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From high to low malaria transmission in Zanzibar-challenges and opportunities to achieve elimination

Artikel i vetenskaplig tidskrift
Författare A. Björkman
D Shakely
A. S. Ali
U. Morris
H. Mkali
A. K. Abbas
A. W. Al-Mafazy
K. A. Haji
J. Mcha
R. Omar
J. Cook
Kristina Elfving
Max Petzold
M. C. Sachs
B. Aydin-Schmidt
C. Drakeley
M. Msellem
A. Mårtensson
Publicerad i BMC medicine
Volym 17
Nummer/häfte 1
Sidor 14
ISSN 1741-7015
Publiceringsår 2019
Publicerad vid Institutionen för biomedicin, avdelningen för infektionssjukdomar
Institutionen för medicin, avdelningen för samhällsmedicin och folkhälsa, enheten för hälsometri
Sidor 14
Språk en
Länkar dx.doi.org/10.1186/s12916-018-1243-...
Ämneskategorier Folkhälsovetenskap, global hälsa, socialmedicin och epidemiologi

Sammanfattning

BACKGROUND: Substantial global progress in the control of malaria in recent years has led to increased commitment to its potential elimination. Whether this is possible in high transmission areas of sub-Saharan Africa remains unclear. Zanzibar represents a unique case study of such attempt, where modern tools and strategies for malaria treatment and vector control have been deployed since 2003. METHODS: We have studied temporal trends of comprehensive malariometric indices in two districts with over 100,000 inhabitants each. The analyses included triangulation of data from annual community-based cross-sectional surveys, health management information systems, vital registry and entomological sentinel surveys. RESULTS: The interventions, with sustained high-community uptake, were temporally associated with a major malaria decline, most pronounced between 2004 and 2007 and followed by a sustained state of low transmission. In 2015, the Plasmodium falciparum community prevalence of 0.43% (95% CI 0.23-0.73) by microscopy or rapid diagnostic test represented 96% reduction compared with that in 2003. The P. falciparum and P. malariae prevalence by PCR was 1.8% (95% CI 1.3-2.3), and the annual P. falciparum incidence was estimated to 8 infections including 2.8 clinical episodes per 1000 inhabitants. The total parasite load decreased over 1000-fold (99.9%) between 2003 and 2015. The incidence of symptomatic malaria at health facilities decreased by 94% with a trend towards relatively higher incidence in age groups > 5 years, a more pronounced seasonality and with reported travel history to/from Tanzania mainland as a higher risk factor. All-cause mortality among children < 5 years decreased by 72% between 2002 and 2007 mainly following the introduction of artemisinin-based combination therapies whereas the main reduction in malaria incidence followed upon the vector control interventions from 2006. Human biting rates decreased by 98% with a major shift towards outdoor biting by Anopheles arabiensis. CONCLUSIONS: Zanzibar provides new evidence of the feasibility of reaching uniquely significant and sustainable malaria reduction (pre-elimination) in a previously high endemic region in sub-Saharan Africa. The data highlight constraints of optimistic prognostic modelling studies. New challenges, mainly with outdoor transmission, a large asymptomatic parasite reservoir and imported infections, require novel tools and reoriented strategies to prevent a rebound effect and achieve elimination.

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