MALARIA 1
http://www.wartamedika.com/2006/09/pencegahan-malaria.html
20 September 2006
Pencegahan Malaria
Pencegahan tanpa obat, yaitu dengan menghindari gigitan nyamuk dengan cara :
1.Menggunakan kelambu (bed net) pada waktu tidur, lebih baik lagi dengan kelambu berinsektisida.
2.Mengolesi badan dengan obat anti gigitan nyamuk (repellent).
3.Menggunakan pembasmi nyamuk, baik bakar, semprot maupun lainnya.
4.Memasang kawat kasa pada jendela dan ventilasi.
5.Letak tempat tinggal diusahakan jauh dari kandang ternak.
6.Mencegah penderita malaria dan gigitan nyamuk agar infeksi tidak menyebar.
7.Membersihkan tempat hinggap/istirahat nyamuk dan memberantas sarang nyamuk.
8.Hindari keadaan rumah yang lembab, gelap, kotor dan pakaian yang bergantungan serta genangan air.
9.Membunuh jentik nyamuk dengan menyemprotkan obat anti larva (bubuk abate) pada genangan air atau menebarkan ikan atau hewan (cyclops) pemakan jentik.
10.Melestarikan hutan bakau agar nyamuk tidak berkembang biak di rawa payau sepanjang pantai.
Pencegahan dengan obat. Obat yang biasa digunakan adalah klorokuin difosfat, karena obat ini efektif terhadap semua jenis parasit malaria. Aturan pemakaiannya adalah :
Pendatang sementara ke daerah endemis, dosis klorokuin adalah 300 mg/minggu, 1 minggu sebelum berangkat selama berada di lokasi sampai 4 minggu setelah kembali.
Penduduk daerah endemis dan penduduk baru yang akan menetap tinggal, dosis klorokuin 300 mg/minggu. Obat hanya diminum selama 12 minggu (3 bulan).
Semua penderita demam di daerah endemis diberikan klorokuin dosis tunggal 600 mg jika daerah itu plasmodium falciparum sudah resisten terhadap klorokuin ditambahkan primakuin sebanyak tiga tablet.
http://www.malariajournal.com/content/7/1/132
Presumptive treatment of fever cases as malaria: help or hindrance for malaria control?
Roly D Gosling , Christopher J Drakeley , Alex Mwita and Daniel Chandramohan
Malaria Journal 2008, 7:132doi:10.1186/1475-2875-7-132
Published:
16 July 2008
Abstract (provisional)
Background
Malaria incidence has been reported to be falling in several countries in sub-Saharan Africa in recent years. This fall appears to have started before the widespread introduction of insecticide-treated nets. In the new era of calls to eliminate and eradicate malaria in sub-Saharan Africa, exploring possible causes for this fall seem pertinent.
Presentation of the hypothesis
The authors explore an argument that presumptive treatment of fever cases as malaria may have played a role in reducing transmission of malaria by the prophylactic effect of antimalarials and their widespread use. This strategy, which is already in practise is termed Opportunistic Presumptive Treatment (OPT).
Testing the hypothesis
Further comparison of epidemiological indicators between areas with OPT and more targeted treatment is required. If data suggest a benefit of OPT, combining long acting antimalarials that have an anti-gametocyticidal activity component plus using high levels of vector control measures may reduce transmission, prevent resistant strains spreading and be easily implemented.
Implications of the hypothesis
OPT is practised widely by presumptive treatment of fever in health facilities and home management of fever. Improving diagnosis using rapid diagnostic tests and thus reducing the number of doses of antimalarials given may have counter intuitive effects on transmission in the context of elimination of malaria in high to moderate transmission settings.
Background
There is an increasing body of evidence suggesting that the burden of malaria in sub-
Saharan Africa has been decreasing over the past decade and continues to do so (see
table)[1-7]. The causes of this decline are unclear yet with the current calls for
elimination and eradication of malaria[8] the identification of factors causing this
decrease, in particular those related to control strategies, would seem paramount.
To date the decrease in malaria transmission has been documented in a number of
countries including Kenya[2], Tanzania[3, 4], Mozambique[5], Swaziland[5], South
Africa[5], Guinea Bissau[6] and Eritrea[7]. The decrease in cases in Southern Africa
coincides with indoor residual spraying (IRS) programmes[5] but for the other reports
there is no single clear intervention that could explain the declines. In Kenya it was noted
that the decline started before the widespread use of insecticide-treated nets (ITNs)[2].
The decline appears to be broadly continent wide: there has been a reported decrease in
the mean prevalence of Plasmodium falciparum parasites in cross-sectional surveys from
35% between 1985 and1999 to 20% since 2000[1].Thus, the decline in malaria predates
scaling-up of vector control measures including widespread use of ITNs. During the
1980s and 90s the mainstay of malaria control in Africa was presumptive treatment of
fever with an anti-malarial. This strategy has been promoted by the Integrated
Management of Childhood Illness (IMCI) and is adopted as policy in many developing
countries[9]. In places where transmission is low or decreasing this strategy leads to overdiagnosis
of malaria cases[10].
