Since the year 2000, a concerted campaign against malaria has led to unprecedented levels of intervention coverage across sub-Saharan Africa. Understanding the effect of this control effort is vital to inform future control planning. However, the effect of malaria interventions across the varied epidemiological settings of Africa remains poorly understood owing to the absence of reliable surveillance data and the simplistic approaches underlying current disease estimates. Here we link a large database of malaria field surveys with detailed reconstructions of changing intervention coverage to directly evaluate trends from 2000 to 2015 and quantify the attributable effect of malaria disease control efforts. We found that Plasmodium falciparum infection prevalence in endemic Africa halved and the incidence of clinical disease fell by 40% between 2000 and 2015. We estimate that interventions have averted 663 (542–753 credible interval) million clinical cases since 2000. Insecticide-treated nets, the most widespread intervention, were by far the largest contributor (68% of cases averted). Although still below target levels, current malaria interventions have substantially reduced malaria disease incidence across the continent. Increasing access to these interventions, and maintaining their effectiveness in the face of insecticide and drug resistance, should form a cornerstone of post-2015 control strategies.

SummaryBackgroundMass drug administration for elimination of Plasmodium falciparum malaria is recommended by WHO in some settings. We used consensus modelling to understand how to optimise the effects of mass drug administration in areas with low malaria transmission.MethodsWe collaborated with researchers doing field trials to establish a standard intervention scenario and standard transmission setting, and we input these parameters into four previously published models. We then varied the number of rounds of mass drug administration, coverage, duration, timing, importation of infection, and pre-administration transmission levels. The outcome of interest was the percentage reduction in annual mean prevalence of P falciparum parasite rate as measured by PCR in the third year after the final round of mass drug administration.FindingsThe models predicted differing magnitude of the effects of mass drug administration, but consensus answers were reached for several factors. Mass drug administration was predicted to reduce transmission over a longer timescale than accounted for by the prophylactic effect alone. Percentage reduction in transmission was predicted to be higher and last longer at lower baseline transmission levels. Reduction in transmission resulting from mass drug administration was predicted to be temporary, and in the absence of scale-up of other interventions, such as vector control, transmission would return to pre-administration levels. The proportion of the population treated in a year was a key determinant of simulated effectiveness, irrespective of whether people are treated through high coverage in a single round or new individuals are reached by implementation of several rounds. Mass drug administration was predicted to be more effective if continued over 2 years rather than 1 year, and if done at the time of year when transmission is lowest.InterpretationMass drug administration has the potential to reduce transmission for a limited time, but is not an effective replacement for existing vector control. Unless elimination is achieved, mass drug administration has to be repeated regularly for sustained effect.FundingBill & Melinda Gates Foundation.

In many countries health system data remain too weak to accurately enumerate Plasmodium falciparum malaria cases. In response, cartographic approaches have been developed that link maps of infection prevalence with mathematical relationships to predict the incidence rate of clinical malaria. Microsimulation (or ‘agent-based') models represent a powerful new paradigm for defining such relationships; however, differences in model structure and calibration data mean that no consensus yet exists on the optimal form for use in disease-burden estimation. Here we develop a Bayesian statistical procedure combining functional regression-based model emulation with Markov Chain Monte Carlo sampling to calibrate three selected microsimulation models against a purpose-built data set of age-structured prevalence and incidence counts. This allows the generation of ensemble forecasts of the prevalence–incidence relationship stratified by age, transmission seasonality, treatment level and exposure history, from which we predict accelerating returns on investments in large-scale intervention campaigns as transmission and prevalence are progressively reduced.

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In the past several decades, a number of largely atheoretical individual and meta-analytic studies of couple relationship education (CRE) programs have focused on program effectiveness without considerations of how these programs work and for whom. To address this gap in the literature, the current study drew upon assumptions from social-cognitive and behavioral theories that are implicit in CRE design to assess the influence of short-term changes from pre- to posttreatment in behaviors and commitment on changes in relationship quality among a racially and economically diverse group of 2,824 individuals who participated in a CRE program. Findings from structural equation modeling indicated that the best-fitting model for both men and women was one in which changes in behaviors predicted changes in relationship quality via their influence on changes in commitment. Further, a series of moderational analyses provided some evidence to suggest that the strength of the relationships between these variables may depend to a small extent on the social address of the participants (race, income) and to a greater extent on characteristics of the CRE experience (i.e., beginning the class at lower levels of functioning, attending with a partner). Findings help us begin to understand the influences among domains of change that occur as a result of participating in a CRE program, as well as offering some useful information to practitioners on demographic and contextual moderators of program outcomes. Implications for future research on the mechanisms of change for CRE are presented.

The association between depression and marital satisfaction has been clearly documented. Theoretical approaches describe the direction of effects as depression leading to marital dissatisfaction (stress generation model) and, alternately, marital dissatisfaction leading to depression (marital discord model). Clinical research indicates that treating the relationship of unstable couples can result in improvements in relationship satisfaction and depression. However, many unstable couples may not attend therapy and choose rather to attend Couple and Relationship Education (CRE). Using 250 ethnically diverse couples in community CRE classes, the authors found that relationally unstable participants of CRE report improvements in depressed affect and relationship quality after program participation. Additionally, decreased depressed affect predicted increased relationship quality, not vice versa, and there were no differences by sex. The authors note the potential value of CRE for unstable couples and recommend that interventionists utilize an inclusive approach, devoting attention to the couple relationship as well as individual distress variables.

A 13-year-old castrated male cat was examined because of a 2-week history of weakness, cervical ventroflexion, and dysphagia. Clinicopathologic abnormalities included hypokalemia and high serum creatine kinase activity. Abdominal ultrasonography revealed a 15-mm spherical mass in the area of the left adrenal gland. Plasma aldosterone concentration was high, and plasma renin activity was low. Findings were diagnostic of primary hyperaldosteronism. The cat responded well to intravenous and oral potassium supplementation while in the hospital. The owner declined surgery; therefore, repeated follow-up abdominal ultrasonography was recommended. The cat did well clinically with medical management alone until day 334, when it was lost to follow-up.

The current study represents a novel test of parenting outcomes among participants in couple and relationship education (CRE). Utilizing a systems theory framework and empirical linkages between couple functioning and parenting, this study examined the extent to which several parenting dimensions (coparenting conflict, parental involvement, and positive discipline practices) change after CRE participation and, importantly, whether and how these changes are related to changes in dimensions of couple functioning. In a sample of 623 adult parents, diverse in gender, race, and marital status, positive changes were found in the parenting dimensions over time. In addition, levels of change in the couple domain were associated with levels of changes in the parenting domain over the same period of time, with a pattern of stronger links between conceptually similar dimensions of couple functioning and parenting.