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A descriptive cross sectional survey using an interviewer-administered questionnaire was carried out among 700 caregivers whose children had fever during the previous two weeks. The aim was to determine the community effectiveness of malaria treatment using arthemeter-lumefantrine (AL) among under-5-year-olds in a rural community in southwestern Nigeria. A total of 353 (50.9%) children received AL. About half of these children (49%) were said to have been treated within 24 hours of onset of symptoms; 44% took the drug for the stipulated period of time; 42% received the correct dosage; and only 4% received all the treatment steps. With a drug efficacy of 100%, AL achieved a community effectiveness of 4%. The greatest effort in the home management of malaria strategy should be in reducing delay in treatment and improving dosage and duration of treatment. [ABSTRACT FROM AUTHOR]

Traditional healers play an important role in the provision of healthcare in many communities in Africa. This study aimed to improve home management of malaria in children by assessing the healer's knowledge and practice. A semi-structured questionnaire interview of 127 traditional healers selected by proportionate sampling technique from two rural and two urban local government areas (LGAs) of southwestern Nigeria was followed by a training program. Malaria ranked first (87%) among the illnesses managed by the healers. Diagnosis of fever was often (72%) based on client history, physical examination (24.4%), consulting oracles (18.9%), and interpretation of dreams (3.1%). Treatment of malaria was with boiled herbs ('agbo'; 72%), ground herbs ('agunmu'; 14%), and incisions and scarifications (3%). Forty-one (32.5%) healers had referred febrile children to a health facility. Younger healers and those who had at least a secondary education were more likely to refer patients (p < 0.05 in both cases). Thirty-six healers (28.4%) had previous formal training on management of fevers, most of whom were the younger (p < 0.05), educated healers (p > 0.05), with fewer years of practice (p > 0.05). Research into traditional herbs (48%), better acknowledgment by government (23.6%), and collaboration with other health sectors were suggestions to improve practice. Traditional healers, especially the older, less-educated, and long-practicing healers, urgently require formal training and collaboration with other healthcare providers to improve knowledge and promote early referral of children with fever. [ABSTRACT FROM AUTHOR]

The prevalence of malaria parasitemia at booking was studied in 1,848 pregnant women in a secondary hospital in Ibadan, Nigeria. Main outcome variables were patent parasitemia and fever. 8.4% had patent malaria parasitaemia. Most clients (89%) with parasitemia were asymptomatic. Febrile subjects booked at an earlier gestational age [22.7 versus 24.2 weeks] than afebrile patients (p = 0.0052). Anemia was more prevalent among patients with patent parasitemia than those without (58.1% versus 22.6%, p<0.0001). Malaria parasitaemia was higher among nulliparous women than other parity groups (p<0.0001). Symptomatic malaria was associated with early booking for antenatal care and malaria parasitemia was a significant determinant of anemia. The prevalence of malaria parasitaemia in this study is much lower than in previous reports. [ABSTRACT FROM AUTHOR]

A cluster sample of 2,052 mothers and other caregivers of children from southwest Nigeria was studied. Qualitative and quantitative methods of data collection were employed, including semi-structured questionnaires, focus groups, in-depth interviews, and parasitological investigation forms/blood smears. 'Too much work' (17.7%) and 'too much sun' (12.6%) were the two most-often mentioned causes of malaria. Malaria was not perceived as a serious disease. Convulsions and anemia are not perceived as complications of malaria and are preferentially treated by traditional healers. Fifty-eight and one-half percent of children with malaria were treated at home. Choice of drugs used was based on previous experience and advice from various members of the community. Fathers (53.5%) and mother (32.5%) decided on where ill children received treatment. Mothers (51.5%) paid for the drugs more often than fathers (44.6%). Symptoms described as 'iba lasan,' which means 'ordinary fever,' conform to the clinical case definition of malaria. Cultural practices that are likely to influence appropriate treatment-seeking include cultural perception of malaria as ordinary fever, wrong perceptions of severe malaria, and father's role as decision maker. [ABSTRACT FROM AUTHOR]

Background: In Nigeria ACT use at the community level has not been evaluated and the use of antimalarial drugs (commonly chloroquine (CQ)) at home has been shown to be largely incorrect. The treatment regimen of ACT is however more complicated than that of CQ. There is thus a need to determine the feasibility of using ACT at the home level and determine community perception on its use.Methods: A before and after qualitative study using key informant interviews (KII) and focus group discussions (FGDs) was conducted in selected villages in Ona-Ara local government area. At baseline, 14 FGDs and 14 KIIs were conducted. Thereafter, community medicine distributors (CMDs) were trained in each village to dispense artemeter-lumenfantrine (AL) to febrile children aged 6-59 months presumed to have uncomplicated malaria. After one year of drug distribution, nine KIIs and 10 FGDs were conducted. Participants and key informants were mothers and fathers with children under five years, traditional heads of communities, opinion leaders and health workers.Results: None of the participants have heard of AL prior to study. Participants were favourably disposed to introduction of AL into the community. Mothers/caregivers were said to have used AL in place of the orthodox drugs and herbs reported commonly used prior to study after commencement of AL distribution. The use of CMDs for drug distribution was acceptable to the participants and they were judged to be efficient as they were readily available, distributed correct dose of AL and mobilised the community effectively. AL was perceived to be very effective and no significant adverse event was reported. Major concerns to the sustainability of the program were the negative attitudes of health workers towards discharge of their duties, support to the CMDs and the need to provide CMDs incentives. In addition regular supply of drugs and adequate supervision of CMDs were advised.Conclusion: Our findings showed that the use of AL at home and community level is feasible with adequate training of community medicine distributors and caregivers. Community members perceived AL to be effective thus fostering acceptability. The negative attitudes of the health workers and issue of incentives to CMDs need to be addressed for successful scaling-up of ACT use at community level. [ABSTRACT FROM AUTHOR]

Objective To describe the development of a treatment guideline for the effective case management of malaria in children at the home level. Methods Thirty-three mothers selected from 11 communities in a rural health district, community members and the research team developed a guideline for treatment of malaria at home by caregivers using a participatory approach. This was done in phases using modified focus group discussion sessions. Suggested ideas were depicted in illustrations by a graphic artist. Results A guideline which illustrated the presentation of clinical types of malaria, the appropriate steps to take for each type and the correct dosage schedule of chloroquine (based on the age of the child) for treatment of uncomplicated malaria was developed. The guideline was in cartoon format and the script in the local language. Conclusion Use of a participatory approach was found acceptable and effective in the development of the guideline. This approach is therefore recommended irrespective of the target population or the intervention to be developed. Practice implications Preparation of educational materials with contributions from end users does not only build capacity at the local level but also increases the acceptability and ownership of such materials. [ABSTRACT FROM AUTHOR]