Presentation of hypothesis
The commonest drugs used for presumptive treatment of fever cases as malaria in the
past 50 years of malaria control are chloroquine (CQ) and sulphadoxine-pyrimethamine
(SP). Both these drugs have a long half-life and their efficacy and effectiveness for
prophylaxis have been clearly documented[11]. Thus, treating most febrile illness with
antimalarials, practiced widely in sub-Saharan Africa has lead to a mass and frequently
applied treatment against malaria that not only cleared parasitaemia in true cases of
malaria but also provided chemoprophylaxis for three weeks in the case of CQ and four
weeks in the case of SP. We term this Opportunistic Presumptive Treatment (OPT).
The mechanism of OPT is to effectively treat those who are infected and prevent reinfection
in both those who are and in those who are not infected. As most infections
occur focally[12, 13], correctly treating these individuals clears active infection and
prevents new infection in those most at risk of malaria. This in turn reduces the parasite
burden in individuals and the infectious reservoir in the community. In low incidence
areas, depending on frequency of treatment of fever as malaria, the community may be
receiving enough anti-malarial prophylaxis to reduce transmission due to decreased
carriage of parasites and thus, cause a gradual decline in malaria burden.
Testing the hypothesis
The likelihood is that the fall in malaria is multi-factorial with general economic
development, climate change and malaria control strategies playing roles and identifying
the role OPT has played is complex. However, as treatment of all fever cases remains
standard practice in many endemic countries a longitudinal comparison of
epidemiological parameters between current practice (OPT) and more targeted treatment
of parasite positive febrile cases in the context of other control methods (e.g.ITN) should
be undertaken. Strategies for evaluation could be (1) OPT with an ACT or non-ACT for
all fever cases without any other obvious cause (current practice); (2) OPT plus an
antibiotic for all fever cases; (3) ACT for confirmed cases of malaria (slide or rapid test
positive) and OPT with non ACT plus an antibiotic for fever cases confirmed negative for
malaria.
OPT has similarities to mass administration of antimalarial drugs (MDA). MDA for
limited time periods has been tried for reducing transmission in the past without marked
or sustained success[14]. However, OPT, given to individuals at high risk of carrying
parasites for several years may have a different outcome than MDA. Since OPT is given
to individuals who have a febrile illness an artemesinin in combination with a long-acting
partner drug such as amodiaquine, mefloquine or piperiquine could be used. Artemesinins
would act to reduce gametocyte carriage[15] while the long-acting partner drug would
prevent new blood stage infections and thus new gametocyte production. Alternatively,
non-ACTs using a combination of long acting drugs maybe preferred, thus saving the
artemesinin component for treatment of proven disease, and these could be combined
with gametocidal drugs such as primaquine or tafenoquine.
Programmes using long-acting drugs are at risk of inducing drug resistance. Both CQ and
SP are no longer recommended for treating clinical malaria in Africa due to high levels of
resistance. Combining long acting drugs and using high levels of vector control measures
to reduce transmission of resistant strains may reduce the risk of drug resistance. Studies
to evaluate the impact of OPT in combination with vector control measures on
transmission of malaria, the emergence of drug resistance and cost-effectiveness in Africa
will be complex, large and expensive, and will require several years of follow up time.
However, implementation of OPT would be relatively easy as the delivery mechanism is
largely in place and the practise of presumptive treatment of fever is common amongst
health professionals and the community.
Implications of the hypothesis
Currently OPT is delivered through the routine health care delivery system in most parts
of Africa. Home management of malaria[16] is an extension of OPT in the communities.
Due to pressures of over-diagnosis of malaria which has adverse outcomes for
patients[10] and misinforms malaria control programmes, introduction of rapid diagnostic
tests are being considered as a cost effective measure to improve the accuracy of
diagnosis of malaria[17]. If the hypothesis is true, restricting antimalarial treatment to
confirmed cases of malaria only will have little impact on control in high/moderate
endemic settings as fewer people will be exposed to prophylactic levels of drugs.
Treating fever cases confirmed as malaria with ACT and as non malaria with non-ACT
OPT plus an antibiotic would circumvent this problem and have the added advantage of
broadening syndromic management of fever to cover the most serious alternative
diagnoses (i.e. bacterial sepsis). However, any widespread use of drugs will result in the
community being exposed to drugs and their associated problems of side effects and drug
resistance.
As transmission decreases there will be a point at which there is no benefit to be gained
from treating asymptomatic carriers and preventing infection by prophylaxis. The level of
transmission where changing strategies becomes advantageous is not known. However,
when this point is reached active case detection and treatment plus surveillance for
outbreaks would be the control method of choice.
Malaria remains a huge public health issue that needs the full armoury of current
interventions. The good news is that, for whatever reason, malaria seems to be decreasing
in many parts of sub-Saharan Africa. The recent call for eradication of malaria is timely
and to achieve this aim all effective interventions need to be scaled up. In areas of
moderate to high transmission mass over-treatment of fever as malaria (OPT) should be
investigated as tool for malaria control. The major risk of this strategy is increasing drug
resistance but the benefits may be much reduced malaria as is evident in parts of Africa.
