Description
Introduction
To eliminate malaria, all populations must be included. For those who are not reached by the health care system, specific interventions must be tailor-made. People working in illegal gold mines are currently the main hosts of malaria in the Amazon, with the risk of resistance emergence linked to misuse of artemisinin-based combination therapies (ACTs) and the spread of malaria when they move. The remoteness of the mines and regulatory issues hinder their access to health care.
Methodology
We have evaluated an innovative strategy (Malakit) based on the distribution of self-diagnosis and self-treatment kits (after training) in the Suriname-French Guiana- Amapá (Brazil) region at strategic border staging areas. These kits contain three rapid diagnostic test and a complete treatment with artemether-lumefantrine (20/120 mg). A quasi-experimental design aimed at determining the effectiveness, safety and acceptability. Evaluation relied on questionnaires at inclusion and follow-up visits, and pre/post intervention surveys. The primary outcome was the proportion of persons reporting a use of certified ACT after a positive malaria diagnosis. The secondary outcomes assessed antimalarial adherence, kit use and impact on malaria epidemiology.
Results and discussion
The results showed effectiveness and good acceptability. From April 2018 to March 2020, 3,733 persons participated in the intervention, which represents 30% of the target population. The proportion of patients reporting a use of certified ACT after a positive diagnosis increased after the intervention from 54.2% to 68.1% (OR 1.8, 95%CI [1.1-3.0]). The kit was used correctly by 71.7% [65.8-77.7] of the 223 persons reporting having used a malakit during the follow-up visits. No serious adverse events related to the misuse of malakit have been reported. The intervention appears to have accelerated the decline in malaria cases diagnosed in Suriname and Brazil from French Guiana by 42.9% and averted 6,848 infections during the intervention. The proportion of P. falciparum decreased from 58.0% to 15.0%.
This innovative international project showed that people with low education can correctly self-manage their malaria symptoms. The strategy has then been included into the Surinamese National Malaria Elimination Programm since 2020. A new research project is currently underway, adding a radical targeted treatment against hypnozoites to the malakit distribution in order to further advance malaria elimination in this particular population.
Conclusions
The Malakit strategy could be useful in other setting facing malaria among hard-to-reach population. The transferability of this complex intervention with many components requires adaptation to other populations and regions, while retaining the main features of the intervention. This must include the diagnosis of the situation to define the relevance of the strategy; the determination of the stakeholders and the framework of the intervention (research project or public health intervention); the adaptation of the kit, training, distribution strategy; and to implement training and supervision for community health workers. Implementing and evaluating the transferability and effectiveness of the Malakit strategy in new contexts will be of interest to increase and refine the evidence of its value, and to decide whether it could be an additional tool in the arsenal recommended in future WHO guidelines.
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