Background: Adverse drug reaction (ADR) is a global and frequently occurring medical emergency with increased cases of mortality annually. ADRs can occur with the use of all drugs including artemisinin-based combination therapy (ACTs) which are currently the treatment of choice for acute uncomplicated malaria globally. Numerous doses of ACTs are administered daily in malaria endemic areas., Aims: This study determined the incidence, pattern of presentation and factors associated with ADRs to two ACTs- artemisinin piperaquine (AP) and artemether-lumefantrine (AL) among children with confirmed acute uncomplicated malaria in Ibadan, Nigeria., Methods: Children aged 2-10 years enrolled into a larger study evaluating the safety and efficacy of artemisinin /piperaquine (AP) and artemether /lumefantrine (AL) using the WHO 28-day protocol were studied. Monitoring for ADR was based on history from the parent and /or child (for occurrences of treatment emergent signs and symptoms), physical examinations and abnormalities in laboratory investigations- full blood count, blood chemistry and liver function tests. Causality assessment for the ADR was by the Naranjo algorithm scale., Result: 108 of 114 (94.7%) children completed the study. Over half [61(56.5%] were males. The mean age of enrollees was 65.1±30.0 months. Day 28 adequate clinical and parasitological response (ACPR) for AP was 96.1% and 90.4% for AL. Observed ADRs were cough, diarrhea, loss of appetite, abdominal pain, rash, irritability, insomnia and headache. The prevalence was similar in the two treatment groups (AL=14%, AP= 11%; ρ=1.000). The incidence of ADR to both ACTs was 12/1000 patients per day. All ADRs were mild and resolved spontaneously. No notable associated factor to ADR was detected in this study., Conclusion: Artemether-lumefantrine and Artemisinin piperaquine were found to be safe in the study population., Competing Interests: The Authors declare that no competing interest exists, (Copyright © 2023 by West African Journal of Medicine.)

Context and Aim: Given the challenges of microscopy, we compared its performance with SD-Bioline malaria rapid diagnostic test (MRDT) and polymerase chain reaction (PCR) and evaluated the time it took for positive results to become negative after treatment of children with acute uncomplicated malaria., Subjects and Methods: We present the report of 485 participants with complete MRDT, microscopy, and PCR data out of 511 febrile children aged 3-59 months who participated in a cohort study over a 12-month period in rural and urban areas of Ibadan, Nigeria. MRDT-positive children received antimalaria and tested at every visit over 28 days. Speciation was also carried out by PCR., Results: With microscopy as the gold standard, SD-Bioline™ had 95.2% sensitivity, 66.4% specificity, 67.5% positive predictive value (PPV), and 94.9 negative predictive value (NPV), while with PCR the findings were 84.3% sensitivity, 66.5% specificity, 72.7% PPV, and 80.1% NPV. PCR speciation of malaria parasites revealed 91.6% Plasmodium falciparum, 18.9% Plasmodium malariae, and 4.4% Plasmodium ovale. Among the 47 children with P. malariae infections, 66.0% were coinfected with P. falciparum, while 54.6% cases of P. ovale occurred as coinfections with P. falciparum. The median time to a negative MRDT was 23.2 days, while the median time to a negative malaria microscopy was 3.8 days. The two survival curves were significantly different., Conclusions: The SD-Bioline TM MRDT performed well, with remarkable persistence of rapid test-positive for an average of 23 days post treatment. The prevalence of P. malaria is somewhat greater than expected., Competing Interests: None

Background: In Nigeria, declining responsiveness to artemether-lumefantrine (AL), the artemisinin-based combination therapy (ACT) of choice since 2005, has been reported. Pyronaridine-artesunate (PA) is a newer fixed-dose ACT recently prequalified by the WHO for the treatment of uncomplicated falciparum malaria. However, PA data from the Nigerian pediatric population is scarce. Therefore, the efficacy and safety of PA and AL using the WHO 28-day anti-malarial therapeutic efficacy study protocol in Ibadan, southwest Nigeria, were compared., Methods: In an open-labelled, randomized, controlled clinical trial, 172 children aged 3-144 months with a history of fever and microscopically confirmed uncomplicated Plasmodium falciparum malaria were enrolled in southwest Nigeria. Enrollees were randomly assigned to receive PA or AL at standard dosages according to body weight for 3 days. Venous blood was obtained for hematology, blood chemistry, and liver function tests on days 0, 3, 7, and 28 as part of the safety evaluation., Results: 165 (95.9%) of the enrolled individuals completed the study. About half (52.3%; 90/172) of enrollees were male. Eighty-seven (50.6%) received AL, while 85 (49.4%) received PA. Day 28, adequate clinical and parasitological response for PA was 92.7% [(76/82) 95% CI 83.1, 95.9] and 71.1% [(59/83) 95% CI 60.4, 79.9] for AL (0.001). Fever and parasite clearance were similar in both groups. Two of six and eight of 24 parasite recurrences were observed among PA- and AL-treated children, respectively. PCR-corrected Day-28 cure rates for PA were 97.4% (76/78) and 88.1% (59/67) for AL (= 0.04) in the per-protocol population after new infections were censored. Hematological recovery at day 28 was significantly better among PA-treated patients (34.9% 2.8) compared to those treated with AL (33.1% 3.0) (0.002). Adverse events in both treatment arms were mild and similar to the symptoms of malaria infection. Blood chemistry and liver function tests were mostly within normal limits, with an occasional marginal rise., Conclusion: PA and AL were well-tolerated. PA was significantly more efficacious than AL in both the PCR-uncorrected and PCR-corrected per-protocol populations during this study. The results of this study support the inclusion of PA in the anti-malarial treatment guidelines in Nigeria., Retrospective Trial Registration: Clinicaltrials.gov: NCT05192265., (© 2023. The Author(s).)