Authors' contributions
All authors discussed and reviewed the ideas presented in the paper. All authors wrote the
paper and read and approved the final version.
Acknowledgments
We thank Colin Sutherland for his insightful comments on the manuscript and the
reviewers who improved the work. The work involved stimulating discussions with many
people including Professor Chris Curtis who sadly passed away, Caroline Maxwell,
Kevin Marsh, Brian Greenwood, Lorenz von Seidlein, Michala Vaaben Rose, Dr Samwel
Gesase, Cally Roper and Azra Ghani to name but a few. RG is funded by the Bill and
Melinda Gates Foundation, CD is funded by the Wellcome Trust, AM is funded by the
Government of Tanzania and DC is funded by the London School of Hygiene and
Tropical Medicine. All authors state no conflict of interest.
Table: Summary of studies describing reduction in malaria in sub-Saharan Africa
Country
/region reference
Years of
study
Measure of
reduction
Reported
reduction
Reported
Reasons
Sub-Saharan
Africa1
1985 to 1999;
2000 to 2007
Parasite
prevalence
abstracted from
over 2,000
sources
15% (average)
reduction
No reason given
Coastal Kenya2 1999 to 2007 Malaria specific
hospital
admissions
63%, 53% and
28% reduction in
3 district
hospitals
Malaria control
interventions
Ifakara,
Tanzania3
1995 to 2000 Incidence of
malaria in <5
year old children
Reduced from
0.8 to 0.43
episodes per
child per year
Economic
improvements,
liberalisation of
health sector and
malaria control
interventions
Zanzibar,
Tanzania4
2003 to 2006 Parasite
prevalence
97% reduction Artemisinin
Combination
Therapy and
Insecticide
Treated Nets
Mozambique,
South Africa
and Swaziland5
2000-2004 Parasite
prevalence
> 60% fall in
parasite
prevalence in all
3 zones studied
Indoor residual
spraying
Guinea-Bissau6 1994 versus
2003/2004
Parasite
prevalence
Reduced from
44-79% to 3%
Untreated bed
nets and
urbanisation
Eritrea7 2000 to 2004 Incidence of
clinical malaria
and case fatality
rate reported by
health facilities
Decrease in
malaria incidence
of 83.3% and
case fatality by
from 0.21 to
0.14%
Climate change
and malaria
control methods (
ITNs, IRS and
early case
detection and
treatment)
PERSENTASE PENDERITA PENYAKIT MALARIA DIOBATI
MENURUT PROVINSI TAHUN? 2003
No.
Provinsi
Penderita Malaria
Klinis + Positif
Diobati
% Diobati
(1)
(2)
(3)
(4)
(5)
????? 1
?Nanggroe Aceh Darussalam
10,771
6,159
57.18
????? 2
?Sumatera Utara
61,841
55,133
89.15
????? 3
?Sumatera Barat
-
-
-
????? 4
?Riau
34,818
34,353
98.66
????? 5
?Jambi
45,324
39,616
87.41
????? 6
?Sumatera Selatan
36,133
34,906
96.60
????? 7
?Bengkulu
19,030
19,030
100.00
????? 8
?Lampung
48,136
31,077
64.56
????? 9
?Kepulauan Bangka Belitung
10,622
10,622
100.00
??? 10
?DKI Jakarta
-
-
-
??? 11
?Jawa Barat
17,770
15,737
88.56
??? 12
?Jawa Tengah
81,745
80,405
98.36
??? 13
?DI Yogyakarta
25
25
100.00
??? 14
?Jawa Timur
75,288
25,931
34.44
??? 15
?Banten
78
78
100.00
??? 16
?Bali
19,091
19,091
100.00
??? 17
?Nusa Tenggara Barat
31,607
31,607
100.00
??? 18
?Nusa Tenggara Timur
378,711
264,010
69.71
??? 19
?Kalimantan Barat
34,600
26,753
77.32
??? 20
?Kalimantan Tengah
27,976
13,662
48.83
??? 21
?Kalimantan Selatan
899
899
100.00
??? 22
?Kalimantan Timur
16,162
11,336
70.14
??? 23
?Sulawesi Utara
125,081
38,264
30.59
??? 24
?Sulawesi Tengah
58,501
57,925
99.02
??? 25
?Sulawesi Selatan
11,264
9,403
83.48
??? 26
?Sulawesi Tenggara
41,258
40,944
99.24
??? 27
?Gorontalo
1,332
1,332
100.00
??? 28
?Maluku
17,947
11,033
61.48
??? 29
?Maluku Utara
32,982
32,982
100.00
??? 30
?Papua
133,688
121,632
90.98
Jumlah
1,372,680
1,033,945
75.32
Sumber : Hasil Pengumpulan dan Pengolahan Indikator Kinerja SPM bidang Kesehatan dari 325 Kab/Kota, per 1 Oktober 2004
Keterangan : (-) tidak ada data
PERSENTASE RUMAH/BANGUNAN BEBAS JENTIK NYAMUK AEDES
MENURUT PROVINSI TAHUN 2003
No.
