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Background In Africa, the first Plasmodium falciparum artemisinin partial resistance mutation was Kelch13 (K13) 561H, detected and validated at appreciable frequency in Rwanda in 2014. Surveillance to better define the extent of the emergence in Rwanda and neighboring countries is critical. Methods We used novel liquid blood drop preservation with pooled sequencing to provide cost-effective rapid assessment of resistance mutation frequencies at multiple collection sites across Rwanda and neighboring regions in Uganda, Tanzania, and the Democratic Republic of the Congo. Malaria-positive samples (N = 5465) from 39 health facilities collected between May 2022 and March 2023 were sequenced in 199 pools. Results In Rwanda, K13 561H and 675V were detected in 90% and 65% of sites, with an average frequency of 19.0% (range, 0%–54.5%) and 5.0% (0%–35.5%), respectively. In Tanzania, 561H had high frequency in multiple sites. 561H appeared at 1.6% in Uganda. 561H was absent from the Democratic Republic of the Congo, although 675V was seen at low frequency. Concerningly, candidate mutations were observed: 441L, 449A, and 469F co-occurred with validated mutations, suggesting that they are arising under the same pressures. Other markers for decreased susceptibility to artemether-lumefantrine are common: P falciparum multidrug resistance protein 1 N86 at 98.0% (range, 63.3%–100%) and 184F at 47.0% (0%–94.3%) and P falciparum chloroquine resistance transporter 76T at 14.7% (0%–58.6%). Additionally, sulfadoxine-pyrimethamine–associated mutations show high frequencies. Conclusions K13 mutations are rapidly expanding in the region, further endangering control efforts with the potential of engendering partner drug resistance. [ABSTRACT FROM AUTHOR]

Background In integrated community case management (iCCM) care, community health workers (CHWs) provide home-based management of fever, diarrhea and fast breathing for children aged <5 y. The iCCM protocol recommends that children with danger signs for severe illness are referred by CHWs to health facilities within their catchment area. This study examines the management of danger signs by CHWs implementing iCCM in a rural context. Methods A retrospective observational study that examined clinical records for all patients with danger signs evaluated by CHWs from March 2014 to December 2018 was conducted. Results In total, 229 children aged <5 y had been recorded as having a danger sign during 2014–2018. Of these children, 56% were males with a mean age of 25 (SD 16.9) mo, among whom 78% were referred by the CHWs as per the iCCM protocol. The age category of 12 to 35 mo had the highest numbers of prereferred and referred cases (54% and 46%, respectively). Conclusions CHWs play a key role in early symptomatic detection, prereferral treatment and early referral of children aged <5 y. Danger signs among children aged <5 y, if left untreated, can result in death. A high proportion of the children with danger signs were referred as per the iCCM protocol. Continuous CHW training is emphasized to reduce the number of referral cases that are missed. More studies need to focus on children aged 12–35 mo and why they are the most referred category. Policymakers should occasionally revise iCCM guidelines to detail the types of danger signs and how CHWs can address these. [ABSTRACT FROM AUTHOR]

Background Malaria epidemics result from extreme precipitation and flooding, which are increasing with global climate change. Local adaptation and mitigation strategies will be essential to prevent excess morbidity and mortality. Methods We investigated the spatial risk of malaria infection at multiple timepoints after severe flooding in rural western Uganda employing longitudinal household surveys measuring parasite prevalence and leveraging remotely sensed information to inform spatial models of malaria risk in the 3 months after flooding. Results We identified clusters of malaria risk emerging in areas (1) that showed the greatest changes in Normalized Difference Vegetation Index from pre- to postflood and (2) where residents were displaced for longer periods of time and had lower access to long-lasting insecticidal nets, both of which were associated with a positive malaria rapid diagnostic test result. The disproportionate risk persisted despite a concurrent chemoprevention program that achieved high coverage. Conclusions The findings enhance our understanding not only of the spatial evolution of malaria risk after flooding, but also in the context of an effective intervention. The results provide a "proof of concept" for programs aiming to prevent malaria outbreaks after flooding using a combination of interventions. Further study of mitigation strategies—and particularly studies of implementation—is urgently needed. [ABSTRACT FROM AUTHOR]

Background Malaria epidemics are a well-described phenomenon after extreme precipitation and flooding. Yet, few studies have examined mitigation measures to prevent post-flood malaria epidemics. Methods We evaluated a malaria chemoprevention program implemented in response to severe flooding in western Uganda. Children aged ≤12 years from 1 village were eligible to receive 3 monthly rounds of dihydroartemisinin-piperaquine (DP). Two neighboring villages served as controls. Malaria cases were defined as individuals with a positive rapid diagnostic test result as recorded in health center registers. We performed a difference-in-differences analysis to estimate changes in the incidence and test positivity of malaria between intervention and control villages. Results A total of 554 children received at least 1 round of chemoprevention, with 75% participating in at least 2 rounds. Compared with control villages, we estimated a 53.4% reduction (adjusted rate ratio [aRR], 0.47; 95% confidence interval [CI]:.34–.62; P  < .01) in malaria incidence and a 30% decrease in the test positivity rate (aRR, 0.70; 95% CI:.50–.97; P  = .03) in the intervention village in the 6 months post-intervention. The impact was greatest among children who received the intervention, but decreased incidence was also observed in older children and adults (aRR, 0.57; 95% CI:.38–.84; P  < .01). Conclusions Three rounds of chemoprevention with DP delivered under pragmatic conditions reduced the incidence of malaria after severe flooding in western Uganda. These findings provide a proof-of-concept for the use of malaria chemoprevention to reduce excess disease burden associated with severe flooding. [ABSTRACT FROM AUTHOR]

Background In Integrated Community Case Management (iCCM), village health workers (VHW) assess and treat malaria, pneumonia and diarrhea using a clinical algorithm. Study objectives included: 1) Compare VHWs' performance on case scenario exercises to record review data; 2) assess impact of formal education on performance in the case scenario exercises. Methods 36 VHWs in Bugoye Subcounty, Uganda completed the case scenarios exercise, which included video case scenarios and brief oral case vignettes, between July 2017 and February 2018. We obtained clinical records for all iCCM encounters in the same time period. Results In the video case scenarios, 45% of mock patients received all correct management steps (including all recommended education), while 94% received all critical management steps. Based on the level of data available from record review, 74% of patients in the record review dataset received overall correct management compared to 94% in the video case scenarios. In the case scenarios, VHWs with primary school education performed similarly to those with some or all secondary school education. Conclusions The case scenarios produced higher estimates of quality of care than record review. VHWs often omitted recommended health education topics in the case scenarios. Level of formal education did not appear to influence performance in the case scenarios. [ABSTRACT FROM AUTHOR]