Background: Microscopic evaluation of parasite clearance is the gold standard in antimalarial drug efficacy trials. However, the presence of sub-microscopic residual parasitemia after artemisinin-based combination therapy (ACT) needs to be investigated., Methods: One hundred and twenty (AL: n = 60, PA: n = 60) days 3 and 14 dried blood spots, negative by microscopy were analysed for residual parasitemia using nested PCR. Isolates with residual parasitemia on days 3 and 14 were further genotyped with their corresponding day-0 isolates using merozoite surface proteins msp-1, msp-2, and glurp genes for allelic similarity., Results: Persistent PCR-determined sub-microscopic residual parasitemia at day 3 post ACT treatment was 83.3 (AL) and 88.3% (PA), respectively (ρ = 0.600), while 63.6 and 36.4% (ρ = 0.066) isolates were parasitemic at day 14 for AL and PA, respectively. Microscopy-confirmed gametocytemia persisted from days 0 to 7 and from days 0 to 21 for AL and PA. When the alleles of day 3 versus day 0 were compared according to base pair sizes, 59% of parasites shared identical alleles for glurp, 36% each for 3D7 and FC27, while K1 was 77%, RO33 64%, and MAD20 23%, respectively. Similarly, day 14 versus day 0 was 36% (glurp), 64% (3D7), and 32% (FC27), while 73% (K1), 77% (RO33), and 41% (MAD20), respectively., Conclusion: The occurrence of residual parasitemia on days 3 and 14 following AL or PA treatment may be attributable to the presence of either viable asexual, gametocytes, or dead parasite DNAs, which requires further investigation., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Malaria, helminthiasis and HIV are widespread in developing countries taking a heavy toll on pregnant women. Due to similar environmental and human factors of transmission, they co-exist. The epidemiology and pathology of these diseases have been extensively studied but data on serum cytokine profile changes which is crucial in pregnancy is limited. The aim of this study was to evaluate the co-infections and their impact on peripheral blood cytokines. Blood and stool samples were collected from recruited 18-45-year-old pregnant women in different trimesters who were apparently healthy with no obvious complications in pregnancy. Pretested questionnaires were administered for personal and socio-demographic details. Malaria parasitemia in Giemsa-stained thick blood films was examined microscopically. Stool samples were screened for helminths using Kato-Katz method. Cytokine levels of TNF-α, IFN-γ, IL-1α, IL-2, IL-4, IL-6, IL-10, IL-12p70, IL-13 and IL-17 in 121 serum samples were determined using ELISA. Data were analysed using descriptive statistics and Mann-Whitney U test at α 0.05. Relative to the single infections, there were significant reductions in IFN-γ and IL-13 in second and third trimesters respectively in those with Plasmodium and helminth co-infection. IFN-γ and IL-17 were elevated while IL-1α and IL-12p70 were reduced in co-infection of helminths and HIV. Co-infection of Plasmodium and HIV in second and third trimesters showed significant elevations in IL-1α, IL-10 and IL-17 while TNF-α, IL-4 and IL-12p70 were significantly reduced. HIV in pregnancy and its co-infection with Plasmodium resulted in significant distortions in the cytokine profile. However, helminth and its co-infection with Plasmodium or HIV produced less changes in the cytokine profile., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Although the global malaria burden is decreasing, there are still concerns about overdiagnosis of malaria and the danger of misdiagnosis of non-malaria causes of fever. Clinicians continue to face the challenge of differentiating between these causes despite the introduction of malaria rapid diagnostic tests (mRDTs)., Aim: To determine the prevalence and causes of non-malaria-caused fever in children in South-Western Nigeria., Methods: Secondary analysis of data obtained to evaluate the effect of restricting antimalarial treatment to positive mRDT children in rural and urban areas of southwest Nigeria. Clinical examinations, laboratory tests for malaria parasites (including thick blood film and mRDT) and bacterial identification were performed on children aged 3-59 months (n = 511). The non-malaria group comprised febrile children who had both negative mRDT and microscopy results, while the malaria group included those who were positive for either mRDT or microscopy. We compared the causes of fever among children with non-malaria fever and those with malaria., Results: The prevalence of non-malaria fever and bacteria-malaria co-infection was 37.2% and 2.0%, respectively. Non-malarial pathogens identified were viral (54.7%) and bacterial (32.1%) infections. The bacterial infections included bacteriaemia (2.7%), urinary tract infections (21.6%), skin infections (11.6%) and otitis media (2.6%). The leading bacterial isolates were Staphylococcus aureus, Pseudomonas aeruginosa and Streptococcus pneumoniae., Conclusion: The high prevalence and wide range of non-malarial infections reinforces the need for point-of-care tests to identify bacterial and viral infections to optimize the treatment of febrile illnesses in malaria-endemic areas., (© The Author(s) [2022]. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

There are about 2.1 million children infected with HIV globally and about 120,000 deaths annually. Nigeria has one of the highest rates of pediatric HIV infection globally. Pretreatment HIV drug resistance data inform the choice of first- and second-line antiretroviral therapy (ART) regimens. This study investigated the prevalence of HIV drug-resistant strains among ART-naive children in Ibadan, Nigeria. A total of 20 children aged <15 years were enrolled. Demographic, clinical, and laboratory data were documented. Total nucleic acid was extracted from blood samples after which amplification of HIV-1 pol gene was done using polymerase chain reaction. Amplified gene was sequenced using big dye sequencing method. The sequenced HIV-1 pol gene was typed and analyzed for identification of mutations indicative of drug resistance across the different classes of ART. HIV-1 RNA pol gene was successfully amplified in 12/20 (60%) children. All were identified as HIV-1 and the subtypes were G and CRF 02AG, recombinant of 02&#95;AG/G and recombinant of 02&#95;AG/A1. Drug-resistant mutations (DRMs) were identified in 4/12 (33%). Three out of the four mutations were identified as non-nucleoside reverse transcriptase inhibitors DRM (K103N), whereas the fourth had nucleoside reverse transcriptase inhibitors DRM (M184V). Results from this preliminary study show that drug resistance among ART-naive children is a problem in Ibadan. Pretreatment drug resistance testing is desirable in children before initiation of ART to guide effective treatment.

Background & Objectives: Alterations in plasma apolipoproteins in individuals with malaria infection and their potential roles in the pathogenesis are known but the link between the malaria parasite density and apolipoprotein A1 (apo-A1) level is insufficiently understood. This study was conducted to determine whether the plasma apo-A1 level is influenced by the degree of parasitaemia in malaria infections., Methods: In a case-control study, a convenient sample of children aged 2-10 years with uncomplicated malaria cases (UMC), asymptomatic parasitaemia cases (APC) and healthy children without parasitaemia (HCP) was recruited. The cases consisted of 61 UMC and 21 APC, while the controls consisted of 24 HCP. Levels of apo-A1 was determined using immunoturbidimetric assay and compared among the different degrees of parasite density., Results: Of the 82 participants with parasitaemia, density was ≤1000/μL in 12, 1001-10000/μL in 21 and >10000/μL in 49 children. There was significant difference among the mean values of apolipoprotein A1 of the three groups, viz: UMC [91.4 (95% CI: 81.3, 101.5) mg/dL], APC [67.0 (95% CI: 48.9, 84.9) mg/dL] and HCP [99.0 (95% CI: 76.6, 121.3) mg/dL], p=0.029. Post-hoc analysis revealed that the mean plasma level of apo-A1 in HCP was significantly higher than APC by 32.0±12.4 mg/dL and UMC by 7.5±4.2 mg/dL. However, there were no differences in the mean apolipoprotein A1 levels among the three groups of parasite density., Interpretation & Conclusion: The presence of parasitaemia causes a remarkable reduction in apolipoprotein A1 level that was not influenced by the degree of parasitaemia., Competing Interests: None

Objectives: This study aimed to assess communities' perception and adoption of the evidenced-based malaria diagnosis and case management intervention targeted at under-five children. The effectiveness of trained Volunteer Community Health Workers (VCHWs) to diagnose malaria among under-five children using rapid diagnostic testing kit, provide treatment using Artemisinin Combination Therapy and rectal Artesunate were assessed., Design: A qualitative evaluation study was conducted in October 2015., Setting: Communities in the 6 rural wards in Ona-Ara Local Government Area, Oyo State Nigeria., Participants: Caregivers of under-five children, community-based frontline health workers, and community leaders selected using purposively sampling., Methods: Nine Focus Group Discussions and 15 Key Informant Interviews were conducted using a pre-tested guide. Data were subjected to thematic analysis., Results: It was disclosed that VCHWs promoted people's access to prompt and appropriate malaria treatment. The communities accepted the VCHWs; the reasons given for this included the following: effectiveness of VCHWs in case management of malaria; good inter-personal relationship with caregivers; and the positive health outcomes associated with services provided by them. In addition, community members expressed satisfaction with the VCHWs and provided them with all the support needed to function throughout the malaria case management intervention. The VCHWs considered the support as a great source of encouragement., Conclusions: The use of VCHWs to treat malaria was adjudged to be effective and considered acceptable to the communities. The adoption of the intervention and its integration into the primary health system by the government is advocated for in medically underserved rural communities., Funding: This work was supported by UNICEF/UNDP/World Bank/WHO Special Programme for Research & Training in Tropical Diseases, World Health Organization, Geneva, Switzerland (project ID: A80550 [Nigeria] through funds made available by the European Commission (FP7) for research to improve community access to health interventions in Africa., Competing Interests: Conflict of interest: None declared, (Copyright © The Author(s).)

