Community perspectives on treating asymptomatic infections for malaria elimination in The Gambia

Abstract

Background Innovative and cost-effective strategies that clear asymptomatic malaria infections are required to reach malaria elimination goals, but remain a challenge. This mixed methods study explored people’s attitudes towards the reactive treatment of compound contacts of malaria cases with a 3-day course of dihydroartemisinin-piperaquine (DHAP), the socio-cultural representations of asymptomatic infections, and more specifically their treatment. Methods Prior to the start of the intervention, a sequential mixed method study was carried out. Qualitative data collection involved in-depth interviews and participant observations (including informal conversations) with key informants from the trial communities and the trial staff. Quantitative data were derived from a pre-trial cross-sectional survey on health literacy and health-seeking behaviour among randomly selected members of the study communities. Results In the pre-trial cross-sectional survey, 73% of respondents reported that malaria could be hidden in the body without symptoms. Whilst this may be interpreted as people’s comprehension of asymptomatic malaria, qualitative data indicated that informants had different interpretations of asymptomatic disease than the biomedical model. It was described as: (i) a minor illness that does not prevent people carrying out daily activities; (ii) an illness that oscillates between symptomatic and asymptomatic phases; and, (iii) a condition where disease agents are present in the body but remain hidden, without signs and symptoms, until something triggers their manifestation. Furthermore, this form of hidden malaria was reported to be most present in those living in the same compound with a malaria case (71%). Conclusion Treating asymptomatic malaria with pharmaceuticals was considered acceptable. However, people felt uncertain to take treatment without screening for malaria first, largely due to the lack of symptoms. Knowledge of asymptomatic malaria was not a strong re-inforcement for treatment adherence. In this study, the pre-intervention active engagement of communities existed of having people co-design accurate information messages about their personal risk of malaria, which increased their trust in expert knowledge and thus proved essential for the successful implementation of the community-based intervention.

Rapid Ethnographic Assessment for Potential Anti-Malarial Mass Drug Administration in an Outbreak Area of Santo Domingo, Dominican Republic

“…3 and Box 1. This work further demonstrates the value of rapid ethnographic assessments to inform community engagement [12,18] and adds to previous research on motivations and barriers to MDA for malaria on Hispaniola [19] and elsewhere [20][21][22][23][24].…”

Understanding adherence to reactive treatment of asymptomatic malaria infections in The Gambia

“…In the study setting, the communities had a long political and engagement history with the implementing institution wherein trust in their role was mainly based on their reputation for providing good health care against the backdrop of a limited health system 44 , 45 . VHWs who often collaborated with the MRCG in projects were considered as key stakeholders for further facilitating treatment acceptance and adherence 37 , 46 . Nonetheless, community’s trust in the VHWs and their socio-political leverage was fundamentally dependent on the VHWs perceived capacity to provide curative services for malaria.…”

Ribosomal and non-ribosomal PCR targets for the detection of low-density and mixed malaria infections

“…Although the reason for this high rate of asymptomatic P. vivax infections is unknown, it is probably associated with the unique biology of P. vivax that includes a fast acquisition of clinical immunity as compared with P. falciparum [47]. It is particularly relevant because in different epidemiological settings there are perspectives on treating asymptomatic infections for malaria elimination [48]. In the study area, the results demonstrated that, in general, multiple molecular targets (i.e., ribosomal plus non-ribosomal) did not increase sensitivity to detect subclinical malaria infections.…”

“…Currently, WHO recommends that the use of NAATs be considered only for epidemiological research or surveys mapping submicroscopic infections in low transmission areas [54]. Innovative and cost-effective strategies that identify the real burden of malaria infections (those detected by qPCR) are required to reach malaria elimination goals, but remain a challenge [48].…”