Provinsi
Rumah/Bangunan Diperiksa
Rumah/Bangunan Bebas Jentik
Jumlah
%
(1)
(2)
(3)
(4)
(5)
????? 1
?Nanggroe Aceh Darussalam
57,263
35,005
61.13
????? 2
?Sumatera Utara
212,722
137,473
64.63
????? 3
?Sumatera Barat
119,361
66,666
55.85
????? 4
?Riau
142,263
135,962
95.57
????? 5
?Jambi
175,780
82,449
46.90
????? 6
?Sumatera Selatan
5,687
4,890
85.99
????? 7
?Bengkulu
628
543
86.46
????? 8
?Lampung
320,967
259,617
80.89
????? 9
?Kepulauan Bangka Belitung
1,296
954
73.61
??? 10
?DKI Jakarta
101,330
90,836
89.64
??? 11
?Jawa Barat
1,388,977
466,671
33.60
??? 12
?Jawa Tengah
2,236,404
1,816,569
81.23
??? 13
?DI Yogyakarta
307,219
269,862
87.84
??? 14
?Jawa Timur
2,822,347
2,038,152
72.21
??? 15
?Banten
34,771
26,065
74.96
??? 16
?Bali
67,556
58,891
87.17
??? 17
?Nusa Tenggara Barat
2,582
2,090
80.95
??? 18
?Nusa Tenggara Timur
75,820
34,039
44.89
??? 19
?Kalimantan Barat
17,596
12,075
68.62
??? 20
?Kalimantan Tengah
22,271
13,766
61.81
??? 21
?Kalimantan Selatan
37,557
26,425
70.36
??? 22
?Kalimantan Timur
17,833
15,350
86.08
??? 23
?Sulawesi Utara
84,919
56,821
66.91
??? 24
?Sulawesi Tengah
39,492
30,462
77.13
??? 25
?Sulawesi Selatan
453,343
289,938
63.96
??? 26
?Sulawesi Tenggara
13,551
9,823
72.49
??? 27
?Gorontalo
26,529
9,194
34.66
??? 28
?Maluku
3,093
2,114
68.35
??? 29
?Maluku Utara
1,655
1,053
63.63
??? 30
?Papua
18,730
11,051
59.00
Jumlah
8,809,542
6,004,806
68.16
Sumber: Hasil Pengumpulan dan Pengolahan Indikator Kinerja SPM bidang Kesehatan dari 325 Kab/Kota, per 1 Oktober 2004
http://www.malariajournal.com/content/7/1/133
Malaria in pregnant women in an area with sustained high coverage of insecticide-treated bed nets
Abdunoor M Kabanywanyi , John R MacArthur , Wilma A Stolk , J Dik F Habbema , Hassan Mshinda , Peter B Bloland , Salim Abdulla and S Patrick Kachur
Malaria Journal 2008, 7:133doi:10.1186/1475-2875-7-133
Published:
21 July 2008
Abstract (provisional)
Background
Since 2000, the World Health Organization has recommended a package of interventions to prevent malaria during pregnancy and its sequelae that includes the promotion of insecticide-treated bed nets (ITNs), intermittent preventive treatment in pregnancy (IPTp), and effective case management of malarial illness. It is recommended that pregnant women in malaria-endemic areas receive at least two doses of sulphadoxine-pyrimethamine in the second and third trimesters of pregnancy. This study assessed the prevalence of placental malaria at delivery in women during 1st or 2nd pregnancy, who did not receive intermittent preventive treatment for malaria (IPTp) in a malaria-endemic area with high bed net coverage.
Methods
A hospital-based cross-sectional study was done in Ifakara, Tanzania, where bed net coverage is high. Primi- and secundigravid women, who presented to the labour ward and who reported not using IPTp were included in the study. Self-report data were collected by questionnaire; whereas neonatal birth weight and placenta parasitaemia were measured directly at the time of delivery.
Results
Overall, 413 pregnant women were enrolled of which 91% reported to have slept under a bed net at home the previous night, 43% reported history of fever and 62% were primigravid. Malaria parasites were detected in 8% of the placenta samples; the geometric mean (95%CI) placental parasite density was 3,457 (1,060-1,1271) parasites/ul in primigravid women and 2,178 (881-5,383) parasites/ul in secundigravid women. Fifteen percent of newborns weighed <2,500g at delivery. Self-reported bed net use was statistically associated with lower risk for low birth weight [OR 0.34 (95% CI: 0.16 - 0.74) and OR 0.22 (95% CI: 0.08 - 0.59) for untreated and treated bed nets, respectively], but was not associated with placental parasitaemia [OR 0.74 (0.21 - 2.68) and OR 1.64 (044 - 6.19) for untreated and treated bed nets, respectively].
Conclusion
The observed incidence of LBW and prevalence of placental parasitaemia at delivery suggests that malaria remains a problem in pregnancy in this area with high bed net coverage when eligible women do not receive IPTp. Delivery of IPTp should be emphasized at all levels of implementation to achieve maximum community coverage.
http://www.malariajournal.com/content/pdf/1475-2875-7-133.pdf
http://www.malariajournal.com/content/pdf/1475-2875-7-128.pdf
--
Shigenoi Haruki
20 September 2006
Pencegahan Malaria
Pencegahan tanpa obat, yaitu dengan menghindari gigitan nyamuk dengan cara :
1.Menggunakan kelambu (bed net) pada waktu tidur, lebih baik lagi dengan kelambu berinsektisida.