The COVID-19 pandemic has spread to many malaria endemic countries in sub Saharan Africa. There is little or no experience on how the impact of policies put in place to curtail further spread of the pandemic will affect the epidemiology of malaria during the malaria season. The objective of this write-up is to put in perspective, the need to ensure effective malaria control in the midst of the COVID-19 crises. Proper integration of the COVID-19 safety and treatment guidelines with malaria control policies and effective diagnosis in malaria endemic countries in sub Saharan Africa are important in mitigating morbidity and mortality rates which may rise if malaria cases are neglected due to the current burden of the COVID-19 pandemic., (© Association of Resident Doctors, UCH, Ibadan.)

Background: Malaria in pregnancy has significant adverse consequences for the mother, foetus and baby. Presumptive diagnosis continues despite recommendation for parasite-based diagnosis. We performed Paracheck-Pf TM , an HRP-II based malaria Rapid diagnostic test (Paracheck-Pf RDT) and microscopy among pregnant women in a prospective, cross sectional study, at the University College Hospital in Ibadan, Nigeria., Methods: The study was conducted between 2009-2011. Consecutive pregnant women presumptively diagnosed as having malaria >18 years were enrolled after obtaining written informed consent. Demographic information, symptoms and clinical measurements were obtained. Capillary blood was obtained by finger prick for thick blood smear and RDT evaluation. Summary statistics included mean (standard deviation) for quantitative variables and percentages for categorical variables. Chi-square, analysis of variance (ANOVA), the odds ratio (OR) and 95% confidence intervals (CI) were computed with p-value less than 0.05 considered statistically significant., Results: Of the 746 pregnant women aged 30.9 ± 4.6 years enrolled, 243 (32.7%) were primigravida. The mean gestational age was 23.3 ± 9.2 weeks with about 81% in the second and third trimester. The prevalence of malaria parasitaemia by microscopy and Paracheck-Pf TM were 22.8% and 24.5% respectively. The geometric mean parasite density was 2,091/µL (range 40-156,975/µL). HIV positivity rate was 8.1 % and 16.1% of patients were anaemic (PCV <30%). Women with axillary temperature >37.4°C were significantly more likely to have malaria parasitaemia [p<0.0001] by microscopy. Sensitivity and specificity of Paracheck overall were 69.9% and 88.2% respectively while those at of parasite densities ≥200/µL were 84.8% and 88.7% respectively. Positive and negative predictive values were 66.9% and over 90% respectively., Conclusion: RDTs are a reasonable alternative in view of the need for parasite-based diagnosis of malaria., (© Association of Resident Doctors, UCH, Ibadan.)

Introduction: Histidine Rich Protein 2 based (HRP2-based) malaria rapid diagnostic tests (mRDTs) have been shown to perform as well as routine light microscopy, however, they are limited by some factors including persistence of HRP2 antigenemia. In this paper we report the evaluation of an HRP2-based mRDT in a prospective study that enrolled children and followed them up for 28 days., Methods: Children aged below five years, with acute episode of fever/pyrexia, were enrolled. The enrolled participants had expert malaria microscopy and RDT done at enrolment (Day 0), and on days 1, 2, 3, 7, 14, 21, and 28. The malaria RDT test was considered positive when the antigen and control lines were visible in their respective windows, negative when only the control band was visible and invalid when the control band was not visible. Faint test lines were considered positive. The RDT results were compared to those of expert microscopy., Results: Two hundred and twenty-six children aged 29.2 ± 15.5 months were enrolled. The proportion of children positive by expert malaria microscopy and RDT was 100% and 95.6% respectively. During the 28 day follow up of the children the proportions positive by microscopy and RDT on days 3, 7, 14, and 28 were 1% and 94.6%, 0% and 93.5%, 0% and 91%, and 16.5% and 80.6% respectively. Gender and age dependent analysis of proportion of positive children were similar. Proportion of children with persistence of HRP2 antigen appeared to be lower in those with parasite density below 200/µL, however, this observation requires further evaluation in larger studies., Conclusion: the study revealed a high proportion of persistence of HRP2 antigen in the children 28 days after effective antimalarial therapy. Histidine rich protein 2 based malaria rapid diagnostic tests are not recommended for monitoring of antimalarial therapies., (© Association of Resident Doctors, UCH, Ibadan.)

Background: Malaria rapid diagnostic tests (mRDTs) are the preferred option for programmatic deployment., Aims: There are numerous mRDTs on the Nigerian market and there is a need to guide practitioners on the relative performance of the commonly used brands of mRDT in Nigeria., Subjects and Methods: The performance of three commonly used Histidine-Rich-Protein-2-based mRDTs (SD-Bioline™, Carestart™ and Paracheck-Pf™) against microscopy of Giemsa stained blood and polymerase chain reaction (PCR) was evaluated among 190 febrile under-5 children in Ibadan, Nigeria. We calculated the sensitivity, specificity, predictive values, accuracy, and agreements., Results: There were 53.2% males. The prevalence of malaria parasite by microscopy was 46.8% and 57.9% by PCR. Malaria parasite detection by SD-Bioline™ was 60.5%, Carestart™: 60.0% and Paracheck-Pf™ 60.0%. Using microscopy as the gold standard, the sensitivities of SD-Bioline™, Carestart™ and Paracheck-Pf™ mRDT were 97.8%, 96.7% and 97.8% respectively while the specificities were 73.0%, 72.0% and 74.0% respectively. Using PCR as the gold standard, the sensitivity for both SD-Bioline™ and Paracheck-Pf™ was 85.5% and for CareStart was 84.6% while the specificity of SD-Bioline™, Carestart™, and Paracheck-Pf™ was 73.8%, 72.4%, and 75.0% respectively. The test accuracy was 81.0% for both SD-Bioline™ and Paracheck-Pf™ and 80.0% for Caresatrt™. The kappa coefficient of agreement between PCR and each of SD-Bioline™, Carestart, ParaCheck™ and microscopy was 0.597, 0.578, 0.609 and 0.739 respectively., Conclusion: The performance of the three mRDTs is a proof that any of the three is suitable for use in the diagnosis of malaria in the southwest of Nigeria., Competing Interests: None

Background or Objectives: Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) is widespread in sub-Saharan Africa with similarity in geographical distribution of major pathogens of public health interest. The aim of this study was to assess the effect of malaria and helminths on CD4 count, hematocrit values and viral load among HIV-infected pregnant women., Methods: One hundred and ninety-seven HIV-infected pregnant women aged 18-45 years were recruited from a registered HIV clinic and questionnaires were administered for socio-demographic details. Screening for malaria parasites in blood was through microscopy while helminths were identified in stool using Kato-Katz method. Hematocrit levels were determined through centrifugation of blood collected in capillary tubes. At the time of recruitment, most recent CD4 count and viral load was obtained from the patients' case notes., Results: About three-quarters (73.6%) of the women had above primary school level of education while more than half (60.2%) were petty traders. The prevalence of malaria parasites in the blood samples was 24.9%, while 3% were infected with helminths. There was only a single case of malaria, helminths and HIV co-infection in the study group. Prevalence of anemia was 75.6% with eight cases (4.1%) of severe anemia. About 86.6% of the women with anemia had low CD4 count (χ 2 = 8.801, p=0.032). The mean CD4 count was significantly lower among those with co-infection of malaria and HIV., Conclusion and Global Health Implications: Malaria or helminth infection among HIV-infected women lowers the CD4 count and increases the viral load with little changes in hematocrit values. Routine screening of HIV-infected women for probable multiple infections will aid in improving their overall health and well-being., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to disclose., (Copyright © 2021 Rabiu et al.)

