Impact of the Mass Drug Administration for malaria in response to the Ebola outbreak in Sierra Leone

Abstract

Background: As emergency response to the Ebola epidemic, the Government of Sierra Leone and its partners implemented a large-scale Mass Drug Administration (MDA) with artesunate-amodiaquine (ASAQ) covering >2.7 million people in the districts hardest hit by Ebola during December 2014-January 2015. The World Health Organization (WHO) and the National Malaria Control Programme (NMCP) evaluated the impact of the MDA on malaria morbidity at health facilities and the number of Ebola alerts received at District Ebola Command Centres.

Methods: The coverage of the two rounds of MDA with ASAQ was estimated by relating the number anti-malarial medicines distributed to the estimated resident population. Segmented time-series analysis was applied to weekly data collected from 49 primary health units (PHUs) and 11 hospitals performing malaria parasitological testing during the study period, to evaluate trends of malaria cases and Ebola alerts during the post-MDA weeks compared to the pre-MDA weeks in MDA- and non-MDA-cheifdoms.

Results: After two rounds of the MDA, the number of suspected cases tested with rapid diagnostic test (RDT) decreased significantly by 43 % (95 % CI 38-48 %) at week 1 and remained low at week 2 and 3 post-first MDA and at week 1 and 3 post-second MDA; RDT positive cases decreased significantly by 47 % (41-52 %) at week 1 post-first and remained lower throughout all post-MDA weeks; and the RDT test positivity rate (TPR) declined by 35 % (32-38 %) at week 2 and stayed low throughout all post-MDA weeks. The total malaria (clinical + confirmed) cases decreased significantly by 45 % (39-52 %) at week 1 and were lower at week 2 and 3 post-first MDA; and week 1 post-second MDA. The proportion of confirmed malaria cases (out of all-outpatients) fell by 33 % (29-38 %) at week 1 post-first MDA and were lower during all post-MDA weeks. On the contrary, the non-malaria outpatient cases (cases due to other health conditions) either remained unchanged or fluctuated insignificantly. The Ebola alerts decreased by 30 % (13-46 %) at week 1 post-first MDA and much lower during all the weeks post-second MDA.

Conclusions: The MDA achieved its goals of reducing malaria morbidity and febrile cases that would have been potentially diagnosed as suspected Ebola cases with increased risk of nosocomial infections. The intervention also helped reduce patient case-load to the severely strained health services at the peak of the Ebola outbreak and malaria transmission. As expected, the effect of the MDA waned in a matter of few weeks and malaria intensity returned to the pre-MDA levels. Nevertheless, the approach was an appropriate public health intervention in the context of the Ebola epidemic even in high malaria transmission areas of Sierra Leone.

Fig. 1

Map of chiefdoms in the eight districts covered by two rounds of MDA with ASAQ. a MDA by district (dark shaded); b MDA by chiefdoms (MDA chiefdoms—yellow shaded; and non-MDA chiefdoms—dark-brown shaded)

Fig. 2

Trends of malaria suspected cases tested with RDT, RDT positive cases, RDT TPR and Ebola alert cases in MDA-chiefdoms (n = 34 PHUs) and non-MDA-chiefdoms (n = 14 PHUs). a RDT tested cases. b RDT positive cases. c RDT test positivity rate (TPR). d Ebola alert cases. Dotted vertical lines indicate the start of 1st MDA (week 11) and 2nd MDA (week 17)

Fig. 3

Observed trends of malaria indicators in primary health units (PHUs) of MDA-chiefdoms (n = 34 PHUs) and non-MDA-chiefdoms (n = 14 PHUs). a OPD cases. b Malaria (presumed + confirmed). c Non-malaria cases. d Proportion of malaria of all OPD cases. Dotted vertical lines indicate the start of 1st MDA (week 11) and 2nd MDA (week 17)

Fig. 4

Regression of trends of malaria indicators during pre-MDA and post-MDA weeks in MDA-chiefdoms (n = 34 PHUs) and non-MDA-chiefdoms or controls (n = 14 PHUs). Dotted vertical line shows the start of the first MDA (week 11)