us.
This review was funded by Mrdecins Sans Frontirres.
(1.) World Health Organization/UNICEF. The Africa malaria report 2003. Geneva Geneva, canton and city, Switzerland
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The science that deals with the phenomena of the atmosphere, especially weather and weather conditions.
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Point on the surface of the Earth that is directly above the source (or focus) of an earthquake. There the effects of the earthquake usually are most severe. See also seismology. ; 2001.
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1. Of or relating to the Balkan Peninsula or the Balkan Mountains.
2. Of or relating to the Balkan States or their inhabitants.
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Address for correspondence: Francesco Checchi, Department of Infectious and Tropical Diseases Tropical diseases are infectious diseases that either occur uniquely in tropical and subtropical regions (which is rare) or, more commonly, are either more widespread in the tropics or more difficult to prevent or control. , London School of Hygiene and Tropical Medicine tropical medicine, study, diagnosis, treatment, and prevention of certain diseases prevalent in the tropics. The warmth and humidity of the tropics and the often unsanitary conditions under which so many people in those areas live contribute to the development and , Keppel St, London WC1E 7HT, UK; email: firstname.lastname@example.org
Francesco Checchi, * ([dagger]) Jonathan Cox, ([dagger]) Suna Balkan, ([double dagger double dagger
A reference mark () used in printing and writing. Also called diesis.
Noun 1. ]) Abiy Tamrat, ([section]) Gerardo Priotto, * Kathryn P. Alberti, * Dejan Zurovac, ([double dagger] [paragraph] #) and Jean-Paul Guthmann *
* Epicentre, Paris, France; ([dagger]) London School of Hygiene and Tropical Medicine, London, United Kingdom; ([double dagger]) Medecins Sans Frontieres, Paris, France; ([section]) Medecins Sans Frontieres, Geneva, Switzerland; ([paragraph]) Kenya Medical Research Institute/Wellcome Trust Research Laboratories, Nairobi, Kenya; and (#) University of Oxford, Oxford, United Kingdom
Mr Checchi is an infectious disease Infectious disease
A pathological condition spread among biological species. Infectious diseases, although varied in their effects, are always associated with viruses, bacteria, fungi, protozoa, multicellular parasites and aberrant proteins known as prions. epidemiologist with interests in malaria, sleeping sickness sleeping sickness: see encephalitis; trypanosomiasis.
Protozoal disease transmitted by the bite of the tsetse fly. Two forms, caused by different species of the genus Trypanosoma, occur in separate regions in Africa. , and public health in humanitarian emergencies. He was formerly with Epicentre, Paris, and is now studying for a PhD at the London School of Hygiene and Tropical Medicine.
Table 1. Characteristics of intervention sites and potential determinants of epidemics * Characteristic/ determinant Kisii/Gucha, Kenya Kayanza, Burundi Epidemic period May-August 1999 September 2000- (no. weeks) (15) May 2001 (36) Population 956,000 578,000 Altitude (m) 1,200-2,200 1,400-1,750 Malaria vectors Anopheles funestus A. arabiensis (95%), (constant), A. funestus (5%) A. gambiae sensu lato (seasonal) Malaria species Plasmodium P. falciparum (>90%) (nonepidemic falciparum (>90%) months) Temperature Above average in 3 None apparent anomalies preepidemic months Rainfall Heavy rainfall in Heavy rainfall 5 and anomalies preepidemic rainy 3 months before season after drought epidemic, drought 2 in previous rainy years before season epidemic but not in preepidemic year Land pattern None reported Creation of rice changes paddies and fish ponds Political None Armed conflict instability Population None Forced relocation movement Global acute Not available 10%-15% malnutrition ([dagger]) Drug resistance CQ 24%-87% CQ 100%, SP (in vivo failure (neighboring 54.2%, CQ+SP rates) districts), SP 10% 42.0% (9) (13) Characteristic/ Aweil East, southern determinant Sudan Epidemic period June-November 2003 (no. weeks) (22) Population 307,000 Altitude (m) 430 Malaria vectors Not available (A. gambiae sensu lato presumed) Malaria species P. falciparum (>95%) (nonepidemic months) Temperature Maximum LST anomalies strongly below average during epidemic Rainfall Below average rainfall anomalies in 3 preepidemic years, above average in 2 preepidemic months Land pattern Widespread flooding changes Political Tenuous ceasefire instability Population Seminomadic, movement returnees from north Sudan Global acute 25% malnutrition ([dagger]) Drug resistance CQ 63%, SP 3% (in vivo failure (14) ([double dagger]) rates) Characteristic/ determinant Gutten, Ethiopia Epidemic period July 2003-February (no. weeks) 2004 Population 44,000 Altitude (m) 1,700 Malaria vectors A. arabiensis Malaria species P. falciparum ([approximately equal to] 25%), (nonepidemic P. vivax ([approximately equal to] 75%) months) Temperature None apparent anomalies Rainfall Below average anomalies rainfall in 2 preepidemic and epidemic years but heavy rainfall in preepidemic month Land pattern Creation of water changes ponds Political Inactive insurgency instability Population Government movement resettlement schemes Global acute Not available malnutrition ([dagger]) (probably >5%) Drug resistance SP 78.0% (15) (in vivo failure rates) Characteristic/ determinant Damot Gale, Ethiopia Epidemic period July 2003-January (no. weeks) 2004 (30) Population 287,000 Altitude (m) 1,600-2,100 Malaria vectors A. arabiensis Malaria species P. falciparum ([approximately equal to] 60%), (nonepidemic P. vivax ([approximately equal to] 40%) months) Temperature None apparent anomalies Rainfall Below average rainfall anomalies in 2 preepidemic and epidemic years but heavy rainfall in 3 preepidemic months Land pattern None reported changes Political Inactive insurgency instability Population Government movement resettlement schemes Global acute 28% malnutrition ([dagger]) Drug resistance SP 68.1% (in vivo failure (neighboring zone) rates) (15) * LST, land surface temperature; CQ, chloroquine; SP, sulfadoxine-pyrimethamine. ([dagger]) Among children <5 y of age, malnutrition rates >15% denote a serious situation; values are provided for 2 months before the epidemic. ([double dagger]) Percentages refer to the frequency of single Pfcrt mutations and triple Dhfr mutations in the P. falciparum genome of outpatients sampled in Aweil East. These mutations are predictive of in vivo CQ and SP failure rates, respectively. Table 2. Details of operational response to malaria epidemics by intervention site * Factor Kisii/Gucha, Kenya Kayanza, Burundi Delay of intervention (wks) 7 7 Inpatient care Expansion in bed From 310 to From 65 to capacity 510 beds 125 beds Treatment IM/IV quinine, IM IM/IV quinine artemether Diagnosis Presumptive Blood slide Fixed outpatient care Increase in capacity 2 additional OPDs Increased capacity in 5 OPDs, 2 additional OPDs Treatment SP CQ+SP Diagnosis Presumptive Presumptive Mobile clinics Number 3 6 Catchment population 302,000 Not available Sites visited 45 10 Days per site per week 0.2-0.3 (7) 1.2 (22) (wks of operation) Treatment SP, AS+SP (73.4% CQ+SP of cases) Diagnosis Presumptive Presumptive Aweil East, Factor southern Sudan Delay of intervention (wks) 3 Inpatient care Expansion in bed From [approximately equal to] 80 to capacity [approximately equal to] 120 beds Treatment IM artemether Diagnosis RDT Fixed outpatient care Increase in capacity Conversion of nutritional centers, 2 additional OPDs Treatment AS+SP Diagnosis RDT Mobile clinics Number 14 Catchment population 144,000 Sites visited 43 Days per site per week 1-2 (15) (wks of operation) Treatment AS+SP, artemether for severe cases Diagnosis Presumptive Factor Gutten, Ethiopia Delay of intervention (wks) [greater than or equal to] 12, probably Inpatient care 19 Expansion in bed From 2 to capacity [approximately equal to] 100 beds Treatment IV quinine Diagnosis RDT Fixed outpatient care Increase in