CLAHRC Africa is planning a study with Anja Terlouw and Linda Mipando of the Malawi, Liverpool Wellcome Trust Centre, to reduce the prevalence of malaria in villages in Africa. Artemisinin therapy for clinical cases is the single most cost-effective measure for malaria control, while treatment of pregnant women can also bring an important health gain. Major works to drain swamps and remove standing water are beyond scope. So we are considering community-based interventions.
There are many different community-based approaches to the scourge of malaria. Improving the uptake of bed nets is a very widely used approach (for a beautiful map of how the use of bed nets has improved since 2000, see this Tweet by Bill Gates). Bed nets are impregnated with insecticides that are harmless to humans, and can reduce the load of infected vectors in a locality, as well as protect individuals. But uptake is not universal, in part because they are hard to use in the absence of a bed and many people, especially children, sleep on mats. We plan to investigate methods to mitigate the problems, perhaps including an erectable protective dome, like a small tent, for children:
One problem with bed nets is that anopheline mosquitos are developing resistance to the insecticide.
Other approaches include regular indoor residual spraying so that surfaces are coated in a substance lethal to mosquitoes, but this requires fastidious application of the insecticide and is expensive. Yet another approach is mass treatment of whole populations, as discussed in a recent edition of Science. However, this risks promoting resistant strains on a large scale, so a modification of the mass treatment approach, based on screening and treatment, has been advocated. However, that may be ruinously expensive.
Of course, there are approaches aimed at reducing breeding grounds for the vector, which are certainly effective if they can be implemented. Diagnosing and treating pregnant women is an important strategy. Malaria vaccines are starting to look promising, while we wait for widespread application and evaluation of existential approaches, such as introducing sterile males into the unsuspecting anopheline population.
In the meantime, our plan is to select the most propitious community-based method and roll it out in collaboration with authorities, as part of a cluster RCT, perhaps using a step-wedge design.
— Richard Lilford, CLAHRC WM Director
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