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      Impact and Lessons Learned from Mass Drug Administrations of Malaria Chemoprevention during the Ebola Outbreak in Monrovia, Liberia, 2014

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          Abstract

          Background

          In October 2014, during the Ebola outbreak in Liberia healthcare services were limited while malaria transmission continued. Médecins Sans Frontières (MSF) implemented a mass drug administration (MDA) of malaria chemoprevention (CP) in Monrovia to reduce malaria-associated morbidity. In order to inform future interventions, we described the scale of the MDA, evaluated its acceptance and estimated the effectiveness.

          Methods

          MSF carried out two rounds of MDA with artesunate/amodiaquine (ASAQ) targeting four neighbourhoods of Monrovia (October to December 2014). We systematically selected households in the distribution area and administered standardized questionnaires. We calculated incidence ratios (IR) of side effects using poisson regression and compared self-reported fever risk differences (RD) pre- and post-MDA using a z-test.

          Findings

          In total, 1,259,699 courses of ASAQ-CP were distributed. All households surveyed (n = 222; 1233 household members) attended the MDA in round 1 (r1) and 96% in round 2 (r2) (212/222 households; 1,154 household members). 52% (643/1233) initiated ASAQ-CP in r1 and 22% (256/1154) in r2. Of those not initiating ASAQ-CP, 29% (172/590) saved it for later in r1, 47% (423/898) in r2. Experiencing side effects in r1 was not associated with ASAQ-CP initiation in r2 (IR 1.0, 95%CI 0.49–2.1). The incidence of self-reported fever decreased from 4.2% (52/1229) in the month prior to r1 to 1.5% (18/1229) after r1 (p<0.001) and decrease was larger among household members completing ASAQ-CP (RD = 4.9%) compared to those not initiating ASAQ-CP (RD = 0.6%) in r1 (p<0.001).

          Conclusions

          The reduction in self-reported fever cases following the intervention suggests that MDAs may be effective in reducing cases of fever during Ebola outbreaks. Despite high coverage, initiation of ASAQ-CP was low. Combining MDAs with longer term interventions to prevent malaria and to improve access to healthcare may reduce both the incidence of malaria and the proportion of respondents saving their treatment for future malaria episodes.

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          Most cited references8

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          Review of Mass Drug Administration for Malaria and Its Operational Challenges

          Mass drug administration (MDA) was a component of many malaria programs during the eradication era, but later was seldomly deployed due to concerns regarding efficacy and feasibility and fear of accelerating drug resistance. Recently, however, there has been renewed interest in the role of MDA as an elimination tool. Following a 2013 Cochrane Review that focused on the quantitative effects of malaria MDA, we have conducted a systematic, qualitative review of published, unpublished, and gray literature documenting past MDA experiences. We have also consulted with field experts, using their historical experience to provide an informed, contextual perspective on the role of MDA in malaria elimination. Substantial knowledge gaps remain and more research is necessary, particularly on optimal target population size, methods to improve coverage, and primaquine safety. Despite these gaps, MDA has been used successfully to control and eliminate Plasmodium falciparum and P. vivax malaria in the past, and should be considered as part of a comprehensive malaria elimination strategy in specific settings.
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            Mass administrations of antimalarial drugs.

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              Fighting fire with fire: mass antimalarial drug administrations in an era of antimalarial resistance.

              The emergence and spread of antimalarial resistance has been a major liability for malaria control. The spread of chloroquine-resistant Plasmodium falciparum strains had catastrophic consequences for people in malaria-endemic regions, particularly in sub-Saharan Africa. The recent emergence of artemisinin-resistant P. falciparum strains is of highest concern. Current efforts to contain artemisinin resistance have yet to show success. In the absence of more promising plans, it has been suggested to eliminate falciparum malaria from foci of artemisinin resistance using a multipronged approach, including mass drug administrations. The use of mass drug administrations is controversial as it increases drug pressure. Based on current knowledge it is difficult to conceptualize how targeted malaria elimination could contribute to artemisinin resistance, provided a full treatment course is ensured.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                31 August 2016
                2016
                : 11
                : 8
                : e0161311
                Affiliations
                [1 ]Postgraduate Training for Applied Epidemiology, Robert Koch Institute, Berlin, Germany
                [2 ]European Programme for Intervention Epidemiology Training (EPIET), ECDC, Stockholm, Sweden
                [3 ]Epicentre, Paris, France
                [4 ]Epicentre, Geneva, Switzerland
                [5 ]Médecins Sans Frontières, Operational Centre Paris, Tropical Medicine, New York, New York, United States of America
                [6 ]Médecins Sans Frontières, Operational Centre Paris, Monrovia Project, Monrovia, Liberia
                [7 ]Médecins Sans Frontières, Operational Centre Paris, Desk Urgence, Paris, France
                [8 ]Liberian National Malaria Control Programme, Ministry of Health, Monrovia, Liberia
                [9 ]Institut Veille Sanitaire, Paris, France
                Centers for Disease Control and Prevention, UNITED STATES
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                • Conceptualization: AT EL CO AK MJ CB KP.

                • Formal analysis: AK AT KD KP.

                • Investigation: AK AT MJ CB ACP KL.

                • Methodology: AT AK KP.

                • Project administration: MJ CB.

                • Supervision: AT AK KP.

                • Writing – original draft: AK AT.

                • Writing – review & editing: AK AT EL MJ CB CO KL ACP KD KP.

                Article
                PONE-D-16-10872
                10.1371/journal.pone.0161311
                5007029
                27580098
                9d52a67a-fc10-4f77-a3d7-74899830e84c
                © 2016 Kuehne et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 21 March 2016
                : 3 August 2016
                Page count
                Figures: 3, Tables: 3, Pages: 17
                Funding
                Epicentre (AT, KP) received core funding from Medecins sans Frontieres to conduct this research.
                Categories
                Research Article
                Medicine and Health Sciences
                Parasitic Diseases
                Malaria
                Medicine and Health Sciences
                Tropical Diseases
                Malaria
                Medicine and Health Sciences
                Diagnostic Medicine
                Signs and Symptoms
                Fevers
                Medicine and Health Sciences
                Pathology and Laboratory Medicine
                Signs and Symptoms
                Fevers
                Medicine and Health Sciences
                Pharmacology
                Adverse Reactions
                Medicine and Health Sciences
                Tropical Diseases
                Neglected Tropical Diseases
                Viral Hemorrhagic Fevers
                Ebola Hemorrhagic Fever
                Medicine and Health Sciences
                Infectious Diseases
                Viral Diseases
                Viral Hemorrhagic Fevers
                Ebola Hemorrhagic Fever
                Medicine and Health Sciences
                Oncology
                Cancer Treatment
                Chemoprevention
                Medicine and Health Sciences
                Pharmaceutics
                Drug Therapy
                Drug Administration
                People and Places
                Geographical Locations
                Africa
                Liberia
                Medicine and Health Sciences
                Pharmacology
                Pharmacokinetics
                Drug Distribution
                Custom metadata
                The minimal data set underlying the findings of this study are available on request, in accordance with the legal framework set forth by Médecins Sans Frontières (MSF) data sharing policy (Karunakara U, PLoS Med 2013). MSF is committed to share and disseminate health data from its programs and research in an open, timely, and transparent manner in order to promote health benefits for populations while respecting ethical and legal obligations towards patients, research participants, and their communities. The MSF data sharing policy ensures that data will be available upon request to interested researchers while addressing all security, legal, and ethical concerns. All readers may contact the generic address data.sharing@ 123456msf.org or Ms. Aminata Ndiaye ( aminata.ndiaye@ 123456epicentre.msf.org ) to request the data.

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