2.Mengolesi badan dengan obat anti gigitan nyamuk (repellent).
3.Menggunakan pembasmi nyamuk, baik bakar, semprot maupun lainnya.
4.Memasang kawat kasa pada jendela dan ventilasi.
5.Letak tempat tinggal diusahakan jauh dari kandang ternak.
6.Mencegah penderita malaria dan gigitan nyamuk agar infeksi tidak menyebar.
7.Membersihkan tempat hinggap/istirahat nyamuk dan memberantas sarang nyamuk.
8.Hindari keadaan rumah yang lembab, gelap, kotor dan pakaian yang bergantungan serta genangan air.
9.Membunuh jentik nyamuk dengan menyemprotkan obat anti larva (bubuk abate) pada genangan air atau menebarkan ikan atau hewan (cyclops) pemakan jentik.
10.Melestarikan hutan bakau agar nyamuk tidak berkembang biak di rawa payau sepanjang pantai.
Pencegahan dengan obat. Obat yang biasa digunakan adalah klorokuin difosfat, karena obat ini efektif terhadap semua jenis parasit malaria. Aturan pemakaiannya adalah :
Pendatang sementara ke daerah endemis, dosis klorokuin adalah 300 mg/minggu, 1 minggu sebelum berangkat selama berada di lokasi sampai 4 minggu setelah kembali.
Penduduk daerah endemis dan penduduk baru yang akan menetap tinggal, dosis klorokuin 300 mg/minggu. Obat hanya diminum selama 12 minggu (3 bulan).
Semua penderita demam di daerah endemis diberikan klorokuin dosis tunggal 600 mg jika daerah itu plasmodium falciparum sudah resisten terhadap klorokuin ditambahkan primakuin sebanyak tiga tablet.
http://www.malariajournal.com/content/7/1/132
Presumptive treatment of fever cases as malaria: help or hindrance for malaria control?
Roly D Gosling , Christopher J Drakeley , Alex Mwita and Daniel Chandramohan
Malaria Journal 2008, 7:132doi:10.1186/1475-2875-7-132
Published:
16 July 2008
Abstract (provisional)
Background
Malaria incidence has been reported to be falling in several countries in sub-Saharan Africa in recent years. This fall appears to have started before the widespread introduction of insecticide-treated nets. In the new era of calls to eliminate and eradicate malaria in sub-Saharan Africa, exploring possible causes for this fall seem pertinent.
Presentation of the hypothesis
The authors explore an argument that presumptive treatment of fever cases as malaria may have played a role in reducing transmission of malaria by the prophylactic effect of antimalarials and their widespread use. This strategy, which is already in practise is termed Opportunistic Presumptive Treatment (OPT).
Testing the hypothesis
Further comparison of epidemiological indicators between areas with OPT and more targeted treatment is required. If data suggest a benefit of OPT, combining long acting antimalarials that have an anti-gametocyticidal activity component plus using high levels of vector control measures may reduce transmission, prevent resistant strains spreading and be easily implemented.
Implications of the hypothesis
OPT is practised widely by presumptive treatment of fever in health facilities and home management of fever. Improving diagnosis using rapid diagnostic tests and thus reducing the number of doses of antimalarials given may have counter intuitive effects on transmission in the context of elimination of malaria in high to moderate transmission settings.
Background
There is an increasing body of evidence suggesting that the burden of malaria in sub-
Saharan Africa has been decreasing over the past decade and continues to do so (see
table)[1-7]. The causes of this decline are unclear yet with the current calls for
elimination and eradication of malaria[8] the identification of factors causing this
decrease, in particular those related to control strategies, would seem paramount.
To date the decrease in malaria transmission has been documented in a number of
countries including Kenya[2], Tanzania[3, 4], Mozambique[5], Swaziland[5], South
Africa[5], Guinea Bissau[6] and Eritrea[7]. The decrease in cases in Southern Africa
coincides with indoor residual spraying (IRS) programmes[5] but for the other reports
there is no single clear intervention that could explain the declines. In Kenya it was noted
that the decline started before the widespread use of insecticide-treated nets (ITNs)[2].
The decline appears to be broadly continent wide: there has been a reported decrease in
the mean prevalence of Plasmodium falciparum parasites in cross-sectional surveys from
35% between 1985 and1999 to 20% since 2000[1].Thus, the decline in malaria predates
scaling-up of vector control measures including widespread use of ITNs. During the
1980s and 90s the mainstay of malaria control in Africa was presumptive treatment of
fever with an anti-malarial. This strategy has been promoted by the Integrated
Management of Childhood Illness (IMCI) and is adopted as policy in many developing
countries[9]. In places where transmission is low or decreasing this strategy leads to overdiagnosis
of malaria cases[10].
