April 7, 2014, 3:35 p.m.
Malaria Consortium's Beyond Garki project is an ambitious study which aims to understand changes in malaria epidemiology and recommend strategies to reduce its global impact on the lives of millions
Over the past 15 years the development of new technologies, combined with unprecedented international investment, has seen deaths from malaria plummet by 45% globally, according to WHO. Yet, still over 200m cases occur every year, leading to an estimated 627,000 deaths, the vast majority of which are among children under five years of age.
The scaling up of malaria prevention and control measures, such as artemisinin-based combination therapies (ACTs) and a massive distribution programme of long lasting insecticidal nets (LLINs) have been key to successes in reducing mortality.
"The success of current interventions and the reductions in incidence we have seen gives us reason to believe that malaria might be largely eliminated in areas where it used to be a huge public health problem," says Dr Tarekegn Abeku, senior technical specialist in disease prevention at the Malaria Consortium. Yet major risks in maintaining this momentum remain.
Both the malaria parasite and its mosquito vector have shown themselves capable of evolving and developing resistance to previous control measures and may yet do so again. In such a climate, increasing understanding of the epidemiology of malaria and improving knowledge of the best ways to use current interventions to keep it supressed, are major priorities. Malaria Consortium's Beyond Garki project, which is currently funded by UKaid at the Department of International Development, aims to find answers to these pressing concerns.
The Beyond Garki Project is led by Malaria Consortium and aims to monitor how malaria epidemiology evolves over time and to recommend the optimum use of currently available control strategies based on those observations.
Beyond Garki is a homage to an earlier project carried out by the WHO and the government of Nigeria in the Garki area of Jigawa State, which represented a serious international effort to understand malaria epidemiology in Africa.
Beyond Garki is being carried out in specially selected sites in Ethiopia, Uganda and Cambodia that have different levels of malaria endemicity, and is being planned in Garki in northern Nigeria. This enables recommendations which emerge to have application across a wide range of different settings globally.
"Effectively, we are looking at what is needed to bring malaria to pre-elimination or elimination level, and what conditions are necessary to achieve this," says Dr Abeku.
The project has several study components. Household surveys are carried out in the study communities in Ethiopia and Uganda, which are all linked to a focal health centre. These establish if and when members of the household sleep under insecticide treated nets and whether the walls of the home have been sprayed. A history of household members who have died or contracted malaria is taken, and every mosquito net in the household is individually reviewed and rated. Socio-economic details about the household are gathered, which allows researchers to explore how far family income contributes to malaria outcomes. They also ask how well households are informed about malaria prevention and control methods and what factors determine the use of these methods by household members.
Family members are subsequently asked to give consent for blood samples to be taken. These provide data for malariometric and serological studies which, when combined with historical data collected from medical records, enable researchers to plot malaria intensity within the community over time.
Therapeutic studies are carried out on selected subjects who are currently infected with malaria parasites to track how effective current treatments are and to check for any signs of resistance. Anyone found to have malaria is treated on the spot.
Entomological surveys are also conducted in the study communities to collect mosquitoes for analysis using techniques such as spraying, light traps, window traps and 'human landing' collection. These help determine behaviour patterns of different species of mosquitoes and how they interact with the human population. Captured insects are examined in laboratory conditions, yielding further information about the mosquitoes and the changes in the parasites they bear, which can inform future deterrent strategies.
Each medical centre in the study communities has an automated weather station collecting data on temperature, humidity and rainfall, three factors which influence the life and breeding cycles of mosquito and parasite.
Taken together, the various methodologies used to collect data make Beyond Garki one of the most comprehensive studies of malaria epidemiology.
"Doing a detailed study in a number of small areas lets us look at almost all the factors that impact on malaria at the same time," says Dr Abeku.
"Over several years, it's possible to detect changes, and to understand the effects of these different factors and their interactions, which are not easily understood by routine collection of health information."
The analysis of data gathered thus far is already yielding results. For Dr Abeku, it is important that the project is able to report and share its interim findings as soon as possible.
"As we go forward, we want to produce recommendations which can and should be used immediately by health services and other stakeholders to have greater impact on the disease," he says.
"We want to work with the ministries of health and other partners on how to translate these recommendations into real policies."
The hope – and it's a realistic hope - is that Beyond Garki will help to increase momentum towards a world where malaria is no longer a blight on the lives of millions of people living in the developing world.
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