Acceptability, Feasibility, Drug Safety, and Effectiveness of a Pilot Mass Drug Administration with a Single Round of Sulfadoxine-Pyrimethamine Plus Primaquine and Indoor Residual Spraying in Communities with Malaria Transmission in Haiti, 2018

Abstract

For a malaria elimination strategy, Haiti's National Malaria Control Program piloted a mass drug administration (MDA) with indoor residual spraying (IRS) in 12 high-transmission areas across five communes after implementing community case management and strengthened surveillance. The MDA distributed sulfadoxine-pyrimethamine and single low-dose primaquine to eligible residents during house visits. The IRS campaign applied pirimiphos-methyl insecticide on walls of eligible houses. Pre- and post-campaign cross-sectional surveys were conducted to assess acceptability, feasibility, drug safety, and effectiveness of the combined interventions. Stated acceptability for MDA before the campaign was 99.2%; MDA coverage estimated at 10 weeks post-campaign was 89.6%. Similarly, stated acceptability of IRS at baseline was 99.9%; however, household IRS coverage was 48.9% because of the high number of ineligible houses. Effectiveness measured by Plasmodium falciparum prevalence at baseline and 10 weeks post-campaign were similar: 1.31% versus 1.43%, respectively. Prevalence of serological markers were similar at 10 weeks post-campaign compared with baseline, and increased at 6 months. No severe adverse events associated with the MDA were identified in the pilot; there were severe adverse events in a separate, subsequent campaign. Both MDA and IRS are acceptable and feasible interventions in Haiti. Although a significant impact of a single round of MDA/IRS on malaria transmission was not found using a standard pre- and post-intervention comparison, it is possible there was blunting of the peak transmission. Seasonal malaria transmission patterns, suboptimal IRS coverage, and low baseline parasitemia may have limited the effectiveness or the ability to measure effectiveness.

Figure 1.

Map of operational units (OUs) that received mass drug administration (MDA), indoor residual spraying (IRS), or long-lasting insecticide-treated nets (LLINs) during the 2018 pilot campaign in Grand’Anse, Haiti. The OU numbers are not consecutive in this figure.

Figure 2.

Flowchart of individuals censused and screened for mass drug administration (MDA) eligibility, and who took sulfadoxine–pyrimethamine (SP) and/or primaquine (PQ). The reasons for not participating in MDA include absenteeism/unavailability despite return visits, refusals, and being ineligible based on the inclusion criteria or medical screening. These data were collected during the campaign as part of the monitoring system. SLD = single low dose.

Figure 3.

Timing of surveys and the mass drug administration (MDA)/indoor residual spraying (IRS) campaign, parasite and antibody response prevalence at different time points (T0, baseline; T1, 10 weeks; T2, 6 months; and T3, 14 months) relative to the mean daily precipitation (precip.) and surface temperature (temp.) in Grand’Anse. The indicator bands for the surveys and the MDA/IRS campaign correspond to the actual dates of the fieldwork. Because of large daily variations, precipitation is displayed as the monthly mean to visualize the trend better. Climate data were obtained from the National Aeronautics and Space Administration’s Giovanni interface (https://giovanni.gsfc.nasa.gov/giovanni), a Web-based platform for the visualization and analysis of climate data. For the rainfall data, the Global Precipitation Model at 0.1° spatial resolution was used; for the temperature data, the Global Land Data Assimilation System Version 2 at 0.25° spatial resolution was used. + = presence of antigen or antibody indicating positive test result; AMA1 = apical membrane antigen 1; Etramp 5 ag1 = early transcribed membrane protein 5 antigen 1; HRP2 = histidine-rich protein 2; MSP1 = merozoite surface protein 1; RDT = rapid diagnostic test.

Figure 4.

Prevalence with 95% confidence limits and trend lines for the different biomarkers were collected at each survey time point. Above each dotted trend line is the corresponding equation. AMA1 = apical membrane antigen 1; Etramp 5 ag1 = early transcribed membrane protein 5 antigen 1; HRP2 = histidine-rich protein 2; MSP1 = merozoite surface protein 1; RDT = rapid diagnostic test.