Presentation of hypothesis
The commonest drugs used for presumptive treatment of fever cases as malaria in the
past 50 years of malaria control are chloroquine (CQ) and sulphadoxine-pyrimethamine
(SP). Both these drugs have a long half-life and their efficacy and effectiveness for
prophylaxis have been clearly documented[11]. Thus, treating most febrile illness with
antimalarials, practiced widely in sub-Saharan Africa has lead to a mass and frequently
applied treatment against malaria that not only cleared parasitaemia in true cases of
malaria but also provided chemoprophylaxis for three weeks in the case of CQ and four
weeks in the case of SP. We term this Opportunistic Presumptive Treatment (OPT).
The mechanism of OPT is to effectively treat those who are infected and prevent reinfection
in both those who are and in those who are not infected. As most infections
occur focally[12, 13], correctly treating these individuals clears active infection and
prevents new infection in those most at risk of malaria. This in turn reduces the parasite
burden in individuals and the infectious reservoir in the community. In low incidence
areas, depending on frequency of treatment of fever as malaria, the community may be
receiving enough anti-malarial prophylaxis to reduce transmission due to decreased
carriage of parasites and thus, cause a gradual decline in malaria burden.
Testing the hypothesis
The likelihood is that the fall in malaria is multi-factorial with general economic
development, climate change and malaria control strategies playing roles and identifying
the role OPT has played is complex. However, as treatment of all fever cases remains
standard practice in many endemic countries a longitudinal comparison of
epidemiological parameters between current practice (OPT) and more targeted treatment
of parasite positive febrile cases in the context of other control methods (e.g.ITN) should
be undertaken. Strategies for evaluation could be (1) OPT with an ACT or non-ACT for
all fever cases without any other obvious cause (current practice); (2) OPT plus an
antibiotic for all fever cases; (3) ACT for confirmed cases of malaria (slide or rapid test
positive) and OPT with non ACT plus an antibiotic for fever cases confirmed negative for
malaria.
OPT has similarities to mass administration of antimalarial drugs (MDA). MDA for
limited time periods has been tried for reducing transmission in the past without marked
or sustained success[14]. However, OPT, given to individuals at high risk of carrying
parasites for several years may have a different outcome than MDA. Since OPT is given
to individuals who have a febrile illness an artemesinin in combination with a long-acting
partner drug such as amodiaquine, mefloquine or piperiquine could be used. Artemesinins
would act to reduce gametocyte carriage[15] while the long-acting partner drug would
prevent new blood stage infections and thus new gametocyte production. Alternatively,
non-ACTs using a combination of long acting drugs maybe preferred, thus saving the
artemesinin component for treatment of proven disease, and these could be combined
with gametocidal drugs such as primaquine or tafenoquine.
Programmes using long-acting drugs are at risk of inducing drug resistance. Both CQ and
SP are no longer recommended for treating clinical malaria in Africa due to high levels of
resistance. Combining long acting drugs and using high levels of vector control measures
to reduce transmission of resistant strains may reduce the risk of drug resistance. Studies
to evaluate the impact of OPT in combination with vector control measures on
transmission of malaria, the emergence of drug resistance and cost-effectiveness in Africa
will be complex, large and expensive, and will require several years of follow up time.
However, implementation of OPT would be relatively easy as the delivery mechanism is
largely in place and the practise of presumptive treatment of fever is common amongst
health professionals and the community.
Implications of the hypothesis
Currently OPT is delivered through the routine health care delivery system in most parts
of Africa. Home management of malaria[16] is an extension of OPT in the communities.
Due to pressures of over-diagnosis of malaria which has adverse outcomes for
patients[10] and misinforms malaria control programmes, introduction of rapid diagnostic
tests are being considered as a cost effective measure to improve the accuracy of
diagnosis of malaria[17]. If the hypothesis is true, restricting antimalarial treatment to
confirmed cases of malaria only will have little impact on control in high/moderate
endemic settings as fewer people will be exposed to prophylactic levels of drugs.
Treating fever cases confirmed as malaria with ACT and as non malaria with non-ACT
OPT plus an antibiotic would circumvent this problem and have the added advantage of
broadening syndromic management of fever to cover the most serious alternative
diagnoses (i.e. bacterial sepsis). However, any widespread use of drugs will result in the
community being exposed to drugs and their associated problems of side effects and drug
resistance.
As transmission decreases there will be a point at which there is no benefit to be gained
from treating asymptomatic carriers and preventing infection by prophylaxis. The level of
transmission where changing strategies becomes advantageous is not known. However,
when this point is reached active case detection and treatment plus surveillance for
outbreaks would be the control method of choice.
Malaria remains a huge public health issue that needs the full armoury of current
interventions. The good news is that, for whatever reason, malaria seems to be decreasing
in many parts of sub-Saharan Africa. The recent call for eradication of malaria is timely
and to achieve this aim all effective interventions need to be scaled up. In areas of
moderate to high transmission mass over-treatment of fever as malaria (OPT) should be
investigated as tool for malaria control. The major risk of this strategy is increasing drug
resistance but the benefits may be much reduced malaria as is evident in parts of Africa.