Background: Iron deficiency is a dominant source of anaemia in many settings. To evaluate the key cause of anaemia in the study area, the prevalence of anaemia due to major public health diseases was compared with anaemia due to iron deficiency., Methods: Pregnant women were recruited from ante-natal (n=490) and HIV clinics (n=217) with their personal data documented using a questionnaire. Microscopy of Giemsa-stained thick smears was used for detection of malaria parasites while helminths in stools were detected using direct smear method. Haematocrit values were determined by capillary method. Serum ferritin levels were determined using enzyme-linked immunosorbent assay. Data was analysed using SPSS version 22.0., Results: The mean age of the recruited women was 28.6±5.4 years old. There were 68.1% cases of anaemia of which 35.5% was due to infections only predominantly HIV and malaria, 14.9% from unknown sources while anaemia due to iron deficiency only was 7.1%., Conclusion: It can safely be inferred that malaria and HIV predispose to anaemia than iron deficiency in the study area. Although pregnant women are dewormed and given IPTp for helminths and malaria treatment respectively, there should be complementary routine malaria screening at ANC visits for those with HCT values <33% and those infected with HIV., (© 2020 Rabiu OR et al.)

Background: In the context of task shifting, a promoted approach to healthcare delivery in resource-poor settings, trained community health workers (CHWs) have been shown to be effective in delivering quality care of malaria for febrile under-5 children. While their effectiveness has been documented, the fidelity of implementation (FOI) has not been adequately studied. By understanding and measuring whether an intervention has been performed with fidelity, researchers and practitioners gain a better understanding of how and why an intervention works, and the extent to which outcomes can be improved. The objective of this study was to assess the FOI of a recommended protocol for malaria care by CHWs in a resource-poor setting in Nigeria., Methods: Thirty-five female CHWs who participated in a 3-day training on home management of malaria among under-5 children were studied. They managed 1,646 children over the implementation period and then underwent evaluation via a one-time hospital-based observation by the trainers. During the evaluation, a pre-tested standard checklist was used to compute performance scores for CHWs; doctors and nurses were selected to serve as the gold standard for comparison. Performance scores (PS) recorded during the evaluation were used to assess adherence and compliance with the recommended treatment protocol., Results: Of the 4 skill domains assessed, adherence was greatest for compliance with malaria treatment recommendations (94%) and lowest for post-treatment initiation counseling of home-based caregivers (69%). The average overall adherence of 83% was comparable to adherence by gold standard comparators. Mean PS was not found to be significantly associated with CHW demographics. Scores for clinical evaluation among those whose occupation was not healthcare-related were significantly lowered by 0.52 [95% CI (1.05-0.01), p = 0.05]. Compliance with the treatment protocol increased by 23% for every unit increase in total PS (p = 0.07) and doubled for every unit increase in scores for post-treatment initiation counseling of caregivers (p = 0.002)., Conclusions: Studying intervention fidelity stands to identify the shortcomings of implementation and specific areas to target for improvement in future adoption or implementation. This study concludes that future trainings should emphasize clinical evaluation and post-treatment counseling of caregivers by CHWs to ensure the best outcome for children.

Malaria remains a significant disease, causing epic health problems and challenges all over the world, especially in sub-Saharan Africa. CD209 and CD28 genes act as co-stimulators and regulators of the immune system, while the STAT6 gene has been reported to mediate cytokine-induced responses. Single nucleotide polymorphisms of these genes might lead to differential disease susceptibility among populations at risk for malaria, due to alterations in the immune response. We aim to identify key drivers of the immune response to malaria infection among the three SNPs: CD209 (rs4804803), CD28 (rs35593994) and STAT6 (rs3024974). After approval and informed consent, we genotyped blood samples from a total of 531 children recruited from Nigeria using the Taqman SNP genotyping assay and performed comparative analysis of clinical covariates among malaria-infected children. Our results reveal the CD209 (rs4804803) polymorphism as a susceptibility factor for malaria infection, significantly increasing the risk of disease among children, but not CD28 (rs35593994) or STAT6 (rs3024974) polymorphisms. Specifically, individuals with the homozygous mutant allele (rs4804803G/G) for the CD209 gene have a significantly greater susceptibility to malaria, and presented with higher mean parasitemia. This observation may be due to a defective antigen presentation and priming, leading to an ineffective downstream adaptive immune response needed to combat infection, as well as the resultant higher parasitemia and disease manifestation. We conclude that the CD209 gene is a critical driver of the immune response during malaria infection, and can serve as a predictor of disease susceptibility or a biomarker for disease diagnosis., Competing Interests: The authors declare we have no conflicts of interest.

Objectives: To investigate the consequence of restricting antimalarial treatment to febrile children that test positive to a malaria rapid diagnostic test (MRDT) only in an area of intense malaria transmission., Methods: Febrile children aged 3-59 months were screened with an MRDT at health facilities in south-west Nigeria. MRDT-positive children received artesunate-amodiaquine (ASAQ), while MRDT-negative children were treated based on the clinical diagnosis of non-malaria febrile illness. The primary endpoint was the risk of developing microscopy-positive malaria within 28 days post-treatment., Results: 309 (60.5%) of 511 children were MRDT-positive while 202 (39.5%) were MRDT-negative at enrolment. 18.5% (50/275) of MRDT-positive children and 7.6% (14/184) of MRDT-negative children developed microscopy-positive malaria by day 28 post-treatment (ρ = 0.001). The risk of developing clinical malaria by day 28 post-treatment was higher among the MRDT-positive group than the MRDT-negative group (adjusted OR 2.74; 95% CI, 1.4, 5.4). A higher proportion of children who were MRDT-positive at enrolment were anaemic on day 28 compared with the MRDT-negative group (12.6% vs. 3.1%; ρ = 0.001). Children in the MRDT-negative group made more unscheduled visits because of febrile illness than those in MRDT-positive group (23.2% vs. 12.0%; ρ = 0.001)., Conclusion: Restricting ACT treatment to MRDT-positive febrile children only did not result in significant adverse outcomes. However, the risk of re-infection within 28 days was significantly higher among MRDT-positive children despite ASAQ treatment. A longer-acting ACT may be needed as the first-line drug of choice for treating uncomplicated malaria in high-transmission settings to prevent frequent re-infections., (© 2019 John Wiley & Sons Ltd.)