capacity 1 additional OPD Treatment Quinine (I R if vomited) Diagnosis RDT Mobile clinics Number 5 Catchment population 44,000 Sites visited 5 Days per site per week 2 (wks of operation) Treatment Quinine Diagnosis RDT Damot Gale, Factor Ethiopia Delay of intervention (wks) 20 Inpatient care Expansion in bed From 12 to capacity >100 beds Treatment IV/IR quinine Diagnosis RDT Fixed outpatient care Increase in capacity Supervision and drug supply to 5 OPDs Treatment SP, quinine Diagnosis RDT Mobile clinics Number Not available Catchment population 73,000 Sites visited 14 Days per site per week 0.2-0.5 (4) (wks of operation) Treatment Quinine Diagnosis RDT * IM, intramuscular; IV, intravenous; IR, intrarectal, RDT, rapid diagnostic test; OPD, outpatient department; SP, sulfadoxine-pyrimethamine; CQ, chloroquine, AS, artesunate. Table 3. Epidemiologic profile of malaria at fixed inpatient, fixed outpatient, and mobile health facilities operated by Medecins Sans Frontieres in 5 intervention sites Characteristic Kisii/Gucha Kenya Uncomplicated cases Fixed outpatient centers All ages 13,127 * Age <5 y (%) 2,426 (18.5) Mobile clinics All ages 29,769 Age <5 y (%) 5,376 (18.1) Complicated cases All ages 9,773 ([section]) Age <5 y (%) 5078 (52.0) No. deaths 397 (4.1) (CFR [%]) No. deaths <5 y 164 (3.2) (CFR [%]) Minimal attack rate 22.2 (complicated, <5 (%) ([dagger][dagger]) only; 12/15 weeks) P. falciparum 38-49 (community prevalence at survey) epidemic peak (%) Characteristic Kayanza Burundi Uncomplicated cases Fixed outpatient centers All ages 272,459 Age <5 y (%) Not available Mobile clinics All ages 46,541 Age <5 y (%) Not available Complicated cases All ages 3,953 ([paragraph]) Age <5 y (%) 761 (19.3) No. deaths 108 (2.7) (CFR [%]) No. deaths <5 y 31 (4.1) (CFR [%]) Minimal attack rate 86.5 (36/36 weeks) (%) ([dagger][dagger]) P. falciparum 80 (random sample prevalence at in OPD ([double dagger][double dagger]) epidemic peak (%) queue) Aweil East, Characteristic southern Sudan Gutten Ethiotia Uncomplicated cases Fixed outpatient centers All ages 15,239 15,928 ([dagger]) Age <5 y (%) 7,257 (7.6) 4,758 ([double dagger]) Mobile clinics (29.9) All ages 34,749 7,258 Age <5 y (%) 17,338 (49.9) 1,405 (19.4) Complicated cases All ages 875 (#) 330 ** Age <5 y (%) 683 (78.1) 175 (53.0) No. deaths 50 (5.7) 34 (10.3) (CFR [%]) No. deaths <5 y 39 (5.7) 15 (8.6) (CFR [%]) Minimal attack rate 41.2 (<5 only; 53.4 (15/33 weeks) (%) ([dagger][dagger]) 22/22 weeks) P. falciparum 52-64 (random Not available prevalence at sample in OPD epidemic peak (%) queue) Damot Gale, Characteristic Ethiotia Uncomplicated cases Fixed outpatient centers All ages -- Age <5 y (%) -- Mobile clinics All ages 467 Age <5 y (%) 145 (31.0) Complicated cases All ages 1,291 Age <5 y (%) 595 (46.1) No. deaths 62 (4.8) (CFR [%]) No. deaths <5 y 38 (6.4) (CFR [%]) Minimal attack rate Not available (%) ([dagger][dagger]) P. falciparum 60 (random sample prevalence at by community epidemic peak (%) workers) * Includes data from 3 government clinics (Masimba, Kenyenya, and Etago) for which age breakdown was available. ([dagger]) Includes 2,061 patients treated with intrarectal quinine in inpatient department. ([double dagger]) Includes 1,773 patients <5 years of age treated with intrarectal quinine in inpatient department. ([section]) Includes data from Kisii, Keumbu, and Ogembo hospitals, supported by Medecins Sans Frontieres and other agencies but operated by the government. ([paragraph]) Excludes patients treated in the Kayanza government hospital (data not available). (#) Excludes 110 severe cases treated by mobile clinics (no age breakdown or outcome available). ** Includes only hospitalized patients who met a strict definition of severe malaria, which probably explains the considerably higher case-fatality ratio (CFR) noted in Gutten. ([dagger][dagger]) Ratio of weeks refers to the number of epidemic weeks from which the attack rate was calculated divided by the total number of epidemic weeks. ([double dagger][double dagger]) OPD, outpatient department.