Authors' contributions
All authors discussed and reviewed the ideas presented in the paper. All authors wrote the
paper and read and approved the final version.
Acknowledgments
We thank Colin Sutherland for his insightful comments on the manuscript and the
reviewers who improved the work. The work involved stimulating discussions with many
people including Professor Chris Curtis who sadly passed away, Caroline Maxwell,
Kevin Marsh, Brian Greenwood, Lorenz von Seidlein, Michala Vaaben Rose, Dr Samwel
Gesase, Cally Roper and Azra Ghani to name but a few. RG is funded by the Bill and
Melinda Gates Foundation, CD is funded by the Wellcome Trust, AM is funded by the
Government of Tanzania and DC is funded by the London School of Hygiene and
Tropical Medicine. All authors state no conflict of interest.
Table: Summary of studies describing reduction in malaria in sub-Saharan Africa
Country
/region reference
Years of
study
Measure of
reduction
Reported
reduction
Reported
Reasons
Sub-Saharan
Africa1
1985 to 1999;
2000 to 2007
Parasite
prevalence
abstracted from
over 2,000
sources
15% (average)
reduction
No reason given
Coastal Kenya2 1999 to 2007 Malaria specific
hospital
admissions
63%, 53% and
28% reduction in
3 district
hospitals
Malaria control
interventions
Ifakara,
Tanzania3
1995 to 2000 Incidence of
malaria in <5
year old children
Reduced from
0.8 to 0.43
episodes per
child per year
Economic
improvements,
liberalisation of
health sector and
malaria control
interventions
Zanzibar,
Tanzania4
2003 to 2006 Parasite
prevalence
97% reduction Artemisinin
Combination
Therapy and
Insecticide
Treated Nets
Mozambique,
South Africa
and Swaziland5
2000-2004 Parasite
prevalence
> 60% fall in
parasite
prevalence in all
3 zones studied
Indoor residual
spraying
Guinea-Bissau6 1994 versus
2003/2004
Parasite
prevalence
Reduced from
44-79% to 3%
Untreated bed
nets and
urbanisation
Eritrea7 2000 to 2004 Incidence of
clinical malaria
and case fatality
rate reported by
health facilities
Decrease in
malaria incidence
of 83.3% and
case fatality by
from 0.21 to
0.14%
Climate change
and malaria
control methods (
ITNs, IRS and
early case
detection and
treatment)
PERSENTASE PENDERITA PENYAKIT MALARIA DIOBATI
MENURUT PROVINSI TAHUN? 2003
No.
Provinsi
Penderita Malaria
Klinis + Positif
Diobati
% Diobati
(1)
(2)
(3)
(4)
(5)
????? 1
?Nanggroe Aceh Darussalam
10,771
6,159
57.18
????? 2
?Sumatera Utara
61,841
55,133
89.15
????? 3
?Sumatera Barat
-
-
-
????? 4
?Riau
34,818
34,353
98.66
????? 5
?Jambi
45,324
39,616
87.41
????? 6
?Sumatera Selatan
36,133
34,906
96.60
????? 7
?Bengkulu
19,030
19,030
100.00
????? 8
?Lampung
48,136
31,077
64.56
????? 9
?Kepulauan Bangka Belitung
10,622
10,622
100.00
??? 10
?DKI Jakarta
-
-
-
??? 11
?Jawa Barat
17,770
15,737
88.56
??? 12
?Jawa Tengah
81,745
80,405
98.36
??? 13
?DI Yogyakarta
25
25
100.00
??? 14
?Jawa Timur
75,288
25,931
34.44
??? 15
?Banten
78
78
100.00
??? 16
?Bali
19,091
19,091
100.00
??? 17
?Nusa Tenggara Barat
31,607
31,607
100.00
??? 18
?Nusa Tenggara Timur
378,711
264,010
69.71
??? 19
?Kalimantan Barat
34,600
26,753
77.32
??? 20
?Kalimantan Tengah
27,976
13,662
48.83
??? 21
?Kalimantan Selatan
899
899
100.00
??? 22
?Kalimantan Timur
16,162
11,336
70.14
??? 23
?Sulawesi Utara
125,081
38,264
30.59
??? 24
?Sulawesi Tengah
58,501
57,925
99.02
??? 25
?Sulawesi Selatan
11,264
9,403
83.48
??? 26
?Sulawesi Tenggara
41,258
40,944
99.24
??? 27
?Gorontalo
1,332
1,332
100.00
??? 28
?Maluku
17,947
11,033
61.48
??? 29
?Maluku Utara
32,982
32,982
100.00
??? 30
?Papua
133,688
121,632
90.98
Jumlah
1,372,680
1,033,945
75.32
Sumber : Hasil Pengumpulan dan Pengolahan Indikator Kinerja SPM bidang Kesehatan dari 325 Kab/Kota, per 1 Oktober 2004
Keterangan : (-) tidak ada data
PERSENTASE RUMAH/BANGUNAN BEBAS JENTIK NYAMUK AEDES
MENURUT PROVINSI TAHUN 2003
No.