Prompt diagnosis and appropriate treatment of malaria remain the hallmark for reducing malaria-related mortality in high transmission areas. Plasmodium falciparum histidine-rich protein2 (PfHRP2) based rapid diagnostic tests (RDT) play a vital role in prompt and accurate malaria diagnosis. However, pfhrp2 gene deletion threatens the RDT test sensitivity. This study reports the presence of pfhrp2 and pfhrp3 genes deletion among parasite isolates in Nigeria. Febrile children were screened using histidine-rich protein (HRP2) specific RDT (SD-Bioline RDT) and microscopy for P. falciparum infections. All RDT negative samples were re-evaluated by polymerase chain reaction (PCR). The presence of parasite in RDT false negative cases and randomly selected RDT positive cases were validated using PCRs targeting glutamate-rich protein (glurp) and merozoite surface proteins (msp-1 and msp-2). Thereafter, exon 2 of pfhrp2 and pfhrp3 were amplified, and Sanger sequenced. A total of 511 febrile children were enrolled out of which 309 (61%) were positive by RDT. The presence of pfhrp2 and pfhrp3 genes were analyzed in 66 PCR positive samples comprising of 31 RDT false negative and 35 RDT true positive randomly selected samples. The pfhrp2 and pfhrp3 genes failed to amplify in 17% (11/66) and 6% (4/66) samples, respectively. Seven of the eleven samples had only pfhrp2 deletion while four had both pfhrp2 and pfhrp3 deletions. The absence of the pfhrp2 gene may be responsible for the seven RDT false negative cases observed. Three RDT positive cases lacked pfhrp2 whereas pfhrp3 was absent in only four RDT false negative cases. The pfhrp2 and pfhrp3 amino acid repeat sequences were highly diverse. The P. falciparum isolates lacking pfhrp2 and pfhrp3 genes may be circulating and contributing to RDT false negativity in Nigeria. More studies in larger population and seasonally defined cases will be needed to determine the extent of pfhrp2/3 genes deletion in different geographical areas of Nigeria., (Copyright © 2019 Elsevier B.V. All rights reserved.)

This study assesses the prevalence of asymptomatic Plasmodium falciparum parasitemia positivity and P. falciparum dihydrofolate reductase (pfdhfr) mutations in parasite isolates among pregnant women in Southwest Nigeria. Plasmodium falciparum parasitemia was confirmed by microscopy and nested PCR in 200 pregnant women attending antenatal care. The prevalence of pfdhfr polymorphisms was determined by direct sequencing of the gene fragments containing the C50R, N51I, C59R, S108N, and I164L mutations. Information on the use of antimalarial drugs and methods applied to prevent malaria were obtained by a questionnaire. The prevalence of asymptomatic P. falciparum infection was 30% (60/200). The frequency of the pfdhfr triple-mutant alleles (N51I, C59R, and S108N) was 63% (38/60); none of the isolates carried the I164L mutation. Among the investigated pregnant women, 40% used un-prescribed antimalarials such as dihydroartemisinin (18%), chloroquine (14%) or pyrimethamine (9%), while only 20.5% used sulfadoxine-pyrimethamine for prevention and 39.5% did not use any drug. The prevalence of P. falciparum parasitemia (37%) was higher among pregnant women who had not taken any antimalarial drugs. A significant difference in the prevalence of the pfdhfr triple-mutant alleles was observed among women who took SP (90%) compared to those who did not take any drug (82%) and women who took dihydroartemisinin (67%) p = 0.007). Poor adherence to the World Health Organisation (WHO) strategies for malaria prevention among pregnant women was observed in addition to high prevalence of pfdhfr mutations. These findings underline the need to improve control of malaria among pregnant women in the study area.

Susceptibility to malaria infection has been associated with host genetic polymorphisms that differs between groups. We hypothesize that Toll-interacting proteins (TOLLIP), vitamin D receptor (VDR) and tumor necrosis factor-α (TNF) genes are significant contributors to susceptibility and disease severity in Plasmodium falciparum (Pf) infection. Our aim is to explore the genomic diversity and haplotype frequency of these genes, as well as extrapolate possible association with markers of severity, between malaria-infected and healthy controls. Genomic DNA samples extracted from the blood of 107 malaria-infected patients and 190 uninfected controls were analyzed, with no difference in genotypic or allelic frequencies of TOLLIP and VDR polymorphisms. However, a significant difference in the genotypic (p = 2.20E-16) and allelic frequencies (p = 2.20E-16) of the TNF-α (snp rs1800629) polymorphism was found. The preponderance of the mutant variant among the malaria-infected show a possible impaired capacity to mount an effective immune response, potentially confirmed by our association results. This result calls for analysis of clearly delineated uncomplicated versus severe disease groups, including serum assays, providing a basis to conclude that susceptibility to malaria infection and potential contribution to disease severity is significantly associated with polymorphisms of the tumor necrosis factor-α but not TOLLIP or VDR genes.

Background: Nigeria carries a high burden of malaria which makes continuous surveillance for current information on genetic diversity imperative. In this study, the merozoite surface proteins (msp-1, msp-2) and glutamate-rich protein (glurp) of Plasmodium falciparum collected from two communities representing rural and urban settings in Ibadan, southwestern Nigeria were analysed., Methods: A total of 511 febrile children, aged 3-59 months, whose parents/guardians provided informed consent, were recruited into the study. Capillary blood was obtained for malaria rapid diagnostic test, thick blood smears for parasite count and blood spots on filter paper for molecular analysis., Results: Three-hundred and nine samples were successfully genotyped for msp-1, msp-2 and glurp genes. The allelic distribution of the three genes was not significantly different in the rural and urban communities. R033 and 3D7 were the most prevalent alleles in both rural and urban communities for msp-1 and msp-2, respectively. Eleven of glurp RII region genotypes, coded I-XII, with sizes ranging from 500 to 1100 base pairs were detected in the rural setting. Genotype XI (1000-1050 bp) had the highest prevalence of 41.5 and 38.5% in rural and urban settings, respectively. Overall, 82.1 and 70.0% of samples had multiclonal infection with msp-1 gene resulting in a mean multiplicity of infection (MOI) of 2.8 and 2.6 for rural and urban samples, respectively. Msp-1 and msp-2 genes displayed higher levels of diversity and higher MOI rates than the glurp gene., Conclusion: Significant genetic diversity was observed between rural and urban parasite populations in Ibadan, southwestern Nigeria. The results of this study show that malaria transmission intensity in these regions is still high. No significant difference was observed between rural and urban settings, except for a completely different msp-1 allele, compared to previous reports, thereby confirming the changing face of malaria transmission in these communities. This study provides important baseline information required for monitoring the impact of malaria elimination efforts in this region and data points useful in revising current protocols.

