Monitoring, characterization and control of chronic, symptomatic malaria infections in rural Zambia through monthly household visits by paid community health workers

Abstract

Background: Active, population-wide mass screening and treatment (MSAT) for chronic Plasmodium falciparum carriage to eliminate infectious reservoirs of malaria transmission have proven difficult to apply on large national scales through trained clinicians from central health authorities.

Methodology: Fourteen population clusters of approximately 1,000 residents centred around health facilities (HF) in two rural Zambian districts were each provided with three modestly remunerated community health workers (CHWs) conducting active monthly household visits to screen and treat all consenting residents for malaria infection with rapid diagnostic tests (RDT). Both CHWs and HFs also conducted passive case detection among residents who self-reported for screening and treatment.

Results: Diagnostic positivity was higher among symptomatic patients self-reporting to CHWs (42.5%) and HFs (24%) than actively screened residents (20.3%), but spatial and temporal variations of diagnostic positivity were highly consistent across all three systems. However, most malaria infections (55.6%) were identified through active home visits by CHWs rather than self-reporting to CHWs or HFs. Most (62%) malaria infections detected actively by CHWs reported one or more symptoms of illness. Most reports of fever and vomiting, plus more than a quarter of history of fever, headache and diarrhoea, were attributable to malaria infection. The minority of residents who participated >12 times had lower rates of malaria infection and associated symptoms in later contacts but most residents were tested <4 times and high malaria diagnostic positivity (32%) in active surveys, as well as incidence (1.7 detected infections per person per year) persisted in the population. Per capita cost for active service delivery by CHWs was US$5.14 but this would rise to US$10.68 with full community compliance with monthly testing at current levels of transmission, and US$6.25 if pre-elimination transmission levels and negligible treatment costs were achieved.

Conclusion: Monthly active home visits by CHWs equipped with RDTs were insufficient to eliminate the human infection reservoir in this typical African setting, despite reasonably high LLIN/IRS coverage. However, dramatic impact upon infection and morbidity burden might be attainable and cost-effective if community participation in regular testing could be improved and the substantial, but not necessarily prohibitive, costs are affordable to national programmes.

Figure 1

Map indicating location of health facilities and associated catchment populations enrolled in the study.

Figure 2

Proportion of catchment population tested (A and C) and diagnostic positivity for malaria infection among residents (B and D) in Luangwa (A and B) and Nyimba (C and D).

Figure 3

Age and proportion of covered population tested for malaria infection each month as contacted passively (A and B) and actively (C and D) by community health workers in Luangwa (A and C) and Nyimba (B and D).

Figure 4

Frequency histogram of the number of study participant contacts for each total number of preceding malaria infection tests by community health workers per individual study participant (A) and the relationship between the proportion of those participants diagnosed as being infected and the cumulative number of diagnostic tests for malaria infection per individual participant (B).

Figure 5

Association of diagnostic positivity for malaria infection among patients attending health facilities with diagnostic positivity recorded by community health workers through passive (A) and active (B) participant contacts.

Figure 6

Fractions of risk for reported clinical symptoms which are attributable to malaria infection detected by community health workers through active (A) and passive (B) contact events.

Figure 7

Relationship between the proportion of participant contacts with community health workers in which they experienced fever (A), history of fever (B), headache (C), cough (D), diarrhea (E), vomiting (F), chest pain (G) and breathing problems (H) and the cumulative number of preceding diagnostic tests for malaria infection per individual participant.

Figure 8

Community health worker and health facility staff treatment and diagnostic practice in relation to national guidelines.