Provinsi
Rumah/Bangunan Diperiksa
Rumah/Bangunan Bebas Jentik
Jumlah
%
(1)
(2)
(3)
(4)
(5)
????? 1
?Nanggroe Aceh Darussalam
57,263
35,005
61.13
????? 2
?Sumatera Utara
212,722
137,473
64.63
????? 3
?Sumatera Barat
119,361
66,666
55.85
????? 4
?Riau
142,263
135,962
95.57
????? 5
?Jambi
175,780
82,449
46.90
????? 6
?Sumatera Selatan
5,687
4,890
85.99
????? 7
?Bengkulu
628
543
86.46
????? 8
?Lampung
320,967
259,617
80.89
????? 9
?Kepulauan Bangka Belitung
1,296
954
73.61
??? 10
?DKI Jakarta
101,330
90,836
89.64
??? 11
?Jawa Barat
1,388,977
466,671
33.60
??? 12
?Jawa Tengah
2,236,404
1,816,569
81.23
??? 13
?DI Yogyakarta
307,219
269,862
87.84
??? 14
?Jawa Timur
2,822,347
2,038,152
72.21
??? 15
?Banten
34,771
26,065
74.96
??? 16
?Bali
67,556
58,891
87.17
??? 17
?Nusa Tenggara Barat
2,582
2,090
80.95
??? 18
?Nusa Tenggara Timur
75,820
34,039
44.89
??? 19
?Kalimantan Barat
17,596
12,075
68.62
??? 20
?Kalimantan Tengah
22,271
13,766
61.81
??? 21
?Kalimantan Selatan
37,557
26,425
70.36
??? 22
?Kalimantan Timur
17,833
15,350
86.08
??? 23
?Sulawesi Utara
84,919
56,821
66.91
??? 24
?Sulawesi Tengah
39,492
30,462
77.13
??? 25
?Sulawesi Selatan
453,343
289,938
63.96
??? 26
?Sulawesi Tenggara
13,551
9,823
72.49
??? 27
?Gorontalo
26,529
9,194
34.66
??? 28
?Maluku
3,093
2,114
68.35
??? 29
?Maluku Utara
1,655
1,053
63.63
??? 30
?Papua
18,730
11,051
59.00
Jumlah
8,809,542
6,004,806
68.16
Sumber: Hasil Pengumpulan dan Pengolahan Indikator Kinerja SPM bidang Kesehatan dari 325 Kab/Kota, per 1 Oktober 2004
http://www.malariajournal.com/content/7/1/133
Malaria in pregnant women in an area with sustained high coverage of insecticide-treated bed nets
Abdunoor M Kabanywanyi , John R MacArthur , Wilma A Stolk , J Dik F Habbema , Hassan Mshinda , Peter B Bloland , Salim Abdulla and S Patrick Kachur
Malaria Journal 2008, 7:133doi:10.1186/1475-2875-7-133
Published:
21 July 2008
Abstract (provisional)
Background
Since 2000, the World Health Organization has recommended a package of interventions to prevent malaria during pregnancy and its sequelae that includes the promotion of insecticide-treated bed nets (ITNs), intermittent preventive treatment in pregnancy (IPTp), and effective case management of malarial illness. It is recommended that pregnant women in malaria-endemic areas receive at least two doses of sulphadoxine-pyrimethamine in the second and third trimesters of pregnancy. This study assessed the prevalence of placental malaria at delivery in women during 1st or 2nd pregnancy, who did not receive intermittent preventive treatment for malaria (IPTp) in a malaria-endemic area with high bed net coverage.
Methods
A hospital-based cross-sectional study was done in Ifakara, Tanzania, where bed net coverage is high. Primi- and secundigravid women, who presented to the labour ward and who reported not using IPTp were included in the study. Self-report data were collected by questionnaire; whereas neonatal birth weight and placenta parasitaemia were measured directly at the time of delivery.
Results
Overall, 413 pregnant women were enrolled of which 91% reported to have slept under a bed net at home the previous night, 43% reported history of fever and 62% were primigravid. Malaria parasites were detected in 8% of the placenta samples; the geometric mean (95%CI) placental parasite density was 3,457 (1,060-1,1271) parasites/ul in primigravid women and 2,178 (881-5,383) parasites/ul in secundigravid women. Fifteen percent of newborns weighed <2,500g at delivery. Self-reported bed net use was statistically associated with lower risk for low birth weight [OR 0.34 (95% CI: 0.16 - 0.74) and OR 0.22 (95% CI: 0.08 - 0.59) for untreated and treated bed nets, respectively], but was not associated with placental parasitaemia [OR 0.74 (0.21 - 2.68) and OR 1.64 (044 - 6.19) for untreated and treated bed nets, respectively].
Conclusion
The observed incidence of LBW and prevalence of placental parasitaemia at delivery suggests that malaria remains a problem in pregnancy in this area with high bed net coverage when eligible women do not receive IPTp. Delivery of IPTp should be emphasized at all levels of implementation to achieve maximum community coverage.
http://www.malariajournal.com/content/pdf/1475-2875-7-133.pdf
http://www.malariajournal.com/content/pdf/1475-2875-7-128.pdf
--
Shigenoi Haruki
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