CD14 is a multifunctional receptor expressed on many cell types and has been shown to mediate immune response resulting in the activation of an inflammatory cascade, with polymorphism of its promoter (rs2569190) found to be associated with susceptibility to several diseases. In malaria infection, the CD14 gene demonstrated a pathogenic profile in regulating experimental cerebral malaria, with reports of elevated levels of soluble CD14 in serum of patients but no definitive conclusion. We present a detailed analysis of genetic diversity of CD14 promoter gene (snp -159 C/T; rs2519190) polymorphism between a malaria-infected group and uninfected controls and its association with clinical parameters of disease. Genomic DNA samples obtained from 106 Plasmodium falciparum malaria-infected patients and 277 uninfected controls were elucidated with a polymerase chain reaction-restriction fragment length polymorphism (RFLP) assay. Our results show a significant diversity ( P  = 3.32E-06) in the genotypic frequency (3.8% versus 22.4%) of the rs2569190 mutant variant between the malaria-infected group and controls, respectively. The mutant allele had the lowest frequency among the malaria-infected group demonstrating its necessity for infection. Mean parasitemia (parasites/μL of blood) was significantly regulated based on CD14 polymorphic profile (19 855 versus 37 041 versus 49 396 for homozygote mutants, heterozygotes, and homozygote wild type, respectively). Interestingly, we found no association between CD14 genetic variants with fever, age of patients, or anemia. How this affects disease severity between subregional and continental groups deserves further clarification, including extending these studies in a larger group and among severe and asymptomatic patients with malaria., Competing Interests: Declaration of conflicting interests:The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background:  Community health workers (CHWs) were trained in Burkina Faso, Nigeria, and Uganda to diagnose febrile children using malaria rapid diagnostic tests, and treat positive malaria cases with artemisinin-based combination therapy (ACT) and those who could not take oral medicines with rectal artesunate. We quantified the impact of this intervention on private household costs for childhood febrile illness., Methods:  Households with recent febrile illness in a young child in previous 2 weeks were selected randomly before and during the intervention and data obtained on household costs for the illness episode. Household costs included consultation fees, registration costs, user fees, diagnosis, bed, drugs, food, and transport costs. Private household costs per episode before and during the intervention were compared. The intervention's impact on household costs per episode was calculated and projected to districtwide impacts on household costs., Results:  Use of CHWs increased from 35% of illness episodes before the intervention to 50% during the intervention (P < .0001), and total household costs per episode decreased significantly in each country: from US Dollars (USD) $4.36 to USD $1.54 in Burkina Faso, from USD $3.90 to USD $2.04 in Nigeria, and from USD $4.46 to USD $1.42 in Uganda (all P < .0001). There was no difference in the time used by the child's caregiver to care for a sick child (59% before intervention vs 51% during intervention spent ≤2 days). Using the most recent population figures for each study district, we estimate that the intervention could save households a total of USD $29 965, USD $254 268, and USD $303 467, respectively, in the study districts in Burkina Faso, Nigeria, and Uganda., Conclusions:  Improving access to malaria diagnostics and treatments in malaria-endemic areas substantially reduces private household costs. The key challenge is to develop and strengthen community human resources to deliver the intervention, and ensure adequate supplies of commodities and supervision. We demonstrate feasibility and benefit to populations living in difficult circumstances., Clinical Trials Registration:  ISRCTN13858170., (© 2016 World Health Organization; licensee Oxford Journals.)

Background:  The World Health Organization recommends that malaria treatment be based on demonstration of the infecting Plasmodium parasite specie. Malaria rapid diagnostic tests (RDTs) are recommended at community points of care because they are accurate and rapid. We report on parasitological results in a malaria study in selected rural communities in 3 African countries., Methods:  In Nigeria, community health workers (CHWs) performed RDTs (SD-Bioline) and thick blood smears on all children suspected to have malaria. Malaria RDT-positive children able to swallow received artemisinin-based combination therapy (Coartem). In all countries, children unable to take oral drugs received prereferral rectal artesunate irrespective of RDT result and were referred to the nearest health facility. Thick blood smears and RDTs were usually taken at hospital admission. In Nigeria and Burkina Faso, RDT cassettes and blood smears were re-read by an experienced investigator at study end., Results:  Trained CHWs enrolled 2148 children in Nigeria. Complete parasitological data of 1860 (86.6%) enrollees were analyzed. The mean age of enrollees was 30.4 ± 15.7 months. The prevalence of malaria parasitemia in the study population was 77.8% (1447/1860), 77.6% (1439/1855), and 54.1% (862/1593) by RDT performed by CHWs vs an expert clinical research assistant vs microscopy (gold standard), respectively. Geometric mean parasite density was 6946/µL (range, 40-436 450/µL). There were 49 cases of RDT false-negative results with a parasite density range of 40-54 059/µL. False-negative RDT results with high parasitemia could be due to non-falciparum infection or result from a prozone effect. Sensitivity and specificity of SD-Bioline RDT results as read by CHWs were 94.3% and 41.6%, respectively, while the negative and positive predictive values were 86.1% and 65.6%, respectively. The level of agreement in RDT reading by the CHWs and experienced research staff was 86.04% and κ statistic of 0.60. The malaria parasite positivity rate by RDT and microscopy among children with danger signs in the 3 countries was 67.9% and 41.8%, respectively., Conclusions:  RDTs are useful in guiding malaria management and were successfully used for diagnosis by trained CHWs. However, false-negative RDT results were identified and can undermine confidence in results and control efforts., (© 2016 World Health Organization; licensee Oxford Journals.)

Background:  Malaria-endemic countries are encouraged to increase, expedite, and standardize care based on parasite diagnosis and treat confirmed malaria using oral artemisinin-based combination therapy (ACT) or rectal artesunate plus referral when patients are unable to take oral medication., Methods:  In 172 villages in 3 African countries, trained community health workers (CHWs) assessed and diagnosed children aged between 6 months and 6 years using rapid histidine-rich protein 2 (HRP2)-based diagnostic tests (RDTs). Patients coming for care who could take oral medication were treated with ACTs, and those who could not were treated with rectal artesunate and referred to hospital. The full combined intervention package lasted 12 months. Changes in access and speed of care and clinical course were determined through 1746 random household interviews before and 3199 during the intervention., Results:  A total of 15 932 children were assessed: 6394 in Burkina Faso, 2148 in Nigeria, and 7390 in Uganda. Most children assessed (97.3% [15 495/15 932]) were febrile and most febrile cases (82.1% [12 725/15 495]) tested were RDT positive. Almost half of afebrile episodes (47.6% [204/429]) were RDT positive. Children eligible for rectal artesunate contributed 1.1% of episodes. The odds of using CHWs as the first point of care doubled (odds ratio [OR], 2.15; 95% confidence interval [CI], 1.9-2.4; P < .0001). RDT use changed from 3.2% to 72.9% (OR, 80.8; 95% CI, 51.2-127.3; P < .0001). The mean duration of uncomplicated episodes reduced from 3.69 ± 2.06 days to 3.47 ± 1.61 days, Degrees of freedom (df) = 2960, Student's t (t) = 3.2 (P = .0014), and mean duration of severe episodes reduced from 4.24 ± 2.26 days to 3.7 ± 1.57 days, df = 749, t = 3.8, P = .0001. There was a reduction in children with danger signs from 24.7% before to 18.1% during the intervention (OR, 0.68; 95% CI, .59-.78; P < .0001)., Conclusions:  Provision of diagnosis and treatment via trained CHWs increases access to diagnosis and treatment, shortens clinical episode duration, and reduces the number of severe cases. This approach, recommended by the World Health Organization, improves malaria case management., Clinical Trials Registration:  ISRCTN13858170., (© 2016 World Health Organization; licensee Oxford Journals.)

Background:  Use of community health workers (CHWs) to increase access to diagnosis and treatment of malaria is recommended by the World Health Organization. The present article reports on training and performance of CHWs in applying these recommendations., Methods:  Two hundred seventy-nine CHWs were trained for 3-5 days in Burkina Faso, Nigeria, and Uganda, and 19 were certified to diagnose and treat only uncomplicated malaria and 235 to diagnose and treat both uncomplicated and severe malaria. Almost 1 year after training, 220 CHWs were assessed using standard checklists using facility staff responses as the reference standard., Results:  Training models were slightly different in the 3 countries, but the same topics were covered. The main challenges noticed were the low level of education in rural areas and the involvement of health staff in the supervision process. Overall performance was 98% (with 99% in taking history, 95% in measuring temperature, 85% for measuring respiratory rates, 98% for diagnosis, 98% for classification, and 99% for prescribing treatment). Young, single, new CHWs performed better than their older, married, more experienced counterparts., Conclusions:  Training CHWs for community-based diagnosis and treatment of uncomplicated and severe malaria is possible with basic and refresher training and close supervision of CHWs' performance., Clinical Trials Registration:  ISRCTRS13858170., (© 2016 World Health Organization; licensee Oxford Journals.)

Background:  The World Health Organization recommends that all malaria management be based on parasitological identification. We monitored performance of trained community health workers (CHWs) in adhering to this recommendation to restrict artemisinin-based combination therapies (ACTs) to positive rapid diagnostic test (RDT)-confirmed cases in children in 3 malaria-endemic sub-Saharan African countries., Methods:  In 33 villages in Burkina Faso, 45 villages in Nigeria, and 84 villages in Uganda, 265 CHWs were trained over a minimum of 3 days to diagnose malaria using RDTs (prepare, read, record results, and inform the patient about results) and treat RDT-confirmed uncomplicated malaria cases with ACTs. In Nigeria, CHWs were also taught to obtain a thick blood smear. Spent RDT kits and prepared blood slides were collected and interpreted independently in Burkina Faso and Nigeria to confirm CHWs' diagnoses. Interviews were held with 12 of 17 CHWs who prescribed ACTs for patients with RDT-negative test results, and with 16 of 29 caregivers to determine factors related to noncompliance., Results:  Of 12 656 patients treated with ACTs in the participating countries (5365 in Burkina Faso, 1648 in Nigeria, and 5643 in Uganda), 29 patients (8 from Burkina Faso, 17 from Nigeria, 4 from Uganda) were RDT negative. The small number of RDT-negative ACT-treated cases limits statistical analysis. Only a few CHWs were involved, and they were more likely to be traders rather than farmers (odds ratio [OR], 6.15; 95% confidence interval [CI], 2.09-18.07; P = .0004). RDT-negative children who were treated with ACTs had a significantly higher probability of residing in a village other than that of the CHW (OR, 3.85; 95% CI, 1.59-9.30; P = .0018). Parental pressure was identified in interviews with parents., Conclusions:  Noncompliance with results of RDT tests is relatively rare when CHWs are trained and well supervised., Clinical Trials Registration:  ISRCTN13858170., (© 2016 World Health Organization; licensee Oxford Journals.)

Background:  The efficacy of artemisinin-based combination therapy (ACT) and rectal artesunate for severe malaria in children is proven. However, acceptability of a package of interventions that included use of malaria rapid diagnostic tests (RDTs), ACTs, and rectal artesunate when provided by community health workers (CHWs) is uncertain. This study assessed acceptability of use of CHWs for case management of malaria using RDTs, ACTs, and rectal artesunate., Methods:  The study was carried out in Burkina Faso, Nigeria, and Uganda in 2015 toward the end of an intervention using CHWs to provide diagnosis and treatment. Focus group discussions (FGDs) and key informant interviews (KIIs) were conducted with parents of sick children, community leaders, and health workers to understand whether they accepted the package for case management of malaria using CHWs. Transcripts from FGDs and KII recordings were analyzed using content analysis. The findings were described, interpreted, and reported in the form of narratives., Results:  Treatment of malaria using the CHWs was acceptable to caregivers and communities. The CHWs were perceived to be accessible, diligent, and effective. There were no physical, social, or cultural barriers to accessing the CHWs' services. Respondents were extremely positive about the intervention and were concerned that CHWs had limited financial and nonfinancial incentives that would reduce their motivation and willingness to continue., Conclusions:  Treatment of malaria using CHWs was fully accepted. CHWs should be compensated, trained, and well supervised., Clinical Trials Registration:  ISRCTN13858170., (© 2016 World Health Organization; licensee Oxford Journals.)

Background:  Children aged <5 years were enrolled in a large study in 3 countries of sub-Saharan Africa because they had danger signs preventing them from being able to take oral medications. We examined compliance and factors associated with compliance with referral advice for those who were treated with rectal artesunate., Methods:  Patient demographic data, speed of accessing treatment after danger signs were recognized, clinical symptoms, malaria microscopy, treatment-seeking behavior, and compliance with referral advice were obtained from case record forms of 179 children treated with prereferral rectal artesunate in a multicountry study. We held focus group discussions and key informant interviews with parents, community health workers (CHWs), and facility staff to understand the factors that deterred or facilitated compliance with referral advice., Results:  There was a very high level of compliance (90%) among patients treated with prereferral rectal artesunate. Age, symptoms at baseline (prostration, impaired consciousness, convulsions, coma), and malaria status were not related to referral compliance in the analysis., Conclusions:  Teaching CHWs to diagnose and treat young children with prereferral rectal artesunate is feasible in remote communities of Africa, and high compliance with referral advice can be achieved., (© 2016 World Health Organization; licensee Oxford Journals.)

Background:  Community health workers (CHWs) are an important element of care provision for a wide range of conditions, but their turnover rate is high. Many studies have been conducted on health workers' motivation, focusing on formal sector staff but not CHWs. Although CHWs are easy to recruit, motivating and retaining them for service delivery is difficult. This article investigates factors influencing CHW motivation and retention in health service delivery., Methods:  Quantitative and qualitative data were collected to identify the key factors favoring motivation and retention of CHWs as well as those deterring them. We interviewed 47, 25, and 134 CHWs in Burkina Faso, Nigeria, and Uganda, respectively, using a structured questionnaire. Focus group discussions (FGDs) were also conducted with CHWs, community participants, and facility health workers., Results:  Except for Burkina Faso, most CHWs were female. Average age was between 38 and 41 years, and most came from agricultural communities. The majority (52%-80%) judged they had a high to very high level of satisfaction, but most CHWs (approximately 75%) in Burkina Faso and Uganda indicated that they would be prepared to leave the job, citing income as a major reason. Community recognition and opportunities for training and supervision were major incentives in all countries, but the volume of unremunerated work, at a time when both malaria-positive cases and farming needs were at their peak, was challenging., Conclusions:  Most CHWs understood the volunteer nature of their position but desired community recognition and modest financial remuneration., Clinical Trials Registration:  ISRCTN13858170., (© 2016 World Health Organization; licensee Oxford Journals.)